Children ages 4 – 18
Attention-Deficit/Hyperactivity Disorder (ADHD) Clinical Practice Guideline
Attention-deficit/ hyperactivity disorder (ADHD) continues to be the most common neurobehavioral disorder of childhood. To make the diagnosis of ADHD, the clinician needs to establish that at least six or more core symptoms per dimension are present in either or both of the dimensions of inattention and/or hyperactivity/ impulsivity.
This guideline is adapted from the 2011 American Academy of Pediatrics’ Guideline For the Diagnosis, Evaluation and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents ages 4-18. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) continues to be the most common neurobehavioral disorder of childhood and occurs in approximately 5-8 percent of children and youth.
Based on new recommendations from the American Academy of Pediatrics (AAP) issued in October 2011, clinicians in primary care should initiate an evaluation for ADHD for any child 4-18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
THE NEW GUIDELINE FOCUSES ON SIX KEY ACTION STATEMENTS. ACTION STATEMENT #1
➊➊The primary care clinician should initiate an evaluation for ADHD for any child 4-18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
The high prevalence of ADHD and limited mental health resources require primary care to play a significant role in the care of their patients with ADHD so that children with this condition receive the appropriate diagnosis and treatment.
ACTION STATEMENT #2
➋➋To make the diagnosis of ADHD, the primary care clinician should determine that DSM-V criteria have been met:
a. Impairment in more than one major setting. b. Information should be obtained primarily from reports from parents, teachers and other school and mental health clinicians involved in the child’s care. c. Should rule out alternative cause. To make the diagnosis of ADHD, the clinician needs to establish that at least six or more core symptoms per dimension are present in either or both of the dimensions of inattention and/or hyperactivity/impulsivity.
(see inside for core symptoms of ADHD)
1
Core symptoms of ADHD INATTENTION DIMENSION
HYPERACTIVITY DIMENSIONS 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”
Avoids tasks that require sustained attention
Talks excessively
Loses things Easily distracted Forgetful
ADDED CHALLENGES IN DETERMINING THE PRESENCE OF KEY SYMPTOMS CHALLENGES IN IDENTIFYING KEY SYMPTOMS Adolescents may have multiple teachers and obtaining teacher reports may be more challenging. Also, parents might have less opportunity to observe their adolescent’s behaviors than they had when their children were younger.
Preschool aged children are not likely to have separate observers if they do not attend a preschool or child care program, and if they do, staff in those programs might be less qualified than certified teachers to provide accurate observations. Adolescents may have multiple teachers and obtaining teacher reports may be more challenging. Also, parents might have less opportunity to observe their adolescent’s behaviors than they had when their children were younger. ACTION STATEMENT #3
➌➌In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral, developmental and physical conditions.
These include but are not limited to, learning problems, language disorder, disruptive behavior, anxiety, mood disorders, tic disorders, seizures, developmental coordination disorder, or sleep disorders. Adolescents newly diagnosed with ADHD should be assessed for symptoms and signs of substance abuse, and if found, treatment for addiction should precede treatment for ADHD.
ACTION STATEMENT #4
➍➍The primary care clinician should recognize ADHD as a chronic condition
and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home.
This recommendation is based on the evidence that ADHD continues to cause symptoms and dysfunction in many children who have the condition over long periods of time, even into adulthood and the treatments available address symptoms and function but are usually not curative.
ACTION STATEMENT #5
➎➎Recommendation for treatment of children and youth with ADHD vary depending on the patients’ age.
a. For children ages 4-5, prescribe evidence-based parent and/or teacher administered behavior therapy as first line of treatment. 2
• May prescribe methylphenidate if the behavior interventions do not provide significant improvement. b. In areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment. c. For children ages 6-11, prescribe FDA-approved medications for ADHD and/or evidence-based parent and/ or teacher administered behavior therapy as treatment for ADHD, preferably both.
The evidence is strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order).
d. For children ages 12-18 years, prescribe FDA approved medications for ADHD with the assent of the adolescent. • And may prescribe behavior therapy as treatment for ADHD.
BEHAVIOR THERAPY Behavior therapy is usually implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior to improve the child’s ability to regulate his or her own behavior. The techniques involve positive reinforcement, planned ignoring, or combination of both, or consequences or punishment when goals are not met. There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectation for each task. Behavior therapy programs coordinating efforts at school as well as home might enhance the effects. ACTION STATEMENT #6
➏➏Primary care clinicians should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects.
MEDICATIONS Stimulant medications are highly effective for most children in reducing core symptoms of ADHD. All approved stimulant medications are methylphenidate or amphetamine compounds, which have similar effects and adverse effects. Given the extensive evidence of efficacy and safety, they remain the first choice of medication treatment.
Pre-school ii Only those pre-school children with ADHD who have moderateto-severe dysfunction should be considered for medication (symptoms that have persisted for at least nine months, dysfunction that is manifested in both the home and other settings, dysfunction that has not responded adequately to behavior therapy).
ii There is moderate evidence that methylphenidate is safe and efficacious in preschool-aged children; its use in this age group remains off-label. ii Other medications: atomoxetine and two selective a2adrenergic agonists extended-release guanfacine and extended-release clonidine have demonstrated efficacy in reducing core symptoms. However, none of them have been approved for use in pre-school aged children.
Adolescents ii Diversion of ADHD medication (use for other than its intended medical purposes) is a special concern among adolescents. Clinicians should monitor symptoms and prescription refill requests for signs of misuse or diversion of ADHD medications. ii Consider prescribing medication with no abuse potential such as atomoxetine and extended-release guanfacine (Intuniv) or extended-release clonidine (Kapvay) which are not stimulants. ii Or stimulant medication with less abuse potential such as lisdexamfetamine (Vyvanse), dermal methylphenidate (Daytrana), or OROS methylphenidate (Concerta). ii Given the risks of driving by adolescents with ADHD, special concern should be taken to provide medication coverage for symptom control while driving. Longer acting or late afternoon short-acting medication might be helpful in this regard.
