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AAP updates 2011 ADHD guideline
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The AAP has updated its clinical practice ADHD guideline for the first time since 2011. The recommendations focus predominantly on evaluation, diagnosis and treatment of children aged 4 to 18 years.
“Pediatricians need to know that the revised guideline is essentially the same as the 2011 guideline but that it is important to rule out other or co-occurring conditions, including learning and language disorder, oppositional defiant disorder, anxiety, depression and autism,” Mark L. Wolraich, MD, FAAP, lead author of the guideline and the CMRI/Shaun Walters Emeritus Professor of Pediatrics at Oklahoma University Health Sciences Center (OUHSC), told Infectious Diseases in Children.
Wolraich said the guideline stresses the importance of assessing and monitoring children’s functioning. Because ADHD is a chronic condition, primary care physicians should manage children and adolescents with the condition in the same manner that they would patients with special health care needs, following the principles of the chronic care model and the medical home.
In a related report, Wolraich and colleagues wrote that ADHD remains one of the most common behavioral conditions and the second most common chronic illness among children.
According to findings from survey data collected between 1997 and 2016, 7.9% of children aged 4 to 17 years received an ADHD diagnosis.
Wolraich and colleagues noted that the updated guideline focuses mostly on the addition of a key action statement regarding the diagnosis and treatment of ADHD in children and teens who have comorbid conditions. Further, the researchers updated the process of care algorithm to help providers use the guideline recommendations more effectively, and there is also a supplement to identify barriers to ADHD care.
The AAP recommends the following for the diagnosis and treatment of ADHD for children and adolescents:
- A diagnosis of ADHD for patients aged 17 years and older requires fewer problem behaviors.
- Other conditions with comparable signs and symptoms to ADHD, like depression, anxiety, substance use, autism and trauma, should be ruled out.
- Although treatment remains similar, children need ongoing support from medical providers and coordination with schools and other community members.
- Children who have not reached their 6th birthday should receive behavior management from their parents as first-line treatment.
The researchers also suggested areas where future research should focus:
- Reliable instruments for examining the nature or degree of functional impairment in children and teens with ADHD should be identified and/or developed for use in primary care.
- Developmentally informed assessments should be refined for children aged 4 to younger than 6 years.
- Medications and other treatments that are used clinically, but are not FDA approved, should be studied.
“Pediatricians will need to set up their practice to allow for collecting and monitoring information on their patients who have ADHD,” said Wolraich. “They will need to explore using telephone, external communication systems and/or electronic medical records to ensure adequate coordination of services. They will need to work with other parents and professional organizations to ensure adequate coverage for the needed services.” – by Katherine Bortz
Resources:
Wolraich ML, et al. Pediatrics. 2019;doi:10.1542/peds.2019-1682.
Wolraich ML, et al. Pediatrics. 2019;doi:10.1542/peds.2019-2528.
Xu G, et al. JAMA Netw Open. 2018;doi:10.1001/jamanetworkopen.2018.1471.
Disclosures: Wolraich reports a Continuing Medical Education trainings relationship with the Resource for Advancing Children’s Health Institute. Please see the guideline for all other authors’ relevant financial disclosures.
Perspective
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Thomas J. Power, PhD, ABPP
This guideline published by the AAP provides an update and improvement on the practice guideline published by AAP in 2011. Like the previous version, the updated guideline emphasizes the importance of assessing ADHD among youth aged 4 to 18 years using rating scales completed by parents and teachers, treating ADHD with medication and behavior therapies, using behavior therapy as a first-line treatment with preschoolers, screening for and assessing co-existing conditions (eg, anxiety, depression and sleep problems), providing comprehensive family education, and coordinating care with school and community professionals.
The new guideline places a stronger emphasis on including psychosocial (behavioral and skill training) interventions in a comprehensive care plan for children and adolescents with ADHD. It provides much more information about evidence-based psychosocial interventions for adolescents.
In addition, the 2019 guideline highlights approaches to overcome barriers to evidence-based care, including recommendations to improve the education of health and mental health trainees and professionals, strategies to improve billing and reimbursement for services and strategies to improve care coordination within health practices and across systems of care.
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