FROM THE AMERICAN ACADEMY OF PEDIATRICS
Supplemental Information
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
Practice guidelines provide a broad ability of records and school input, the facilitate a clinician’s accurate docu- outline of the requirements for high- family’s schedule, and the reimburse- mentation of the process. quality evidence-based care. In sup- ment structure will all play a role in port of consistent and comprehensive determining the pace at which a family SIGNS AND SYMPTOMS THAT care for children and adolescents with and child/adolescent move through SUGGEST ADHD symptoms of attention and hyperactiv- the process of care. 4- to 18- y-old patient identified with signs or symptoms suggesting ADHD. Symptoms can come from parents’ direct concerns or the mental health screen ity disorders within a typical, busy pe- Similarly, continued systematic moni- recommended by the TFOMH See TFOMH Algorithms diatric practice, the AAP has developed toring (to include reconsideration of See action statement 1 the following suggested process-of- the diagnosis if improvements in Many parents bring their child/adoles- care algorithm (see Supplemental Fig symptoms are not apparent) is an on- cent to the primary care clinician with 2) that provides discrete and manage- going process, to be addressed specific concerns about the child’s/ad- able steps through which a primary throughout the child’s/adolescent’s olescent’s ability to sustain attention, care clinician can fulfill the key action care within the practice, and in transi- curb activity level, and/or inhibit im- statements offered in the guideline. tion planning as the adolescent moves pulsivity. In these cases, it is clear that The algorithm is entirely consistent into the adult care system. with the practice guideline and is the clinician should initiate an evalua- The algorithm assumes that the pri- tion for ADHD. However, in many in- based on the practical experience and mary care practice has adopted men- stances, the chief concern might in- advice of clinicians experienced in the tal health surveillance and screening clude behaviors and characteristics diagnosis and management of ADHD in as described by the AAP Task Force on associated with ADHD without mention children and adolescents. Because of Mental Health.1 In light of the preva- of the core ADHD symptoms. For exam- the detail provided, the process algo- lence of ADHD, the severity of the con- ple, children/adolescents might have rithm does not have the same level of sequences of untreated ADHD, and the difficulty remaining organized, plan- evidence base as the key action state- availability of effective treatments for ments that are provided in the practice ADHD, the AAP recommends that every ning activities, or inhibiting their initial guideline. The steps of the algorithm child/adolescent identified with signs thoughts or actions, which are behav- are based primarily on consensus or symptoms suggestive of ADHD be iors that fall under the umbrella of ex- among expert clinicians. evaluated for ADHD. It is important to ecutive functions or cognitive control. This algorithm and each of its constit- document all aspects of the diagnostic Problems with executive functions are uent steps is not intended to be com- and treatment procedures in patients’ correlated with ADHD. Moreover, chil- pleted in any single office visit or any records. Use of rating scales for the dren/adolescents might have difficulty specific number of visits; the experi- diagnosis of ADHD, for assessment for making or keeping friends, following ence of the clinician, the volume of the comorbid conditions, and as a method the rules of the classroom, or regulat- practice, the longevity of the relation- for monitoring treatment and provid- ing their behavior. Problems within the ship between the clinician and family, ing information provided to parents, realm of social relationships are also the severity of the concerns, the avail- such as management plans, can help correlated with ADHD. In these cases,
PEDIATRICS Volume , Number , SI1 Overview of the 1 4- to 18- y-old patient identified with signs or symptoms suggesting ADHD. ADHD Care Process Symptoms can come from parents’ direct concerns or the mental health screen recommended by the TFOMH See TFOMH Algorithms See action statement 1
Perform Diagnostic Evaluation for ADHD and Evaluate or Screen for Other/Coexisting Conditions: See action statements 2–3 2 Family (parents, guardian, other frequent caregivers): School Child/adolescent Chief concerns (and important community informants): (as appropriate for child’s age and History of symptoms (eg, age of onset and Concerns developmental status): course over me) Interview, including concerns regarding Validated ADHD instrument Family history behavior, family rela onships, peers, school Evalua on of coexis ng condi ons Past medical history For adolescents: validated self-report Report on how well pa ents func on in instrument of ADHD and coexis ng Psychosocial history academic, work, and social interac ons condi ons Review of systems Academic records (eg, report cards, Report of child’s self-iden fied impression Validated ADHD instrument standardized tes ng, psychoeduca onal of func on, both strengths and weaknesses evalua ons) Evalua on of coexis ng condi ons Clinician’s observa ons of child’s behavior Administra ve reports (eg, disciplinary Physical and neurologic examina on Report of func on, both strengths and ac ons) weaknesses
3 5 DSM-IV 4 Assess impact on Yes diagnosis of Yes Coexisting treatment plan ADHD? conditions? Further evaluation/ See action referral as needed No statement 3
6 7 Exit this guideline. No Yes Evaluate or refer, as 8 Other appropriate. condition? Iden fy the child as 9 CYSHCN if Provide educa on to family and child appropriate. No re: concerns (eg, triggers for Coexisting disorders No ina en on or hyperac vity) and preclude primary care behavior-management strategies or management? 10 11 Inattention and/or school-based strategies hyperactivity/impulsivity Apparently problems typical or No not rising to DSM-IV diagnosis developmental Provide educa on of family and child variation? re: concerns (eg, triggers for ina en on or hyperac vity) and behavior Yes management strategies or school- 12 13 based strategies ESTABLISH MANAGEMENT TEAM Yes Follow-up and Enhanced establish co- Collaborate with Surveillance management plan 14 family, school, Establish team Identify child as See TFOMH and child to including CYSHCN Algorithms Provide educa on identify target coordination plan addressing concern (eg, goals. expecta ons for a en on as a func on of age)
Enhanced Surveillance 15
BEGIN TREATMENT See action statement 5 Op on: Medica on (ADHD only and past medical or Op on: Behavior management Op on: Collaborate with family history of cardiovascular (developmental varia on, school to enhance supports disease considered) problem or ADHD) and services (developmental Ini ate treatment varia on, problem, or ADHD) Titrate to maximum benefit, Iden fy service or approach minimum adverse effects Monitor target outcomes Iden fy changes Monitor target outcomes Monitor target outcomes See action statement 6
16 17 Do No Reevaluate to confirm diagnosis symptoms and/or provide education to improve improve? adherence.
Reconsider treatment plan including Legend Yes changing of the medication or dose, adding a medication approved for = Start adjuvant therapy, and/or Follow-up for 18 changing behavioral therapy. = Action/ chronic care process management at least 2x/year for = Decision ADHD issues = Continued care See action statement 4 SUPPLEMENTAL APPENDIX FIGURE 2 ADHD process-of-care algorithm. TFOMH indicates Task Force on Mental Health; CYSHCN, child/youth with special health care needs.1
SI2 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix initiating the diagnostic evaluation pediatric providers is important to ob- ● At least 6 of the 9 behaviors de- might be appropriate. tain. The process might be facilitated if scribed in the hyperactive/impul- the family is given the responsibility to sive domain occur often and to a de- Perform Diagnostic Evaluation for provide other informants with the gree inconsistent with the child’s ADHD and Evaluate or Screen for questionnaires or data-collection developmental age. ● Presence of some impairment in 2
Perform Diagnostic Evaluation for ADHD and Evaluate or Screen for Other/Coexisting Conditions: or more major settings (eg, home See action statements 2–3 Family and school) for at least 6 months. (parents, guardian, other frequent caregivers): School Child/adolescent Chief concerns (and important community informants): (as appropriate for child’s age and ● Presence of some symptoms of History of symptoms (eg, age of onset and Concerns developmental status): course over me) Interview, including concerns regarding Validated ADHD instrument ADHD that caused impairment (ac- Family history behavior, family rela onships, peers, school Evalua on of coexis ng condi ons Past medical history For adolescents: validated self-report cording to the history) before 7 Report on how well pa ents func on in instrument of ADHD and coexis ng Psychosocial history academic, work, and social interac ons condi ons years of age. Review of systems Academic records (eg, report cards, Report of child’s self-iden fied impression Validated ADHD instrument standardized tes ng, psychoeduca onal of func on, both strengths and weaknesses evalua ons) ● Symptoms have persisted for at Evalua on of coexis ng condi ons Clinician’s observa ons of child’s behavior Administra ve reports (eg, disciplinary Physical and neurologic examina on Report of func on, both strengths and ac ons) least 6 months. weaknesses ● Evidence of significant clinical im- pairment in social, academic, or oc- cupational functioning because of Coexisting Disorders forms to be used and to request other the behaviors. Ideally, the primary care office staff records and reports. ● Symptoms are not attributable to can ask the assistance of the parent(s) To make a diagnosis of ADHD, the clini- another physical, situational, or in obtaining information on the pur- cian needs to establish that at least 6 mental health condition. pose of a visit at the time of scheduling. or more core symptoms per dimen- DSM-IV-TR2 criteria define 3 subtypes If possible, an extended visit is often sion presented in Supplemental Table of ADHD: desirable for the evaluation of ADHD. 2 are present in either or both of the ● ADHD primarily of the inattentive As a general approach to the initial dimensions of inattention and/or type (ADHD/I, having the inappropri- evaluation, data on the child’s/adoles- hyperactivity/impulsivity. ately often occurrence of at least 6 cent’s symptoms and functioning (eg, Diagnostic criteria for ADHD in school- of 9 inattention behaviors and Ͻ6 home or school questionnaires) aged children and adolescents include hyperactive-impulsive behaviors); should be gathered from parents, documentation of the following crite- ● school personnel, and other sources, ADHD primarily of the hyperactive- preferably before the visit. This strat- ria: impulsive type (ADHD/HI, having the egy allows the primary care pediatri- ● At least 6 of the 9 behaviors de- inappropriately often occurrence of cian to focus on pertinent issues for scribed in the inattentive domain at least 6 of 9 hyperactive-impulsive that child/adolescent and family at the occur often and to a degree incon- behaviors and Ͻ6 inattention be- time of the visit. Parental consent to sistent with the child’s developmen- haviors); and authorize the release of school data to tal age, and/or ● ADHD combined type (ADHD/C, hav-
