“It has been 8 years since The American Academy of Pediatrics (AAP) updated the Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents was last revised,” explains Mark L. Wolraich, MD, FAAP. With the AAP typically reviewing guidelines every 3 years to either reaffirm or revise them, and psychiatric diagnostic criteria for ADHD revised in the DSM-5 during this interval, The AAP recently updated the guideline, which was originally published in 2000 and later revised in 2011 alongside an accompanying process of care algorithm (PoCA).
New to guideline is the addition of a key action statement focused on the diagnosis and treatment of comorbid conditions in patients with ADHD (Table). To assist physicians in implementing the guideline recommendation, the PoCA was also updated.
The guideline update keeps medication and behavioral therapy as the recommended central treatments for ADHD Behavioral therapy in the form of parent training in behavior management (PTBM) is the first line of treatment in children aged 4 to 6if acceptable to the parents. Medication in the form of methylphenidate is recommended as appropriate if PTBM is not successful, available, or acceptable to the parents. “In older children (6 to 12), evidence is strong for the benefits of both medication and behavioral intervention,” explains Dr. Wolraich. “Given the importance of patient and parent input in making a treatment program successful, it is best to go with their preferences. In adolescents the evidence is stronger for medication.”
ComorbiditiesDr. Wolraich suggests clinicians “consider ADHD as a chronic illness like asthma or diabetes, for which there are very effective symptomatic, but no curative, treatments,” adding that it is important to follow up, because like any other chronic illness, ongoing help will be needed. “Most children with ADHD will have at least one co-occurring condition, and other conditions such as learning disabilities, anxiety and/or depression can cause some similar symptoms; it is important to identify other causes or co-occurring conditions,” he explains. “While it is important to identify and monitor the 18 core symptoms, the most important aspect is to improve function.”
AAP produces accompanying tools to help physicians provide the best care possible. “We produced a how-to supplement (PoCA) and a supplement outlining the common barriers to implementation,” Dr. Wolraich says. “Additionally, the AAP has revised its ADHD toolkit, quality improvement module (EQIPP), and parent book and pamphlet to help pediatric clinicians incorporate the recommendations into their practice.”
Looking forward, Dr. Wolraich feels “communication between pediatric clinicians and school teachers needs to improve and make better use of electronic communication while preserving personal health information. More realistic compensation for the time required to provide appropriate care is also needed.”