The Committee on Quality Improvement and the Subcommittee on Attention-Deficit/Hyperactivity Disorder of the American Academy of Pediatrics (AAP) has issued a new clinical practice guideline for the treatment of school-aged children (six to 12 years) with attention-deficit/hyperactivity disorder (ADHD). This guideline, intended for primary care physicians who have accurately established the diagnosis of ADHD, primarily focuses on the treatment of children with ADHD without major comorbidity. A detailed treatment algorithm is included in the guideline. The guideline, published in the October 2001 issue of Pediatrics, represents the second in a series of AAP policies on ADHD; the first set of guidelines, published in the May 2000 issue of Pediatrics, focused on the accurate diagnosis of ADHD.
The recommendations are based on the quality of evidence (good, fair, poor) and the strength of the recommendation: strong (high-quality scientific evidence or strong expert consensus), and fair or weak (lesser quality or limited data and expert consensus). The following are the complete recommendations from the guideline:
Recommendation 1. Primary care physicians should establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong).
According to the AAP, physicians should educate the family and child about ADHD by serving as a source of information, providing resources, and coordinating health and other services as indicated. Fostering a partnership with the family, child, teachers, nurses, psychologists, and counselors is critical in providing long-term care, along with the development of child-specific treatment plans and goals, including plans for follow-up. As with other chronic conditions, new data impact the components of care; therefore, physicians should keep apprised of new information and closely monitor the literature for changes in treatment.
Recommendation 2. The treating physician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong).
Because the core symptoms of ADHD (inattention, impulsivity, hyperactivity) impact the child's performance in many areas (home, school, community), the main focus of treatment should be to maximize function. The committees recommend development of three to six specific outcomes and desired changes before developing a treatment plan. These realistic and measurable outcomes may include improvements in relationships, self-esteem, and school performance, and a decrease is disruptive behaviors.
Recommendation 3. The physician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).
While the long-term efficacy of stimulant medications remains unclear, short-term efficacy in improving, for most children, the core symptoms of ADHD and social and classroom behaviors has been demonstrated. According to the AAP guideline, stimulants comprise the first-line treatment and include methylphenidate or dextroam-phetamine (short-, intermediate-, and long-acting formulations). The AAP does not recommend routine use of pemoline, a long-acting stimulant, because of rare but potentially fatal hepatotoxicity. Nonstimulant medications fall outside the scope of the guidelines.
Second-line treatment includes antidepressants. Based on available evidence, only two other medications are indicated for ADHD as defined in the guideline—tricyclic antidepressants (imipramine, desipramine) and bupropion. A table outlining the daily dosage schedules, duration and prescribing schedule is included in the report.
Although dosing schedules may vary, and response to initial dosage may not be indicative of the proper drug regimen, physicians are advised to titrate upward from an initial low dose for better response. If side effects and/or no further improvement in response occur, the AAP recommends titrating downward. Optimally, the aim is to find the best dose that achieves the highest efficacy with minimal side effects.
Recommendation 3A. For children taking stimulants, if one stimulant does not work at the highest feasible dose, the physician should recommend another.
This recommendation is based on data that indicate most children who do not respond to one stimulant will respond to an alternate one, and on the safety and efficacy of stimulant versus nonstimulant medications. A lack of response is an indication that the accuracy of the diagnosis should be reviewed and/or an evaluation for a coexisting comorbidity should be performed.
As a separate treatment modality or as an adjunct to medication, behavior therapy has proved to be a successful intervention—while it is implemented and maintained. The goal is to adjust the physical and social environments to change behavior, using one or more of the following techniques: positive reinforcement, time-out, response cost, or token economy. Parents or caretakers receive training in the various modalities and in conjunction with teachers, usually implement behavior therapy.
Recommendation 4. When the selected management for a child with ADHD has not met target outcomes, physicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions (strength of evidence: weak; strength of recommendation: strong).
A lack of response to treatment may be the result of unrealistic target symptoms, incorrect diagnosis, lack of information about the child's behavior, not adhering to the therapeutic regimen, the presence of a coexisting condition, or treatment failure. True treatment failure includes lack of response to two or three stimulant medications and/or behavior therapy, and the existence of a coexisting condition.
Recommendation 5. The physician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child (strength of evidence: fair; strength of recommendation: strong).
In addition to a system of follow-up office visits, the AAP recommends that continued communication with others involved (e.g., teachers, counselors) should be maintained. Behavior report cards and checklists are examples of two methods of obtaining ongoing information.
Child-specific treatment plans, increased treatment options, and long-term efficacy are areas in which the AAP recommends further research.