SUPPLEMENTAL TABLE 2 Core Symptoms of ADHD (Adapted From the DSM-IV-TR) Inattention Dimension Hyperactivity-Impulsivity Dimension Hyperactivity Impulsivity Careless mistakes Fidgety Blurts answers before questions are completed Difficulty sustaining attention Unable to stay seated Difficulty awaiting turn Seems not to listen Moves excessively (restless) Interrupts/intrudes on others Fails to finish tasks Difficulty engaging in leisure activities quietly Difficulty organizing “On the go” Talks excessively Avoids tasks that require sustained attention Loses things Easily distracted Forgetful
PEDIATRICS Volume , Number , SI3 ing the inappropriately often occur- mation required to make a diagnosis have not been found to reliably differ- rence of at least 6 of 9 behaviors in on the basis of the DSM-IV-TR criteria. entiate between youth with and with- both the inattention and Broad-band rating scales that assess out ADHD.14,15 Appropriate further as- hyperactive-impulsive dimensions). mental health functioning in general sessment is indicated if an underlying There is also evidence that the criteria do not provide reliable and valid indi- etiology is suspected. Assessments are appropriate for preschool-aged cations of ADHD diagnoses but might such as screening for high lead levels, children3 and adolescents.4 The use of help in screening for co-occurring be- low iron or ferritin levels or abnormal specific DSM-IV-TR criteria decreases havioral conditions.7 thyroid hormone levels or imaging variation among clinicians in how the No current instruments routinely used studies should be pursued only if other diagnosis is made and will facilitate in primary care practice reliably as- historic or physical information sug- communication among professionals sess the nature or degree of functional gests their presence. Conditions such and patients. impairment in children with ADHD, al- as sleep disorders, such as apnea, ab- sence seizures, hyperthyroidism, or DSM-IV-TR criteria require evidence of though parent-report instruments mood or anxiety disorders might pres- impairing symptoms before 7 years of might help. Some measures that are ent with ADHD symptoms and might be age. In some cases, the symptoms of available are limited, because they relieved when the primary condition is ADHD might not be recognized by par- mostly provide only a global rating (eg, treated. ents or teachers until the child is older the Strengths and Difficulties Ques- 8 than 7 years, when school tasks be- tionnaire [SDQ] Impact Scale and the Current criteria do not describe gen- come more challenging. In children for Children’s Global Assessment Scale der or developmental differences, al- 9 whom the problems are identified af- [CGAS] ) or have more limited valida- though numerous studies have found ter 7 years of age, history can often tion (eg, the performance component that the frequency of symptomatic be- 10,11 identify an earlier age of onset of some of the Vanderbilt Scales ). Review of haviors varies significantly across of the symptoms. Delayed recognition documents, such as report cards and gender and age groups (for a review, might be seen more often in the inat- results of standardized testing, and ev- see Barkley16). Compared with other idence of detention, suspensions, or tentive subtype of ADHD.5 girls, girls with ADHD experience more expulsions from school can also serve depression, anxiety, distress, poor If symptoms arise suddenly, without as evidence of functional impairment. teacher relationships, stress, external previous history, primary care clini- With information obtained from the locus of control, and impaired aca- cians should consider other condi- parent and school, the clinician will demics. Compared with boys with tions including head trauma, physical need to make a clinical judgment ADHD, girls with ADHD experience or sexual abuse, neurodegenerative about the effect of the core and asso- more impairment in self-reported anx- disorders, mood or anxiety disorders, ciated symptoms of ADHD on academic iety, distress, depression, and external substance abuse, or a major psycho- achievement, classroom performance, locus of control. Furthermore, the be- logical stress in the family or school. family and social relationships, inde- havioral characteristics specified in The requirements that a child must pendent functioning and safety/acci- the DSM-IV-TR, despite efforts to stan- have significant impairment in func- dental injuries, self-perception, leisure dardize them, remain subjective, to a tion and some impairment in at least 2 activities, and self-care (such as bath- great extent, and may be interpreted settings are the most challenging as- ing, toileting, dressing, and eating). Ad- differently by different observers. Cul- pects of the DSM-IV-TR criteria for the ditional guidance regarding functional tural norms and expectations of par- clinician to obtain accurate informa- assessment is available through the ents or teachers may influence the tion. The presence of functional im- AAP ADHD toolkit and the Task Force on perspectives of various informants. pairments is often the most troubling Mental Health.15,16 The rates of ADHD and its treatment issue for children, families, and teach- In the absence of other concerns and have been found to be different for ers and is a central requirement in findings on medical history, family and different racial/ethnic groups.17,18 The making the diagnosis of ADHD6 (also social history, and physical examina- clinician must remain sensitive to cul- see Behavior Management”). tion of the child, no further diagnostic tural differences in the appropriate- As was determined in the previous testing will help to reach the diagnosis. ness of behaviors and perceptions of guideline, parent and teacher rating Compared with clinical interviews, mental health conditions. Other fac- scales that use DSM-IV-TR criteria for standardized psychological tests, such tors, such as poverty and access to ADHD are helpful in obtaining the infor- as computerized tests of attention, care, likely contribute to the cultural
SI4 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix differences. These complexities in the tient might suggest undiagnosed ciency) primary sleep disorders.22 diagnosis mean that clinicians who cases of ADHD. Sleep-assessment measures that have use DSM-IV-TR criteria must apply Updating the medical history can fo- been shown to be useful in the pediat- them in the context of sound clinical cus on factors associated with ADHD, ric primary care practice setting in- judgment. such as preterm delivery, neonatal clude brief screening tools25 and 26,27 The DSM-IV-TR does include a category problems, congenital infections, and parent-report surveys. Overnight of “ADHD not otherwise specified.” This head trauma. The psychosocial his- polysomnography should be strongly category is meant for children who tory should include environmental fac- considered for children with symp- meet many but not the full criteria for tors, such as family stress and prob- toms suggestive of and/or risk factors ADHD, such as children who meet all lematic relationships that might for obstructive sleep apnea syndrome the symptom and impairment criteria contribute to the child’s/adolescent’s and restless-leg syndrome/periodic 28 but whose age of onset is later than 7 overall functioning. limb-movement disorder. years or children who have clinically It is important to obtain history of con- In addition, even in the absence of pri- significant impairment but do not ditions that might mimic ADHD symp- mary sleep disorders, modest reduc- meet all the symptom requirements. toms or might co-occur with the condi- tions in sleep duration, such as those Clinically significant impairment is re- tion. Co-occurring conditions are associated with environmentally re- quired in diagnosing a child with ADHD. discussed later in the process algo- lated insufficient sleep, might be asso- Children with inattentive or hyperac- rithm. Several available question- ciated with detectable deterioration in tive/impulsive symptoms but less than naires also provide a screen for coex- vigilance and attention in children with significant impairment are character- isting conditions and a report of ADHD and should be evaluated and ad- 29 ized as having “problems.” function. It is important to obtain a dressed. Common clinical presenta- history that would suggest lead expo- tions of insomnia in children with FAMILY sure, absence seizures, or other men- ADHD include bedtime resistance, de- tal illnesses such as anxiety or mood layed sleep onset, night wakings, and A comprehensive diagnostic evalua- disorders and Tourette disorder. A full early-morning awakening. Both a base- tion typically begins with identifying review of systems might also reveal line assessment (ie, before initiating the family’s chief concerns. The clini- other symptoms, such as sleep distur- treatment) and ongoing periodic cian also needs to have the family bances, that may assist in formulating screening for sleep problems should members complete a validated ADHD a differential diagnosis and/or may be be included in the management of all instrument. Family members should considered in the development of man- children with ADHD. Sleep diaries are be asked to provide a history of signs agement plans. The patient should also useful adjuncts in quantifying sleep- and symptoms. This history includes be screened for hearing and/or visual onset latency and night wakings and determining the onset, frequency, and problems. assessing variability in sleep pat- duration of problem behaviors, situa- Primary sleep disorders, such as ob- terns.30 The differential diagnosis of in- tions in which they increase or de- structive sleep apnea syndrome and somnia in children with ADHD includes: crease, previous treatments and their restless-leg syndrome/periodic limb- ● ADHD medication (stimulant and results, and the family’s understand- movement disorder, might present nonstimulant) effects: ing of the issues. The family history with symptoms of inattention, hyper- ● Direct effects on sleep architec- should include any medical syn- activity, and impulsivity or are fre- ture (ie, prolonged sleep-onset la- dromes, developmental delays, cogni- quently associated with ADHD.18–21 All tency and decreased sleep dura- tive limitations, learning disorders, or children being evaluated for ADHD tion, increased night wakings)31– mental illness in family members, in- should be systematically screened for 33; and cluding ADHD and mood, anxiety, and symptoms of (ie, frequent snoring, ob- bipolar disorders. In addition, parental served breathing pauses; restless ● Indirect effects such as inade- tobacco and substance use is relevant sleep, urge to move their legs at night; quate control of ADHD symptoms to risk factors for ADHD.17 Family mem- daytime sleepiness) and risk factors in the evening and medication bers might not have been formally di- for (ie, adenotonsillar hypertrophy, withdrawal or rebound agnosed with ADHD; asking about fam- asthma/allergies, obesity; family his- symptoms.23,34 ily members’ school experience and tory of restless-leg syndrome/periodic ● Sleep problems associated with co- problems similar to those of the pa- limb-movement disorder, iron defi- existing psychiatric conditions (ie,
