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The American Academy of Pediatrics has expanded its clinical practice guideline for diagnosing, evaluating, and treating attention-deficit/hyperactivity disorder in children to include preschoolers and adolescents.
The updated guideline was prompted by new evidence that has become available regarding the diagnosis and treatment of ADHD since clinical recommendations for diagnosis and evaluation of the disorder in children aged 6-12 years were published in 2000, and recommendations for treatment in that age group were published in 2001. The guideline, published in the November issue of Pediatrics, now includes recommendations for preschool- and adolescent-age children aged 4-18 years, as well as recommendations for managing symptomatic children and adolescents who don’t meet all the criteria for an ADHD diagnosis (Pediatrics 2011 [doi:10.1542/peds.2011-2654]).
"Since the original guidelines were written in 2000 and 2001, there have been additional studies that further clarified the diagnosis and treatment of children and youths with ADHD," said Dr. Mark Wolraich, chair of the AAP’s subcommittee on ADHD, which developed the updated guideline.
The updated guideline includes six key action statements for primary care clinicians, with most based on level B evidence quality and accompanied by a "strong recommendation."
For example, action statement 1 (based on level B evidence) states that an evaluation for ADHD should be initiated for any child aged 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. The authors "strongly recommend" this action, stating that ADHD goes undiagnosed in a considerable number of children, and systematic identification of children with these problems will likely decrease the rate of undiagnosed and untreated ADHD.
Furthermore, the subcommittee members stated, "There is now increased evidence that appropriate diagnosis can be provided for preschool-aged children (4-5 years of age) and for adolescents."
Action statement 5 addresses treatment in the various age groups. For example, statement 5a addresses preschool children aged 4-5 years, and notes that evidence-based parent- and/or teacher-administered behavior therapy should be used first line in this age group (a strong recommendation based on level A evidence), and that methylphenidate can be prescribed if behavior interventions are ineffective (a recommendation based on level B evidence). Statement 5b addresses elementary school-age children aged 6-11 years, and notes that Food and Drug Administration-approved medications for ADHD (strong recommendation based on level A evidence), and/or evidence-based parent- and/or teacher-administered behavior therapy – and preferably both (strong recommendation based on level B evidence) should be used in this age group.
"The evidence is particularly strong for stimulant medication and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended release clonidine (in that order)," the subcommittee members wrote.
Statement 5c addresses adolescents aged 12-18 years, and notes that the primary care clinician should prescribe FDA-approved medication for ADHD with the assent of the adolescent (a strong recommendation based on level A evidence), and also that they may prescribe behavioral therapy (a recommendation based on level C evidence). Use of both is preferred.
The remaining action statements address the following:
• ADHD diagnosis should be based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria – after ruling out other causes – and based on information obtained primarily from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. This action statement (action statement 2, quality of evidence B, strong recommendation) also provides guidance for use of the Diagnostic and Statistical Manual for Primary Care (DSM-PC) for children with behaviors relating to activity level, impulsivity, and inattention who don’t fully meet DSM-IV criteria for ADHD. The DSM-PC provides guidance on the treatment of these children, and also considers environmental influences on behavior, as well as differential diagnoses with a developmental perspective.
• Assessment for co-existing emotional or behavioral, developmental, and physical conditions is important (action statement 3, quality of evidence B, strong recommendation). The comorbid emotional or behavioral conditions might be anxiety, depressive, oppositional defiant, and conduct disorders, and the comorbid developmental conditions might include learning and language disorders or other neurodevelopmental disorders. The coexisting physical conditions might include tics or sleep apnea.
• ADHD should be recognized as a chronic condition and management of children and youth with this condition should be based on the principles of the chronic care model and the medical home (action statement 4, quality of evidence B/strong recommendation).
• Doses of medication should be titrated to achieve maximum benefit with minimal adverse effects (action statement 6, quality of evidence B/strong recommendation).
Each action statement includes caveats for special circumstances based on age group, certain symptoms, and/or comorbidities to provide further guidance for the clinician.
