Supplemental Information ALGORITHM IMPLEMENTING THE KEY ACTION STATEMENTS OF THE AAP ADHD CLINICAL PRACTICE GUIDELINES: AN ALGORITHM AND EXPLANATION FOR PROCESS OF CARE FOR THE EVALUATION, DIAGNOSIS, TREATMENT, AND MONITORING OF ADHD IN CHILDREN AND ADOLESCENTS I. INTRODUCTION Practice guidelines provide a broad outline of the requirements for high- quality, evidence-based care. The AAP “Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder” provides the evidence- based processes for caring for children and adolescents with ADHD symptoms or diagnosis. This document supplements that guideline. It provides a PoCA that details processes to implement the guidelines; describes procedures for the evaluation, treatment, and monitoring of children and adolescents with ADHD; and addresses practical issues related to the provision of ADHD-related care within a typical, busy pediatric practice. The algorithm is entirely congruent with the guidelines and is based on the practical experience and expert advice of clinicians who are experienced in the diagnosis and management of children and adolescents with ADHD. Unlike the guidelines, this algorithm is based primarily on expert opinion and has a less robust evidence base because of the lack of clinical studies specifically addressing this approach. Understanding that providing appropriate care to children with ADHD in a primary care setting faces a number of challenges and barriers, the subcommittee has also provided an additional article describing needed changes to address barriers to care (found in the Supplemental Information). In this algorithm, we describe a continuous process; as such, its constituent steps are not intended to be completed in a single office visit or in a specific number of visits. Evaluation, treatment, and monitoring are ongoing processes to be addressed throughout the child’s and adolescent’s care within the practice and in transition planning as the adolescent moves into the adult care system. Many factors will influence the pace of the process, including the experience of the PCC, the practice’s volume, the longevity of the relationship between the PCC and family, the severity of concerns, the availability of academic records and school input, the family’s schedule, and the payment structure. An awareness of the AAP “Primary Care Approach to Mental Health Care Algorithm, ” which is available on the AAP Mental Health Initiatives Web site, will enhance the integration of the procedures described in this document (http:// www.aap.org/mentalhealth). That algorithm describes the process to integrate an initial psychosocial assessment at well visits and a brief mental health update at acute and chronic care visits. Mental health concerns, including symptoms of inattention and impulsivity, may present when (1) elicited during the initial psychosocial assessment at a routine well visit, (2) elicited during a brief mental health update at an acute or chronic visit, or (3) presented during a visit triggered by a family or school concern. When concerns are identified, the algorithm describes the process of conducting a brief primary care intervention, secondary screening, diagnostic assessment, treatment, and follow-up. Like this document, the mental health algorithm is intended to present a process that may involve more than 1 visit and may be completed over time. This algorithm assumes that the primary care practice has adopted the initial psychosocial assessment and mental health update, as described by the AAP Mental Health Initiatives. 153 It begins with steps paralleling the secondary assessment of the general mental health algorithm. Both algorithms focus on the care team and include the family as a part of that team. In light of the prevalence of ADHD, the severe consequences of untreated ADHD, and the availability of effective ADHD treatments, the AAP recommends that every child and adolescent identified with signs or symptoms suggestive of ADHD be evaluated for ADHD or other conditions that may share its symptomatology. Documenting all aspects of the diagnostic and treatment procedures in the patient’s records will improve the ability of the FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 144, Number 4, October 2019 1
Transcript
Supplemental Information
ALGORITHM
IMPLEMENTING THE KEY ACTIONSTATEMENTS OF THE AAP ADHDCLINICAL PRACTICE GUIDELINES:AN ALGORITHM AND EXPLANATIONFOR PROCESS OF CARE FOR THEEVALUATION, DIAGNOSIS, TREATMENT,AND MONITORING OF ADHD INCHILDREN AND ADOLESCENTS
I. INTRODUCTION
Practice guidelines provide a broadoutline of the requirements for high-quality, evidence-based care. TheAAP “Clinical Practice Guideline:Diagnosis and Evaluation of the ChildWith Attention-Deficit/HyperactivityDisorder” provides the evidence-based processes for caring forchildren and adolescents with ADHDsymptoms or diagnosis. Thisdocument supplements thatguideline. It provides a PoCA thatdetails processes to implement theguidelines; describes procedures forthe evaluation, treatment, andmonitoring of children andadolescents with ADHD; andaddresses practical issues related tothe provision of ADHD-related carewithin a typical, busy pediatricpractice. The algorithm is entirelycongruent with the guidelines and isbased on the practical experienceand expert advice of clinicians whoare experienced in the diagnosis andmanagement of children andadolescents with ADHD. Unlike theguidelines, this algorithm is basedprimarily on expert opinion and hasa less robust evidence base becauseof the lack of clinical studies
specifically addressing this approach.Understanding that providingappropriate care to children withADHD in a primary care setting facesa number of challenges and barriers,the subcommittee has also providedan additional article describingneeded changes to address barriersto care (found in the SupplementalInformation).
In this algorithm, we describea continuous process; as such, itsconstituent steps are not intended tobe completed in a single office visit orin a specific number of visits.Evaluation, treatment, and monitoringare ongoing processes to be addressedthroughout the child’s and adolescent’scare within the practice and intransition planning as the adolescentmoves into the adult care system.Many factors will influence the pace ofthe process, including the experienceof the PCC, the practice’s volume, thelongevity of the relationship betweenthe PCC and family, the severity ofconcerns, the availability of academicrecords and school input, the family’sschedule, and the payment structure.
An awareness of the AAP “PrimaryCare Approach to Mental HealthCare Algorithm,” which is availableon the AAP Mental Health InitiativesWeb site, will enhance theintegration of the proceduresdescribed in this document (http://www.aap.org/mentalhealth). Thatalgorithm describes the process tointegrate an initial psychosocialassessment at well visits and a briefmental health update at acute andchronic care visits. Mental health
concerns, including symptoms ofinattention and impulsivity, maypresent when (1) elicited during theinitial psychosocial assessment ata routine well visit, (2) elicitedduring a brief mental health updateat an acute or chronic visit, or (3)presented during a visit triggered bya family or school concern.
When concerns are identified, thealgorithm describes the process ofconducting a brief primary careintervention, secondary screening,diagnostic assessment, treatment,and follow-up. Like this document,the mental health algorithm isintended to present a process thatmay involve more than 1 visit andmay be completed over time.
This algorithm assumes that theprimary care practice has adopted theinitial psychosocial assessment andmental health update, as described bythe AAP Mental Health Initiatives.153 Itbegins with steps paralleling thesecondary assessment of the generalmental health algorithm. Bothalgorithms focus on the care team andinclude the family as a part of that team.
In light of the prevalence of ADHD,the severe consequences of untreatedADHD, and the availability of effectiveADHD treatments, the AAPrecommends that every child andadolescent identified with signs orsymptoms suggestive of ADHD beevaluated for ADHD or otherconditions that may share itssymptomatology. Documenting allaspects of the diagnostic andtreatment procedures in the patient’srecords will improve the ability of the
II a. A Child or Adolescent PresentsWith Signs and SymptomsSuggesting ADHD
The algorithm’s steps can beimplemented when a child oradolescent presents to a PCC for an
assessment for ADHD. This may occurin a variety of ways.
Pediatricians and other PCCstraditionally have long-standingrelationships with the child and family,which foster the opportunity toidentify concerns early on. The youngchild may have a history of knownADHD risks, such as having parentswho have been diagnosed with ADHDor having extremely low birth weight.
In those instances, the PCC wouldmonitor for emerging issues.
Many parents bring their child oradolescent to the PCC with specificconcerns about the child’s oradolescent’s ability to sustainattention, curb activity levels, and/orinhibit impulsivity at home, school, orin the community. In many instances,the parents may express concernsabout behaviors and characteristics
SUPPLEMENTAL FIGURE 2ADHD care algorithm. CYSHCN, children and youth with special health care needs; TFOMH, Task Force on Mental Health.
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that are associated with ADHD butmay not mention the core ADHDsymptoms. For example, parents mayreport that their child is getting poorgrades, does not perform well in teamsports (despite being athletic), hasfew friends, or is moody and quick toanger. These children and adolescentsmay have difficulty remainingorganized; planning activities; orinhibiting their initial thoughts,actions, or emotions, which arebehaviors that fall under the umbrellaof executive functioning (ie, planning,prioritizing, and producing) orcognitive control. Problems withexecutive functions may be correlatedwith ADHD and are common amongchildren and adolescents with ADHD.As recommended by Bright Futures (anational health promotion andprevention initiative led by theAAP157), routine psychosocialscreening at preventive visits mayidentify concerns on the part ofparent or another clinician (see belowfor more information on co-occurringconditions.)
Finally, parents may bring a child toa PCC for ADHD evaluation on the
basis of the recommendation ofa teacher, tutor, coach, etc.
(See the ADHD guideline’s KAS 1.)