PEDIATRICS Volume , Number , SI5 anxiety and mood disorders, disrup- by the AAP Task Force on Mental should be asked to complete a vali- tive behavior disorders).34,35 Health.13 The situation might be more dated ADHD instrument or behav- ● Circadian-based phase delay in complicated when parents disagree, ior scale based on DSM-IV-TR criteria sleep-wake patterns, which have particularly in divorce situations when for ADHD and provide observations been shown to occur in some chil- parents with shared custody perceive that might suggest coexisting or al- dren with ADHD, which results in the child’s problems and strengths dif- ternative conditions, including dis- both prolonged sleep onset and dif- ferently. Under such circumstances, ruptive behavior disorders, depres- ficulty waking in the morning.36 the clinician must use communication sion and anxiety disorders, tics, or skills to find a consensus on the diag- learning disabilities. Report of ● Inadequate sleep hygiene (ie, incon- nosis and plan. Eliciting information function, both strengths and weak- sistent bedtimes and wake times, from extended family members might nesses, might be gleaned by ques- absence of a bedtime routine, elec- help clarify some of the differences. tionnaires or academic records tronics in the bedroom, caffeine that can include report cards; stan- use).37 SCHOOL AND/OR OTHER dardized testing in reading, mathe- ● Intrinsic deficit associated with COMMUNITY INFORMANTS matics, and written expression; vali- ADHD. Numerous studies have found Multiple informants are required for dated functional assessment tools that nonmedicated children with 44 clinicians to determine the nature mentioned previously ; and previ- ADHD and no comorbid mood or anx- and severity of symptoms, impact of ous psychoeducational evaluations. iety disorders have significantly the symptoms on function in 2 or These records can help establish a greater bedtime resistance, more more settings, and whether the child’s/adolescent’s profile of aca- sleep-onset difficulties, and more child/adolescent meets DSM-IV-TR demic and behavioral performance frequent night awakenings when criteria for the diagnosis of ADHD. In in school, the presence of a learning compared with typically developing most cases, the teacher provides disability, difficulty in following 38 control children. In addition, some those reports. The reports of parents school rules, the quality of peer in- children with ADHD seem to have ev- and teachers are often sufficient for teractions, and the extent of school idence of increased daytime sleepi- the ADHD diagnosis, but information absences. ness even in the absence of a pri- from the patient is essential for iden- If the records indicate that the child 39,40 mary sleep disorder. tifying the internalizing conditions of is having difficulty learning aca- A sound assessment of functioning in mood and anxiety disorders. Rating demic skills, the physician should de- major areas can then be used to con- scales recommended by the Task termine if the child has been as- struct an educational and behavioral Force on Mental Health may be help- sessed for a potential learning profile including not only concerns but ful. In some circumstances, it might problem by the school, because also strengths or talents. The most be desirable to solicit information there is a high comorbidity between common areas of functioning affected from additional sources. School re- learning disabilities and ADHD. The by ADHD include academic achieve- ports, for example, might be more school assessment might use a ment; peer, parent, sibling, and adult difficult to obtain—or less compre- response-to-intervention model as authority-figure relationships; partici- hensive—in cases that involve part of the diagnostic process in pation in recreation such as sports; preschool-aged children and adoles- which learning problems are evalu- and behavior and emotional regula- cents. Other adults who are active in ated on the basis of the child’s re- tion, including risky behavior. One sys- the life of an adolescent, such as sponse to evidence-based academic tematic approach to the assessment of coaches, pastors, or scout leaders, interventions, or a multidisciplinary function can use the framework of the can be asked to complete rating team evaluation might be conducted International Classification of Func- scales to develop a full profile of the by the school. If the child has an Indi- tioning, Disability, and Health.6,41 adolescent, although the accuracy of vidualized Education Program, this Suggestions and recommendations their reporting has not been studied document should be reviewed by the for scales such as the modified Patient Teachers might indicate their major clinician. Health Questionnaire-9 Modified for concerns by using questionnaires If the child continues to struggle de- Adolescents (PHQ-A)42 and Screen for or verbal input by telephone or spite the school’s interventions and Child Anxiety Related Emotional Disor- through direct conversation. An ap- treatment for ADHD, further psychoe- ders (SCARED)43 have been developed propriate school representative ducational or neuropsychological as-
SI6 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix sessment is necessary. The clinician children/adolescents with learning at home, in school, at work, and among might want to recommend that the disabilities, a teacher in the area of peers as well as validated functional as- evaluations be performed by an inde- strong function and a teacher in the sessment tools.44 Whenever possible, the pendent psychologist or neuropsy- area of weak function). The ADHD tool- individual child’s or youth’s own view of chologist. Despite the importance of kit13 provides materials relevant to this what he or she would like to see changed the psychological assessments, in- school data collection. should be considered primary targets surance coverage is quite variable, Teacher and parent reports frequently for intervention, because these goals and families should be encouraged disagree,46 and there also might be dis- might at times differ widely from parent to investigate their coverage when agreement between parents. These ob- or school concerns. pursuing independent psychological servations might not be inaccurate, The clinician must keep in mind the evaluations. Financing community- because parents and teachers ob- tendency of many children/adoles- based evaluations has been ad- serve the children under different cir- cents to underreport their ADHD and dressed in a previous AAP state- cumstances. When there is disagree- other disruptive behavior symptoms. ment.45 Children with intellectual or ment, it is helpful to obtain more However, the baseline impressions of other developmental disabilities information such as the circumstance the child/adolescent can then be used might also have ADHD, but the as- under which the individuals observed as the basis for shaping the patient’s sessment in these cases is more the child, the demands on the child understanding of ADHD and coexisting complicated, because one must en- during those observations, the observ- symptoms as well as monitoring func- sure that the academic expectations ers’ understanding of the behaviors tion in social, behavioral, and aca- are matched to the child’s academic and how to deal with them, and the ob- demic domains. Active involvement of abilities and the level of ADHD symp- servers’ understanding of ADHD and the children/adolescents might be toms exceeds what would be ex- how it is treated as well as the role useful to empower them to under- pected for a child’s developmental they play with the child. As noted pre- stand and participate in their own di- level. Primary care physicians in- viously, obtaining information from ad- agnostic formulation and, later, to ob- volved in assessing ADHD in children ditional sources, such as grandpar- tain “buy in” to their treatment plan with intellectual disabilities will ents, coaches, or Sunday school and improve adherence to treatment. need to collaborate closely with a teachers, can be helpful. The clini- Recommendations of the AAP Task school psychologist or independent cian’s decision about the diagnosis is a Force on Mental Health and the Guide- psychologist. clinical judgment made on the basis of lines for Adolescent Depression in Pri- In addition to the academic informa- all the information that is available. mary Care (GLAD-PC)47,48 include using tion, information should be re- validated diagnostic rating scales for quested that characterizes the CHILD/ADOLESCENT adolescent mood and anxiety disor- child’s/adolescent’s level of func- The clinician should conduct an age- ders for clinicians who wish to use this tioning with regards to peer, appropriate interview, including the format. In addition, the CRAFFT (car, re- teacher, and other authority figure child’s/adolescent’s concern regarding lax, alone, forget, friends, trouble) is relationships; ability to follow direc- his or her own behavior, and regarding an available screen for substance 49 tions; organizational skills; history of family relationships, peers, and school. It abuse. classroom disruption; and assign- is important to include a discussion of Clinical observations of the patient ment completion. Administrative his or her strengths, goals, and difficul- should be recorded and include his or reports of disciplinary action, such ties. Along with the interview, the use of her level of attention, activity, and im- as suspensions and expulsions, and an appropriate validated self-report pulsivity during the encounter. An im- descriptions of behavior at school instrument of ADHD and co-existing portant caveat is that the findings seen reflect social function and behav- conditions, primarily for adolescents, in other settings, including core symp- ioral regulation and suggest the pos- can aid in the assessment of risk of ADHD toms, are often not observed during sibility of coexisting conditions. and anxiety and mood disorders. It is office visits.50 For adolescents who have multiple also important to ask about delusional Special attention should be paid to lan- teachers, it is desirable to obtain be- thinking and suicidal thoughts or ac- guage skills in preschool-aged and havior and impairment ratings from at tions. This evaluation should also pro- young school-aged children, because least 2 teachers in academic subjects vide a baseline of the child’s/adoles- difficulties with language can be a (eg, math and English teachers or, for cent’s self-identified report of function symptom of a language disorder and
