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Peds 20192528 PDF
Peds 20192528 PDF
PEDIATRICS Volume 144, number 4, October 2019:e20192528 FROM THE AMERICAN ACADEMY OF PEDIATRICS
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INTRODUCTION implementation of such a resource. In care to the patient and his or her
This article updates and replaces the response, this guideline is supported family. There is some evidence that
2011 clinical practice guideline by 2 accompanying documents, African American and Latino children
revision published by the American available in the Supplemental are less likely to have ADHD
Academy of Pediatrics (AAP), “Clinical Information: (1) a process of care diagnosed and are less likely to be
Practice Guideline: Diagnosis and algorithm (PoCA) for the diagnosis treated for ADHD. Special attention
Evaluation of the Child with and treatment of children and should be given to these populations
Attention-Deficit/Hyperactivity adolescents with ADHD and (2) an when assessing comorbidities as they
Disorder.”1 This guideline, like the article on systemic barriers to the relate to ADHD and when treating for
previous document, addresses the care of children and adolescents with ADHD symptoms.3 Given the
evaluation, diagnosis, and treatment ADHD. These supplemental nationwide problem of limited access
of attention-deficit/hyperactivity documents are designed to aid PCCs to mental health clinicians,4
disorder (ADHD) in children from age in implementing the formal pediatricians and other PCCs are
4 years to their 18th birthday, with recommendations for the evaluation, increasingly called on to provide
special guidance provided for ADHD diagnosis, and treatment of children services to patients with ADHD and to
care for preschool-aged children and and adolescents with ADHD. Although their families. In addition, the AAP
adolescents. (Note that for the this document is specific to children holds that primary care pediatricians
purposes of this document, and adolescents in the United States should be prepared to diagnose and
“preschool-aged” refers to children in some of its recommendations, manage mild-to-moderate ADHD,
from age 4 years to the sixth international stakeholders can modify anxiety, depression, and problematic
birthday.) Pediatricians and other specific content (ie, educational laws substance use, as well as co-manage
primary care clinicians (PCCs) may about accommodations, etc) as patients who have more severe
continue to provide care after needed. (Prevention is addressed in conditions with mental health
18 years of age, but care beyond this the Mental Health Task Force professionals. Unfortunately, third-
age was not studied for this guideline. recommendations.2) party payers seldom pay
appropriately for these time-
Since 2011, much research has PoCA for the Diagnosis and consuming services.5,6
Treatment of Children and
occurred, and the Diagnostic and
Adolescents With ADHD To assist pediatricians and other
Statistical Manual of Mental Disorders,
In this revised guideline and PCCs in overcoming such obstacles,
Fifth Edition (DSM-5), has been
accompanying PoCA, we recognize the companion article on systemic
released. The new research and DSM-
that evaluation, diagnosis, and barriers to the care of children and
5 do not, however, support dramatic
treatment are a continuous process. adolescents with ADHD reviews the
changes to the previous
The PoCA provides recommendations barriers and makes recommendations
recommendations. Hence, this new
for implementing the guideline steps, to address them to enhance care for
guideline includes only incremental
although there is less evidence for the children and adolescents with ADHD.
updates to the previous guideline.
One such update is the addition of PoCA than for the guidelines. The
a key action statement (KAS) about section on evaluating and treating
comorbidities has also been expanded ADHD EPIDEMIOLOGY AND SCOPE
the diagnosis and treatment of
coexisting or comorbid conditions in in the PoCA document. Prevalence estimates of ADHD vary
children and adolescents with ADHD. on the basis of differences in research
Systems Barriers to the Care of methodologies, the various age
The subcommittee uses the term
Children and Adolescents With ADHD
“comorbid,” to be consistent with the groups being described, and changes
DSM-5. There are many system-level barriers in diagnostic criteria over time.7
that hamper the adoption of the best- Authors of a recent meta-analysis
Since 2011, the release of new practice recommendations contained calculated a pooled worldwide ADHD
research reflects an increased in the clinical practice guideline and prevalence of 7.2% among children8;
understanding and recognition of the PoCA. The procedures estimates from some community-
ADHD’s prevalence and recommended in this guideline based samples are somewhat higher,
epidemiology; the challenges it raises necessitate spending more time with at 8.7% to 15.5%.9,10 National survey
for children and families; the need for patients and their families, data from 2016 indicate that 9.4% of
a comprehensive clinical resource for developing a care management children in the United States 2 to
the evaluation, diagnosis, and system of contacts with school and 17 years of age have ever had an
treatment of pediatric ADHD; and the other community stakeholders, and ADHD diagnosis, including 2.4% of
barriers that impede the providing continuous, coordinated children 2 to 5 years of age.11 In that
Evidence Review
This article followed the latest
version of the evidence base update
format used to develop the previous 3
clinical practice guidelines.24–26
Under this format, studies were only
included in the review when they met
a variety of criteria designed to
ensure the research was based on
a strong methodology that yielded
confidence in its conclusions.