II b. Perform a Diagnostic Evaluationfor ADHD and Evaluate or Screen forComorbid Disorders
When a child or adolescent presentswith concerns about ADHD, asdescribed above, the clinician shouldinitiate an evaluation for ADHD. (Seethe ADHD guideline’s KASs 2 and 3.)
II c. Gather Information From theFamily
As noted previously, therecommendations in theaccompanying guideline are intendedto be integrated with the broadermental health algorithm developed aspart of the AAP Mental HealthInitiatives.2,133,153 It is also importantfor pediatricians and other PCCs to beaware of health disparities and socialdeterminants that may affect patientoutcomes and to provide culturallyappropriate care to all children andadolescents in their practice,including during the initial evaluation
and assessment of the patient’scondition.145,146,154,155,158
Ideally, the PCC’s office staff obtainsinformation from the family about thevisit’s purpose at scheduling so thatan extended visit or multiple visitscan be made available for the initialADHD evaluation. This also increasesthe efficiency of an initial evaluation.Data on the child’s or adolescent’ssymptoms and functioning can begathered from parents, schoolpersonnel, and other sources beforethe visit. Parents can be given ratingscales that are to be completed beforethe visit by teachers, coaches, andothers who interact with the child.This strategy allows the PCC to focuson the most pertinent issues for thatchild or adolescent and family at thetime of the visit. (See later discussionfor more information on ratingscales.) Note that schools will notrelease data to pediatric providerswithout written parental consent.
During the office evaluation session,the PCC reviews the patient’s medical,family, and psychosocial history.Developmental history is presumedto be part of the patient’s medical
SUPPLEMENTAL FIGURE 3Evaluate for ADHD. TFOMH, Task Force on Mental Health.
SUPPLEMENTAL FIGURE 4Perform a diagnostic evaluation for ADHD and evaluate or screen for comorbid disorders
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history. Family members (includingparents, guardians, and other frequentcaregivers) are asked to identify theirchief concerns and provide a history ofthe onset, frequency, and duration ofproblem behaviors, situations thatincrease or decrease the problems,previous treatments and their results,and the caregivers’ understanding ofthe issues. It is important to assessbehaviors and conditions that arefrequent side effects of stimulantmedication (ie, sleep difficulties, tics,nail-biting, skin-picking, headaches,stomachaches, or afternoonirritability) and preexisting conditions,so they are not confused with thefrequent side effects of stimulants.This enables the PCC to comparechanges if medication is initiated later.
A sound assessment of symptoms andfunctioning in major areas can beused to construct an educational andbehavioral profile that includes thechild’s strengths and talents. Manychildren with ADHD exhibitenthusiasm, exuberance, creativity,flexibility, the ability to detect andquickly respond to subtle changes inthe environment, a sense of humor,a desire to please, etc. The mostcommon areas of functioning affectedby ADHD include academicachievement; relationships withpeers, parents, siblings, and adultauthority figures; participation inrecreational activities, such as sports;and behavior and emotionalregulation, including risky behavior.
The child’s and family’s histories canprovide information about the statusof symptoms and functioning andhelp determine age of onset and otherfactors that may be associated withthe presenting problems. It alsoidentifies any potential traumaticevents that the child may haveexperienced, such as a family death,separation from the family, orphysical or mental abuse.
The child or adolescent’s medicalhistory can help identify factorsassociated with ADHD, such as
prenatal and perinatal complicationsand exposures (eg, preterm delivery,maternal hypertension, prenatalalcohol exposure), childhoodexposures, and head trauma.
The family history includes anymedical syndromes, developmentaldelays, cognitive limitations, learningdisabilities, trauma or toxic stress, ormental illness in the patient andfamily members, including ADHD,mood, anxiety, and bipolar disorders.Ask what the family has already tried,what works, and what does not workto avoid wasting time oninterventions that have already beenattempted unsuccessfully. Parentaltobacco and substance use, includingtheir use prenatally, are relevant riskfactors for, and correlate with,ADHD.159 ADHD is highly heritableand is often seen in other familymembers who may or may not havebeen formally diagnosed with ADHD.For this reason, asking about familymembers’ school experience,including time and task management,grades, and highest grade levelachieved, can aid in treatmentdecisions.
The psychosocial history is importantin any ADHD evaluation and usuallyincludes queries about environmentalfactors, such as family stress andproblematic relationships, whichsometime contribute to the child oradolescent’s overall functioning. Thecaregivers’ current and pastapproaches to parenting and thechild’s misbehavior can provideimportant information that mayexplain discrepancies betweenreporters. For example, parents mayreduce their expectations for theirchild with ADHD as a means to relieveparenting stress. When theseexpectations are reduced (eg,eliminating chores, not monitoringhomework completion, etc), parentsmay experience far fewer problemswith the child than do teachers whomay have maintained expectations forthe child to complete tasks and followrules. Knowing the parents’ approach
to parenting may help the PCCunderstand differences in ratingscompleted by parents versusteachers.
Further evidence for an ADHDdiagnosis includes an inability toindependently complete dailyroutines in an age-appropriatemanner as well as multiple and short-lasting friendships, trouble keepingand/or making friends, staying uplate to complete assignments, andlate, incomplete, and/or lostassignments. Somatic symptoms andschool avoidance are more commonamong girls and may mask an ADHDdiagnosis. With information obtainedfrom the parents and schoolpersonnel, the PCC can make a clinicaljudgment about the effect of the coreand associated ADHD symptoms onacademic achievement, classroomperformance, family and socialrelationships, independentfunctioning, and safety and/orunintentional injuries.
If other issues exist, such as self-injuries, comorbid mental healthissues also need to be evaluated.Possible areas of functionalimpairment that require evaluationinclude domains such as self-perception, leisure activities, andself-care (ie, bathing, toileting,dressing, and eating). Additionalguidance regarding functionalassessment is available through theAAP ADHD Toolkit2 and the AAPMental Health Initiatives.133,160 TheADHD Toolkit2 is being revisedconcurrently with the development ofthese updated guidelines. Afterpublication, the toolkit may beaccessed at https://www.aap.org/en-us/professional-resources/quality-improvement/Pages/Quality-Improvement-Implementation-Guide.aspx. Additionally, a new Education inQuality Improvement for PediatricPractice Module was developed onthe basis of the new clinicalrecommendations and can also beaccessed by using the samelink above.
The patient needs to be screened forhearing and/or visual problemsbecause these can mimic inattention.A full review of systems may revealother symptoms or disorders, such assleep disturbances, absence seizures,or tic disorders, which may assist informulating a differential diagnosisand/or developing managementplans. Internal feelings such asanxiety and depression can occur butmay not be noticeable to parents andteachers, so it is important to elicitfeedback about them from the patientas well.
The information gathered from thisdiagnostic interview, combined withthe data from the rating scales (seebelow), provides an excellentfoundation for determining thepresence of symptoms andimpairment criteria needed todiagnose ADHD.
II d. Use Parent Rating Scales andOther Tools
Rating scales that use the DSM-5criteria for ADHD can help obtain theinformation that will contribute tomaking a diagnosis. Rating scales forparents that use DSM-5 criteria forADHD are helpful in obtaining thecore symptoms required to makea diagnosis on the basis of the DSM-5.161 Because changes in the 18 coresymptoms are essentially unchangedfrom DSM-IV criteria, DSM-IV–basedrating scales can be used if DSM-5rating scales are not readily available.Some of these symptom rating scalesinclude symptoms of commonlycomorbid conditions and measures ofimpairment in a variety of domainsthat are also required fora diagnosis.41,162 Some availablemeasures are limited because theyprovide only a global rating.163,164
Caregiver and teacher endorsementof the requisite number of ADHDsymptoms on the rating scales is notsufficient for diagnosis. A rating scaledocuments the presence ofinattention, hyperactivity, andimpulsivity symptoms but not
whether these symptoms are actuallyattributable to ADHD versusa mimicking condition. Caregiversmay misread or misunderstand someof the behaviors. Furthermore, ratingscales do not inform the PCC aboutcontextual influences that mayaccount for the symptoms andimpairment. Likewise, broadbandrating scales that assess generalmental health functioning do notprovide reliable and valid indicationsof ADHD diagnoses, although they canhelp to screen for concurrentbehavioral conditions.165
Nevertheless, parent ratings providevaluable information on theirperspective of the child’s symptomsand impairment and add informationabout normative levels of the parents’perspectives, which help the PCCdetermine the degree with which theproblems are or are not in the typicalrange for the child’s age and sex.Finally, broad rating scales that assessgeneral mental health functioning donot provide sufficient informationabout all the ADHD core symptomsbut may help screen for theconcurrent behavioral conditions.165
To address the rating scales’limitations, pediatricians and otherPCCs need to interview parents andmay need to review documents suchas report cards and standardized testresults and historical records ofdetentions, suspensions, and/orexpulsions from school, which canserve as evidence of functionalimpairment. Further evidence mayinclude difficulty developing andmaintaining lasting friendships. Thisinformation is discussed below.
