Professional Documents
Culture Documents
ABSTRACT. This clinical practice guideline provides should be directed to target outcomes and adverse
evidence-based recommendations for the treatment of effects, with information gathered from parents, teach-
children diagnosed with attention-deficit/hyperactivity ers, and the child.
disorder (ADHD). This guideline, the second in a set of
policies on this condition, is intended for use by clini- This guideline is intended for use by primary care
cians working in primary care settings. The initiation of clinicians for the management of children between 6 and
treatment requires the accurate establishment of a diag- 12 years of age with ADHD. In light of the high preva-
nosis of ADHD; the American Academy of Pediatrics lence of ADHD in pediatric practice, the guideline
(AAP) clinical practice guideline on diagnosis of children should assist primary care clinicians in treatment. Al-
with ADHD1 provides direction in appropriately diag- though many of the recommendations here also may
nosing this disorder. apply to children with coexisting conditions, this guide-
The AAP Committee on Quality Improvement selec- line primarily addresses children with ADHD but with-
ted a subcommittee composed of primary care and out major coexisting conditions. The guideline is not
developmental-behavioral pediatricians and other ex- intended for use in the treatment of children with mental
perts in the fields of neurology, psychology, child psy- retardation, pervasive developmental disorder, moderate
chiatry, education, family practice, and epidemiology. to severe sensory deficits such as visual and hearing
The subcommittee partnered with the Agency for Health- impairment, chronic disorders associated with medica-
care Research and Quality and the Evidence-based Prac- tions that may affect behavior, and those who have ex-
tice Center at McMaster University, Ontario, Canada, to perienced child abuse and sexual abuse. This guideline is
develop the evidence base of literature on this topic.2 The not intended as a sole source of guidance for the treat-
resulting systematic review, along with other major stud- ment of children with ADHD. Rather, it is designed to
ies in this area, was used to formulate recommendations assist the primary care clinician by providing a frame-
for treatment of children with ADHD. The subcommittee work for decision-making. It is not intended to replace
also reviewed the multimodal treatment study of chil- clinical judgment or to establish a protocol for all chil-
dren with ADHD3 and the Canadian Coordinating Office dren with this condition, and may not provide the only
for Health Technology Assessment report (CCOHTA).4 appropriate approach to this problem.
Subcommittee decisions were made by consensus where
definitive evidence was not available. The subcommittee ABBREVIATIONS. AAP, American Academy of Pediatrics; ADHD,
report underwent extensive review by sections and com- attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and
mittees of the AAP as well as by numerous external Statistical Manual of Mental Disorders, Fourth Edition; MTA, multi-
organizations before approval from the AAP Board of modal treatment study of children with ADHD; CCOHTA, Cana-
Directors. dian Coordinating Office for Health Technology Assessment.
The guideline contains the following recommenda-
tions for the treatment of a child diagnosed with ADHD:
T
he American Academy of Pediatrics (AAP) rec-
• Primary care clinicians should establish a treatment ognizes the importance of accurate diagnosis
program that recognizes ADHD as a chronic condition. and management of children with attention-
• The treating clinician, parents, and child, in collabora- deficit/hyperactivity disorder (ADHD). The AAP
tion with school personnel, should specify appropriate
target outcomes to guide management.
developed a practice guideline for the diagnosis of
• The clinician should recommend stimulant medication ADHD among children from 6 to 12 years of age who
and/or behavior therapy as appropriate to improve are evaluated by primary care clinicians.1 The signif-
target outcomes in children with ADHD. icant components of the diagnostic guideline include
• When the selected management for a child with 1) the use of explicit criteria for the diagnosis using
ADHD has not met target outcomes, clinicians should the Diagnostic and Statistical Manual of Mental Health
evaluate the original diagnosis, use of all appropriate Disorders, Fourth Edition (DSM-IV) criteria5; 2) the
treatments, adherence to the treatment plan, and pres- importance of obtaining information about the
ence of coexisting conditions. child’s symptoms in more than 1 setting (especially
• The clinician should periodically provide a systematic from schools); and 3) the search for coexisting con-
follow-up for the child with ADHD. Monitoring
ditions that may make the diagnosis more difficult or
complicate treatment planning.