The updated guideline was developed in collaboration with several organizations whose representatives formed the working subcommittee. The group met over a 2-year period to review changes in practice that have occurred over time and issues that have been identified since the previous guideline were published. A multilevel systematic approach was used to identify the literature that built the evidence base for the diagnosis and treatment recommendations, which underwent extensive peer review by committees, sections, councils, and task forces within the AAP, as well as numerous outside groups and individuals. The guidelines will be reviewed and/or revised in 5 years, unless evidence emerges that warrants an earlier revision, they noted.
"As occurred with the initial guidelines, we hope the revised guidelines will provide the process that primary care clinicians treating children and youth can use to provide the best evidence-based practices for their patients who have or are suspected of having ADHD," Dr. Wolraich said.
Development of the new ADHD guideline was funded by the AAP with support from the Partnership for Policy Implementation initiative. Multiple subcommittee members reported financial disclosures, which are included in the Pediatrics article where the guideline is published. Dr. Wolraich, for example, reported that he has served periodically as a consultant to Shire, Eli Lilly, Shinogi, and Next Wave Pharmaceuticals. The article states that all conflicts were "resolved through a process approved by the AAP Board of Directors."
The expansion of the AAP ADHD clinical practice guideline to include recommendations for preschool-age children is one of a number of welcome and beneficial changes to help guide the management of patients with ADHD, according to Dr. David O. Childers.
"I’m really glad to see that they are endorsing identification and intervention in 4- to 5-year-olds. That has been practiced, but it really hasn’t been endorsed or considered an official standard of care," he said.
Furthermore, the recommendation to start with behavior therapy in this age group, moving to treatment with methylphenidate only if necessary, is a good strategy, he said, noting that the updated guideline recognizes – importantly – that while methylphenidate is off label for this indication, strong evidence exists showing that it has a better safety and efficacy profile for younger children than the only FDA-approved medication (dextroamphetamine) for ADHD in children under age 6 years.
Dr. Childers also praised the subcommittee’s decision to highlight the potential for substance abuse in adolescents with ADHD as well as the importance of obtaining assent in the adolescent population, the comorbidities associated with ADHD, the importance of evaluating younger children in more than one setting to assess symptoms, the value of behavior therapy strategies, the strength of the evidence for stimulant versus other types of medications in 6- to 11-year-olds, the chronic nature of ADHD, and the need for medication dose titration to "best effect – not first effect."
One thing he said he would have liked to have seen included is a greater emphasis on the DSM-IV’s requirement that children be assessed based on their developmental level. A child with language delay, for example, will have an attention level commensurate with their language skills rather than their age, therefore an assessment that doesn’t take this into consideration could lead to a misdiagnosis, he explained.
Dr. Childers is assistant professor of pediatrics and chief of the division of developmental pediatrics at the University of Florida, Jacksonville. He said he had no relevant financial disclosures.
The expansion of the AAP ADHD clinical practice guideline to include recommendations for preschool-age children is one of a number of welcome and beneficial changes to help guide the management of patients with ADHD, according to Dr. David O. Childers.
"I’m really glad to see that they are endorsing identification and intervention in 4- to 5-year-olds. That has been practiced, but it really hasn’t been endorsed or considered an official standard of care," he said.
Furthermore, the recommendation to start with behavior therapy in this age group, moving to treatment with methylphenidate only if necessary, is a good strategy, he said, noting that the updated guideline recognizes – importantly – that while methylphenidate is off label for this indication, strong evidence exists showing that it has a better safety and efficacy profile for younger children than the only FDA-approved medication (dextroamphetamine) for ADHD in children under age 6 years.
Dr. Childers also praised the subcommittee’s decision to highlight the potential for substance abuse in adolescents with ADHD as well as the importance of obtaining assent in the adolescent population, the comorbidities associated with ADHD, the importance of evaluating younger children in more than one setting to assess symptoms, the value of behavior therapy strategies, the strength of the evidence for stimulant versus other types of medications in 6- to 11-year-olds, the chronic nature of ADHD, and the need for medication dose titration to "best effect – not first effect."
One thing he said he would have liked to have seen included is a greater emphasis on the DSM-IV’s requirement that children be assessed based on their developmental level. A child with language delay, for example, will have an attention level commensurate with their language skills rather than their age, therefore an assessment that doesn’t take this into consideration could lead to a misdiagnosis, he explained.