II e. Gather Information From Schooland Community Informants
Information from parents is not theonly source that informs diagnosticdecisions for children andadolescents because a key criterionfor an ADHD diagnosis is the displayof symptoms and impairments inmultiple settings. Gathering data fromother adults who regularly interact
with the child or adolescent beingevaluated provides rich additionalinformation for the evaluation.
The information from various sourcesmay be inconsistent because parentsand teachers observe the children atdifferent times and under differentcircumstances, as describedpreviously.166 Disagreement mayresult from differences in students’behavior and performance indifferent classrooms, theirrelationship with the teachers, orvariations in teachers’ expectations,as well as training in or experiencewith behavior management. Classeswith high homework demands orclasses with less structure are oftenthe most problematic for studentswith ADHD. Investigating theseinconsistencies can lead tohypotheses about the child that helpinform the eventual clinical diagnosesand treatment decisions.167
Teachers and Other School Personnel
Teachers and other school personnelcan provide critically importantinformation because they developa rich sense of the typical range ofbehaviors within a specific age groupover time. School and classroomssettings provide the greatest socialand performance expectations thatpotentially tax children andadolescents with ADHD. Parents andolder children may be the bestsources for identifying the schoolpersonnel who can best completerating scales for an ADHD evaluation.
The value of school ratings increasesas children age because parents oftenhave less detailed information abouttheir child’s behavior andperformance at school as the studentmoves into the higher grades. Withelementary and middle schoolchildren, the classroom teacher isusually the best source; he or she maybe the only source necessary. Otherschool staff, such as a specialeducation teacher or schoolcounselor, may be valuable sources ofinformation. Direct communication
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with a school psychologist and/orschool counselor may provideadditional information on the child’sfunctioning within the context of theclassroom and school.
In secondary schools, studentsinteract with many teachers whooften instruct.100 students daily. Asa result, high school teachers may notknow the students as well aselementary and middle schoolteachers do. Parents and studentsmay be encouraged to choose the 2 or3 teachers who they believe know thestudent best and solicit their input(eg, math and English teachers or, forchildren or adolescents with learningdisabilities, a teacher in an area ofstrong function and a teacher in anarea of weak function). Regardless ofthe presence of a learning disability, itis helpful to obtain feedback from theteacher of the class in which the childor adolescent is having the mostdifficulty. The ADHD Toolkit providesmaterials relevant to school datacollection.
Teachers may communicate theirmajor concerns using questionnairesor verbally in person, via secure e-mail(if available), or over the telephone. Itis important to ask an appropriateschool representative to completea validated ADHD instrument orbehavior scale based on the DSM-5criteria for ADHD. A schoolrepresentative’s report might includeinformation about any comorbid oralternative conditions, includingdisruptive behavior disorders,depression and anxiety disorders, tics,or learning disabilities. As noted, someparent rating scales have a version forteachers and assess symptoms andimpairment in multiple domains.41
Teacher rating scales exist thatspecifically target behavior andperformance at school,168 whichprovide a comprehensive and detaileddescription of a student’s schoolfunctioning relative to normative data.
In addition to the academicinformation, it is important to request
information characterizing the childor adolescent’s level of functioningwith regard to peer, teacher, and otherauthority figure relationships, abilityto follow directions, organizationalskills, history of classroom disruption,and assignment completion.
Academic Records
In addition to ratings from teachersand other school staff, academicrecords are sometimes available toinform a PCC’s evaluation. Theserecords include report cards; resultsfrom reading, math, and writtenexpression standardized tests; andother assessments of academiccompetencies. If a child werereferred for an evaluation for specialeducation services, his or her file islikely to contain a report on theevaluation, which can be usefulduring an ADHD evaluation. Schoolrecords pertaining to officediscipline referrals, suspensions,absences, and detentions canprovide valuable information aboutsocial function and behavioralregulation. Parents often keep reportcards from early grades, which canprovide valuable information aboutage of onset for children older than12 years. Teachers in primarygrades often provide informationpertaining to important informationabout the history of the presentingproblems.
Other Community Sources
It can be helpful to obtaininformation not only from schoolprofessionals but also fromadditional sources, such asgrandparents, faith-basedorganization group leaders, scoutingleaders, sports coaches, and others.Depending on the areas in which thechild or adolescent exhibitsimpairment, these adults may beable to provide a valuableperspective on the nature of thepresenting problems, although theaccuracy of their reporting has notbeen studied.
II f. Gather Information From theChild or Adolescent
Another source of information is fromthe child or adolescent. Thisinformation is often collected butcarries less weight than informationfrom other sources because ofchildren’s and adolescents’ limitedability to accurately report theirstrengths and weaknesses, includingthose associated with ADHD.169 Asa result, information gathered from thechild about specific ADHD behaviorsmay do little to inform the presence orabsence of symptoms and impairmentsbecause evidence suggests that childrentend to minimize their problems andblame others for concerns.170
Nevertheless, self-report may provideother values. First, self-report is theprimary means by which one canscreen for internalizing conditionssuch as depression and anxiety. TheAAP Mental Health Initiatives133 andthe Guidelines for AdolescentDepression in Primary Care171–173
recommend the use of validateddiagnostic rating scales for adolescentmood and anxiety disorders forclinicians who wish to use thisformat.174–178 As measures of internalmental disorders, these data are likelyto be more valid than the reports ofadults about their children’s behaviors.
Second, youth with ADHD are proneto talk impulsively and excessivelywhen adults show an interest inthem. They may share usefulinformation about the home orclassroom that parents and teachersdo not know or impart. In addition,many share their experience withrisky and dangerous behaviors thatmay be unknown to the adults intheir lives. This information can becritical in both determininga diagnosis and designing treatment.
Third, even if little information ofvalue is obtained, the fact that thePCC takes the time to meet alone andask questions of the child oradolescents demonstrates respectand lays the foundation for
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collaboration in the decision-makingand treatment process to follow. Thisrelationship building is particularlyimportant for adolescents.
Fourth, by gaining an understandingof the child’s perspective, the PCC cananticipate the likely acceptance orresistance to treatment.
Interviewing the child or adolescentprovides many important benefitsbeyond the possibility of informingthe diagnosis and warrants itsinclusion in the evaluation. Forexample, part of this interviewincludes asking the child oradolescent to identify personal goals(eg, What do you want to be whenyou grow up? What do you think thatrequires? How can we help you getthere?). It is helpful when childrenperceive the pediatrician and otherPCCs as seeking to help them achievetheir goals rather than arbitrarilylabeling them as deficient, defective,or needing to be fixed in some way.
II g. Clinical Observations andPhysical Examination of the Child orAdolescent
The physical and neurologicexamination needs to becomprehensive to determine iffurther medical or developmentalassessments are indicated. Baselineheight, weight, BP, and pulsemeasurements are required to berecorded in the medical record. It isimportant to look for behaviors thatare consistent with ADHD’ssymptoms, including the child’s levelof attention, activity, and impulsivityduring the encounter. Yet, ADHD iscontext dependent, and for thisreason, behaviors and core symptomsthat are seen in other settings areoften not observed during an officevisit.179 Although the presence ofhyperactivity and inattention duringan office visit may provide supportingevidence of ADHD symptoms, theirabsence is not considered evidencethat the child does not have ADHD.
Observations of a broad range ofbehaviors can be important for
considering their contribution to thepresenting problems and thepotential diagnosis of otherconditions. Careful attention to thesevarious behaviors can provide usefulinformation when beginning the nextstep involving making diagnosticdecisions. For example, hearing andvisual acuity problems can often leadto inattention and overactivity atschool. Attending to concerns aboutanxiety is also important given thatyoung children may becomeoveractive when they are in anxiety-provoking situations like a clinic visit.
In addition, observing the child’slanguage skills is important becausedifficulties with language can bea symptom of a language disorderand predictor of subsequent readingproblems. This observation isparticularly important with youngchildren given that languagedisorders may present as problemswith sustaining attention andimpulsivity. A language disorder mayalso involve pragmatic usage or thesocial use of language, which cancontribute to social impairment. If thePCC, family, and/or school haveconcerns about receptive, expressive,or pragmatic language, it is importantto make a referral for a formal speechand language evaluation. Dysmorphicfeatures also need to be notedbecause symptoms of ADHD aresimilar to characteristics of childrenwith some prenatal exposures andgenetic syndromes (eg, fetal alcoholexposure,180,181 fragile X syndrome).
Many children with ADHD have poorcoordination, which may be severeenough to warrant a diagnosis ofdevelopmental coordination disorderand referral to occupational and/orphysical therapy. Findings of poorcoordination can affect how well thechild performs in competitive sports,a frequent source of socialinteractions for children, and canadversely affect the child’s writingskills. Detecting any motor or verbaltics is important as well, particularlybecause the use of stimulant
medications may cause orexacerbate tics.
