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What's New with ADHD? winter 2020 | volume 34 | issue 1 A journal of Dayton Children’s Hospital what’s new with ADHD? by Mollie Walton, MD and Craig Boreman, MD 1 learning objectives recommended (CPG) and the 2011 behavioral rating scales revision, the AAP Following the completion of this article, to help establish the collaborated with the reader should be able to: diagnosis, and outlined several organizations 1. Utilize the updated clinical practice standards for follow-up to form an ADHD guideline for diagnosis and treatment and monitoring.12 The subcommittee un- of ADHD. guidelines were revised der the oversight of 2. Describe the approach to the evaluation in 2011 and published the AAP Council on and treatment of ADHD in the primary with an accompany- Quality Improvement practice setting. ing process of care and Patient Safety.13 3. Give examples of co-existing conditions algorithm (PoCA). The This subcommittee’s associated with ADHD. major change with this membership included revision was the appli- representation of a cable age for diagnosis wide range of primary Attention-deficit/ toms tend to persist.1, 2 and treatment, previ- care and subspecial- hyperactivity Learning and language ously 6-12 years of age, ty groups. The group difficulties are common and was broadened met over a 3.5-year disorder (ADHD) comorbid conditions to include age 4- to period (2015-2018) to is one of the most associated with ADHD.3 6-year-olds and review practice chang- common neuro- Boys are twice as likely as adolescents up to es and newly identified behavioral girls to receive the ADHD age 18 years.12 Since issues since the 2011 4, 5, 6 disorders of diagnosis, perhaps the release of the guidelines. The sub- because hyperactive 2011 guideline, the committee developed childhood and can behaviors, generally seen Diagnostic and a series of research profoundly affect more frequently in boys, Statistical Manual of questions to direct an children’s academic are easily observable and Mental Disorders has evidence-based review achievement, social potentially disruptive. The been revised to the sponsored by one of majority of both boys and fifth edition, and new the Evidence-Based interactions and girls with ADHD also ADHD-related research Practice Centers of the well-being. meet criteria for an has been published. U.S. Agency for Health- Reported prevalence of additional mental health The DSM-5 criteria care Research and ADHD varies based on disorder.7, 8 Boys are more are similar to the 2011 Quality (AHRQ); these differences in research likely to exhibit external- guidelines with two questions assessed methods, the age izing conditions, such exceptions. Fewer diagnostic and groups being described, as oppositional defiant problem behaviors treatment areas on and changes in the disorder or conduct are required for those the basis of research diagnostic criteria over disorder;7, 9, 10 whereas 17 years or older, and published from 2011- time. Notwithstanding, internalizing conditions, there must be evidence 2016, pertaining a 2016 national survey like anxiety or depres- that symptoms began to children and indicated that 8.4% of sion, are more common before age 12 years adolescents 4-18 children 2-17 years of among girls.11 instead of before age years of age.13 age in the United States 7 years.12 Interestingly, The American Acade- clinical questions currently had ADHD, these interim publica- my of Pediatrics (AAP) pertaining to ADHD representing 5.4 million tions do not support 5 first published clinical diagnosis were as children. Symptoms of dramatic changes to recommendations for follows: ADHD appear in child- previous recommen- hood, and most children evaluation and diagno- dations. Thus, the new 1. What is the with ADHD continue to sis of pediatric ADHD guideline published comparative diagnostic have symptoms, with in 2000, with treatment in October of this year accuracy of approach- associated impairment, recommendations includes only incremen- es that can be used through adolescence and following in 2001. tal updates to the in the primary care into adulthood. With time, These guidelines 2011 guideline. setting or by specialists the overt hyperactive established the use to diagnose ADHD and impulsive symptoms of the Diagnostic and As with the original among children tend to decline, whereas Statistical Manual of 2000 clinical younger than 7 years the inattentive symp- Mental Disorders practice guidelines of age? criteria for diagnosis, 2 2. What is the compar- published Clinical 2) an article on tine and the ative diagnostic accu- Practice Guideline for systemic barriers to extended-release racy of EEG, imaging the Diagnosis, Evalu- the care of patients alpha-2 agonists, or executive function ation and Treatment with ADHD. The guanfacine and approaches that can of Attention-Deficit/ necessary complex clonidine, remain be used in the prima- Hyperactivity Disorder care best occurs in the secondary alter- ry care setting or by (ADHD) in Children the patient-centered native medications. specialists to diagnose