PEDIATRICS Volume , Number , SI7 predictor of subsequent reading prob- meet across the major settings of sources from the AAP Task Force on lems; such language disorders might his or her life? Mental Health might be helpful. present as problems with attention ● Have these criteria been present for and impulsivity. Likewise, social inter- 6 months or longer? TYPICAL OR DEVELOPMENTAL actions should be noted during the ex- VARIATION: ● Was the onset of these or similar amination, because they are another behaviors present before the age of possible area of deficiency. Apparently 7 years? typical or The physical and neurologic exami- developmental ● What functional impairments, if any, variation? nation must be comprehensive. A are caused by these behaviors? physical and neurologic examination Yes should be conducted to determine if ● Could any other condition be a bet- further medical or developmental as- ter explanation for the behaviors? Provide educa on sessments are indicated. Baseline ● Is there evidence of coexisting prob- addressing concern (eg, expecta ons for a en on height, weight, blood pressure, and lems or disorders? as a func on of age) pulse measurements should be taken. On the basis of this information, the Enhanced Among the signs to note are hearing clinician should be able to arrive at a Surveillance and visual acuity and cardiovascular preliminary diagnosis. Evaluation might reveal that the status. Dysmorphic features should child’s/adolescent’s inattention, ac- also be noted, because ADHD might be OTHER DISORDERS tivity level, and impulsivity are within associated with genetic syndromes the normal range of development; (eg, fetal alcohol syndrome and fragile If symptoms arise suddenly, with- mildly or inconsistently elevated in X). The neurologic evaluation should out any previous history, primary comparison to peers; or not associ- include developmental and mental sta- care clinicians should consider ated with any functional impairment tus observations including affect; com- other conditions, including head in behavior, academics, social skills, munication skills, including speech trauma, physical or sexual abuse, or other domains. It is important for and language; tics; and gross and fine neurodegenerative disorders, the clinician to probe further to de- motor coordination. Many children mood and anxiety disorders, sub- termine if the parental concerns re- with ADHD will have poor coordination, stance abuse, or a major psycho- garding the child/adolescent are at- which might be severe enough to war- logical stress in the family or in tributable to other issues in the rant a diagnosis of developmental co- school, such as bullying. family, such as parental tension or ordination disorder. The findings can Exit this guideline. drug abuse in another family mem- affect how well the child can perform Yes Evaluate or refer, as Other appropriate. ber; whether they are caused by in competitive sports and can also ad- condition? Iden fy the child as CYSHCN if other issues in school, such as social versely affect his or her writing skills. appropriate. pressures or bullying; or whether Through history and examination of If the evaluation identifies or sug- they are within the spectrum of typi- the child’s fine and gross motor skills, gests that another disorder is the cal development. Parent education the clinician can identify these deficits cause of the concerning signs and about contributions to their con- and address them in the management symptoms, then it is appropriate to cerns and to the spectrum of devel- plan. exit this algorithm. The approach in opmental variation might be helpful. that case is dictated by the results of Education about the range of typical DSM-IV diagnosis of the evaluation. If a referral is made, development and strategies for im- ADHD? the primary care clinician should proving a child’s/adolescent’s be- frame the referral questions clearly haviors when they are problematic As a result of the diagnostic evalua- and expect these referral questions might be helpful. A schedule of en- tion, a primary care clinician should be to be answered in a manner that will hanced surveillance absolves the able to answer the following ques- ensure that a comanagement plan family of the need to reinitiate con- tions: that addresses the families’ and tact if the situation deteriorates. If a ● How many inattentive and hyperac- child’s/adolescent’s ongoing needs recommendation for continued rou- tive/impulsive behavior criteria for for education and general and spe- tine systematic surveillance is made, ADHD does the child/adolescent cialty health care is established. Re- then assurance that ongoing con-
SI8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix
Provide Education to the Family and Child/Adolescent Inattention and/or hyperactivity/impulsivity Education for the family and child/ Apparently problems adolescent about ADHD is an impor- typical or No not rising to DSM-IV Diagnosis tant element in the care plan when developmental Provide educa on of family and child variation? re: concerns (eg, triggers for ina en on ADHD is diagnosed or inattention, hy- or hyperac vity) and behavior management strategies or school peractivity, and/or impulsivity (prob- based strategies lem level) is identified. Family educa- tion continues throughout the Enhanced Surveillance course of treatment. It includes an- ticipatory guidance in such areas as transitions (eg, from elementary to middle and middle to high schools and from high school to college or cerns can be revisited in future pri- pulsivity; behavior-management options, employment) and working with mary care visits would be important. including a behavior-therapy or parent- schools and developmental chal- ing program; strategies for improving INATTENTION, HYPERACTIVITY, AND/ lenges that might be affected by school performance or behavior; and the OR IMPULSIVITY (PROBLEM LEVEL): ADHD, including driving, gender, and recommendations provided in the inat- drugs. Children/adolescents whose symptoms tention and hyperactivity/impulsivity Family education includes all mem- do not meet the criteria for diagnosis of cluster guidance in the Task Force on bers of the family, including develop- ADHD might still encounter difficulties or Mental Health ADHD toolkit.13 mentally age-appropriate information impairment in some settings, as de- for the affected child/adolescent and scribed in the DSM-PC Child and Adoles- ATTENTION-DEFICIT/HYPERACTIVITY any siblings. Topics include the disor- cent Version.51 DISORDER: der; the symptoms; the assessment Professional consensus is that medica- If the child/adolescent is found to meet process; commonly coexisting disor- tion is not an appropriate treatment for the DSM-IV-TR criteria for ADHD, includ- ders; treatment choices and their ap- children/adolescents with inattention, ing commensurate functional disabili- plication, likely effects, and outcomes; hyperactivity, and/or impulsivity prob- ties, such diagnosis should be made, and long-term implications; impact on lems that do not meet the DSM-IV-TR cri- progress through the process-of-care al- school performance; and social teria for ADHD. Children/adolescents gorithm continues as shown. participation. with these problems and their families A critical piece of the treatment plan might benefit from education, including is to empower children/adolescents identifying and eliminating triggers that to understand their condition and prompt inattention, hyperactivity, or im- the degree of impairment that it has on their daily life, including strate- gies for addressing symptoms and
DSM-IV impairments. At every stage, this ed- diagnosis of Yes Coexisting ucation must continue in a manner ADHD? conditions? consistent with the child’s/adoles- cent’s own level of understanding. In addition, it is helpful for a child/ado- No lescent with ADHD to know the name of any medication that he or she will be using as well as common adverse Provide educa on to family and child re: concerns (eg, triggers for effects. ina en on or hyperac vity) and behavior-management strategies or The issue of how the patient thinks of based strategies himself or herself is another area to address; it should be clarified that the condition does not mean that he
PEDIATRICS Volume , Number , SI9 or she is less smart than other chil- the school with information from the of ADHD.51 For example, children with dren/adolescents. It can also be evaluation that will help the school de- ADHD and coexisting anxiety disorders helpful to identify and support areas termine eligibility for special educa- might find that ADHD medications de- of strength and help the child/ado- tion services and develop appropriate crease anxiety symptoms as well as lescent with ADHD to learn how to adaptations. Advocacy and support ADHD behaviors. In the cases of severe identify when he or she needs help groups such as CHADD (Children and learning disorders or oppositional de- and how to procure it. Adults With Attention-Deficit/Hyperac- fiant disorder, a trial of treatment for Education for parents should include tivity Disorder) can also provide infor- ADHD might indicate whether the ap- proactive strategies that can help mation and support to families. parent coexisting condition can be make the home environment more The ADHD toolkit13 provides lists of ed- modulated with treatment of the ADHD. facilitative for their child/adolescent ucational resources including Web- Other patients might require addi- with ADHD. For example, making ad- based resources, organizations, and tional therapeutic treatments, such as aptations and providing structure books that might be useful to parents cognitive behavioral therapy or a dif- that enables the child/adolescent to and students. ferent or additional medication, to ad- best use his or her strengths and COEXISTING CONDITIONS: equately treat the ADHD and coexisting compensate for deficits can be help- condition. ful to parents. Such strategies in- If other disorders are suspected or de- Untreated substance use disorder clude providing greater consistency tected during the diagnostic evalua- needs to be addressed first before in the parents’ behavior toward their tion, an assessment of the urgency of fully addressing the patient’s ADHD child/adolescent with ADHD, forming these conditions and their impact on treatments. daily routines and schedules, and the ADHD treatment plan needs to be displaying house rules in prominent made. If the primary care clinician requires places as visual reminders. It may Urgent conditions, such as suicidal the advice of another subspecialist, help parents to communicate about thoughts or acts or other behaviors then the clinician should consider their child’s/adolescent’s behavior with the potential to severely injure carefully when to initiate treatment for and each parent’s response as well the child/adolescent or other peo- ADHD. In some cases, it might be advis- as the parental division of labor. It is ple, such as severe temper out- able to delay the start of medication also important to check on the par- bursts or child abuse, should be ad- until the role of each member of the ents’ well-being, because parents of dressed immediately with services treatment team is established. For ex- children/adolescents with ADHD fre- capable of handling crisis ample, with some coexisting psychiat- quently are under stress and might situations. ric disorders, such as severe anxiety, not take into consideration their own The evidence shows that coexisting depression, and bipolar disorder, a co- well-being or that of other family conditions, such as oppositionality and managing developmental behavioral members. These concerns are par- anxiety, might improve with treatment pediatrician or psychiatrist might take ticularly relevant when a parent also has ADHD or associated conditions.