SIDE EFFECTS THE MOST COMMON STIMULANT ADVERSE EFFECTS ARE: ii Appetite loss ii Abdominal pain ii Headaches ii Sleep disturbance ii Irritability ii Behavioral rebound (temporary worsening of symptoms with medication wear off) The Multimodal Therapy of ADHD (MTA) study revealed a more persistent effect of stimulants on decreasing growth velocity than have most previous studies, particularly when children were on higher and more consistently administered doses. The effects diminished by the third year of treatment, but no compensatory rebound effects were found. However, diminished growth was in the range of 1-2 cm. An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations or other psychotic symptoms. Sudden cardiac death among children using stimulant medications is extremely rare, and evidence is conflicting as to whether stimulant medication increases the risk of sudden death. It is important to include in the history specific cardiac symptoms, Wolf-Parkinson-White syndrome, history of sudden death in the family, hypertrophic cardiomyopathy and long QT syndrome. 3
Pre-school children might experience increased mood lability and dysphoria.
FOR NON-STIMULANT ATOMOXETINE, THE ADVERSE EFFECTS INCLUDE: ii Initial somnolence ii Gastrointestinal tract symptoms, particularly if the dosage is increased too rapidly
ii A general guide for visits to the primary care clinician is for the face-to-face visits to occur initially on a monthly basis until there is a consistent optimal response, and then every three months in the first year of treatment. ii Subsequent visits will depend on the response but should occur at least two times per year, until it is clear that target goals are progressing and stable, and then periodically as determined by the family and the clinician.
ii Decrease in appetite
When to refer
ii Increase in suicidal thoughts (less common)
At any point at which a clinician feels that he or she is not adequately trained or is uncertain about making a diagnosis or continuing with treatment, a referral to a pediatric or mental health subspecialist should be made. If a diagnosis of ADHD is made by a subspecialist, the primary care clinician should develop a management strategy with the subspecialist that ensures the child will continue to receive appropriate care consistent with a medical home model wherein the primary care physician partners with parents so that both health and mental health needs are integrated.
ii Hepatitis (rare) There is a black-box warning on atomoxetine of the possibility of suicidal ideation when initiating medication management. Early symptoms of suicidal ideation might include thinking about self harm and increasing agitation. If this occurs, further evaluation, reconsideration about the use of atomoxetine and more frequent monitoring should be considered and if necessary, referral to a mental health clinician should be made.
PRIMARY CARE CLINICIANS SHOULD TITRATE DOSES OF MEDICATION FOR ADHD TO ACHIEVE MAXIMUM BENEFIT WITH MINIMUM ADVERSE EFFECTS. The findings from the MTA study suggested that more than 70 percent of children and youth with ADHD respond to one of the stimulant medications at an optimal dose when a systematic trial is used. Titration to maximum best control of symptoms without adverse effects is recommended instead of titration strictly on a milligram-per-kilogram basis. Changing medication doses and occasionally changing a medication might be necessary for optimal medication management. Advise the parents and child that the process might require a few months to achieve optimal success.
Some coexisting conditions can be treated in the primary care setting, but others will require referral and co-management with a subspecialist. The primary care clinician might benefit from additional support and guidance or might need to refer a child with ADHD and co-existing conditions, such as severe mood or anxiety disorder, to subspecialists for assessment and management. Primary care physicians involved in assessing ADHD in children with intellectual disabilities will need to collaborate closely with a school psychologist or independent psychologists.
If the maximum dose of a stimulant preparation is reached and less-than-satisfactory results have been achieved or intolerable adverse effects occur before adequate efficacy with a medication from one of the stimulant groups (methylphenidate or amphetamine), a medication from the other stimulant group should be recommended with a similar titration plan. At least half of the children/adolescents whose symptoms fail to respond to one stimulant medication may have a positive response to the alternative medication.
Monitoring and follow up ii Stimulant medication can be effectively titrated on a threeto seven-day basis. During the first month of treatment, medication doses may be titrated with a weekly or biweekly telephone call to the family. ii A face-to-face follow up visit is recommended by the fourth week of medication, during which clinicians review their responses to the varying doses and monitor adverse effects, pulse, blood pressure, and weight.
BEHAVIOR THERAPY Behavior therapy is usually implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior to improve the child’s ability to regulate his or her own behavior.
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FDA-APPROVED MEDICATIONS: DOSING AND PHARMACOKINETICS INITIAL TITRATION DOSE
FREQUENCY
TIME TO INITIAL EFFECT
DURATION
MAXIMUM DOSE
MIXED AMPHETAMINE Adderalla Side bar can be a bulleted list, SALTS
2.5–5.0 mg
qday-BID
20-60 min
6 hrs
40 mg
5.0-, 7.5-, 10.0-, 12.5-, 15.0-, 20.0-, and 30.0-mg tablets
numbered list or just Adderall paragraph XRa text like this if you have a lot of DEXTROAMPHETAMINE Dexedrinea/ text to flow in.
5 mg
qday
20-60 min
10-12 hrs
40 mg
5-, 10-, 15-, 20-, 25-, and 30-mg capsules
2.5 mg
BID-TID
20-60 min
4-6 hrs
40 mg
5-and 10-mg (Dextrostat only) tablets
5 mg
qday-BID
≥60 min
≥6 hrs
40 mg
5-, 10-, and 15-mg capsules
20 mg
qday
60 min
10-12 hrs
70 mg
20-, 30-, 40-, 50-, 60-, and 70-mg capsules
Concerta
18 mg
qday
20-60 min
10-12 hrs
54 mg (