and Adolescents. This medical home.13 Behavior therapy is ADHD among patients updates and replaces Updated from 2011, the recommended as the age 7-18 years? the 2011 clinical prac- guidelines are relevant first-line treatment for tice guideline revision for primary care pe- preschoolers. In this 3. What are the adverse published by the AAP, diatricians, pediatric respect, behavior ther- effects of being labeled titled Clinical Practice nurse practitioners and apy describes behavior correctly or incorrectly Guideline: Diagnosis physician assistants, management for pre- as having ADHD? and Evaluation and family medicine schoolers with ADHD 4. Are there more for- of the Child with practitioners.12 The as parent training in mal neuropsychologi- Attention-Deficit/ steps recommended behavior management cal, imaging or genetic Hyperactivity Disor- in the guideline neces- (PTBM).12 tests that improve the der. This most recent sitate spending more The release of revised diagnostic process? guideline, similar to its time with patients and AAP guidelines for predecessor, addresses their families; develop- treatment questions the care of pediatric the evaluation, diag- ing a care management were as follows: patients with ADHD nosis and treatment of system of contacts offers clinicians 1. What are the ADHD in children from with school and other updates and opportu- comparative safety age 4-18 years. The community members; nities as they continue and effectiveness of revised AAP guidelines and providing con- to provide long-term, pharmacologic and/ also include a process tinuous, coordinated comprehensive care or nonpharmacologic of care algorithm and patient care. Given the for this common and treatments of ADHD in a paper on barriers nationwide dilemma pervasive condition. improving outcomes to care. of limited access to associated with ADHD? mental health clinicians, Since 2011, the primary care physi- 2. What is the risk of ADHD-related research cians are increasingly references diversion of pharmaco- reflects increased charged to provide 1. Molina BS, Hinshaw logic treatment? understanding in and services to patients recognition of the SP, Swanson JM, et 3. What are the with ADHD and their prevalence and epide- al.; MTA Cooperative comparative safety families. To assist miology of ADHD; the Group. The MTA at and effectiveness of primary care physi- challenges it presents 8 years: Prospective different monitoring cians in overcoming for both children and follow-up of children strategies to evaluate such obstacles, the their families; the need treated for com- the effectiveness of companion articles for a comprehensive bined-type ADHD treatment or changes on systemic barriers clinical resource for in the ADHD status (for reviews and makes in a multisite study. the evaluation, diag- example, worsening or recommendations to J Am Acad Child nosis and treatment of resolving symptoms)? address the barriers to Adolesc Psychiatry. ADHD; and the barriers enhance care for these 2009;48(5):484-500. Guided by the evidence that may impede its patients. Recommend- quality and grade, the implementation.13 In 2. Holbrook JR, ed treatments remain subcommittee devel- response, the revised essentially unchanged. Cuffe SP, Cai B, et al. oped seven key action guideline is supported The stimulant class of Persistence of statements for the by two accompanying medications, includ- parent-reported ADHD evaluation, diagnosis documents: 1) a PoCA ing methylphenidate symptoms from and treatment of for the diagnosis and amphetamines, childhood through ADHD in children and and treatment of chil- are generally the initial adolescence in a com- adolescents. In October dren and adolescents treatments. Atomoxe- munity sample. J Atten 2019, Pediatrics with ADHD, and Disord. 2016;20(1):11-20. 3 3. Mueller KL, Tomblin 6. Pastor PN, Reuben nosis and medication 11. Tung I, Li JJ, Meza JI, JB. Examining the co- CA, Duran CR, Haw- treatment for atten- et al. Patterns of morbidity of language kins LD. Association tion-deficit/hyperac- comorbidity among disorders and ADHD. between diagnosed tivity disorder–United girls with ADHD: A Top Lang Disord. ADHD and selected States, 2003. MMWR meta-analysis. Pediatrics. 2012;32(3):228-246. characteristics among Morb Mortal Wkly Rep. 2016;138(4): e20160430. children aged 4-17 2005;54(34):842-847. 4. Wolraich ML, McKe- 12. Wolraich ML, years: United States, own RE, Visser SN, et 9. Cuffe SP, Visser SN, Hagan JF. Updated 2011-2013. NCHS Data al. The prevalence of Holbrook JR, et al. ADHD guideline Brief, No. 201. Hyatts- ADHD: Its diagnosis ADHD and psychiatric addresses evaluation, ville, MD: National and treatment in four comorbidity: Functional diagnosis, treatment from Center for Health school districts across outcomes in a school- ages 4-18. AAP News. Statistics; 2015. two states. J Atten Dis- based sample of chil- September 30, 2019. ord. 2014;18(7):563-575. 7. Elia J, Ambrosini P, dren [published online 13. Wolraich ML, Berrettini W. ADHD ahead of print Novem- 5. Danielson ML, Hagan JF, et al.
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