DSM-IV Assess impact on Parents will likely benefit if they learn Yes diagnosis of Yes Coexisting treatment plan ADHD? conditions? about optimal ways to partner with Further evaluation/ schools such that teachers can be- referral as needed come part of the educational and inter- vention teams. Parents will benefit Provide educa on to family and child No from being informed about school ser- re: concerns (eg, triggers for Coexisting disorders ina en on or hyperac vity) and preclude primary care vices that are available to address behavior-management strategies or their child’s/adolescent’s needs, in- cluding the Individuals With Disabili- Yes ties Education Act (IDEA) and the Reha- Follow-up and bilitation Act (504) services provided establish co- management plan by their state, and the eligibility re- See TFOMH Algorithms quirements for them. With a parent’s permission, the clinician can provide
SI10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix responsibility for treatment of both ● Does the family need support in tings so that the history and treat- the ADHD and the coexisting illness. learning how to establish, measure, ment plan does not need to be con- At other times, such as in the case of a and monitor target goals? stantly reinvented? child or adolescent with coexisting ● Have the family’s goals been identi- ● Is the follow-up plan sufficient to mild depression or obsessive- fied and addressed in the care plan? provide comprehensive, coordi- compulsive disorder, a mental health ● Does the family have an understand- nated, family-centered, culturally clinician, developmental-behavioral ing of effective behavior- competent, ongoing care? pediatrician, neurodevelopmental dis- management techniques for re- ability clinician, or child neurologist sponding to tantrums, oppositional COLLABORATE WITH THE FAMILY, may treat the coexisting condition behavior, or poor compliance to re- SCHOOL, AND CHILD/ADOLESCENT TO IDENTIFY TARGET GOALS: while the primary care clinician over- quests and commands? sees the treatment for ADHD, or the ● Whereas an initial stimulant medica- consulting physician may advise the Is help needed for normalizing peer and family relationships? tion trial might focus on normalizing primary care physician about the core symptoms of ADHD, a longer-term ● Does the child/adolescent need help treatment of the coexisting condition comprehensive plan should focus on in academic areas? If so, has a for- to the extent that the primary care phy- identifying and addressing individual- sician is comfortable treating both the mal evaluation been performed and ized and specific behavioral, academic, ADHD and coexisting problems. reviewed to distinguish work pro- and social target goals and treat- ESTABLISH MANAGEMENT TEAM duction problems secondary to Collaborate with ments. The clinician should assist par- family, school, Establish team Identify child as ADHD from coexisting learning or and child to including ents, teachers, other informants, and CYSHCN identify target coordination plan language disabilities? goals. the child/adolescent in developing tar- ● Does the child/adolescent need help get goals in the areas of function most in achieving independence in self- commonly affected by ADHD: academ- IDENTIFY AS A CHILD/YOUTH WITH help or schoolwork production? ics; peer, parent, or sibling relation- SPECIAL HEALTH CARE NEEDS: ● Does the child/adolescent or family ships; and safety in the community. Any child who meets the criteria for require help with optimizing, orga- Other goals might be identified by us- ADHD should be considered a child/ nizing, planning, or managing ing the International Classification of youth with special health care needs. schoolwork flow? Function (ICF) analysis conducted in The AAP encourages clinicians to de- the diagnostic phase of the clinical ● Does the family need help in recog- velop systems that ensure that the pathway.6 nition, understanding, or manage- medical home needs of all children/ ment of coexisting conditions? It is not necessary to develop goals in youth with chronic illnesses are met. every area all at once. Families might These needs—and strategies for ● Is there a plan in place to systemat- ically educate the child/adolescent be encouraged to identify up to 3 of the meeting them—are discussed in fur- most impairing areas on which they ther detail elsewhere in this guideline about ADHD and its treatment as well as the child’s/adolescent’s own will initially work; parents and the and in other AAP resources such as child/adolescent can then add other strengths and weaknesses? The Building Your Medical Home Tool- targets as indicated by their relative ● kit and Addressing Mental Health Con- Is there a plan in place to empower importance. Such an exercise will facil- cerns in Primary Care: A Clinician’s the child/adolescent with the knowl- itate greater understanding of the ef- 43,53 Toolkit. edge and understanding that will in- fects of the disorder on each member crease his or her adherence to of the family and might lead to an im- Management Issues treatments, and has that begun as proved collaboration in the develop- Questions that are important to con- early as possible and been ad- ment of a few specific and measurable sider in developing a management dressed at the child’s/adolescent’s outcomes. It is helpful to incorporate plan include the following: developmental level? the child’s/adolescent’s strengths and ● Does the family need further assis- ● Does the family have a copy of a care resilient factors in considering target tance in understanding the core plan that summarizes findings and goals and in generating a treatment symptoms of ADHD and their child’s/ treatment recommendations that plan. Goals for the school require input adolescent’s target symptoms and can be updated and used in school from the teachers in terms of both coexisting conditions? settings and other professional set- identification and measurement.
PEDIATRICS Volume , Number , SI11 Establishing measurable goals in in- BEGIN TREATMENT See action statement 5 terpersonal domains and behavior in Op on: Medica on (ADHD only and past medical or Op on: Behavior management Op on: Collaborate with family history of cardiovascular (developmental varia on, school to enhance supports unstructured settings might be partic- disease considered) problem or ADHD) and services (developmental ularly important. Whenever possible, it Ini ate treatment varia on, problem, or ADHD) Titrate to maximum benefit, Iden fy service or approach minimum adverse effects Monitor target outcomes Iden fy changes is important to make progress “count- Monitor target outcomes Monitor target outcomes able.” For behaviors such as “fre- See action statement 6 quency of yelling” or frequency of missing assignments, charts may be suggested as strategies for recording the event so that parents, teachers, the cent, parents, teachers, the primary medication to initiate for ADHD ther- child/adolescent, and clinicians can all care clinician, therapists, subspecial- apy. With the greater availability of agree on how much progress has been ists, and other adults (such as coaches medications approved by the FDA for made. In this way, successes can be or religious leaders) who will be ac- children/adolescents with ADHD, it has built on in a systematic way. Such tively engaged in supporting and mon- become increasingly unlikely that clini- strategies can help a family accurately itoring the treatment of ADHD. It is cians need to consider the off-label use assess and see progress of behavior helpful for the primary care clinician of other medications. The choice of for- changes. A daily single-page report or an assigned “care coordinator” to mulation depends on factors such as card can be used to identify and moni- ensure that each team member is the efficacy of each agent for a given tor 4 or 5 behaviors that affect function aware of his or her role and that both child/adolescent, the preferred length at school, and these reports can be routine and as-needed communication of coverage time, whether a child can shared with the parents. Other strate- strategies and expectations for re- swallow pills or capsules, and ex- gies and tools are available to clini- ports (frequency, scope) are clear. Col- pense. The extended-release formula- cians in the AAP ADHD toolkit13 and to laboration with the school goes be- tions are generally more expensive parents in the book ADHD: What Every yond the initial report of diagnosis and than the immediate-release formula- Parent Needs to Know.52 is best facilitated by agreement on a tions but might be preferred by many standardized, reliable system for ex- As treatment proceeds, in addition to families and children/adolescents, be- changing communications. using a DSM-IV-TR–based ADHD rating cause they provide the benefits of con- scale to monitor core symptom TREATMENT: sistent and sustained coverage with changes, formal and informal queries fewer administrations per day. Long- can be made in the areas of function Medication acting formulations usually preclude most commonly affected by ADHD (eg, This treatment option is restricted to the need for school-based administra- academic achievement; peer, parent, children/adolescents who meet the di- tion of ADHD medication. Better cover- or sibling relationships; and safety in agnostic criteria for ADHD. age with fewer administrations leads the community). Progress can also be Although it is a rare occurrence55 to greater convenience for the family monitored by determining progress on and more evidence is required to and, therefore, might also lead to bet- the target goals. At every visit, it is identify whether it is an increased ter adherence to the medication man- helpful to gradually empower chil- risk, it is important to obtain a agement plan. Some patients, particu- dren/adolescents to become full part- careful history of cardiac symp- larly some adolescents, might require ners in their treatment plan by adoles- toms; a cardiac family history, par- more than 12 hours of coverage to en- cence. Information from the school, ticularly of arrhythmias, sudden sure adequate focus and concentra- including ADHD symptoms (rating death, and death at a young age tion during evening study time and scale completed by the teacher), from cardiac conditions; and vital driving; in these cases, a short-acting grades, and any other formal testing signs, cardiac physical examina- preparation might be used in addition results, are also helpful at these visits. tion, and further evaluation on the to a long-acting preparation. basis of clinical judgment. The ease with which preparations can ESTABLISH TEAM AND Stimulant medications and several be administered and the minimization COORDINATION PLAN: nonstimulant medications are now of adverse effects are important for It is best for the treatment team to in- available, as outlined in Supplemental the quality-of-life concerns that chil- clude everyone involved in the care of Table 3. The presence of a tic disorder dren, youth, and parents express the child/adolescent: the child/adoles- might affect the decision about which around the decision to use medication.