The level of efficacy for each
treatment was defined on the basis of
child-focused outcomes related to FIGURE 1
AAP rating of evidence and recommendations.
both symptoms and impairment.
Hence, improvements in behaviors on
the part of parents or teachers, such
sites/default/files/pdf/cer-203-adhd- demonstrated a preponderance of
as the use of communication or
final_0.pdf. benefits over harms, the KAS provides
praise, were not considered in the
a “strong recommendation” or
review. Although these outcomes are The evidence is discussed in more
“recommendation.”27 Clinicians
important, they address how detail in published reports and
should follow a “strong
treatment reaches the child or articles.25
recommendation” unless a clear and
adolescent with ADHD and are,
Guideline Recommendations and Key compelling rationale for an
therefore, secondary to changes in the
Action Statements alternative approach is present;
child’s behavior. Focusing on
clinicians are prudent to follow
improvements in the child or The AAP policy statement, a “recommendation” but are advised
adolescent’s symptoms and “Classifying Recommendations for to remain alert to new information
impairment emphasizes the Clinical Practice Guidelines,” was and be sensitive to patient
disorder’s characteristics and followed in designating aggregate preferences27 (see Fig 1).
manifestations that affect children evidence quality levels for the
and their families. available evidence (see Fig 1).27 The When the scientific evidence
AAP policy statement is consistent comprised lower-quality or limited
The treatment-related evidence relied
with the grading recommendations data and expert consensus or high-
on a recent review of literature from
advanced by the University of quality evidence with a balance
2011 through 2016 by the AHRQ of
Oxford Centre for Evidence Based between benefits and harms, the KAS
citations from Medline, Embase,
Medicine. provides an “option” level of
PsycINFO, and the Cochrane Database
recommendation. Options are clinical
of Systematic Reviews. The subcommittee reached consensus
interventions that a reasonable
on the evidence, which was then used
The original methodology and report, health care provider might or might
to develop the clinical practice
including the evidence search and not wish to implement in the
guideline’s KASs.
review, are available in their entirety practice.27 Where the evidence
and as an executive summary at When the scientific evidence was at was lacking, a combination of
https://effectivehealthcare.ahrq.gov/ least “good” in quality and evidence and expert consensus
PoCA for more information on should conduct a clinical interview children younger than 18 years (ie,
implementing this KAS.) with parents, examine and observe preschool-aged children, elementary
the child, and obtain information and middle school–aged children, and
Special Circumstances: Preschool-Aged from parents and teachers through adolescents) and are only minimally
Children (Age 4 Years to the Sixth DSM-based ADHD rating scales.40 different from the DSM-IV. Hence, if
Birthday) Normative data are available for the clinicians do not have the ADHD
DSM-5–based rating scales for ages Rating Scale-5 or the ADHD Rating
There is evidence that the diagnostic
criteria for ADHD can be applied to 5 years to the 18th birthday.41 There Scale-IV Preschool Version,42 any
preschool-aged children.33–39 A are, however, minimal changes in the other DSM-based scale can be used to
review of the literature, including the specific behaviors from the DSM-IV, provide a systematic method for
multisite study of the efficacy of on which all the other DSM-based collecting information from parents
methylphenidate in preschool-aged ADHD rating scales obtained and teachers, even in the absence of
children, found that the DSM-5 normative data. Both the ADHD normative data.
criteria could appropriately identify Rating Scale-IV and the Conners
children with ADHD.25 Rating Scale have preschool-age Pediatricians and other PCCs should
normative data based on the DSM-IV. be aware that determining the
To make a diagnosis of ADHD in The specific behaviors in the DSM-5 presence of key symptoms in this age
preschool-aged children, clinicians criteria for ADHD are the same for all group has its challenges, such as
TABLE 3 KAS 2: To make a diagnosis of ADHD, the PCC should determine that DSM-5 criteria have been met, including documentation of symptoms and
impairment in more than 1 major setting (ie, social, academic, or occupational), with information obtained primarily from reports from parents
or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescent’s care. The PCC should
also rule out any alternative cause. (Grade B: strong recommendation.)
Aggregate evidence Grade B
quality
Benefits Use of the DSM-5 criteria has led to more uniform categorization of the condition across professional disciplines. The criteria are
essentially unchanged from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), for children up to
their 18th birthday, except that DSM-IV required onset prior to age 7 for a diagnosis, while DSM-5 requires onset prior to age 12.
