ADHD Management Plan/Sample 1

1 1mgDose 2mgDose am/pmTimeam/pmDose 1mgDose 2mgDose 3mg Medication to be given on nonschool days Medication given fornumber of days School authorization signed by parent and MD Rx written for duplicate bottle for administration at school Side effects explained/information givenCommon Side Effects:decreased appetite, sleep problems, transient stomachache, transient headache, behavioral reboundCall your doctor immediately if any infrequent side effects occur:weight loss, increased heart rate and/or blood pressure,dizziness, growth suppression, hallucinations/mania, exacerbation of tics and Tourette syndrome (rare)ADHD Management Plan Sample 1 Date:To t h e f a m i l y o f, please refer to this plan between visits if you have questions about you are still unsure, call us at for s doctor isPager #Parent/GuardianRelationshipContact Number(s)School NameSchool Phone Teacher Contact Name Grade Teacher s E-mail AddressGoalsWhat improvements would you most like to see?

2 Specific behavior you would like to see improve:At Home:At School:Plansto reach these Evaluation School testing scheduled date Parent and Teacher Vanderbilts completedAdditional Resources and Treatment Strategies F/U parent vanderbilt givencompleted F/U Teacher vanderbilt given to parent F/U Teacher vanderbilt to be faxed to schoolcompleted Behavioral Modification Counseling Referral to Parenting Tips Sheet given CHADD phone number given: 800/233-4050 Community Resources/Referrals:Next Follow-up Visit:Copyright 2002 American Academy of Pediatrics and National Initiative for Children sHealthcare QualityThe information contained in this publication should not be used as a substitute for themedical care and advice of your pediatrician.

3 There may be variations in treatment thatyour pediatrician may recommend based on individual facts and 1mgDose 2mgDose am/pmTimeam/pmDose 1mgDose 2mgDose 3mgADHD Management Plan Sample 2 Patient s doctor isPager #Parent/GuardianRelationshipContact Number(s)School NameSchool Phone Teacher Contact Name Grade Level Te a c h e r s E-mail AddressFax improvements would you most like to see?Plansto reach these Evaluation Parent Assessment received and follow-up appointment scheduled for ____/____/____ Te a c h e r A s s essment will be done by Ms/Mr School testing scheduled on this date ____/____/____Additional Resources and Treatment Strategies Behavioral Modification Counseling Referral to Parenting Tips Sheet given Parent Follow-up form completed ____/____/____ Teacher Follow-up form completed ____/____/____ CHADD phone number given: 800/233-4050 Common Side EffectsIf Any Infrequent Side Effects Occur, Call Your Doctor Immediately!

4 Decreased appetite Weight loss Sleep problemsIncreased heart rate and/or blood pressureTr a n s i e n t h e a dacheDizzinessTr a n s i e n t s t o m a c h a c heGrowth suppressionBehavioral reboundHallucinations/maniaExacerbation of tics and Tourette syndrome (rare)The recommendations in this publication do not indicate an exclusive course of treatmentor serve as a standard of medical care. Variations, taking into account individual circum-stances, may be 2002 American Academy of Pediatrics and National Initiative for Children sHealthcare QualityHE0351 NICHQ vanderbilt Assessment Scale TEACHER InformantTeacher s Name: _____ Class Time: _____ Class Name/Period: _____ Today s Date: _____ Child s Name: _____ Grade Level: _____Directions:Each rating should be considered in the context of what is appropriate for the age of the child you are ratingand should reflect that child s behavior since the beginning of the school year.

5 Please indicate the number of weeks or months you have been able to evaluate the behaviors: this evaluation based on a time when the child was on medication was not on medication not sure?SymptomsNeverOccasionallyOftenVery Often 1. Fails to give attention to details or makes careless mistakes in schoolwork0123 2. Has difficulty sustaining attention to tasks or activities01233. Does not seem to listen when spoken to directly01234. Does not follow through on instructions and fails to finish schoolwork0123(not due to oppositional behavior or failure to understand)5. Has difficulty organizing tasks and activities01236. Avoids, dislikes, or is reluctant to engage in tasks that require sustained0123mental effort7. Loses things necessary for tasks or activities (school assignments,0123pencils, or books)8.