Dr. Childers is assistant professor of pediatrics and chief of the division of developmental pediatrics at the University of Florida, Jacksonville. He said he had no relevant financial disclosures.
The expansion of the AAP ADHD clinical practice guideline to include recommendations for preschool-age children is one of a number of welcome and beneficial changes to help guide the management of patients with ADHD, according to Dr. David O. Childers.
"I’m really glad to see that they are endorsing identification and intervention in 4- to 5-year-olds. That has been practiced, but it really hasn’t been endorsed or considered an official standard of care," he said.
Furthermore, the recommendation to start with behavior therapy in this age group, moving to treatment with methylphenidate only if necessary, is a good strategy, he said, noting that the updated guideline recognizes – importantly – that while methylphenidate is off label for this indication, strong evidence exists showing that it has a better safety and efficacy profile for younger children than the only FDA-approved medication (dextroamphetamine) for ADHD in children under age 6 years.
Dr. Childers also praised the subcommittee’s decision to highlight the potential for substance abuse in adolescents with ADHD as well as the importance of obtaining assent in the adolescent population, the comorbidities associated with ADHD, the importance of evaluating younger children in more than one setting to assess symptoms, the value of behavior therapy strategies, the strength of the evidence for stimulant versus other types of medications in 6- to 11-year-olds, the chronic nature of ADHD, and the need for medication dose titration to "best effect – not first effect."
One thing he said he would have liked to have seen included is a greater emphasis on the DSM-IV’s requirement that children be assessed based on their developmental level. A child with language delay, for example, will have an attention level commensurate with their language skills rather than their age, therefore an assessment that doesn’t take this into consideration could lead to a misdiagnosis, he explained.
Dr. Childers is assistant professor of pediatrics and chief of the division of developmental pediatrics at the University of Florida, Jacksonville. He said he had no relevant financial disclosures.
The American Academy of Pediatrics has expanded its clinical practice guideline for diagnosing, evaluating, and treating attention-deficit/hyperactivity disorder in children to include preschoolers and adolescents.
The updated guideline was prompted by new evidence that has become available regarding the diagnosis and treatment of ADHD since clinical recommendations for diagnosis and evaluation of the disorder in children aged 6-12 years were published in 2000, and recommendations for treatment in that age group were published in 2001. The guideline, published in the November issue of Pediatrics, now includes recommendations for preschool- and adolescent-age children aged 4-18 years, as well as recommendations for managing symptomatic children and adolescents who don’t meet all the criteria for an ADHD diagnosis (Pediatrics 2011 [doi:10.1542/peds.2011-2654]).
"Since the original guidelines were written in 2000 and 2001, there have been additional studies that further clarified the diagnosis and treatment of children and youths with ADHD," said Dr. Mark Wolraich, chair of the AAP’s subcommittee on ADHD, which developed the updated guideline.
The updated guideline includes six key action statements for primary care clinicians, with most based on level B evidence quality and accompanied by a "strong recommendation."
For example, action statement 1 (based on level B evidence) states that an evaluation for ADHD should be initiated for any child aged 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. The authors "strongly recommend" this action, stating that ADHD goes undiagnosed in a considerable number of children, and systematic identification of children with these problems will likely decrease the rate of undiagnosed and untreated ADHD.
Furthermore, the subcommittee members stated, "There is now increased evidence that appropriate diagnosis can be provided for preschool-aged children (4-5 years of age) and for adolescents."
Action statement 5 addresses treatment in the various age groups. For example, statement 5a addresses preschool children aged 4-5 years, and notes that evidence-based parent- and/or teacher-administered behavior therapy should be used first line in this age group (a strong recommendation based on level A evidence), and that methylphenidate can be prescribed if behavior interventions are ineffective (a recommendation based on level B evidence). Statement 5b addresses elementary school-age children aged 6-11 years, and notes that Food and Drug Administration-approved medications for ADHD (strong recommendation based on level A evidence), and/or evidence-based parent- and/or teacher-administered behavior therapy – and preferably both (strong recommendation based on level B evidence) should be used in this age group.