Risks, harm, cost The DSM-5 does not specifically state that symptoms must be beyond expected levels for developmental (rather than chronologic) age
to qualify for an ADHD diagnosis, which may lead to some misdiagnoses in children with developmental disorders.
Benefit-harm The benefits far outweigh the harm.
assessment
Intentional vagueness None.
Role of patient Although there is some stigma associated with mental disorder diagnoses, resulting in some families preferring other diagnoses, the
preferences need for better clarity in diagnoses outweighs this preference.
Exclusions None.
Strength Strong recommendation.
Key references Evans et al25; McGoey et al42; Young43; Sibley et al46
TABLE 4 KAS 3: In the evaluation of a child or adolescent for ADHD, the PCC should include a process to at least screen for comorbid conditions, including
emotional or behavioral conditions (eg, anxiety, depression, oppositional defiant disorder, conduct disorders, substance use), developmental
conditions (eg, learning and language disorders, autism spectrum disorders), and physical conditions (eg, tics, sleep apnea). (Grade B: strong
recommendation.)
Aggregate evidence Grade B
quality
Benefits Identifying comorbid conditions is important in developing the most appropriate treatment plan for the child or adolescent with
ADHD.
Risks, harm, cost The major risk is misdiagnosing the comorbid condition(s) and providing inappropriate care.
Benefit-harm There is a preponderance of benefits over harm.
assessment
Intentional vagueness None.
Role of patient None.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Cuffe et al51; Pastor and Reuben52; Bieiderman et al53; Bieiderman et al54; Bieiderman et al72; Crabtree et al57; LeBourgeois et al58;
Chan115; Newcorn et al60; Sung et al61; Larson et al66; Mahajan et al65; Antshel et al64; Rothenberger and Roessner63; Froehlich et al62
comorbidity, particularly substance Recommendations for the Treatment 6 years against the harm of delaying
use disorders.71,72 They also have of Children and Adolescents With treatment (Table 6). (Grade B: strong
lower educational achievement than ADHD: KAS 5a, 5b, and 5c recommendation.)
those without ADHD73,74 and Recommendations vary depending on
increased rates of incarceration.75–77 the patient’s age and are presented A number of special circumstances
Treatment discontinuation also for the following age ranges: support the recommendation to
places individuals with ADHD at initiate PTBM as the first treatment
a. preschool-aged children: age of preschool-aged children (age
higher risk for catastrophic
4 years to the sixth birthday; 4 years to the sixth birthday) with
outcomes, such as motor vehicle
crashes78,79; criminality, including b. elementary and middle ADHD.25,83 Although it was limited to
drug-related crimes77 and violent school–aged children: age 6 years children who had moderate-to-
reoffending76; depression71; to the 12th birthday; and severe dysfunction, the largest
interpersonal issues80; and other c. adolescents: age 12 years to the multisite study of methylphenidate
injuries.81,82 18th birthday. use in preschool-aged children
revealed symptom improvements
The KASs are presented, followed by after PTBM alone.83 The overall
To continue providing the best care, it
information on medication, evidence for PTBM among
is important for a treating
psychosocial treatments, and special preschoolers is strong.
pediatrician or other PCC to engage in
circumstances.
bidirectional communication with
teachers and other school personnel PTBM programs for preschool-aged
as well as mental health clinicians KAS 5a children are typically group programs
involved in the child or adolescent’s For preschool-aged children (age and, although they are not always
care. This communication can be 4 years to the sixth birthday) with paid for by health insurance, they
difficult to achieve and is discussed in ADHD, the PCC should prescribe may be relatively low cost. One
both the PoCA and the section on evidence-based behavioral PTBM evidence-based PTBM, parent-child
systemic barriers to the care of and/or behavioral classroom interaction therapy, is a dyadic
children and adolescents with ADHD interventions as the first line of therapy for parent and child. The
in the Supplemental Information, as is treatment, if available (grade A: PoCA contains criteria for the
the medical home model.69 strong recommendation). clinician’s use to assess the quality of
Methylphenidate may be considered PTBM programs. If the child attends
if these behavioral interventions do preschool, behavioral classroom
Special Circumstances: Inattention not provide significant improvement interventions are also recommended.
or Hyperactivity/Impulsivity and there is moderate-to-severe In addition, preschool programs (such
(Problem Level) continued disturbance in the 4- as Head Start) and ADHD-focused
Children with inattention or through 5-year-old child’s organizations (such as CHADD84) can
hyperactivity/impulsivity at the functioning. In areas in which also provide behavioral supports. The
problem level, as well as their evidence-based behavioral issues related to referral, payment,
families, may also benefit from the treatments are not available, the and communication are discussed in
chronic illness and medical home clinician needs to weigh the risks of the section on systemic barriers in
principles. starting medication before the age of the Supplemental Information.