The recommendations in this statement do not indicate an exclusive course This guideline is based on an extensive review of
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
the medical, psychological, and educational litera-
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- ture. The objectives of the literature review were to
emy of Pediatrics. determine the long- and short-term effectiveness and
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each recommendation, the subcommittee graded the professionals to develop an effective treatment plan.
quality of evidence on which the recommendation was A therapeutic alliance among clinicians, parents, and
based and the strength of the recommendation. the child is enhanced when attention is directed to-
Grades of evidence were grouped into 3 categories— ward cultural values that affect the child’s health and
good, fair, or poor. Recommendations were made at health care. The long-term care of a child with
3 levels. Strong recommendations were based on ADHD requires an ongoing partnership among cli-
high-quality scientific evidence or, in the absence of nicians, parents, teachers, and the child. Other school
high-quality data, strong expert consensus. Fair and personnel—nurses, psychologists, and counselors—
weak recommendations were based on lesser quality can also help with developing and monitoring plans.
or limited data and expert consensus. Clinical op- Studies of children and adults with several chronic
tions are identified as interventions for which the conditions indicate better adherence to treatment
subcommittee could not find compelling evidence plans, improved health and disease status measures,
for or against. Clinical options are defined as inter- and higher levels of satisfaction in the context of a
ventions that a reasonable health care provider comprehensive treatment plan with specific goals,
might or might not wish to implement in his or her follow-up activities, and monitoring.27–28 Thus, care-
practice. ful attention to the key elements of chronic care can
lead to improved outcomes for children and families.
RECOMMENDATION 1: Primary care clinicians Activities specific to the care of children with
should establish a management program that recog- ADHD include providing current information on the
nizes ADHD as a chronic condition (strength of ev- etiology of ADHD, its treatment, long-term out-
idence: good; strength of recommendation: strong). comes, and effects on daily life and family activities.
Attention-deficit/hyperactivity disorder is one of Thorough family understanding of the problem is
the more common chronic conditions of childhood. essential before discussing treatment options and
Studies using parent reports indicate persistence of side effects. What distinguishes this condition from
ADHD of 60% to 80% into adolescence.18 –20 Given most other chronic conditions managed by primary
the high prevalence of ADHD among school-aged care clinicians is the important role that the educa-
children (4% to 12%),1 primary care clinicians will tion system plays in the treatment and monitoring of
encounter children with ADHD in their practices children with ADHD.
regularly and should have a strategy for diagnosis Like other chronic conditions, new research on
and long-term management of this condition. The ADHD will change the information available to par-
primary care of children with ADHD includes atten- ents and clinicians over time and fill many gaps in
tion to the main principles of care for children with diagnosing and understanding the etiology, treat-
any chronic condition, such as ment, long-term effects, and complications related to
ADHD. Families should have access to this informa-
• Providing information about the condition tion. In addition, national, grassroots, parent-run as-
• Updating and monitoring family knowledge and sociations provide support and/or education to care-
understanding on a periodic basis givers and families of individuals with ADHD (eg,
• Counseling about family response to the condition Children and Adults with Attention-Deficit/Hyper-
• Developmentally appropriate education of the activity Disorder [CHADD]). The clinician should be
child about ADHD, with updates as the child aware of community resources that provide these
grows services and know how to make referrals. Primary
• Availability to answer family questions care providers may offer this information directly or
• Ensuring coordination of health and other services collaborate with other providers, especially subspe-
• Helping families set specific goals in areas related cialists and mental health providers, to ensure fam-
to the child’s condition and its effects on daily ilies’ access to needed information.
activities
RECOMMENDATION 2: The treating clinician, par-
• Linking families with other families with children
ents, and the child, in collaboration with school
who have similar chronic conditions as needed
personnel, should specify appropriate target out-
and available21–26
comes to guide management (strength of evidence:
good; strength of recommendation: strong).
As with other chronic conditions, treatment of
ADHD requires the development of child-specific The core symptoms of ADHD (ie, inattention, im-
treatment plans that describe methods and goals of pulsivity, hyperactivity) can result in multiple areas
treatment and means of monitoring care over time, of dysfunction relating to a child’s performance in
including specific plans for follow-up (See Recom- the home, school, or community. The primary goal of
mendation 5.) treatment should be to maximize function. Desired
Primary care clinicians should educate parents and results include
children about the ways in which ADHD can affect
learning, behavior, self-esteem, social skills, and fam- • improvements in relationships with parents, sib-
ily function. This initial phase of patient education is lings, teachers, and peers
critical to demystifying the diagnosis and providing • decreased disruptive behaviors
parents and children with knowledge about the con- • improved academic performance, particularly in
dition. Education enables parents to work with clini- volume of work, efficiency, completion, and accu-
cians, educators, and, in some cases, mental health racy
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TABLE 1. Medications Used in the Treatment of Attention-Deficit/Hyperactivity Disorder
Generic Class (Brand Name) Daily Dosage Schedule Duration Prescribing Schedule
Stimulants (First-Line Treatment)
Methylphenidate
Short-acting Twice a day (BID) to 3 3–5 hr 5–20 mg BID to TID
(Ritalin, Metadate, Methylin) times a day (TID)
Intermediate-acting Once a day (QD) to 3–8 hr 20–40 mg QD or 40 mg in the
(Ritalin SR, Metadate ER, Methylin ER) BID morning and 20 early afternoon
Extended Release QD 8–12 hr 18–72 mg QD
(Concerta, Metadate CD, Ritalin LA*)
Amphetamine
Short-acting BID to TID 4–6 hr 5–15 mg BID or 5–10 mg TID
(Dexedrine, Dextrostat)
Intermediate-acting QD to BID 6–8 hr 5–30 mg QD or 5–15 mg BID
(Adderall, Dexedrine spansule)
Extended Release QD 10–30 mg QD
(Adderall-XR*)
Antidepressants (Second-Line Treatment)
Tricyclics (TCAs) BID to TID 2–5 mg/kg/day†
Imipramine, Desipramine
Bupropion
(Wellbutrin) QD to TID 50–100 mg TID
(Wellbutrin SR) BID 100–150 mg BID
* Not FDA approved at time of publication.