Finally, it is important to evaluate thechild’s cardiovascular status becausecardiovascular health must beconsidered if ADHD medicationbecomes an option. Cardiac illness israre, and more evidence is requiredto determine if children oradolescents with ADHD are atincreased risk when taking ADHDmedications. Nevertheless, beforeinitiating therapy with stimulantmedications, it is important to obtainthe child or adolescent’s history ofspecific cardiac symptoms, as well asthe family history of sudden death,cardiovascular symptoms, Wolff-Parkinson-White syndrome,hypertrophic cardiomyopathy, andlong QT syndrome. If any of these riskfactors are present, clinicians shouldobtain additional evaluation with anECG and possibly consult witha pediatric cardiologist.
II h. Gather Information AboutConditions That Mimic or AreComorbid With ADHD
It is important for the PCC to obtaininformation about the status andhistory of conditions that may mimicor are comorbid with ADHD, such asdepression, anxiety disorders, andposttraumatic stress disorder. Severalvalidated rating scales are within thepublic domain and can help identifycomorbid conditions. Examplesinclude the Pediatric SymptomChecklist-17 as a screen fordepression and anxiety182; the Screenfor Child Anxiety Related EmotionalDisorders, more specifically foranxiety disorders176; the PatientHealth Questionnaire modified foradolescents; the Screening to BriefIntervention tool183,184; and the Childand Adolescent Trauma Screen forexposure to trauma.185 All includequestionnaire forms for both parentsand patients.2 The results help thePCC assess the extent to whichreported impairment and/or distressare associated with ADHD versus
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comorbid conditions. Theseconditions are described in greaterdetail later.
Safety and Serious Mental IllnessConcerns
PCCs may be asked to completemental health or safety assessments,particularly for adolescents.Assessment requests may come fromschools or other settings aftera behavioral crisis, aggressivebehavior, or destructive behaviorshave occurred. With patient orguardian consent, information may beshared regarding diagnosis andcurrent treatment strategies.Pediatricians and other PCCs areencouraged to exercise caution whenasked to predict the likelihood offuture behaviors in the absence ofdetailed understanding of theenvironment in which the behaviorsoccurred. Self-injurious behaviors orthreats of self-harm are seriousconcerns that, when possible, shouldimmediately be referred tocommunity mental health crisisservices or experienced child mentalhealth professionals. PCCs areencouraged to provide furthermonitoring of the child or adolescentwith these comorbidities.
III. MAKING DIAGNOSTIC DECISIONS
After gathering all of the relevantavailable information, the PCC willconsider an ADHD diagnosis as wellas a diagnosis of other related and/orcomorbid disorders. The primary
decision-making process involvescomparing the information obtainedto the DSM-5 criteria for ADHD.Although this assessment isstraightforward, there are someissues the PCC needs to consider,including development, sex, and otherdisorders that may fit the presentingproblems better than ADHD (seebelow for more on these issues).
III a. DSM-5 Criteria for ADHD
The DSM-5 criteria define 4dimensions of ADHD:
1. ADHD/I (314.00 [F90.0]);
2. ADHD/HI (314.01 [F90.1]);
3. ADHD/C (314.01 [F90.2]); and
4. ADHD other specified andunspecified ADHD (314.01[F90.8]).
To make a diagnosis of ADHD, thePCC needs to establish that 6 or more(5 or more if the adolescent is17 years or older) core symptoms arepresent in either or both of theinattention dimension and/or thehyperactivity-impulsivity dimensionand occur inappropriately often. Thecore symptoms and dimensions arepresented in Supplemental Table 2.
• ADHD/I: having at least 6 of 9inattention behaviors and less than6 hyperactive-impulsive behaviors;
• ADHD/HI: having at least 6 of 9hyperactive-impulsive behaviorsand less than 6 inattentionbehaviors;
• ADHD/C: having at least 6 of 9behaviors in both the inattentionand hyperactive-impulsivedimensions; and
• ADHD other specified andunspecified ADHD: Thesecategories are meant for childrenwho meet many of the criteria forADHD, but not the full criteria, andwho have significant impairment.“ADHD other specified” is used ifthe PCC specifies those criteria thathave not been met; “unspecifiedADHD” is used if the PCC does notspecify these criteria.
In school-aged children andadolescents, diagnostic criteria forADHD include documentation of thefollowing criteria:
• At least 6 of the 9 behaviorsdescribed in the inattentive domainoccur often, and to a degree, that isinconsistent with the child’sdevelopmental age. (Foradolescents 17 years and older,documentation of at least 5 of the 9behaviors is required.)
• At least 6 of the 9 behaviorsdescribed in the hyperactive-impulsive domain occur often, andto a degree, that is inconsistentwith the child’s developmental age.(For adolescents 17 years andolder, documentation of at least 5 ofthe 9 behaviors is required.)
• Several inattentive or hyperactive-impulsive symptoms were presentbefore age 12 years.
• There is clear evidence that thechild’s symptoms interfere with orreduce the quality of his or hersocial, academic, and/oroccupational functioning.
• The symptoms have persisted for atleast 6 months.
• The symptoms are not attributableto another physical, situational, ormental health condition.
Clear evidence exists that thesecriteria are appropriate forpreschool-aged children (ie, age4 years to the sixth birthday),elementary and middle school-agedchildren (ie, age 6 years to the 12thbirthday), and adolescents (ie, age12 years to the 18th birthday).30,31
DSM-5 criteria have also beenupdated to better describe howinattentive and hyperactive-impulsivesymptoms present in olderadolescents and adults.
DSM-5 criteria require evidence ofsymptoms before age 12 years. Insome cases, however, parents andteachers may not recognize ADHDsymptoms until the child is older than12 years, when school tasks and
SUPPLEMENTAL FIGURE 5Making diagnostic decisions.
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responsibilities become morechallenging and exceed the child’sability to perform effectively inschool. For these children, history canoften identify an earlier age of onsetof some ADHD symptoms. Delayedrecognition may also be seen moreoften in ADHD/I, which is morecommonly diagnosed in girls.
If symptoms arise suddenly withoutprevious history, the PCC needs toconsider other conditions, includingmood or anxiety disorders, substanceuse, head trauma, physical or sexualabuse, neurodegenerative disorders,sleep disorders (including sleepapnea), or a major psychological stressin the family or school (such asbullying). In adolescents and youngadults, PCCs are encouraged toconsider the potential for falsereporting and misrepresentation ofsymptoms to obtain medications forother than appropriate medicinal use(ie, diversion, secondary gain). Themajority of states now requireprescriber participation in prescriptiondrug monitoring programs, which canbe helpful in identifying andpreventing diversion activities.Pediatricians and other PCCs mayconsider prescribing nonstimulantmedications that minimize abusepotential, such as atomoxetine andextended-release guanfacine orextended-release clonidine.
In the absence of other concerns andfindings on prenatal or medicalhistory, further diagnostic testing willnot help to reach an ADHD diagnosis.Compared to clinical interviews,standardized psychological tests, suchas computerized attention tests, havenot been found to reliablydifferentiate between youth with andwithout ADHD.187,188 Appropriatefurther assessment is indicated if anunderlying etiology is suspected.Imaging studies or screening for highlead levels and abnormal thyroidhormone levels can be pursued if theyare suggested by other historic orphysical information, such as historyor symptoms of a tumor or significant
brain injury. When childrenexperience trauma, their evaluationneeds to include the consideration ofboth the trauma and ADHD becausethey can co-occur and can exacerbateADHD symptoms. Toxic stress hasshown to be associated with theincidence of pediatric ADHD, but theconclusion that ADHD isa manifestation of this stress has notbeen demonstrated.188
Patients with ADHD commonly havecomorbid conditions, such asoppositional defiant disorder, anxiety,depression, and language andlearning disabilities. These conditionsmay present with ADHD symptomsand need evaluation because theirtreatment may relieve symptoms.Additionally, some conditions maypresent with ADHD symptoms andrespond to treatment of the primarycondition, such as sleep disorders,absence seizures, andhyperthyroidism. (Comorbidconditions are discussed later in thisdocument.)
In addition, the behavioralcharacteristics specified in the DSM-5remain subjective and may beinterpreted differently by variousobservers. Rates of ADHD and itstreatment have been found to bedifferent for different racial and/orethnic groups.50,189 Cultural normsand the expectations of parents orteachers may influence reporting ofsymptoms. Hence, the clinicianbenefits from being sensitive tocultural differences about theappropriateness of behaviors andperceptions of mental healthconditions.145,155
After the diagnostic evaluation, a PCCwill be able to answer the followingquestions:
• How many inattentive andhyperactive/impulsive behaviorcriteria for ADHD does the child oradolescent manifest across majorsettings of his or her life?
• Have these criteria been present for6 months or longer?
• Was the onset of these or similarbehaviors present before the child’s12th birthday?
• What functional impairments arecaused by these behaviors?
• Could any other condition bea better explanation for thebehaviors?
• Is there evidence of comorbidproblems or disorders?