6 Is easily distracted by extraneous stimuli01239. Is forgetful in daily activities012310. Fidgets with hands or feet or squirms in seat012311. Leaves seat in classroom or in other situations in which remaining 0123seated is expected12. Runs about or climbs excessively in situations in which remaining 0123seated is expected13. Has difficulty playing or engaging in leisure activities quietly012314. Is on the go or often acts as if driven by a motor 012315. Talks excessively012316. Blurts out answers before questions have been completed012317. Has difficulty waiting in line012318. Interrupts or intrudes on others (eg, butts into conversations/games) 0123 19. Loses temper012320. Actively defies or refuses to comply with adult s requests or rules0123 21. Is angry or resentful012322.

7 Is spiteful and vindictive012323. Bullies, threatens, or intimidates others012324. Initiates physical fights012325. Lies to obtain goods for favors or to avoid obligations (eg, cons others)012326. Is physically cruel to people012327. Has stolen items of nontrivial value012328. Deliberately destroys others property012329. Is fearful, anxious, or worried012330. Is self-conscious or easily embarrassed012331. Is afraid to try new things for fear of making mistakes0123 The recommendations in this publication do not indicate an exclusive course of treatmentor serve as a standard of medical care. Variations, taking into account individual circum-stances, may be 2002 American Academy of Pediatrics and National Initiative for Children sHealthcare QualityAdapted from the vanderbilt Rating Scales developed by Mark L.

8 Wolraich, - 0303D4D4 NICHQ vanderbilt Assessment Scale TEACHER Informant, continuedTeacher s Name: _____ Class Time: _____ Class Name/Period: _____Today s Date: _____ Child s Name: _____ Grade Level: _____Symptoms (continued)NeverOccasionallyOftenVery Often32. Feels worthless or inferior012333. Blames self for problems; feels guilty012334. Feels lonely, unwanted, or unloved; complains that no one loves him or her 012335. Is sad, unhappy, or depressed0123 SomewhatPerformanceAboveof aAcademic PerformanceExcellentAverageAverageProble mProblematic36. Reading1234537. Mathematics1234538. Written expression12345 SomewhatAboveof aClassroom Behavioral PerformanceExcellentAverageAverageProble mProblematic39. Relationship with peers1234540. Following directions1234541.

9 Disrupting class1234542. Assignment completion1234543. Organizational skills12345 Comments:Please return this form to: _____Mailing address: _____Fax number:_____For Office Use OnlyTotal number of questions scored 2 or 3 in questions 1 9:_____Total number of questions scored 2 or 3 in questions 10 18:_____Total Symptom Score for questions 1 18:_____Total number of questions scored 2 or 3 in questions 19 28:_____Total number of questions scored 2 or 3 in questions 29 35:_____Total number of questions scored 4 or 5 in questions 36 43:_____Average Performance Score:_____11-20/rev0303 How to Establish a School-Home Daily Report CardUsed w ith per mission of William E. Pelham, Jr, Available for downloading at no cost in expanded format at Select the Areas for Improvement. Discuss the child s behavior with all school staff who work with the child.

10 Determine the child s greatest areas of impairment. Define goals toward which the child should be working regarding the areas of impairment. Key domains: Improving peer relations Improving academic work Improving classroom rule-following and relationships with adults2. Determine How the Goals Will Be Defined. Identify specific behaviors ( target behaviors ) that can be changed to make progress toward the goals easier. Ta r g e t b e h a v i o r s m ust be meaningful and clearly defined/ observed/counted by teacher and child. Examples of target behaviors in the key domains: Improving peer relations:does not interrupt other children during their work time, does not tease other children, plays without fighting at recess Improving academic work:has materials and assignments necessary to do tasks, completes assigned academic tasks,is accurate on assigned tasks, completes and returns homework Improving classroom rule-following and relationships with adults:obeys the teacher when commands are given,does not talk back to the teacher, follows classroom rules Additional target behaviors are listed on the attached sheet,Sample Report Card Decide on Behaviors and Criteria for the Daily Report Card.