† Prescribing and monitoring information in Physicians’ Desk Reference.
Unlike most other medications, stimulant dosages According to the Physicians’ Desk Reference43 and
usually are not weight dependent. Clinicians should medication package insert, methylphenidate is con-
begin with a low dose of medication and titrate traindicated in children with seizure disorders, a
upward because of the marked individual variability history of seizure disorder, or abnormal electroen-
in the dose-response relationship. The first dose that cephalograms. Studies of the use of methylphenidate
a child’s symptoms respond to may not be the best have not, however, demonstrated an increase in sei-
dose to improve function. Clinicians should continue zure frequency or severity when it is added to ap-
to use higher doses to achieve better responses.3 This propriate anticonvulsant medications.44 – 46
strategy may require reducing the dose when a Children who receive too high a dose or who are
higher dose produces side effects or no further im- overly sensitive may become overfocused on the
provement. The best dose of medication for a given medication or appear dull or overly restricted. Many
child is the one that leads to optimal effects with times this side effect can be addressed by lowering
minimal side effects. The dosing schedules vary de- the dose. Rarely, with high doses, some children
pending on target outcomes, although no consistent experience psychotic reactions, mood disturbances,
controlled studies compare different dosing sched- or hallucinations.
ules. For example, if there is a need for relief of No consistent reports of behavioral rebound, mo-
symptoms only during school, a 5-day schedule may tor tics, or dose-related growth delays have been
be sufficient. By contrast, a need for relief of symp- found in controlled studies,47 although they are re-
toms at home and school suggests a 7-day schedule.
ported clinically.33 Appetite suppression and weight
Stimulants are generally considered safe medica-
loss are common side effects of stimulant medica-
tions, with few contraindications to their use. Side
tion, with no apparent difference between methyl-
effects occur early in treatment and tend to be mild
phenidate and dextroamphetamine. Concern for
and short-lived.35 The most common side effects are
decreased appetite, stomachache or headache, de- growth delay has been raised, but a prospective fol-
layed sleep onset, jitteriness, or social withdrawal. low-up study into adult life48 has found no signifi-
Most of these symptoms can be successfully man- cant impairment of height attained. Studies of stim-
aged through adjustments in the dosage or schedule ulant use have found little or no decrease in expected
of medication. Approximately 15% to 30% of chil- height, with any decrease in growth early in treat-
dren experience motor tics, most of which are tran- ment compensated for later on.49 –54 Many clinicians
sient, while on stimulant medications. In addition, recommend drug holidays during summers, al-
approximately half of children with Tourette syn- though no controlled trials exist to indicate whether
drome have ADHD. The effects of medication on holidays have gains or risks, especially related to
tics are unpredictable. The presence of tics before weight gain.
or during medical management of ADHD is not an 3A: For children on stimulants, if one stimulant does
absolute contraindication to the use of stimulant not work at the highest feasible dose, the clinician
medications.41,42 A review of 7 studies comparing should recommend another.
