Recommendations

From the American Academy of Pediatrics (AAP)

Video on ADHD

CDC Expert Commentary – Attention Deficit/Hyperactivity Disorder Video Thumb

A CDC expert comments on the new clinical practice guidelines.

AAP has released a new clinical practice guideline that provides evidence-based recommendations for the diagnosis and treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline is intended for use by clinicians working in primary care settings. The guideline replaces two previously published clinical guidelines that were published by AAP in 2000 and 2001. CDC conducted the systematic review of evidence for the diagnosis and evaluation of ADHD.

Important changes to the recent guidelines include:

Expanded age range of coverage. The previous guidelines covered children 6-12 years of age; the current guideline covers children 4-18 years of age.
Expanded Scope. The new guidelines include consideration of behavioral interventions and directly addresses problem-level concerns in children based on the Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version.
A Process of Care for Diagnosis and Treatment. AAP included a process of care algorithm to guide clinical process .
Integration with the Task Force on Mental Health. The guideline was conceived and developed to fit within the broader mission of the AAP Task Force on Mental Health to foster stronger ties to families and mental health clinicians, to intervene early, and to work to prevent mental health conditions.

Additionally, the Subcommittee on ADHD, Steering Committee on Quality Improvement and Management developed a single set of recommendations for diagnosis, evaluation, and treatment of ADHD.

Diagnosis and Evaluation

Here are the recommendations for the diagnosis and evaluation of ADHD based on the guidelines:

The primary care clinician should provide initiate an evaluation for ADHD for any child 4 through 18 years of age who shows presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
To make a diagnosis of ADHD, the primary care clinician should determine that diagnostic criteria have been met based on Diagnostic and Statistical Manual of Mental Disorders – Fifth edition (DSM-5, which replaced the Fourth Edition (DSM-IV) in May 2013). Making a diagnosis includes documenting that the child is impaired in more than 1 major setting (e.g., in school and at home). The primary care clinician should include reports from parents or guardians, teachers, and/or other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any other possible cause.
• When evaluating a child for ADHD, the primary care clinician should assess whether other conditions are present that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorders or other neurodevelopmental disorders), and physical (e.g., tics, sleep apnea) conditions.
The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Care for such children and youth should follow the principles of the chronic care model and the medical home.

Treatment

The guideline contains the following recommendations for the treatment of ADHD:

Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:
- For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to severe continuing disturbance in the child’s function. In areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment. Read more about evidence based treatment options for preschoolers.
- For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US Food and Drug Administration–approved medications for ADHD and/or evidence-based parentand/or teacher-administered behavior therapy as treatment for ADHD, preferably both. The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order). The school environment, program, or placement is a part of any treatment plan.
- For adolescents (12–18 years of age), the primary care clinician should prescribe Food and Drug Administration–approved medications for ADHD with the assent of the adolescent and may prescribe behavior therapy as treatment for ADHD, preferably both.
The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects.