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Recommendations

Physician talking to child

AAP published a clinical practice guideline that provides recommendations based on the best available medical evidence (evidence-based) for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder (ADHD). This guideline is intended for use by healthcare providers working in primary care settings, like pediatricians and family physicians.

Diagnosis and Evaluation

Here are the recommendations for the diagnosis and evaluation of ADHD based on the AAP guideline:

  • The primary care clinician should provide initiate an evaluation for ADHD for any child 4 through 18 years of age who shows or presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
  • To make a diagnosis of ADHD, the primary care clinician should determine that diagnostic criteria have been met based on the Diagnostic and Statistical Manual of Mental Disorders – Fifth edition (DSM-5, which replaced the Fourth Edition (DSM-IV) in May 2013). Making a diagnosis includes documenting that the child has difficulties in more than 1 major setting (e.g., in school and at home). The primary care clinician should include reports from parents or guardians, teachers, and/or other school and mental health clinicians involved in the child’s care. The primary care clinician should also exclude any other possible cause for the symptoms.
  • When evaluating a child for ADHD, the primary care clinician should assess whether other conditions are present that might coexist with ADHD, including emotional or behavioral (such as anxiety, depressive, oppositional defiant, and conduct disorders), developmental (such as learning and language disorders or other neurodevelopmental disorders), and physical (such as tics, sleep apnea) conditions.
  • The primary care clinician should recognize ADHD as a chronic (long-standing) condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Care for such children and youth should follow the principles of the chronic care model and the medical home.

Read more about this recommendation.

Did you know?

The behavior therapy with best evidence with young children with ADHD is Parent Training in Behavior Therapy.

From the American Academy of Pediatrics (AAP)

	Infographic: ADHD Treatments For Preschoolers (ages 4–5)

View or download full size

View or download for ages 6-17

Treatment

The guideline contains the following recommendations by AAP for the treatment of ADHD:

  • Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:
    • For preschool-aged children (4–5 years of age), the primary care clinician
      • Should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment and
      • May prescribe methylphenidate (a medication to treat ADHD) if the behavior therapy does not provide significant improvement and the child continues to have moderate to severe symptoms.

In areas where evidence-based behavioral therapy is not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment. Read more about evidence based treatment options for preschoolers.

    • For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US Food and Drug Administration–approved medications for ADHD and/or evidence-based parent and/or teacher-administered behavior therapy as treatment for ADHD, although preferably both medication and behavior therapy should be used together. The evidence is particularly strong for stimulant medications and sufficient, although less strong, for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order). The school environment, program, or placement is a part of any treatment plan. For example, school programs might provide classroom adaptations, such as preferred seating, modified work assignments, and test modifications (such as location for taking the test and extended test time), as well as behavior plans or special education.
    • For adolescents (12–18 years of age), the primary care clinician should prescribe Food and Drug Administration–approved medications for ADHD with the assent of the adolescent and may prescribe behavior therapy as treatment for ADHD, although preferably both medication and behavior therapy should be used together..
  • The primary care clinician should monitor and alter, as needed, the dose of medication given to the child for ADHD in order to achieve the maximum benefit while minimizing any problems from taking the medication.

Read more about this recommendation.

Read more about how the school environment can be part of a behavior therapy plan.

Changes in guidelines

Video on ADHD

CDC Expert Commentary – Attention Deficit/Hyperactivity Disorder Video Thumb

A CDC expert comments on the new clinical practice guidelines.

More

The current AAP guideline was published in 2011 and it replaces two previously published clinical guidelines that were published in 2000 and 2001. CDC conducted a review of the published literature on the best available medical evidence for the diagnosis and evaluation of ADHD, which was used to inform the AAP guideline.

Important changes to the guideline include:

  • Expanded age range of coverage. The previous guidelines covered children 6-12 years of age; the current guideline covers children 4-18 years of age.
  • Expanded Scope. The new guideline includes consideration of behavioral therapy, and directly addresses problem-level concerns in children based on the Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version.
  • A Process of Care for Diagnosis and Treatment. AAP included an algorithm to guide evaluation, diagnosis, treatment, and monitoring of ADHD in children and adolescents.
  • Integration with the Task Force on Mental Health. The guideline was conceived and developed to fit within the broader mission of the AAP Task Force on Mental Health to foster stronger ties to families and mental health clinicians, to intervene early, and to work to prevent mental health conditions.

Additionally, the guideline, developed by the Subcommittee on ADHD, Steering Committee on Quality Improvement and Management, represents a single set of recommendations for diagnosis, evaluation, and treatment of ADHD.

 

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