stimulants with placebo or with other medications
indicated no increase in tics in children treated with At least 80%3 of children will respond to one of the
stimulants.2 stimulants if they are tried in a systematic way. Chil-
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measures makes meta-analysis of the effects of be- medications and/or behavioral/environmental in-
havior therapy alone or in association with medi- terventions. As noted in 3A, when one stimulant
cations very difficult. Double-blind, randomized, medication appears ineffective (despite appropriate
placebo-controlled trials are difficult to perform, in titration), clinicians should carry out a trial of a sec-
part because of the difficulty of keeping examiners ond stimulant medication. Continuing lack of re-
and participants unaware of whether the child is sponse to treatment may reflect 1) unrealistic target
receiving treatment or placebo. Thus, the usual symptoms; 2) lack of information about the child’s
evidence-based medicine searches turn up few stud- behavior; 3) an incorrect diagnosis; 4) a coexisting
ies for review.2 Alternative experimental methods, condition affecting the treatment of the ADHD;
such as rigorous single-subject designs, are used fre- 5) lack of adherence to the treatment regimen; or 6) a
quently in the psychological literature. Studies that treatment failure. As discussed previously, treatment
compare the behavior of children during periods on of ADHD, while decreasing a child’s level of impair-
and off behavior therapy demonstrate the effective- ment, may not fully eliminate the core symptoms
ness of behavior therapy17; however, behavior ther- of inattention, hyperactivity, and impulsivity. Simi-
apy has been demonstrated to be effective only while larly, children with ADHD may continue to have
it is implemented and maintained. difficulties with peer relationships despite adequate
A number of individual studies indicate positive treatment, and treatment for ADHD frequently
effects of behavior therapy in addition to medica- shows no association with improvements in aca-
tions. Almost all studies comparing behavior therapy demic achievement as measured by standardized in-
with stimulants alone indicate a much stronger effect struments.
from stimulants than from behavior therapy. When Evaluation of treatment outcomes requires a care-
comparing behavior therapy to stimulant medica- ful collection of information from multiple sources,
tions, efficacy of their combined treatment could not including parents, teachers, other adults in the
be demonstrated to be greater than medication alone child’s environment (eg, coaches), and the child. If
for the core symptoms of ADHD.2 The MTA study3 the target symptoms are realistic and the lack of
found that the combined treatment (medication man- effectiveness is clear, the primary care clinician
agement with behavior therapy), compared with should reassess the accuracy of the diagnosis of
medication alone, offered improved scores on aca- ADHD. This reassessment should include review of
demic measures, measures of conduct, and some the data initially obtained to make the diagnosis, as
specific ADHD symptoms (although not on global described in the AAP clinical practice guideline for
the diagnosis of children with ADHD.1 Reassessment
ADHD symptom scales). Although these trends were
usually will require gathering new information from
consistent, few reached statistical significance. In ad-
the child, school, and family about the core symp-
dition, parents and teachers of children receiving
toms of ADHD and their impact on the child’s func-
combined therapy were significantly more satisfied
tioning. Clinicians should reconsider other condi-
with the treatment plan.13,14,58 – 60
tions that can mimic ADHD.
A wide range of clinicians, including psycholo-
As indicated in the diagnostic clinical practice
gists, school personnel, community mental health guideline,1 other conditions commonly accompany
therapists, or the primary care clinician, can imple- ADHD in children, especially oppositional/conduct
ment behavior therapy directly or train others to disorders, anxiety, depression, and learning disor-
implement behavior therapy. Many clinicians prefer ders. These conditions often complicate the treat-
to refer to community resources for behavior ther- ment of ADHD; clinicians should determine if chil-
apy because behavior therapy with parents is time- dren who do not respond to treatment have these
consuming and often does not lend itself to the struc- conditions, either by direct determination in their
ture and schedule of the primary care office. Schools offices or by referral to appropriate subspecialists
may provide behavior therapy with teachers in the (eg, developmental-behavioral pediatricians, child
context of a Rehabilitation Act (Section 504) plan or psychiatrists, psychologists, or other mental health
an individual education plan. Where ADHD has a clinicians) or the school system (eg, school psychol-
significant impact on a child’s educational abilities, ogists for learning disabilities) for further evaluation.
Section 504 requires schools to make classroom ad- These coexisting conditions may not have been fully
aptations to help children with ADHD function in evaluated initially because of the severity of the
that setting. Adaptations may include preferential ADHD, or the child may have developed another
seating, decreased assignment and homework load, condition with time. Standard psycho-educational
and behavior therapy implemented by the teacher. testing may clarify the role of learning and language
RECOMMENDATION 4: When the selected manage- disorders, although other disorders require different
ment for a child with ADHD has not met target assessments.
outcomes, clinicians should evaluate the original Treatment plans for ADHD typically require chil-
diagnosis, use of all appropriate treatments, adher- dren, families, and schools to enter into a long-term
ence to the treatment plan, and presence of coexisting plan that includes a complex medication schedule
conditions (strength of evidence: weak; strength of along with environmental and behavioral interven-
recommendation: strong). tions. Environmental and behavioral interventions
will require ongoing efforts by parents, teachers, and
Most school-aged children with ADHD respond the child. A common cause of nonresponse to treat-
to a therapeutic regimen that includes stimulant ment is lack of adherence to the treatment plan.