On the basis of this information, theclinician is usually able to arrive ata preliminary diagnosis of whetherthe child or adolescents has ADHD ornot. (For children and adolescentswho do not receive an ADHDdiagnosis, see below.)
III b. Developmental Considerations
Considerations About the Child orAdolescent’s Age
Although the diagnostic criteria forADHD are the same for children up toage 17 years, developmentalconsiderations affect theinterpretation of whether a symptomis present. Before school age, theprimary set of distinguishingsymptoms involve hyperactivity,although this can be difficult toidentify as outside of the normalrange given the large variability inthis young age group. Similarly,difficulties sustaining attention aredifficult to determine with youngchildren because of considerablevariability in presentation and thelimited demands for children in thisage group to sustain attention overtime. (See below for moreinformation on developmentaldelays.)
Some children demonstratehyperactivity and inattention that areclearly beyond the normal range.They may experience substantialimpairment to an extent that baby-sitters or child care agencies refuse tocare for them, parents are unable totake them shopping or to restaurants,or they routinely engage in dangerousor risky behaviors. In these extremecases, the PCC may be able to make
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PEDIATRICS Volume 144, Number 4, October 2019 9
the decision for an ADHD diagnosismore quickly than other scenariosthat require a thorough assessment.For other young children, thediagnosis will be less obvious, anddevelopmental and environmentalissues may lead the PCC to becautious in making an ADHDdiagnosis. In these situations,monitoring for the emergence orclarification of ADHD symptoms and/or providing a diagnosis of otherspecified ADHD or unspecified ADHDare appropriate options.
Adolescence is anotherdevelopmental period whendevelopmental considerations arewarranted. Beginning at age 17 years,there are only 5 symptoms ofinattention and/or 5 symptoms ofhyperactivity/impulsivity requiredfor an ADHD diagnosis. Hyperactivitytypically diminishes for most childrenduring adolescence, but problemsassociated with impulsivity can bedangerous and can include impaireddriving, substance use, risky sexualbehavior, and suicide. Disorganizationof time and resources can beassociated with substantial academicproblems at school. Parent-childconflict and disengagement fromschool can provide a context thatcontributes toward poor long-termoutcomes. Comorbid depression andconduct disorder are common but donot negate the importance ofdiagnosing ADHD when thedevelopmental path warrants it andthe ADHD symptoms exacerbateproblems associated with thecomorbid conditions.
Adolescence is the firstdevelopmental period for which ageof onset of symptoms must bedocumented before 12 years. Schoolrecords and parent reports are oftenthe richest source for making thisdetermination. It is important to tryto identify adolescents (or theirparents) who are pursuinga diagnosis of ADHD for secondarygains such as school accommodations,standardized testing
accommodations, and/or stimulantprescriptions. In addition,impairment sometimes emergeswhen expectations for the adolescentmarkedly increase or whenaccommodations are removed. Theteenager’s level of functioning maystay the same, but when faced withthe expectations of advancedplacement courses or a part-time job,failure to keep pace with increasingexpectations may lead to concernsthat warrant an evaluation for ADHD.These examples emphasize theimportance of determining an earlyage of onset.
Considerations About the Child orAdolescent’s Sex
ADHD is diagnosed in boys abouttwice as often as it is diagnosed ingirls. There are many hypothesesabout reasons for this difference; theprimary reason appears to simply bethat the disorder is more common inboys than girls. Some have raisedconcerns that the difference may beattributable to variances in society’sexpectations for boys versus girls orunderdiagnosis in girls, but thesereasons are unlikely to account forthe large difference in diagnoses.Hence, no adjustment is needed interms of the standards for girls tomeet the criteria for an ADHDdiagnosis compared with boys.
Girls are less likely to exhibithyperactivity symptoms, which arethe most easily observable of allADHD symptoms, particularly inyounger patients. This fact mayaccount for a portion of the differencein diagnosis between girls and boys.As a result, it is important to fullyconsider a diagnosis of ADHD,predominantly inattentivepresentation, when evaluating girls.
Symptoms of inattention alone cancomplicate the diagnosis becauseinattention is 1 of the most commonsymptoms across all disorders in theDSM-5. After puberty, it is morecommon for depression and anxietyto be diagnosed in girls than in boys,
and symptoms of inattention may bea result of these disorders as well asADHD. Examining the age of onsetand considering other distinguishingfeatures, such as avoidance andanhedonia, can help the PCC clarifythis challenging differential whenevaluating girls for ADHD. Forexample, does the inattention occurprimarily in anxiety-provokingsituations or when the child oradolescent is experiencing periods oflow mood and then remit when theanxiety or mood improves?
III c. Consideration of ComorbidConditions
If other disorders are suspected ordetected during the diagnosticevaluation, an assessment of theurgency of these conditions and theirimpact on the ADHD treatment planshould be made. Comorbid conditionsprovide unique challenges fortreatment planning. Urgentconditions need to be addressedimmediately with services capable ofhandling crisis situations. Theseconditions include suicidal thoughtsor acts and other behaviors with thepotential to severely injure the child,adolescent, and/or other people,including severe temper outbursts orchild abuse. Note that adolescents arepotentially more likely to providehonest answers if the PCC askssensitive questions in the absence ofthe parents and may respond morereadily to rating scales that assessmood or anxiety. In addition,substance use disorders requireimmediate attention and may precedeor coincide with beginning treatmentof ADHD. Additional information isavailable in the complex ADHDguideline published by the SDBP.67
Evidence shows that comorbidconditions may improve withtreatment of ADHD, includingoppositional behaviors andanxiety.140 For example, children withADHD and comorbid anxietydisorders may find that addressingthe ADHD symptoms with
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medications also decreases anxiety ormood symptoms. Other children mayrequire additional therapeutictreatments to treat the ADHDadequately and treat comorbidconditions, including cognitivebehavioral therapy (CBT), academicinterventions, or different and/oradditional medications.
The PCC may evaluate and treat thecomorbid disorder if it is within his orher training and expertise. Inaddition, the PCC can provideeducation to the family and child oradolescent about triggers forinattention and/or hyperactivity. Ifthe PCC requires the advice ofa subspecialist, the clinician isencouraged to consider carefullywhen to initiate treatment of ADHD.In some cases, it may be advisable todelay the start of medication until therole of each member of the treatmentteam is established (see below).Integrated care models can be helpful(see www.integratedcareforkids.org).
The following are brief discussions ofsleep disorders, psychiatric disorders,
emotion dysregulation, exposure totrauma, and learning disabilities, allof which can manifest in mannerssimilar to ADHD and can complicatemaking a diagnosis.
(See the ADHD guideline’s KAS 3.)
Sleep Disorders
Sleepiness impairs most people’sability to sustain attention and oftenleads to caffeine consumption tocounter these effects. In the sameway, sleep disturbance can lead tosymptoms and impairment thatmimic or exacerbate ADHDsymptoms. A child with ADHD mayhave difficulty falling asleep becauseof the busy thoughts caused by ADHD.Some sleep disorders are frequentlyassociated with ADHD or present assymptoms of inattention,hyperactivity, and impulsivity, such asobstructive sleep apnea syndromeand restless legs syndrome and/orperiodic limb movement disorder(RLS/PLMD).190–193
The differential diagnosis of insomniain children and adolescents withADHD includes the following:
• inadequate sleep hygiene (eg,inconsistent bedtimes and waketimes, absence of a bedtimeroutine, electronics in the bedroom,caffeine use)194;
• circadian-based phase delay insleep-wake patterns, which havebeen shown to occur in somechildren with ADHD, resulting inboth prolonged sleep onset anddifficulty waking in themorning201; and
SUPPLEMENTAL FIGURE 6Consideration of comorbid conditions. TFOMH, Task Force on Mental Health.
• intrinsic deficit associated withADHD. Authors of numerousstudies have reported thatnonmedicated children with ADHDwithout comorbid mood or anxietydisorders have significantly greaterbedtime resistance, more sleeponset difficulties, and morefrequent night awakenings whencompared with typically developingchildren in control groups.202 Inaddition, some children with ADHDappear to have evidence ofincreased daytime sleepiness, evenin the absence of a primary sleepdisorder.202–204
For this reason, all children andadolescents who are evaluated forADHD need to be systematicallyscreened for symptoms of primarysleep disorders, such as frequentsnoring, observed breathing pauses,restless sleep, urge to move one’s legsat night, and excessive daytimesleepiness. (Issues of access to theseservices are discussed in theaccompanying section, SystemicBarriers to the Care of Children andAdolescents with ADHD.) In addition,screenings generally include primarysleep disorders’ risk factors, such asadenotonsillar hypertrophy, asthmaand allergies, obesity, a family historyof RLS/PLMD, and iron deficiency.199
Sleep assessment measures that havebeen shown to be useful in thepediatric primary care practicesetting include brief screeningtools205 and parent-reportsurveys.206,207 Overnightpolysomnography is generallyrequired for children who havesymptoms suggestive of and/or riskfactors for obstructive sleep apneasyndrome and RLS/PLMD.208,209
If the results suggest the presence ofa sleep disorder, the PCC needs toobtain a comprehensive sleep history,including assessment of theenvironment in which the childsleeps; the cohabitants in the room;the bedtime routine, including itsinitiation, how long it takes for thechild fall asleep, sleep duration, and
any night-time awakenings; and whattime the child wakes up in themorning and his or her state whenawakening. It is important todetermine sleep interventionsattempted and their results. Evenwhen no primary sleep disordersoccur, modest reductions in sleepduration or increases in sleepdisruption may be associated withincreased, detectable problems withattention in children and adolescentswith ADHD.210 Although fullydisentangling sleep disruption fromADHD may not be possible becausesignificant sleep problems and theirassociated impairment are oftencomorbid with ADHD, sleepdisruptions often warrantconsideration as an additional targetfor treatment. In addition, somechildren with ADHD appear to showevidence of increased daytimesleepiness, even in the absence ofa primary sleep disorder.203,204
Significant sleep problems and theirassociated impairment are oftencomorbid with ADHD and, for manychildren, are considered as anadditional target for treatment.