In areas in which evidence-based The evidence is particularly strong for it is best to introduce components at
behavioral treatments are not stimulant medications; it is sufficient, the start of high school, at about
available, the clinician needs to but not as strong, for atomoxetine, 14 years of age, and specifically focus
weigh the risks of starting extended-release guanfacine, and during the 2 years preceding high
methylphenidate before the age extended-release clonidine, in that school completion.
of 6 years against the harm of order (see the Treatment section, and
delaying diagnosis and treatment. see the PoCA for more information on Psychosocial Treatments
Other stimulant or nonstimulant implementation). Some psychosocial treatments for
medications have not been children and adolescents with ADHD
adequately studied in children in KAS 5c have been demonstrated to be
this age group with ADHD. For adolescents (age 12 years to the effective for the treatment of ADHD,
18th birthday) with ADHD, the PCC including behavioral therapy and
KAS 5b should prescribe FDA-approved training interventions.24–26,85 The
For elementary and middle medications for ADHD with the diversity of interventions and
school–aged children (age 6 years to adolescent’s assent (grade A: strong outcome measures makes it
the 12th birthday) with ADHD, the recommendation). The PCC is challenging to assess a meta-analysis
PCC should prescribe US Food and encouraged to prescribe evidence- of psychosocial treatment’s effects
Drug Administration (FDA)–approved based training interventions and/or alone or in association with
medications for ADHD, along with behavioral interventions as treatment medication treatment. As with
PTBM and/or behavioral classroom of ADHD, if available. Educational medication treatment, the long-term
intervention (preferably both PTBM interventions and individualized positive effects of psychosocial
and behavioral classroom interven- instructional supports, including treatments have yet to be determined.
tions). Educational interventions school environment, class Nonetheless, ongoing adherence
and individualized instructional placement, instructional placement, to psychosocial treatment is
supports, including school environment, and behavioral supports, are a key contributor to its beneficial
class placement, instructional a necessary part of any treatment effects, making implementation of
placement, and behavioral supports, plan and often include an IEP or a chronic care model for child health
are a necessary part of any a rehabilitation plan (504 plan) important to ensure sustained
treatment plan and often include an (Table 8). (Grade A: strong adherence.86
Individualized Education Program recommendation.) Behavioral therapy involves training
(IEP) or a rehabilitation plan (504 Transition to adult care is an adults to influence the contingencies
plan) (Table 7). (Grade A: strong important component of the chronic in an environment to improve the
recommendation for medications; care model for ADHD. Planning for behavior of a child or adolescent in
grade A: strong recommendation for the transition to adult care is an that setting. It can help parents and
PTBM training and behavioral ongoing process that may culminate school personnel learn how to
treatments for ADHD implemented after high school or, perhaps, after effectively prevent and respond to
with the family and school.) college. To foster a smooth transition, adolescent behaviors such as
interrupting, aggression, not symptoms. The positive effects of setting. Less research has been
completing tasks, and not complying behavioral therapies tend to persist, conducted on training interventions
with requests. Behavioral parent and but the positive effects of medication compared to behavioral treatments;
classroom training are well- cease when medication stops. nonetheless, training interventions
established treatments with Optimal care is likely to occur when are well-established treatments to
preadolescent children.25,87,88 Most both therapies are used, but the target disorganization of materials
studies comparing behavior therapy decision about therapies is heavily and time that are exhibited by
to stimulants indicate that stimulants dependent on acceptability by, and most youth with ADHD; it is likely
have a stronger immediate effect on feasibility for, the family. that they will benefit younger
the 18 core symptoms of ADHD. Training interventions target skill children, as well.25,89 Some training
Parents, however, were more satisfied development and involve repeated interventions, including social
with the effect of behavioral therapy, practice with performance feedback skills training, have not been shown
which addresses symptoms and over time, rather than modifying to be effective for children with
functions in addition to ADHD’s core behavioral contingencies in a specific ADHD.25
TABLE 8 KAS 5c: For adolescents (age 12 years to the 18th birthday) with ADHD, the PCC should prescribe FDA-approved medications for ADHD with the
adolescent’s assent (grade A: strong recommendation). The PCC is encouraged to prescribe evidence-based training interventions and/or
behavioral interventions as treatment of ADHD, if available. Educational interventions and individualized instructional supports, including school
environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include
an IEP or a rehabilitation plan (504 plan). (Grade A: strong recommendation.)
