For the first time in a decade, the American Academy of Pediatrics (APA) has updated its ADHD Diagnosis and Treatment Guideline to offer new information and special considerations involved in assessing and managing attention deficit hyperactivity disorder (ADHD) in preschool age children and adolescents. Previous guidelines addressed the assessment, diagnosis, and treatment in children ages 6 through 12 years. The new practice guideline expands recommendations to include children age 4 through 18 years.
ADHD affects approximately 7 to 9% percent of children in the United States, according to the Centers for Disease Control and Prevention. The previous guideline's 6 - 12 year age grouping left out a considerable number of these children. Over the past ten years an abundance of research and evidence has increased knowledge and understanding about ADHD. The APA incorporates this evidence into their new guideline; expanding recommendations to include both preschool age children and teenagers. The revised guideline also provides information on interventions to help kids with hyperactive/impulsive behaviors that do not meet the full diagnostic criteria for ADHD.
Summary of Updated Practice Guideline
The 2011 Clinical Practice Guideline for the diagnosis, evaluation and treatment of ADHD includes 6 Key Action Statements:
1. Primary care clinicians should initiate an ADHD evaluation for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
2. In order to receive a diagnosis of ADHD, the child must meet the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (including documentation of impairment in more than 1 major setting). Reports and information on the child should be obtained primarily from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause for the child’s behavior and symptoms.
3. In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions.
4. ADHD should be viewed as a chronic condition and, therefore, clinicians must consider children and adolescents with ADHD as children and youth with special health care needs.
5. Recommendations for treatment of children and youth with ADHD vary depending on the child’s age and severity of symptoms.
- For preschool age children (4–5 years of age) behavioral interventions should be the first line of treatment. Many children this age experience improvement in symptoms with behavioral therapy alone. If the behavioral interventions do not provide significant improvement and if there is moderate-to-severe continuing disturbance in the child’s function (symptoms that have persisted for at least 9 months and impairment that is present in both the home and other settings such a preschool or child care), then methylphenidate may be considered. Due to the questions and concerns about the possible effects on a child’s growth during this rapid growth period, the clinician will need to weigh the risks of starting medication at an early age against the harm of delaying treatment. An additional special consideration for this age group includes the slower rate at which preschool age children metabolize stimulant medication. If medication is initiated in this age group, it should be started at a lower dose than is given for elementary age children and increased in smaller increments, as needed.
- For elementary school-aged children (6–11 years of age) a combination of behavioral interventions at home (increased structure and organizational strategies, consistently providing rewards and positive reinforcement for desired behaviors, using planned ignoring as an active strategy, providing consequences for inappropriate behaviors, and shaping a child’s behavior by gradually increasing expectations as skills are developed and tasks are achieved) and at school (behavioral plans as well as classroom accommodations such as preferred seating, modified work assignments, test modifications) and medication treatment is recommended.
- For adolescents (12–18 years of age) medication treatment with the assent of the adolescent is recommended. Behavioral therapy may also be prescribed. Preferably both medication and behavior interventions will be used, though behavioral therapy tends to be less effective for this age group. Special considerations for adolescents with newly diagnosed ADHD include assessment for symptoms of substance abuse, diversion of ADHD medication – or using the medication for other than its intended medical purpose, and the importance of providing medication coverage for symptom control during the times that the adolescent is driving.
6. Primary care clinicians should titrate doses of medication for ADHD to achieve maximum benefit with minimum side effects. It is important for clinicians to provide education to parents so that parents will understand the process involved in optimal medication management. That is, that changing medication dose and occasionally changing a medication might be necessary, that the process might require several months to achieve optimal success, and that the effectiveness of medication will need to be systematically monitored at regular intervals.
Medication is not appropriate for children whose symptoms do not meet the criteria for diagnosis of ADHD, though these children and families may benefit from parent training, behavioral therapy, and help in identifying and eliminating triggers that lead to inattention, hyperactivity, or impulsivity.
Ongoing Assessment and Treatment of ADHD
ADHD is a chronic condition. It is one of the most common neurobehavioral disorders of childhood. Symptoms of ADHD may continue into adolescence and adulthood. Evaluation, diagnosis, and treatment of ADHD is an ongoing process that involves a team approach including involvement of parents, the child, the doctor, teachers, and other relevant adults or caregivers. Open and ongoing communication and assessment is necessary as the demands and needs of a child with ADHD will change over time.
If left untreated, ADHD can have a serious impact on academic achievement, social and family relationships, productivity at work, can increase a child’s risk for accidental injury and a teen’s risk for unplanned pregnancy, and can lead to the development of depression, anxiety, conduct disorder, and substance abuse. Early identification and appropriate treatment of ADHD is extremely important and can help to improve a child’s achievement, happiness, and overall well-being.
The goal of the APA practice guideline is to provide primary care clinicians with a standardized outline of requirements in order to provide consistent, quality, evidenced based care for children and families with concerns about or symptoms that suggest attention problems. Within the framework of these guidelines, treatment for ADHD should focus on identifying and addressing individualized and specific behavioral, academic and social target goals and treatments.
The APA also recognizes that ADHD is a genetically linked condition. Because a number of parents of children with ADHD also have ADHD, extra support might be necessary to help those parents provide consistency in following through with the treatment plan.
If you have questions or concerns that your child might have ADHD, be sure to talk with your pediatrician.
ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics Volume 128, Number 5. November 2011. Published online October 16, 2011.
Centers for Disease Control and Prevention. Data from the National Health Interview Survey 1998-2009. Attention Deficit Hyperactivity Disorder Among Children Aged 5-17 Years in the United States. Number 70, August 2011.