A variety of issues need to beconsidered when determining if sleepproblems constitute an additionaldiagnosis of insomnia disorder or arelinked to ADHD-related treatmentissues. First, a child’s sleep can beaffected if he or she is already takingstimulant medication or regularlyconsuming caffeine. The dosage andtiming of this consumption needs tobe tracked and manipulated toexamine its effects; simplemodifications of timing and dosage ofstimulant consumption can improvesleep onset, duration, and quality.Second, sleep problems can occurfrom inadequate sleep health and/orhygiene194 or from other disorders,such as anxiety and mood disorders,when the rumination and worryassociated with them impairs ordisrupts the child’s sleep.Restructuring behavior preceding andat bedtime can dramatically improve
sleep and diminish associatedimpairments. These potential causesof sleep disturbance and the relatedimpairments that mimic orexacerbate ADHD symptoms need tobe considered before diagnosingADHD, related problems, or insomniadisorder.
Trauma
Children with ADHD are at higher-than-normal risk of experiencingsome forms of trauma, includingcorporal punishment and accidents(often because of their risk-takingbehaviors). In addition, posttraumaticstress disorder may manifest somesimilar symptoms. Depending on thechild, the trauma may have beena one-time event or one to which theyare consistently exposed. Exposure totrauma may exacerbate or lead tosymptoms shared by traumadisorders and ADHD (eg, inattention).As a result, when evaluating a childfor ADHD, obtaining a brief traumahistory and screening for indicatorsof impairing responses to trauma canbe helpful. Although a trauma historydoes not inform the diagnosis ofADHD, it may identify an alternativediagnosis and inform treatment andother interventions, including referralfor trauma-focused therapy andreporting suspected abuse.
Mental Health Conditions
In children or adolescents who havecoexisting mild depression, anxiety, orobsessive-compulsive disorder, thePCC may undertake the treatment ofall disorders if doing so is within hisor her abilities. Another option is tocollaborate with a mental healthclinician to treat the coexistingcondition while the PCC oversees theADHD treatment. As a third option,the consulting specialists may adviseabout the treatment of the coexistingcondition to the extent that the PCC iscomfortable treating both ADHD andthe coexisting problems. With somecoexisting psychiatric disorders, suchas severe anxiety, depression, autism,schizophrenia, obsessive-compulsive
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disorder, oppositional defiantdisorder, conduct disorder, andbipolar disorder, a comanagingdevelopmental-behavioralpediatrician or child and adolescentpsychiatrist might take responsibilityfor treatment of both ADHD and thecoexisting illness.
Many children with ADHD exhibitemotion dysregulation, which isconsidered to be a common feature ofthe disorder and one that ispotentially related to other executivefunctioning deficits.211 A childexhibiting emotion dysregulationwith either or both positive (eg,exuberance) or negative (eg, anger)emotions along with symptoms ofADHD can be considered as a goodcandidate for an ADHD diagnosis.Sometimes behavior related toemotion dysregulation can lead thePCC to consider other diagnoses suchas disruptive mood dysregulationdisorder, intermittent explosivedisorder, and bipolar disorder. All 3may be diagnosed with ADHD.Intermittent explosive disorder andbipolar disorder are rare in children,and data are currently inadequate toknow the prevalence of disruptivemood dysregulation disorder. Giventhe base rates, these other diagnosesare unlikely, although they do occur inchildhood. If the PCC has anyuncertainty about making thesedistinctions, referring the child toa clinical child psychologist or childmental health professionals may bewarranted.
Learning Disabilities
Learning disabilities frequently co-occur with ADHD and can lead tosymptoms and impairment that aresimilar to those in children withADHD. As a result, screening forlearning disabilities’ presence, such asvia the Vanderbilt ADHD RatingScale,212 is important given thattreatment of ADHD and learningdisabilities differ markedly.
Learning disabilities involveimpairment related to learning
specific academic content, usuallyreading or math, although there isincreased awareness about disordersof written expression. Theimpairment is not attributable todifficulties with sustaining attention;however, some children with learningdisabilities have trouble sustainingattention in class because they cannotkeep up and then disengage. A carefulevaluation for learning disabilitiesincludes achievement testing,cognitive ability testing, andmeasures of the child’s learning inresponse to evidence-basedinstruction. Such thoroughevaluations are typically not availablein a PCC practice. If screeningsuggests the possibility of learningdisabilities, the PCC can help adviseparents on how to obtain schoolpsychoeducational evaluations orrefer the child to a psychologist orother specialist trained in conductingthese evaluations.
The PCC’s attention is directed tolanguage skills in preschool-agedand young school-aged childrenbecause difficulties in languageskills can be a symptom ofa language disorder and predictor ofsubsequent reading problems.Language disorders may present asproblems with attention andimpulsivity. Likewise, socialinteractions need to be noted duringthe examination because they maybe impaired when the child oradolescent’s language skills aredelayed or disordered.
Children who have intellectual orother developmental disabilitiesmay have ADHD, but assessment ofthese patients is more difficultbecause a diagnosis of ADHD wouldonly be appropriate if the child oradolescent’s level of inattention orhyperactivity/impulsivity isdisproportionate to his or herdevelopmental rather thanchronological age. Therefore,assessment of ADHD in individualswith intellectual disabilities requiresinput from the child or adolescent’s
education specialists, schoolpsychologists, and/or independentpsychologists. Although it isimportant to attempt to differentiatewhether the presenting problemsare associated with learningdisabilities, ADHD, or somethingelse, it is important to consider thepossibility that a child has multipledisorders. Pediatricians and otherPCCs who are involved in assessingADHD in children with intellectualdisabilities will need to collaborateclosely with school or independentpsychologists.
Summary
Overall, there are many factors thatinfluence a diagnostic decision.Frequently, these decisions must bemade without the benefit of all ofthe relevant information described.Family and cultural issues thataffect parents’ expectations for theirchild and perceptions about mentalhealth can further complicate thisprocess. Poverty, family history,access to care, and many otherfactors that a PCC will probably notknow when making the diagnosiscan also be formative in the child’spresentingproblems.145,146,154,155,158 The PCCwill wisely remain sensitive toindividual variations in parents’beliefs, values, and perception oftheir culture and community whencompleting the assessment anddetermining a diagnosis. Thesefactors add complexities to theassessment and diagnostic processand make a good evaluation anddiagnosis a function of clinicalexperience, judgment, anda foundation in science.
IV. TREATMENT
If the child meets the DSM-5 criteriafor ADHD, including commensuratefunctional disabilities, progressthrough the PoCA.
(See the AHDH guideline’s KASs 5and 6.)
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PEDIATRICS Volume 144, Number 4, October 2019 13
IV a. Establish Management Team:Identify the Patient as a Child WithSpecial Health Care Needs
Any child who meets the criteria forADHD is considered a “child or youthwith special health care needs”; thesechildren are best managed ina medical home.213–217 In addition,the AAP encourages clinicians todevelop systems to allow themedical home to meet all needs ofchildren with chronic illnesses.These needs and strategies formeeting them are discussed infurther detail in AAP resourcessuch as the Building Your MedicalHome toolkit and AddressingConcerns in Primary Care: AClinician’s Toolkit. Care in themedical home is reviewed in theAAP publication Bright Futures:Guidelines for Health Supervision ofInfants, Children, and Adolescents,Fourth Edition. Pediatricians andother PCCs who provide effective
medical homes identify familystrengths and recognize theimportance of parents in the careteam.218–221 The PCC may provideeducation about the disorder andtreatment options, medication,and/or psychosocial treatmentand monitor response to treatmentsover time as well as the child’sdevelopment.
