The American Academy of Pediatrics (AAP) offers guidelines for doctors on assessment, diagnosis and treatment of ADHD in children. Previously, their guidelines targeted children between the ages of 6 and 12 years old. New guidelines were released in October 2011 to include recommendations for assessment, diagnosis and treatment of children with ADHD from 4 years old to 18 years old, addressing special considerations for both preschool children and adolescents. There are also recommendations for interventions for children who may have hyperactive or impulsive behaviors but do not meet the full diagnostic criteria for ADHD.
Summary of Revised APA Clinical Practice Guidelines for ADHD
The following is a summary of the main points of the new guidelines:
- For children between the ages of 4 and 18 years of age who have symptoms of inattention, hyperactivity or impulsivity and are experiencing academic or behavioral problems, the primary care physician should initiate (or make a referral for) an ADHD evaluation.
- The primary care physician should rule out any alternative cause for the child's behavior and symptoms.
- Children receiving a diagnosis of ADHD must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, including impairment in more than one major setting, for example home and school. Information about a child's behaviors should be obtained from parents, guardians, teachers, school personnel and mental health professionals involved in the child's care.
- Evaluations for ADHD should include assessment for common co-existing conditions, such as anxiety, depression, oppositional defiant disorder and conduct disorder, developmental disorders, such as learning disabilities and physical conditions, such as tics or sleep apnea.
- ADHD should be considered a chronic condition and therefore children with ADHD should be seen as having special health care needs.
- Primary care clinicians, when prescribing medication for ADHD, should titrate doses. This means they should begin with a low dose and slowly increase the dose as needed. This practice helps to minimize side effects by allowing the body to adapt to medication as well as helps in finding the correct dosage for each child. In addition, doctors should educate parents on the use of medication - explaining titration, that changing medications or dosages may occasionally be necessary and that finding the correct medication and correct dosage may take several months.
Age Specific Guidelines and Recommendations
In addition to the previous points, there are a number of age-specific recommendations included in the new guidelines:
Pre-school children (ages 4 to 5 years old) - Behavioral strategies and interventions should be the first line of treatment for young children. Many children's symptoms significantly improve with only behavioral strategies. Medication, specifically methylphenidate, can be tried if symptoms do not improve with behavioral strategies alone and there is moderate to severe disturbance in the child's daily functioning. Symptoms should have persisted for at least 9 months and impairment is present in more than one major setting (home and preschool or day care). If medication is used the following should be considered:
- Because of questions and concerns about the impact of stimulant medications on a child's growth, rapid growth during this period of time should be considered and the benefits of medication should be weighed against the risks of delaying treatment.
- Preschool children metabolize medication slower than older children and therefore medication should be started at a low dose than given to elementary age children and should be increased in smaller increments, as needed.
Elementary age children (ages 6 to 11 years old) - behavioral interventions, both at home and school, should be included in any treatment plan, with or without medication, as needed. Behavioral interventions include:
- Increased structure
- Organizational strategies
- Reward and consequences behavior programs
- Increasing expectations as a child develops skills
- Classroom accommodations such as preferred seating and modified work assignments
Adolescents (ages 12 to 18 years old) - A combination of medication and behavioral strategies is recommended. It is noted that behavioral strategies are usually less effective for this age group than for younger children but behavioral interventions should be included in the overall treatment plan. Adolescents, especially those newly diagnosed, should be screened for substance abuse, abuse of medication (including using medication for other than prescribed reasons) and special consideration for making sure medication covers times when the adolescent is driving.
These guidelines are meant to give primary care physicians a way to provide consistent, quality and evidence-based treatments for children with ADHD while at the same time understanding that every child has unique needs that should be identified and addressed. Goals for behavioral, academic and social interactions should be created and monitored throughout treatment. In addition, because ADHD is considered to be genetic, physicians should be aware that extra support may be needed for parents in follow through of the treatment plan.
"AAP Expands Ages for Diagnosis and Treatment of ADHD in Children," 2011, Oct 16, AAP Press Release
"ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents," Pediatrics Volume 128, Number 5. November 2011.
Published On: November 15, 2011