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tive, and comprehensive treatment plans for children most effective and efficient methods for affecting
with these conditions. change in clinician practices need to be determined.
This determination must be broad, taking into ac-
Expanded Treatment Options count clinician, practice, family, community, and
A major research challenge pertaining to the treat- policy issues that affect treatment. Research also
ment of ADHD is the development and evaluation of should evaluate the role of school- and community-
new treatments for this condition. The 2 current treat- based professionals, as well as primary care clini-
ments (stimulant medication and behavior therapy) cians, in delivering treatment services. Little is
reduce the symptoms and functional consequences known about how short- or long-term effectiveness
of ADHD, but only for as long as they are adminis- varies as a function of the school and community-
tered. Treatments with more lasting or even curative based professional involvement. Further, the studies
effects are needed. A significant number of children of service delivery need to include a public health
do not respond to stimulant medications or have and service system approach. They should consider
severe side effects. Some families cannot implement child and family outcomes and cost-effectiveness of
behavioral programs. Expanding the available med- care. Linking outcomes to service parameters is an
ical and behavioral treatment regimens with addi- important step in encouraging practice or system
tional safe and effective options would be useful change.
for such a prevalent chronic condition where not
all children respond to current treatments or adhere Epidemiology and Etiology
to them. Studying common-sense approaches, such The great growth in the diagnosis of ADHD has
as decreasing environmental distraction, should be led to major new work in the study of treatments. As
done. There is also the need for well-designed rigor- indicated previously, these efforts should continue
ous studies of currently promoted but less well- and expand. Less investigation has addressed the
established therapies such as occupational therapy, etiology of ADHD (ie, its biological and socioenvi-
biofeedback, herbs, vitamins, and food supplements. ronmental causes) and the opportunities arising from
These interventions are not supported by evidence- that understanding for prevention. For example,
based studies at the present time. would different social and behavioral arrangements
Long-term Outcomes in young families affect the onset of ADHD symp-
toms? Would early intervention in some way de-
Most studies about ADHD and its treatment have crease rates of ADHD? A clear need exists for active
been short-term. The long-term outcome of children work in understanding the etiology and prevention
with ADHD with or without coexisting conditions of ADHD.
has not been well studied. Furthermore, there is min-
imal information about the role of stimulant medica-
tion and/or behavior therapy in the natural history CONCLUSION
of the disorder. Future research should correct these This clinical practice guideline offers recommen-
deficits. For this chronic condition, efficacy and dations for the treatment of school-aged children
safety studies must be extended from weeks or with ADHD in primary care practice. The guideline
months to years. Long-term outcome studies must be emphasizes 1) consideration of ADHD as a chronic
prospective in design and consider changes over condition; 2) explicit negotiations about target
time in core symptoms of ADHD, coexisting condi- symptoms; 3) use of stimulant medication and be-
tions, and functional outcomes such as occupational havior therapy; and 4) close monitoring of treat-
successes and long-term relationships. ment outcomes and failures. The guideline further
provides suggestions for pediatric office-based
Service Delivery management of ADHD. It should help primary
Another major research area should address the care clinicians in their treatment of a common child
optimal services and procedures for successful man- health problem.
agement of ADHD in the real world (ie, in clinical
Subcommittee on
practice and classrooms). Much of the popular con- Attention-Deficit/Hyperactivity Disorder
troversy over the inappropriate use of stimulant James M. Perrin, MD, Cochairperson
medication relates to how clinicians actually pre- Martin T. Stein, MD, Cochairperson
scribe them. Future research needs to study how Robert W. Amler, MD
medications are actually prescribed and what factors Thomas A. Blondis, MD
affect physician practice patterns. Research that in- Heidi M. Feldman, MD, PhD
cludes monitoring the outcomes of training will lead Bruce P. Meyer, MD
to the ability to develop better methods to assist Bennett A. Shaywitz, MD
clinicians in using effective treatment practices. Spe- Mark L. Wolraich, MD
cifically, basic information such as who are the most Consultants
appropriate clinicians to manage ADHD; the best Anthony DeSpirito, MD
schedule for follow-up; and the most valid, reliable, Charles J. Homer, MD, MPH
sensitive, and cost-effective ways to monitor treat- Esther Wender, MD
ment is essential. Such research must go beyond Liaison Representatives
physician self-reporting and into scrutinizing and Ronald T. Brown, PhD
evaluating actual practices in clinics and offices. The Society for Pediatric Psychology
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Attention-Deficit/Hyperactivity Disorder (ADHD)
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