Aggregate evidence Grade A for Medications; Grade A for Training and Behavioral Therapy
quality
Benefits Training interventions, behavioral therapy, and FDA-approved medications have been demonstrated to reduce behaviors associated
with ADHD and to improve function.
Risks, harm, cost Both therapies increase the cost of care. Psychosocial therapy requires a high level of family and/or school involvement and may lead
to unintended increased family conflict, especially if treatment is not successfully completed. FDA-approved medications may have
some adverse effects, and discontinuation of medication is common among adolescents.
Benefit-harm Given the risks of untreated ADHD, the benefits outweigh the risks.
assessment
Intentional vagueness None.
Role of patient Family preference, including patient preference, is likely to predict engagement and persistence with a treatment.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Evans et al25; Webster-Stratton et al87; Evans et al95; Fabiano et al93; Sibley and Graziano et al94; Langberg et al96; Schultz et al97; Brown
and Bishop104; Kambeitz et al105; Bruxel et al106; Froehlich et al108; Joensen et al109
TABLE 9 KAS 6: The PCC should titrate doses of medication for ADHD to achieve maximum benefit with tolerable side effects. (Grade B: strong
recommendation.)
Aggregate evidence Grade B
quality
Benefits The optimal dose of medication is required to reduce core symptoms to, or close to, the levels of children without ADHD.
Risks, harm, cost Higher levels of medication increase the chances of side effects.
Benefit-harm The importance of adequately treating ADHD outweighs the risk of adverse effects.
assessment
Intentional vagueness None.
Role of patient The families’ preferences and comfort need to be taken into consideration in developing a titration plan, as they are likely to predict
preferences engagement and persistence with a treatment.
Exclusions None
Strength Strong recommendation
Key references Jensen et al140; Solanto147; Brinkman et al149
to identify conditions, including ADHD, experience, or resources to diagnose for evaluating ADHD in
intervene early, and partner with both and treat children and adolescents preschoolers;
families and specialists for the benefit with ADHD, especially if severity or • study of medications and other
of children’s health. A wealth of useful comorbid conditions make these therapies used clinically but not
information is available at the AAP patients complex to manage. In these FDA approved for ADHD;
Mental Health Initiatives Web site situations, comanagement with • determination of the optimal
(https://www.aap.org/en-us/advocacy- specialty clinicians is recommended. schedule for monitoring children
and-policy/aap-health-initiatives/ The SDBP is developing a guideline to and adolescents with ADHD,
Mental-Health/Pages/Tips-For- address such complex cases and aid including factors for adjusting
Pediatricians.aspx). pediatricians and other PCCs to that schedule according to age,
It is also important for PCCs to be manage these cases; the SDBP symptom severity, and progress
aware of health disparities and social currently expects to publish this reports;
document in 2019.67
determinants that may impact patient • evaluation of the effectiveness and
outcomes and strive to provide adverse effects of medications used
culturally appropriate care to all in combination, such as a stimulant
children and adolescents in their AREAS FOR FUTURE RESEARCH with an a-adrenergic agent,
practice.145,146,154,155 There is a need to conduct research selective serotonin reuptake
on topics pertinent to the diagnosis inhibitor, or atomoxetine;
The accompanying PoCA provides
supplemental information to support and treatment of ADHD, • evaluation of processes of care to
PCCs as they implement this developmental variations, and assist PCCs to identify and treat
guideline’s recommendations. In problems in children and adolescents comorbid conditions;
particular, the PoCA describes steps in primary care. These research • evaluation of the effectiveness of
for preparing the practice that provide opportunities include the following: various school-based interventions;
useful recommendations to clinicians. • assessment of ADHD and its • comparisons of medication use
For example, the PoCA includes common comorbidities: anxiety, and effectiveness in different
information about using standardized depression, learning disabilities, ages, including both harms and
rating scales to diagnose ADHD, and autism spectrum disorder; benefits;
assessing for comorbid conditions,
• identification and/or development • development of methods to involve
documenting all aspects of the
of reliable instruments suitable for parents, children, and adolescents
diagnostic and treatment procedures
use in primary care to assess the in their own care and improve
in the patient’s records, monitoring
nature or degree of functional adherence to both psychosocial and
the patient’s treatment and outcomes,
impairment in children and medication treatments;
and providing families with written
adolescents with ADHD and to • conducting research into
management plans.
monitor improvement over time; psychosocial treatments, such as
The AAP acknowledges that some • refinement of developmentally cognitive behavioral therapy and
PCCs may not have the training, informed assessment procedures cognitive training, among others;
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