"The evidence is particularly strong for stimulant medication and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended release clonidine (in that order)," the subcommittee members wrote.
Statement 5c addresses adolescents aged 12-18 years, and notes that the primary care clinician should prescribe FDA-approved medication for ADHD with the assent of the adolescent (a strong recommendation based on level A evidence), and also that they may prescribe behavioral therapy (a recommendation based on level C evidence). Use of both is preferred.
The remaining action statements address the following:
• ADHD diagnosis should be based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria – after ruling out other causes – and based on information obtained primarily from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. This action statement (action statement 2, quality of evidence B, strong recommendation) also provides guidance for use of the Diagnostic and Statistical Manual for Primary Care (DSM-PC) for children with behaviors relating to activity level, impulsivity, and inattention who don’t fully meet DSM-IV criteria for ADHD. The DSM-PC provides guidance on the treatment of these children, and also considers environmental influences on behavior, as well as differential diagnoses with a developmental perspective.
• Assessment for co-existing emotional or behavioral, developmental, and physical conditions is important (action statement 3, quality of evidence B, strong recommendation). The comorbid emotional or behavioral conditions might be anxiety, depressive, oppositional defiant, and conduct disorders, and the comorbid developmental conditions might include learning and language disorders or other neurodevelopmental disorders. The coexisting physical conditions might include tics or sleep apnea.
• ADHD should be recognized as a chronic condition and management of children and youth with this condition should be based on the principles of the chronic care model and the medical home (action statement 4, quality of evidence B/strong recommendation).
• Doses of medication should be titrated to achieve maximum benefit with minimal adverse effects (action statement 6, quality of evidence B/strong recommendation).
Each action statement includes caveats for special circumstances based on age group, certain symptoms, and/or comorbidities to provide further guidance for the clinician.
The updated guideline was developed in collaboration with several organizations whose representatives formed the working subcommittee. The group met over a 2-year period to review changes in practice that have occurred over time and issues that have been identified since the previous guideline were published. A multilevel systematic approach was used to identify the literature that built the evidence base for the diagnosis and treatment recommendations, which underwent extensive peer review by committees, sections, councils, and task forces within the AAP, as well as numerous outside groups and individuals. The guidelines will be reviewed and/or revised in 5 years, unless evidence emerges that warrants an earlier revision, they noted.
"As occurred with the initial guidelines, we hope the revised guidelines will provide the process that primary care clinicians treating children and youth can use to provide the best evidence-based practices for their patients who have or are suspected of having ADHD," Dr. Wolraich said.
Development of the new ADHD guideline was funded by the AAP with support from the Partnership for Policy Implementation initiative. Multiple subcommittee members reported financial disclosures, which are included in the Pediatrics article where the guideline is published. Dr. Wolraich, for example, reported that he has served periodically as a consultant to Shire, Eli Lilly, Shinogi, and Next Wave Pharmaceuticals. The article states that all conflicts were "resolved through a process approved by the AAP Board of Directors."
The American Academy of Pediatrics has expanded its clinical practice guideline for diagnosing, evaluating, and treating attention-deficit/hyperactivity disorder in children to include preschoolers and adolescents.
The updated guideline was prompted by new evidence that has become available regarding the diagnosis and treatment of ADHD since clinical recommendations for diagnosis and evaluation of the disorder in children aged 6-12 years were published in 2000, and recommendations for treatment in that age group were published in 2001. The guideline, published in the November issue of Pediatrics, now includes recommendations for preschool- and adolescent-age children aged 4-18 years, as well as recommendations for managing symptomatic children and adolescents who don’t meet all the criteria for an ADHD diagnosis (Pediatrics 2011 [doi:10.1542/peds.2011-2654]).
"Since the original guidelines were written in 2000 and 2001, there have been additional studies that further clarified the diagnosis and treatment of children and youths with ADHD," said Dr. Mark Wolraich, chair of the AAP’s subcommittee on ADHD, which developed the updated guideline.
The updated guideline includes six key action statements for primary care clinicians, with most based on level B evidence quality and accompanied by a "strong recommendation."