SI12 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix
SUPPLEMENTAL TABLE 3 FDA-Approved Medications: Dosing and Pharmacokinetics Medication Brand Initial Titration Dose Frequency Time to Duration, h Maximum Dose Available Doses Initial Effect Mixed amphetamine Adderalla 2.5–5.0 mg QD–BID 20–60 min 6 40 mg 5.0-, 7.5-, 10.0-, 12.5-, 15.0-, salts 20.0-, and 30.0-mg tablets Adderall XRa 5 mg QD 20–60 min 10 40 mg 5-, 10-, 15-, 20-, 25-, and 30-mg capsules Dextroamphetamine Dexedrinea/ 2.5 mg BID–TID 20–60 min 4–6 40 mg 5- and 10-mg (Dextrostat only) Dextrostat tablets Dexedrine 5 mg QD–BID Ն60 min Ն6 40 mg 5-, 10-, and 15-mg capsules Spansulea Lisdexamfetamine Vyvanse 20 mg QD 60 min 10–12 70 mg 20-, 30-, 40-, 50-, 60-, and 70- mg capsules Methylphenidate Concerta 18 mg QD 20–60 min 12 54 mg (Ͻ13 y); 72 18-, 27-, 36-, and 54-mg mg (Ն13 y) capsules Methyl ER 10 mg QD 20–60 min 8 60 mg 10- and 20-mg tablets Methylin 5 mg BID–TID 20–60 min 3–5 60 mg 5-, 10-, and 20-mg tablets and liquid and chewable forms Daytrana 10 mgb Apply for 9 h 60 min 11–12 30 mg 10-, 15-, 20-, and 30-mg patches Ritalina 5 mg BID–TID 20–60 min 3–5 60 mg 5-, 10-, and 20-mg tablets Ritalin LA 20 mg QD 20–60 min 6–8 60 mg 20-, 30-, and 40-mg capsules Ritalin SRa 20 mg QD–BID 1–3 h 2–6 60 mg 20-mg capsules Metadate CD 20 mg QD 20–60 min 6–8 60 mg 10-, 20-, 30-, 40-, 50-, and 60- mg capsules Dexmethylphenidate Focalina 2.5 mg BID 20–60 min 3–5 20 mg 2.5-, 5.0-, and 10.0-mg tablets Focalin XR 5 mg QD 20–60 min 8–12 30 mg 5-, 10-, 15-, and 20-mg capsules Atomoxetine Strattera 0.5 mg/kg per d, then increase QD–BID 1–2 wk At least 10–12 h 1.4 mg/kg 10-, 18-, 25-, 40-, 60-, 80-, and to 1.2 mg/kg per d; 40 mg/d 100-mg capsules for adults and children at Ͼ154 lb, up to 100 mg/d Extended-release Intuniv 1 mg/d QD 1–2 wk At least 10–12 h 4 mg/d 1-, 2-, 3-, and 4-mg tablets guanfacine Extended-release Kapvay 0.1 mg/d QD–BID 1–2 wk At least 10–12 h 0.4 mg/d 0.1- and 0.2-mg tablets clonidine QD indicates daily; BID, twice daily; TID, three times daily. a Available in a generic form. b Dosages for the dermal patch are not equivalent to those of the oral preparations.
Other context issues that should also basis of individual preferences of the technology can be opened and sprin- be considered in deciding which med- clinician and family. Some children/ad- kled on food for patients who have dif- ication to recommend include the time olescents will respond better to or dis- ficulty swallowing tablets or capsules. of day when the targeted symptoms play more adverse effects with 1 com- Immediate-release methylphenidate, occur, when homework is usually pound group or the other. Because which comes in liquid and chewable done, whether medication remains ac- these effects cannot be determined in forms, and a methylphenidate trans- tive when teenagers are driving, advance, if a trial with 1 group is un- dermal patch are also available as al- whether medication alters sleep initia- successful (poor efficacy or adverse ternatives to tablets or capsules. tion, and risk status for drug use. effects), a trial on a medication from It is helpful to prepare families for the All approved stimulant medications the other group should be undertaken. initial medication (titration) process, are methylphenidate or amphetamine For cases in which there is concern including what it will entail and how compounds, which have similar effects about possible abuse or diversion of long it might take. The usual procedure and adverse effects. Given the exten- the medication or there is a strong is to begin with a low dose of medica- sive evidence of efficacy and safety, family preference against stimulant tion and titrate to the dose that pro- they remain the first choice of medica- medication, an FDA-approved non- vides maximum benefit and minimal tion treatment. Thus, the decision re- stimulant medication may be consid- adverse effects. Initially, core symp- garding which compound a clinician ered as the first choice of medication. tom reduction is more likely to indicate first prescribes should be made on the The medications that use a microbead medication effects; the effects of im-
PEDIATRICS Volume , Number , SI13 provement in function require a more sults from the MTA study indicate that recommended with a similar titra- extended time period. Stimulant medi- there are a number of children/adoles- tion plan. At least half of the chil- cations can be effectively titrated on a cents who, by 3 years after starting dren/adolescents whose symptoms 3- to 7-day basis. During the first month medication, continue to improve even fail to respond to 1 stimulant medi- of treatment, medication dose may be if the medication has been discontin- cation may have a positive response titrated with a weekly or biweekly tele- ued.57 The findings suggest that chil- to the alternative medication.56 phone call to the family. The increasing dren/adolescents who are stable in Families concerned about the use of doses can be provided either by pre- their improvement of ADHD symptoms stimulants or with concerns about scriptions that allow dose adjust- may be given a trial off medication af- abuse or diversion may choose to ments upward or, for some of the med- ter several years to determine if med- start with atomoxetine or extended- ications, by 1 prescription of tablets/ ication is still needed. This process is release guanfacine or extended- capsules of the same strength with best undertaken with close monitoring release clonidine. In addition, those instructions to administer progres- of the child’s/adolescent’s core symp- whose symptoms do not respond to sively higher amounts by doubling or toms and function at home, in school, either stimulant group might still re- tripling the initial dose. Another ap- and in the community. spond to atomoxetine or extended- proach similar to that used in the MTA Whenever possible, improvements in release guanfacine or extended- 56 study is for parents to be directed to core symptoms and target goals release clonidine. Extended release administer different doses of the same should be monitored in an objective guanfacine or extended release clo- preparation, each for 1 week at a time way (eg, going from 60% to 20% miss- nidine also may be added as an ad- (eg, Saturday through Friday). At the ing assignments per week [see the junctive therapy in children who par- end of each week, teacher and parent ADHD toolkit13]), and the core symp- tially respond to stimulant feedback and/or DSM-IV-TR–based toms can be monitored by use of one medication. ADHD rating scales can be completed of the DSM-IV-TR–based ADHD rating through a telephone interview, fax, or scales such as the Vanderbilt ADHD There is a block-box warning on secure electronic system. In addition follow-up scales. Clinicians are en- atomoxetine of the possibility of to the ADHD rating scale, parents and couraged to educate parents that al- suicidal ideation when initiating teachers should be asked to review ad- though medication can be effective medication management. Early verse effects and target goals. in facilitating schoolwork produc- symptoms of suicidal ideation A face-to face follow-up visit is recom- tion, it has not been shown to be ef- might include thinking about self- mended by the fourth week of medica- fective in addressing learning dis- harm and increasing agitation. If tion, during which clinicians review abilities. A child/adolescent who there are any concerns about sui- the responses to the varying doses and continues to experience academic cidal ideation in children pre- monitor adverse effects, pulse, blood underachievement after attaining scribed atomoxetine, further evalu- pressure, and weight. To ensure that some control of ADHD behavioral ation, reconsideration about the progress in symptom control is being symptoms should be assessed for a use of atomoxetine, and more fre- maintained, clinicians should continue coexisting condition, including learn- quent monitoring should be consid- to monitor levels of core symptoms ing and language disabilities, other ered, and if necessary, referral to a and improvement in specified target mental health disorders, or other mental health clinician should be goals. A general guide for visits to the psychosocial stressors. Noncompli- made. primary care clinician is for the face to ance with the treatment plan should Atomoxetine is a selective face visits to occur initially on a also be assessed. norepinephrine-reuptake inhibitor monthly basis, until there is a consis- If the maximum dose of a stimulant and might result in maximum re- tent optimal response, and then every preparation is reached and less- sponse only after approximately 4 to 6 3 months in the first year of treatment. than-satisfactory results have been weeks. Extended-release guanfacine Subsequent visits will depend on the achieved or intolerable adverse ef- and extended-release clonidine are ␣ response but should occur at least 2 fects occur before adequate efficacy 2A-adrenergic agonists and might re- times per year, until it is clear that tar- with a medication from one of the sult in maximum response in approxi- get goals are progressing and stable, stimulant groups (methylphenidate mately 2 to 4 weeks. Parents may be and then periodically as determined by or amphetamine), a medication from encouraged to complete weekly symp- the family and the clinician. Recent re- the other stimulant group should be tom and adverse-effect monitoring, as
