What’s new in ADHD diagnosis, treatment?
Clinical practice guideline based on a review of evidence includes companion guide to implementation
- Copyright © 2011, The American Academy of Pediatrics
A new AAP clinical practice guideline based on the latest scientific evidence provides recommendations for diagnosing and treating attention-deficit/hyperactivity disorder (ADHD) in 4- to 18-year-olds. The guideline replaces diagnostic and treatment recommendations from 2000 and 2001, respectively.
The new guidance from the AAP Steering Committee on Quality Improvement and Management, Subcommittee on Attention-Deficit/Hyperactivity Disorder offers more detailed and better organized information for how clinicians can provide the best diagnostic care and treatment for patients with ADHD. Released during the AAP National Conference & Exhibition, the practice guideline is available at http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2011-2654. It also will be published in the November issue of Pediatrics (2011;128:1007-1022).
Detailed supplemental information helps pediatricians implement the guideline by taking them through each aspect of the process. Titled Appendix to ADHD Clinical Practice Guideline: Implementing the Key Action Statements — An Algorithm and Explanation for Process of Care for the Evaluation, Diagnosis, Treatment and Monitoring of ADHD in Children and Adolescents (http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1/zpe611117822p.pdf), the document served as the basis of the revised AAP ADHD Toolkit.
Using the new guideline
The new guideline covers a broader age range and divides recommendations by preschool, elementary and adolescent categories when appropriate. It also is more aligned with the recommendations and care processes of the AAP Task Force on Mental Health.
In addition, treatment recommendations have been updated to include all medications approved by the Food and Drug Administration to manage ADHD, with evidence for their safety and efficacy. Behavior therapy continues to be recommended, and evidence-based interventions are described in more detail.
As before, the guideline stresses the importance of understanding ADHD as a chronic illness placed within the context of the principles employed in a medical home. This entails:
educating patients and their families about ADHD based on the patient’s age and developmental level,
developing a written management plan with target goals,
developing a system to coordinate services, particularly with the education and mental health systems,
connecting families to support services such as parent groups, and
providing ongoing care with anticipatory guidance about likely challenges, including changing schools or transitioning into adolescence or young adulthood.
The guideline continues to emphasize the importance of identifying and diagnosing any co-occurring conditions such as oppositional defiant, conduct, mood, anxiety and learning disorders as well as intellectual disabilities, developmental coordination disorder and Tourette syndrome. To help with this process, resources are included in a revised ADHD toolkit (see resource box).
The guideline also gives recommendations for the diagnosis and management of children who have inattentive and/or hyperactive/impulsive problems but do not meet the criteria for ADHD.
After the earlier guidelines were published, the Academy sponsored a national collaborative organized by the National Initiative on Children’s Healthcare Quality (NICHQ) and developed a toolkit and an Education in Quality Improvement for Pediatric Practice (EQIPP) module. Other quality improvement initiatives that sprung up across the country utilized the guidelines as their standard for change.
The process to revise the guidelines was similar to that of the original development. An ADHD subcommittee responsible for the revisions included representatives from primary care pediatrics, develop- mental-behavioral pediatrics, child psychiatry, psychology, neurology, family practice and families represented by a member from Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). The process began with an extensive review of the literature. The resulting paper was reviewed by 13 AAP committees, sections and councils, and six external organizations.
The ADHD toolkit was reviewed and revised by NICHQ in collaboration with the AAP Quality Improvement Innovation Network (QUIIN). Members of QUIIN provided advice on what tools they use and feedback on the other tools recommended to address implementation of the guideline. CHADD contributed additional support materials for families.
The 2011 AAP book, Caring for Children with ADHD: A Resource Toolkit for Clinicians, 2nd edition, reflects the clinical practice guideline and includes forms, checklists, tracking tools and parent materials. To order, visit www.aap.org/bookstore.
Dr. Wolraich is chair of the AAP Subcommittee on Attention-Deficit/Hyperactivity Disorder.