Contributing author: Mark L. Wolraich, MD.
In 2000, the American Academy of Pediatrics (AAP) released its first clinical recommendations for the diagnosis and evaluation of ADHD in children and followed that a year later with treatment recommendations. In 2011, the AAP updated these guidelines due to new evidence that has emerged in the management of children with ADHD.
Important Changes to the Guidelines
The AAP’s 2011 guideline update recommends that primary care physicians (PCPs) evaluate children for ADHD from age 4 through 18. The earlier version of the guidelines covered children ages 6 to 12. This change was made because of an accumulation of evidence in recent years in a broader pediatric population. Enough evidence has emerged that we now feel comfortable about the criteria being appropriate for preschoolers and adolescents.
Previously, the AAP had one guideline for diagnosis and evaluation and another for treatment. Now, the academy has included diagnosis, evaluation, and treatment in a single document. The revised guideline also includes recommendations for managing pediatric patients who exhibit some signs and symptoms of ADHD but don’t meet current diagnostic criteria for the condition. This information is particularly applicable to PCPs. Furthermore, a new process-of-care algorithm has been developed to provide physicians with step-by-step guidance on implementing the recommendations, and the AAP’s ADHD toolkit has been revised based on this algorithm.
Key Action Statements for Pediatric ADHD
The 2011 AAP guideline includes a summary of several key action statements:
PCPs should initiate an ADHD evaluation for any child aged 4 to 18 who has school or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
Symptoms and behavior must meet the criteria set forth in the DSM-IV for a diagnosis of ADHD.
Physicians should rely primarily on information from parents, guardians, school, and mental health specialists, and rule out all other causes.
Clinical evaluations should include assessment of conditions that might coexist with ADHD.
ADHD should be viewed as a chronic condition.
Treatment of ADHD varies by age:
For preschool-age children, behavioral interventions are considered first-line therapy. If resources are unavailable, physicians should carefully weigh the risks of drug therapy at an early age with those associated with delayed diagnosis and treatment.
For children aged 6 to 11, combination treatment with medication and behavioral therapy may be used. Evidence for use of stimulants in this age group is strong.
For older children, treatment should begin with medication. Behavioral therapy may be prescribed, but data on it in this age group are not as strong as in younger patients.
Medication for ADHD should be titrated to achieve maximal benefits with minimal adverse events.
Helpful Tools for Clinicians
The 2011 AAP guidelines for diagnosing, evaluating, and treating ADHD in children and adolescents were published in the November 2011 issue of Pediatrics and are available to clinicians online at http://pediatrics.aappublications. org for free. The AAP also updated its ADHD Toolkit, which was designed as a clinical aid for PCPs who diagnose and treat the disorder in children and adolescents. These resources can be valuable for optimizing the management of ADHD going forward.
Readings & Resources (click to view)
American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. Clinical practice guideline for the diagnosis, Evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011 Oct 16 [Epub ahead of print]. Available at: http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf.
American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.
American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/ hyperactivity disorder. Pediatrics. 2001;108:1033-1044.
Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119(suppl 1):S99-S106.
Van Cleave J, Leslie LK. Approaching ADHD as a chronic condition: implications for long-term adherence. J Psychosoc Nurs Ment Health Serv. 2008;46:28-36.