IV b. Establish Management Team:Collaborate With Family, School, andChild to Identify Target Goals
ADHD is a chronic illness; hence,education for both the child oradolescent and other familymembers is a critical element in thecare plan. Family education involvesall members of the family, includingthe provision of developmentallyage-appropriate information for theaffected child or adolescent and anysiblings. Topics may include thedisorder’s potential causes andtypical symptoms, the assessment
process; common coexistingdisorders; ADHD’s effect on schoolperformance and socialparticipation; long-term sequelae;and treatment options and theirpotential benefits, adverse effects,and long-term outcomes. It isimportant to address the patient’sself-concept and clarify thathaving ADHD does not mean thatthe child is less smart than others.At every stage, education mustcontinue in a manner consistent withthe child or adolescent’s level ofunderstanding.
The emphasis for parental educationis on helping parents understand thedisorder, how to obtain additionalaccurate information about ADHDand treatments, and how toeffectively advocate for their child.This may include addressingparental concerns about labelingthe child or adolescent witha disorder by providing information
SUPPLEMENTAL FIGURE 7Treatment. CYSHCN, children and youth with special health care needs.
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on the benefits of diagnosis andtreatment.
Some guidance about effectiveparenting strategies may be helpful,but PTBM is likely to be mostbeneficial for most parents (see thesection on Psychosocial Treatments).Pediatricians and other PCCs areencouraged to be cognizant of thechallenges families may face toattend such training, includingtaking time off from work andcovering the costs associated with theintervention.
Parents may benefit from learningabout optimal ways to partner withschools, particularly their child’steachers, and become part of theeducational and intervention teams.Educating parents about specialeducation and other services can behelpful, but school interventions andadvocacy may be best aided bypartnering closely with an advocateor clinician experienced in workingwith schools (see the PsychosocialTreatment section). With theparent’s permission, the clinicianmay provide educators at theschool with information fromthe evaluation that will help theschool determine eligibility forspecial education services oraccommodations and/or developappropriate services.
In addition, it is helpful to provideassistance to the parent or othercaregiver in understanding and usingany relevant electronic health record(EHR) system. Sometimes, the healthliteracy gap around EHRs can lead toconfusion and frustration on thefamily’s side. Also, providinginformation on community resources,such as other health care providers orspecialists, can be beneficial inaddressing fragmentation andcommunication barriers.
Family education continuesthroughout the course of treatmentand includes anticipatory guidance inareas such as transitions (eg, fromelementary to middle school, middle
to high school, and high school tocollege or employment); working withschools; and developmental challengesthat may be affected by ADHD,including driving, sexual activity, andsubstance use and abuse. For parentswho are interested in understandingthe developmental aspects ofchildren’s understanding about ADHD(ie, causes, manifestations,treatments), several AAP publicationsmay be useful.222–224
Although having a child diagnosedwith ADHD can sometimes providerelief for families, it is important tocheck on the parents’ well-being.Having a disruptive child who hastrouble interacting with others can bestressful for parents, and learningthat their child has a disordersometimes gives them something toblame other than themselves. Helpingfamilies cope with parentingchallenges or making referrals forservices to address their stress ordepression can be an important partof care. These concerns areparticularly relevant when a parenthas ADHD or associated conditions.Parents may require supportbalancing the needs of their childwith ADHD and their other children’sneeds. Advocacy and support groupssuch as the National Resource onADHD (a program of CHADD: https://chadd.org/about/about-nrc/) and theAttention Deficit Disorder Association(www.add.org) can provideinformation and support for families.There also may be local supportorganizations. The ADHD Toolkitprovides lists of educational resourcesincluding Internet-based resources,organizations, and books that may beuseful to parents and children.
IV c. Establish Management Team:Establish Team and CoordinationPlan
Treatment Team
The optimal treatment team includeseveryone involved in the care of thechild: the child, parents, teachers, PCC,therapists, subspecialists, and other
adults (such as coaches or faithleaders) who will be actively engagedin supporting and monitoring thetreatment of ADHD.218–221 It is helpfulfor the PCC or another assigned carecoordinator to make each teammember aware of his or her role, theprocess and timing of routine and as-needed communication strategies, andexpectations for reports (ie, frequency,scope). Collaboration with schoolpersonnel goes beyond the initialreport of diagnosis and is bestfacilitated by agreement ona standardized, reliablecommunication system. Althoughthere are obstacles to achieving thislevel of coordination, if successful, itenhances care and improves outcomesfor the child. (See Systemic Barriers tothe Care of Children and AdolescentsWith ADHD section in theSupplemental Information fora discussion of systemic challenges.)
Treatment Goals
Management plans include theestablishment of treatment goals forthe areas of concern, such as thosemost commonly affected by ADHD:academic performance; relationshipswith peers, parents, and siblings; andsafety. It is not necessary to developgoals in every area at once. Familiesmight be encouraged to identify up to3 of the most impairing areas toaddress initially. Parents and the childor adolescent can add other targets asindicated by their relativeimportance. Other goals may beidentified using the InternationalClassification of Function, Disability,and Health analysis conducted in thediagnostic phase of the clinicalpathway. This process increases theunderstanding of ADHD’s effects oneach family member and may lead toimproved collaboration in developinga few specific and measurableoutcomes. It is helpful to incorporatea child’s strengths and resiliencewhen considering target goals andgenerating the treatment plan.Academic or school goals require theinput of teachers and other personnel
Establishing measurable goals ininterpersonal domains and improvingbehavior in unstructured settingsmay be particularly important.Wherever possible, progress shouldbe quantifiable to monitor thefrequency of behaviors. The numberof achieved and missed goals per daycan be recorded by the parent, child,and/or teacher. Charts may besuggested as strategies to recordevents so that parents, teachers,children, and PCCs can agree on howmuch progress has been madebuilding success in a systematic andmeasurable way. Keeping the focus onprogress toward the identified goalscan keep all family members engaged,provide a rubric for measuringresponse to various treatments, andoffer a vehicle for rewarding success.Such strategies can help a familyaccurately assess and see progress ofbehavior changes. A single-page dailyreport card can be used to identifyand monitor 4 or 5 behaviors thataffect function at school and the cardcan be shared with parents. Otherstrategies and tools are available toclinicians in the AAP ADHD ProviderToolkit, Third Edition,225 and forparents, ADHD: What Every ParentNeeds to Know.226
As treatment proceeds, in addition tousing a DSM-5–based ADHD ratingscale to monitor core symptomchanges, formal and informal queriescan be made in the areas affected byADHD. At every visit, it is helpful forthe PCC to gradually further empowerchildren and adolescents so they areable to be full partners in thetreatment plan by adolescence. Datafrom school are helpful at these visits,including rating scales completed bythe child or adolescent’s teacher,grades, daily behavior ratings (whenavailable), and formal test results.
Management Plan
In addition to educating the family,the PCC can consider developing
a management plan that, over time,addresses the following questions:
• Does the family need furtherassistance in understanding thecore symptoms of ADHD and thechild or adolescent’s targetsymptoms and coexistingconditions?
• Does the family need support inlearning how to establish, measure,and monitor target goals?
• Have the family’s goals beenidentified and addressed in the careplan?
• Does the family have anunderstanding of effective behaviormanagement techniques forresponding to tantrums,oppositional behavior, and/or poorcompliance with requests orcommands?
• Does the family need help onnormalizing peer and familyrelationships?
• Does the child need help inacademic areas? If so, has a formalevaluation been performed andreviewed to distinguish workproduction problems secondary toADHD or attributable to coexistinglearning or language disabilities?
• Does the child or adolescent needassistance in achievingindependence in self-help orschoolwork?
• Does the child or adolescent orfamily require help withoptimizing, organizing, planning, ormanaging schoolwork?
• Does the family need help inrecognizing, understanding, ormanaging coexisting conditions?
• Does the family have a plan toeducate the child or adolescentsystematically about ADHD and itstreatment, as well as the child’sown strengths and weaknesses?
• Does the family have a plan toempower the child or adolescentwith the knowledge andunderstanding that will increasetheir adherence to treatments? Has
that plan been initiated, and is itpitched at the child or adolescent’sdevelopmental level?
• Does the family have a copy ofa care plan that summarizes theevaluation findings and treatmentrecommendations?
• Does the follow-up plan providecomprehensive, coordinated,family-centered, and culturallycompetent ongoing care?
• Does the family have any neededreferrals to specialists to provideadditional evaluations, treatments,and support?
• Does the family have a plan for thetransition from pediatric to adultcare that provides the transitioningyouth with the necessary ADHDself-management skills,understanding of health care andeducational privacy laws, identifiedadult clinician to continue his orher ADHD care, and healthinsurance coverage?
IV d. Treatment: Medication,Psychosocial Treatment, andCollaboration With the School toEnhance Support Services
The decision about the mostacceptable treatment of the childrests with the family and its decisionsabout treatment. The PCC needs toencourage that this decision is basedon accurate and adequateinformation, which often involvescorrecting misinformation orunwarranted concerns aboutmedication. If the family still declinesmedication treatment, the PCC canencourage all other types of effectivetreatment and provide appropriatemonitoring (families who declinemedication are discussed in moredetail below).