For example, action statement 1 (based on level B evidence) states that an evaluation for ADHD should be initiated for any child aged 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. The authors "strongly recommend" this action, stating that ADHD goes undiagnosed in a considerable number of children, and systematic identification of children with these problems will likely decrease the rate of undiagnosed and untreated ADHD.
Furthermore, the subcommittee members stated, "There is now increased evidence that appropriate diagnosis can be provided for preschool-aged children (4-5 years of age) and for adolescents."
Action statement 5 addresses treatment in the various age groups. For example, statement 5a addresses preschool children aged 4-5 years, and notes that evidence-based parent- and/or teacher-administered behavior therapy should be used first line in this age group (a strong recommendation based on level A evidence), and that methylphenidate can be prescribed if behavior interventions are ineffective (a recommendation based on level B evidence). Statement 5b addresses elementary school-age children aged 6-11 years, and notes that Food and Drug Administration-approved medications for ADHD (strong recommendation based on level A evidence), and/or evidence-based parent- and/or teacher-administered behavior therapy – and preferably both (strong recommendation based on level B evidence) should be used in this age group.
"The evidence is particularly strong for stimulant medication and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended release clonidine (in that order)," the subcommittee members wrote.
Statement 5c addresses adolescents aged 12-18 years, and notes that the primary care clinician should prescribe FDA-approved medication for ADHD with the assent of the adolescent (a strong recommendation based on level A evidence), and also that they may prescribe behavioral therapy (a recommendation based on level C evidence). Use of both is preferred.
The remaining action statements address the following:
• ADHD diagnosis should be based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria – after ruling out other causes – and based on information obtained primarily from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. This action statement (action statement 2, quality of evidence B, strong recommendation) also provides guidance for use of the Diagnostic and Statistical Manual for Primary Care (DSM-PC) for children with behaviors relating to activity level, impulsivity, and inattention who don’t fully meet DSM-IV criteria for ADHD. The DSM-PC provides guidance on the treatment of these children, and also considers environmental influences on behavior, as well as differential diagnoses with a developmental perspective.
• Assessment for co-existing emotional or behavioral, developmental, and physical conditions is important (action statement 3, quality of evidence B, strong recommendation). The comorbid emotional or behavioral conditions might be anxiety, depressive, oppositional defiant, and conduct disorders, and the comorbid developmental conditions might include learning and language disorders or other neurodevelopmental disorders. The coexisting physical conditions might include tics or sleep apnea.
• ADHD should be recognized as a chronic condition and management of children and youth with this condition should be based on the principles of the chronic care model and the medical home (action statement 4, quality of evidence B/strong recommendation).
• Doses of medication should be titrated to achieve maximum benefit with minimal adverse effects (action statement 6, quality of evidence B/strong recommendation).
Each action statement includes caveats for special circumstances based on age group, certain symptoms, and/or comorbidities to provide further guidance for the clinician.
The updated guideline was developed in collaboration with several organizations whose representatives formed the working subcommittee. The group met over a 2-year period to review changes in practice that have occurred over time and issues that have been identified since the previous guideline were published. A multilevel systematic approach was used to identify the literature that built the evidence base for the diagnosis and treatment recommendations, which underwent extensive peer review by committees, sections, councils, and task forces within the AAP, as well as numerous outside groups and individuals. The guidelines will be reviewed and/or revised in 5 years, unless evidence emerges that warrants an earlier revision, they noted.
"As occurred with the initial guidelines, we hope the revised guidelines will provide the process that primary care clinicians treating children and youth can use to provide the best evidence-based practices for their patients who have or are suspected of having ADHD," Dr. Wolraich said.
Development of the new ADHD guideline was funded by the AAP with support from the Partnership for Policy Implementation initiative. Multiple subcommittee members reported financial disclosures, which are included in the Pediatrics article where the guideline is published. Dr. Wolraich, for example, reported that he has served periodically as a consultant to Shire, Eli Lilly, Shinogi, and Next Wave Pharmaceuticals. The article states that all conflicts were "resolved through a process approved by the AAP Board of Directors."
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