SI14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix described previously, as an objective is safe and efficacious for children in ing children/adolescents to take measure to monitor efficacy. Because this age group.58 Evidence58 suggests charge of and own their medication symptom change is more gradual with that the rate of metabolizing methyl- management as much as possible. ␣ atomoxetine and 2A-adrenergic ago- phenidate is slower in children 4 and Techniques of motivational inter- nists than with stimulant medications, 5 years of age, so they should be viewing might be useful in improving families who have had previous expe- started at a lower dose that is in- adherence.60 rience with stimulants should be made creased in smaller increments. In ad- aware of this fact. In some patients, a dition, the preschool-aged children Special Circumstances: Families and Children/Adolescents Who Decline modest effect of atomoxetine might be studied in the multisite study58 had Medication seen in 1 week. Atomoxetine might more severe dysfunction, which cause gastrointestinal tract symptoms should be considered in the decision The decision about what is the most and sedation early in treatment, so it is to try treatment with methylpheni- acceptable treatment for their child/ recommended to prescribe half the date. The additional criteria for de- adolescent rests with the family, and treatment dose (0.5 mg/kg) for the fining moderate-to-severe impair- the clinician must respect that deci- first week. Appetite suppression can ment include symptoms present for sion. The clinician should, however, ad- ␣ also occur. Both 2A agonists can at least 9 months and clear impair- dress any misinformation or concerns cause the adverse effect of somno- ment in both the home and day care/ about medication shared by the family, lence. In addition, it is recommended preschool settings that has not re- encourage all other dimensions of that the medications be tapered when sponded to an appropriate treatment, and provide appropriate discontinued to prevent a possible re- behavioral intervention. Limited evi- monitoring. bound in blood pressure. 59 dence and no FDA approval for chil- Special Circumstances: Inattention or dren in this age group are available Special Circumstances: Preschool- Hyperactivity/Impulsivity (Problem for atomoxetine, and no evidence or Aged Children Level) approval for extended-release guan- Medication is not appropriate for chil- Clinicians should initiate ADHD treat- facine or extended-release clonidine dren/adolescents whose symptoms do ment of preschool-aged children are available. (4–5 years of age) with behavior not meet DSM-IV-TR criteria for diagno- sis of ADHD. therapy and should also assess for Special Circumstances: Adolescents other developmental problems, es- Clinicians should assess adolescent Behavior Management pecially with language. If children do patients with ADHD for symptoms of not experience adequate symptom Evidence-based parent training typi- substance use or abuse before begin- and functional improvement with be- cally begins with 7 to 12 weekly group ning medication treatment. If sub- havior therapy (most programs are sessions with a trained therapist or stance abuse is revealed, they should 10–14 weeks long, but the clinician certified instructor. The focus is on have the patient stop the use, and they should check with the therapists parent education about ADHD, the should provide treatment or refer for about their usual length of interven- child’s/adolescent’s behavior prob- tion), the clinician should first evalu- treatment for substance abuse before lems, and difficulties in family relation- ate the adequacy and parental ac- beginning treatment for ADHD. Clini- ships. A typical program aims to im- ceptance of the therapy. If the cians are also encouraged to monitor prove the parents’/caregivers’ symptoms and/or functioning have symptoms and prescription refills for understanding of the child’s/adoles- not improved and the child is at sig- signs of misuse or diversion of ADHD cent’s behavior and to teach them nificant behavioral or developmental medication. skills to help the child/adolescent to risk because of ADHD, medication Special concern should be taken to reduce the behavioral difficulties can be prescribed, as described pre- provide medication coverage for posed by ADHD. viously. It must be noted that, cur- ADHD symptom control while driving. Programs offer specific techniques for rently, the FDA has only approved Longer-acting or late-afternoon/ reinforcing adaptive and positive be- dextroamphetamine for ADHD in chil- short-acting medications might be haviors and decreasing or eliminating dren in this age group, although helpful in this regard. Counseling for inappropriate behaviors, both of there is little evidence to support its adolescents around medication is- which alter the motivation of the child/ safety and efficacy. There is, how- sues should include dealing with re- adolescent to control attention, activ- ever, evidence that methylphenidate sistance to treatment and empower- ity, and impulsivity. These programs
PEDIATRICS Volume , Number , SI15 emphasize establishing positive inter- ty/impulsivity but do not meet the DSM- points or tokens that are given for pos- actions between parents and children; IV-TR criteria and for those children/ itive behaviors, and response cost re- learning how to shape children’s be- adolescents with a developmental fers to points or tokens subtracted for haviors through combinations of variation. inappropriate behaviors. The tokens praising and ignoring; how to give suc- Unless primary care clinicians are or points can then be cashed in after a cessful commands; how to reinforce specifically trained, have trained staff defined period for rewards or privi- positive behaviors; how to extinguish or a colocated therapist, or dedicate leges. Systematic rewards (eg, use of a inappropriate behaviors through ig- many visits to providing the ongoing token economy) are included to in- noring; how to identify which behav- treatment, they might not be effective crease appropriate behavior and elim- iors are handled most appropriately in providing behavior therapy.62 Clini- inate inappropriate behavior. A peri- through punishment; and determining cians might also have difficulties de- odic (often daily) behavior report card how to carry punishments out in a re- termining the skills of behavior thera- can record the child’s/adolescent’s sponsible way. These programs all em- pists listed in the behavioral health progress or performance with regard phasize teaching self-control and insurance plan. This determination is to goals and communicate the child’s/ building positive family relationships. important, because many therapists adolescent’s progress to the parents, If parents strongly disagree about be- focus on a play or interpersonal-talk who then provide reinforcers or con- havior management or have conten- therapy that has not been shown to be sequences based on that day’s perfor- tious relationships, parenting pro- effective in treating the core symp- mance. Such programs are also useful grams will likely be unsuccessful. toms of ADHD. Telephone inquiries of for the purpose of monitoring medica- Other strategies, such as changing the therapists, agencies, and mental tion effects. physical environment to reduce stim- health clinicians regarding their ap- uli to overactivity, are also effective by proach to behavior therapy might al- COLLABORATE WITH THE SCHOOL TO changing the stimuli that trigger prob- low clinicians to develop a resource ENHANCE SUPPORTS AND SERVICES lem behaviors. Depending on the se- list for parents. Clinicians might also Many teachers and schools have effec- verity of the child’s/adolescent’s be- request references from other par- tive strategies for supporting and haviors and the capabilities of the ents of children/adolescents with serving children/adolescents with parents, group or individual training ADHD, professional organizations ADHD. Schools can implement programs will be required. Programs (eg, Association for Behavior and behavior-management programs that typically include support for mainte- Cognitive Therapies), and ADHD advo- directly target ADHD symptoms as well nance and relapse prevention. cacy organizations (eg, CHADD). Par- as interventions to enhance academic Behavior therapy should be differenti- ents who have read authoritatively and social functioning. Schools may ated from psychological interventions written books about behavior thera- also use strategies (eg, daily behavior directed to the child/adolescent and py/behavior parent training might be report cards) to enhance communica- designed to change the child’s/adoles- in a better position to know what tion with families. All schools should cent’s emotional status (eg, play ther- they are looking for in a therapist have specialists (eg, school psycholo- apy) or thought patterns (eg, interper- and ask the salient questions when gists, counselors, special educators) sonal talk therapy). These seeking appropriate therapists. who observe the child/adolescent, psychological interventions do not Some of these resources are avail- identify triggers and reinforcers, and have a demonstrated efficacy for the able in the ADHD toolkit13 and the support teachers in changing the cir- ADHD core symptoms, and gains book ADHD: What Every Parent Needs cumstances of the classroom and achieved in the treatment setting usu- to Know.54 making accommodations to address ally do not transfer into the classroom Classroom behavior management also ADHD symptoms, such as written- or home. By contrast, parent training focuses on shaping the child’s/adoles- output bypass strategies, untimed in behavior therapy and classroom be- cent’s behaviors and may be inte- testing, testing in less distracting envi- havior interventions have successfully grated into classroom routines for all ronments, preferential seating, and changed the behavior of children/ado- students or targeted for a selected routine reminders. lescents with ADHD.61 Behavior therapy child/adolescent in the classroom. Clinicians should be aware of the eligi- is also applicable for children/adoles- Classroom management often begins bility criteria for the 504 Rehabilitation cents who have problems in the do- with increasing the structure of activi- Act and the Individuals With Disabilities mains of inattention or hypersensitivi- ties. Token economy refers to using Education Act supports in their state
SI16 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix and local school district(s)63 and ward target goals, adherence to medi- should understand the process for re- cation and behavior therapy, con- In the early stages of treatment, after a ferral as well as the individuals with cerns, or changes. successful titration period, the fre- whom the physician or parent should Monitoring of children/adolescents quency of follow-up visits will depend make contact. This information can be with inattention or hyperactivity/im- on adherence, coexisting conditions, provided to parents to support their pulsivity problems can help to ensure and persistence of symptoms. As efforts to request classroom adapta- prompt treatment, should their symp- noted previously, a general guide for tions for their child/adolescent with toms worsen to the extent that a diag- visits to the primary care clinician is ADHD, including the use of empirically nosis of ADHD is warranted. for these visits to occur initially on a supported academic interventions to monthly basis, then every 3 months in address achievement difficulties asso- the first year of treatment. More fre- ciated with ADHD symptoms. No Reevaluate to confirm diagnosis and/or provide education to improve quent visits might be necessary if co- adherence. morbid conditions are present. Visits Do Reconsider treatment plan including symptoms changing of the medication or dose, should then be held at least twice each improve? adding a medication approved for adjuvant therapy, and/or year with additional telephone moni- In providing a medical home, primary changing behavioral therapy. toring at the time of medication-refill care clinicians should regularly moni- requests. Ongoing communication tor all aspects of ADHD treatment, to ADHD treatment failure might be a sign with the school regarding medication include: of incorrect or incomplete diagnosis. and services is also needed. ● systematic reassessment of core Clinicians are advised to repeat the full It should be noted that at this