By Fran Lowry
October 17, 2011 (Boston, Massachusetts) — For the first time in a decade, the American Academy of Pediatrics has issued an updated set of guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) that now include younger, preschool children and adolescents.
The guidelines, "ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder," were released here at the American Academy of Pediatrics National Conference & Exhibition and simultaneously published online October 16 in Pediatrics.
Dr. Mark Wolraich
"We wrote the original guidelines in 2000 to 2001, and they were written for children between the ages of 6 and 12 because that’s where most of the available evidence was at the time," Mark Wolraich, MD, CMRI/Shaun Walters professor of pediatrics and chief of the Section of Developmental and Behavioral Pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, told Medscape Medical News.
"Over the years, we have heard about the concern for preschool children and adolescents and what should be done with them. We’ve expanded the age group to include children aged 4 to 18 because there’s certainly new evidence to support recommendations for the broader age group," said Dr. Wolraich, lead author of the guidelines.
Increase in Approved Medications
The last 10 years have also seen an increase in the number of medications that have been approved by the US Food and Drug Administration for the treatment of ADHD, and the new guidelines reflect this. They also emphasize the chronic nature of the disorder
"We had pushed for the idea that ADHD was a chronic illness in the initial guidelines, and that clinicians needed to use chronic illness principles in treating it, and this has been further emphasized," Dr. Wolraich said.
Other key recommendations include:
- assessing children for other conditions that might coexist with ADHD, such as oppositional defiant and conduct disorders, anxiety, and depression;
- making sure that Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria have been met;
- obtaining information primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care;
- first line of treatment for preschool-aged children 4 to 5 years old should be evidence-based parent- or teacher-administered behavior therapy;
- titrating medication doses to achieve the maximum benefit with the least adverse effects; and
- for adolescents, the primary care clinician should prescribe FDA-approved ADHD medications with their consent.
"The challenge in adolescents is you no longer have individual teachers as good reporters of their behavior, because they are going from class to class, and no one has them for a long period of time. It tends to be hard to get good information," Dr. Wolraich said.
He added that it is important to start treating children at a young age.
"When we can identify them earlier and provide appropriate treatment, we can increase their chance of succeeding in school. With our greater awareness now about ADHD and better ways of diagnosing and treating this disorder, more children are being helped."
Clinical Judgment Not Enough
Peter Jensen, MD, codirector of the Division of Child Psychiatry and Psychology at the Mayo Clinic, Rochester, Minnesota, told Medscape Medical News that the updated guidelines give more detailed instructions to help primary care physicians manage these patients.
Dr. Peter Jensen
"What’s wonderful about the updated guidelines is they provide additional guidance and specificity over the guidelines that were published back in 2000 to 2001," Dr. Jensen said.
"Some of these kids have very complex problems; many also have anxiety and depression. The guidelines take note of this, and they also emphasize the use of rating scales from teachers and parents. They take us a step further," he added.
Providing more detailed guidance on the diagnosis and treatment of children with ADHD is important, he said.
"Many doctors treat ADHD by the seat of their pants," he said. "They are well intentioned, but when we are in the midst of a busy office day and frantic parents, and understaffed, our clinical judgment isn’t enough, and we are prone to miss things. If the mom smiles we think all is well. But that is not as accurate as looking at the rating scale from the parents, from the teacher, and talking with Johnnie.
"Clinical judgment is not enough to replace these kinds of tools, and the guidelines add more of that kind of detail and will be more likely to help us keep from making errors of omission and commission."
Dr. Jensen said he suspected that ADHD may be increasing because so many demands for sustained attention are being placed on today’s children.
"We expect our kids to learn more, do more, we expect them not just to go to college but to have 3 or 4 hobbies and activities they do in the afternoon and quickly get that homework done, and then we expose them to many different stimuli.
"They have the TV going, and the Game Boy going. All those things are competitors for attention. If you had a society where homework was not important, almost by definition you’d have fewer parents complaining about their child’s inattention," said Dr. Jensen.
Dr. Wolraich disclosed that he is a past consultant to Shire, Lilly, Shinogi and Nextwave all of which produce medications for ADHD. Dr. Jensen has disclosed no relevant financial relationships.
American Academy of Pediatrics National Conference & Exhibition 2011. Presented October 16, 2011.
Pediatrics. Published online October 16, 2011.