point, symptoms and function; diagnostic evaluation and pay in- there is little evidence to establish the ● regular reassessment of target creased attention to the possibility of optimal, yet practical, follow-up regi- goals; coexisting conditions that mimic or men. It is likely that the regimen will are associated with ADHD, such as need to be tailored to the individual ● assurance that the family is satis- sleep disorders, Asperger syndrome, child/adolescent and family needs on fied with the care they are receiv- or epilepsy (eg, absence epilepsy or ing from other clinicians and thera- the basis of clinical judgment. partial seizures). A coexisting learning pists, if applicable; disorder might also cause an apparent PREPARING THE PRACTICE ● provision of anticipatory guid- treatment failure. In the case of a ance, further child/adolescent Specific office practice procedures child/adolescent previously diagnosed and family education, and transi- that facilitate the optimal and efficient with problem-level inattention or hy- tion planning as needed and diagnosis and treatment process are peractivity, repeating the diagnostic appropriate; critical for successful management of evaluation might result in a diagnosis children/adolescents with ADHD. More ● assurance that care coordination of ADHD, which would allow for in- detail can also be found in the report of is occurring and meeting the needs creased school supports and the inclu- 1 of the child/adolescent and family; the AAP Task Force on Mental Health. sion of medication in the treatment The office process can include: ● confirmation of adherence to any plan. ● prescribed medication regimen, developing a packet of ADHD ques- Treatment failure could also signal with adjustments made as needed; tionnaires and rating scales for par- poor adherence to the treatment plan. ents and teachers to complete be- ● heart rate, blood pressure, height, Increased monitoring and education, fore a scheduled visit; and weight monitoring; and especially by including the patient ● allotting adequate time for ADHD- ● continuing to form a therapeutic re- early in his or her treatment, might in- related visits; lationship with the child/adolescent crease treatment adherence. It is help- ● and empower families and chil- ful to try to identify the issues that re- determining appropriate billing, dren/adolescents to be strong, in- strict adherence. documentation, and monitoring of formed advocates. insurance payments to ensure that Yes Some treatment monitoring can occur they adequately cover the services during general health care visits if the Follow-up for rendered; chronic care clinician inquires about progress to- management at ● implementing methods to track and least 2x/year for ADHD issues
PEDIATRICS Volume , Number , SI17 follow-up patients (refer to medical ● a clear and organized process by evaluation process facilitates cooper- home procedures for more detail); which an evaluation can be initiated ation and communication with the ● asking questions during all clinical when concerns are identified by ei- school toward common goals. For ex- encounters and placing brochures ther parents or school personnel; ample, agreement on the behavior rat- and posters in the office to alert par- ● a packet of information completed ing scales used can facilitate comple- ents and children/adolescents that by parents and a teacher about tion by school personnel. Standard behavior and school problems and each child/adolescent referred to communication forms that monitor ADHD are appropriate issues to dis- the primary care clinician; progress and specific interventions can be faxed between the school and cuss with the clinician; ● a contact person at the practice to the pediatric office to share ● developing an office system for receive information from parents information. monitoring and titrating medication and teachers at the time of evalua- (a follow-up system should include tion and during follow-up; Collaborative systems also extend to other providers who may comanage the clinician’s assessment of family ● an assessment process to investi- care with the primary care clinician. organization, telephone access, and gate coexisting conditions; Providers may include a mental health parent-teacher communication ef- ● a directory of evidence-based inter- professional who sees the child/ado- fectiveness); and ventions available in the lescent for psychosocial interventions ● collaborating with schools and community; or a specialist who addresses difficult other involved community providers ● an ongoing process for follow-up cases, such as a developmental- and resources that can enhance the visits, telephone calls, teacher re- behavioral pediatrician, child psychia- process for ADHD diagnosis and ports, and medication refills; trist, child neurologist, neurodevelop- management, which can be mental disability physician, or ● availability of forms for collecting achieved on a case-by-case basis psychologist. Agreed-on processes for and exchanging information; and through coordination of the diagno- routine communication can also be ● sis and treatment plan among a plan for keeping school staff and used in these relationships. The AAP school staff, the clinician, parents, primary care clinicians up-to-date Task Force on Mental Health provides a and other involved professionals on the process. full discussion of collaborative rela- (note that this less-systematic ap- The clinician might face challenges to tionships with mental health profes- proach carries significant chal- developing such a collaborative pro- sionals, including colocation and inte- lenges, including ensuring consis- cess. As examples, the primary care grated models, in its Chapter Action tent care for all children/ provider might be caring for children/ Kit64 and Pedialink Module. adolescents with ADHD). adolescents from more than 1 school It is important to note that good care A community-level system that reflects system; a school system might be quite frequently requires activities that cur- consensus among district school staff large and not easily accessed; schools rently are not reimbursed. These activ- and local primary care clinicians for might have limited staff and resources ities include contacts with teachers key elements of diagnosis, interven- to complete assessments; or it might and mental health consultants and tions, and ongoing communication can be difficult for the physician and non–face-to-face contact with parents help to ensure consistent, well- teacher or other school personnel to and patients. It would be helpful for cli- coordinated, and cost-effective care. A communicate by telephone because nicians to document the nonreim- community-based system with schools their schedules differ. There are work- bursed efforts and for the national relieves the individual primary care able strategies for addressing each of AAP, state chapters, and clinicians to clinician from negotiating with each these challenges. continue to try to make third-party pay- school about care and communication In the case of multiple or large school ers understand the need for these ef- regarding each patient. Offices that systems in a community, the primary forts and provide compensation for have incorporated medical home prin- care clinician might want to begin with this appropriate care. ciples are ideal for establishing this 1 school psychologist or principal, or kind of community-level system. The several practices can initiate contact COMPLEMENTARY AND UNPROVEN key elements for a community-based collectively with a community school THERAPIES collaborative system include consen- system. Agreement among the clini- Families of children/adolescents with sus on: cians on the components of a good ADHD increasingly ask about comple-
SI18 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix mentary and alternative therapies for sure efficacy, and choose a time frame Evidence and Practice65 or in an article ADHD. Such therapies might include in which they anticipate the changes to in the Journal of Developmental and large doses of vitamins, essential fatty occur. Families should also be strongly Behavioral Pediatrics.52 acids, and other dietary alterations; encouraged to continue to use the chelation; and electroencephalo- more evidence-based interventions at CONCLUSION 65 graphic (EEG) biofeedback. To date, the same time that they are exploring ADHD is the most common neurobio- complementary and alternative there is insufficient evidence to deter- logical disorder of children/adoles- mine whether these therapies lead to treatments. cents; untreated, ADHD can have far- changes in core symptoms of ADHD or Clinicians should respect families’ in- reaching and serious consequences function, and for many of them, there terests and preferences while they ad- on their health and well-being. Fortu- is limited information about their dress and answer questions about nately, effective treatments are avail- safety. For these reasons, these thera- complementary and unproven thera- able, as are methods for assessing pies cannot be recommended. Some pies to preserve and enhance the clini- and diagnosing children/adolescents therapies, chelation, and megavita- cian/family relationship. In addition, with ADHD. The AAP is committed to mins have been proven to cause some primary care clinicians should know supporting primary care physicians in adverse effects and are about additional therapies that fami- providing quality care to children/ado- contraindicated. lies might be administering to ade- lescents with ADHD and their families. Physicians can play a constructive role quately monitor for drug interactions. in helping families make thoughtful Parents and children/adolescents who The algorithm presented here repre- treatment choices by reviewing the do not feel that their choices in health sents a portion of that commitment. It stated goals or effects claimed for a care are respected by their primary is an effort to assist primary care cli- given treatment; the state of evidence care clinician might be less likely to nicians in delivering care that meets to support or discourage use of the communicate about complementary the quality standards of the practice treatment; and known or potential ad- or alternative therapies. guideline. Additional support and guid- verse effects. Physicians should en- Further information about comple- ance can be obtained through the courage families that wish to pursue mentary and other therapies pro- ADHD toolkit12 and the work and publi- these treatments to try 1 intervention moted for the treatment of ADHD can cations of the AAP Task Force on Men- at a time, choose target goals they will be found in a chapter on this topic in tal Health.13 use, monitor core symptoms to mea- Developmental-Behavioral Pediatrics: REFERENCES
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SI20 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supplemental Appendix
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