Pediatricians and other PCCs need toeducate families about the benefitsand characteristics of evidence-basedADHD psychosocial treatment andexplicitly communicate that playtherapy and sensory-relatedtherapies have not been
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demonstrated to be effective.Likewise, for children younger than7 years, individual CBT lacksdemonstrated effectiveness; CBT hassome, but not strong, evidence forchildren 7 to 17 years of age. Familiesshould be made aware that forpsychosocial treatments to beeffective, the therapist needs to workwith the family (not just the child oradolescent) on setting andmaintaining routines, discipline andreward-related procedures, trainingprograms, and creating a homeenvironment that will bring out thebest in the child and minimize ADHD-related dysfunction.
(See the ADHD guideline KASs 5and 6.)
Treatment: Medication
This treatment option is restricted tochildren and adolescents who meetdiagnostic criteria for ADHD.
The FDA has approved stimulantmedications (ie, methylphenidate andamphetamines) and severalnonstimulant medications for thetreatment of ADHD in children andadolescents. New brands ofmethylphenidate and amphetaminescontinue to be introduced, includinglonger-acting products, variousisomeric products, and delayed-release products. Hence, it isincreasingly unlikely thatpediatricians and other PCCs need toconsider the off-label use of othermedications. A free and continuallyupdated list of medications isavailable at www.adhdmedicationguide.com. (See theADHD guideline for information onoff-label use.)
With the expanded choices andconsiderations of the clinical effectscomes the reality that clinical choicesare often heavily restricted byinsurance coverage. Some, but not all,of the problems include changes ininsurance and formulary thatpreclude the use of certainmedications or force a stable patient
to change medications, step therapyrequirements that may delay effectivetreatment, and financial barriers thatpreclude a patient’s use of newerdrugs or those not preferred by thepayer. (See Systemic Barriers to theCare of Children and Adolescentswith ADHD section in theSupplemental Information fora discussion of this issue.)
The choice of stimulant medicationformulation depends on such factorsas the efficacy of each agent fora given child, the preferred length ofcoverage, whether a child canswallow pills or capsules, and out-of-pocket costs. The extended-releaseformulations are generally moreexpensive than the immediate-releaseformulations. Families and childrenmay prefer them, however, because ofthe benefits of consistent andsustained coverage with fewer dailyadministrations. Long-actingformulations usually avoid the needfor school-based administration ofADHD medication. Better coveragewith fewer daily administrationsleads to greater convenience to thefamily and is linked with increasedadherence to the medicationmanagement plan.227
Some patients, particularlyadolescents, may require more than12 hours of coverage daily to ensureadequate focus and concentrationduring the evening, when they aremore likely to be studying and/ordriving. In these cases,a nonstimulant medication or short-acting preparation of stimulantmedication may be used in theevening in addition to a long-actingpreparation in the morning. Of note,stimulant medication treatment ofindividuals with ADHD has beenlinked to better driving performanceand a significant reduced risk ofmotor vehicle crashes.78
The ease with which preparations canbe administered and theminimization of adverse effects arekey quality-of-life factors and are
important concerns for children,adolescents, and their parents. Whenmaking medicationrecommendations, PCCs have toconsider the time of day when thetargeted symptoms occur, whenhomework is usually done, whethermedication remains active whenteenagers are driving, whethermedication alters sleep initiation, andrisk status for substance use orstimulant misuse or diversion.
All FDA-approved stimulantmedications are methylphenidate oramphetamine compounds and havesimilar desired and adverse effects.Given the extensive evidence ofefficacy and safety, these drugsremain the first choice in medicationtreatment. The decision about whatcompound a PCC prescribes firstshould be made on the basis ofindividual clinician and familypreferences and the child’s age. Somechildren will respond better to, orexperience more adverse effects with,1 of the 2 stimulants groups (ie,methylphenidate or amphetamine)over another. Because this cannot bedetermined in advance, medicationtrials are appropriate. If a trial with 1group is unsuccessful because of poorefficacy or significant adverse effects,a medication trial with medicationfrom the other group should beundertaken. At least half of childrenwho fail to respond to 1 stimulantmedication have a positive responseto the alternative medication.228
Of note, recent meta-analyses havedocumented some subtle group-leveldifferences in amphetamine and/ordextroamphetamine andmethylphenidate response. Authorsof 1 such analysis found that, onaverage, youth with ADHD who weretreated with either amphetamine- ormethylphenidate-based medicationsshowed improvement in ADHDsymptoms.229 There was a marginallylarger improvement in clinicians’ADHD symptom ratings foramphetamine-based versusmethylphenidate-based
preparations.229 This meta-analysisindicated that overall adverse effects(including sleep problems andemotional side effects) were moreprominent among those usingamphetamine-based preparations. Thefindings were corroborated by a 2018meta-analysis in which authors foundthat amphetamine and/ordextroamphetamine worsenedemotional lability compared to thepremedication baseline. Authors of themeta-analysis found there wasa tendency for methylphenidate toreduce irritability and anxietycompared to the patients’premedication ratings.230 Amongindividual patients, medication’sefficacy and adverse effects can varyfrom these averages.
Families who are concerned about theuse of stimulants or the potential fortheir abuse and/or diversion maychoose to start with atomoxetine,extended-release guanfacine, orextended-release clonidine. In addition,those not responding to either stimulantgroup may still respond to atomoxetine,extended-release guanfacine, orextended-release clonidine.
There is a black box warning onatomoxetine about the possibility ofsuicidal ideation when initiatingmedication management. Earlysymptoms of suicidal ideation mayinclude thinking about self-harm andincreasing agitation. If there are anyconcerns about suicidal ideation inchildren prescribed atomoxetine,further evaluation (ie, using the PatientHealth Questionnaire-9 rating scale,asking about suicidal ideation,reviewing presence of firearms in thehome, determining if there is goodcommunication between the patientand parents or trusted adults, etc),reconsideration about the use ofatomoxetine, and more frequentmonitoring should be considered;referral to a mental health clinicianmay be necessary.
Atomoxetine is a selectivenorepinephrine reuptake inhibitor
that may demonstrate maximumresponse after approximately 4 to6 weeks of use, although somepatients experience modest benefitsafter 1 week of atomoxetinetreatment. Extended-releaseguanfacine and extended-releaseclonidine are a-2A adrenergicagonists that may demonstratemaximum response in about 2 to 4weeks. It is worth making familiesaware that symptom change is moregradual with atomoxetine and a-2Aadrenergic agonists than the rapideffect seen with stimulantmedications. Atomoxetine may causegastrointestinal tract symptoms andsedation early on, so it isrecommended to prescribe half thetreatment dose (0.5 mg/kg) for thefirst week. Appetite suppression canalso occur. Both a-2A agonists cancause the adverse effect ofsomnolence. It is recommended thata-2A agonists be tapered whendiscontinued to prevent possiblerebound hypertension.
In patients who only respondpartially to stimulant medications, itis possible to combine stimulant andnonstimulant a-2 agonist medicationsto obtain better efficacy (seeMedication for ADHD section in theclinical practice guideline). It ishelpful to ask the family if they haveany previous experience with any ofthe medications because a previousgood or bad experience in otherfamily members may indicatea willingness or reluctance to use 1type or a specific stimulantmedication. When there is concernabout possible use or diversion of themedication or a strong familypreference against stimulantmedication, an FDA-approvednonstimulant medication may beconsidered as the first choice ofmedication.
Medications that use a microbeadtechnology can be opened andsprinkled on food and are, therefore,suitable for children who havedifficulty swallowing tablets or
capsules. For patients who are unableto swallow pills, alternative optionsinclude immediate- and extended-release methylphenidate andamphetamine in a liquid andchewable form, a methylphenidatetransdermal patch, and an orallydisintegrating tablet.
It is often helpful to inform familiesthat the initial medication titrationprocess may take several weeks tocomplete, medication changes can bemade on a weekly basis, andsubsequent changes in medicationmay be necessary. Completion ofADHD rating scales before doseadjustment helps promotemeasurement-based treatment. Theusual procedure is to begin with a lowdose of medication and titrate to thedose that provides maximum benefitand minimal adverse effects. Coresymptom reduction can be seenimmediately with stimulantmedication initiation, butimprovements in function requiremore time to manifest. Stimulantmedications can be effectively titratedwith changes occurring in a 3- to 7-day period. During the first month oftreatment, the medication dose maybe titrated with a weekly or biweeklyfollow-up. The increasing doses canbe provided either by prescriptionsthat allow dose adjustments upwardor, for some of medications, by 1prescription of tablets or capsules ofthe same strength with instructionsto administer progressively higheramounts by doubling or tripling theinitial dose.
Another approach, similar to the oneused in the MTA study,228 is forparents to be directed to administerdifferent doses of the samepreparation, each for 1 week at a time(eg, Saturday through Friday). At theend of each week, feedback fromparents and teachers and/or DSM-5–based ADHD rating scales can beobtained through a phone interview,fax, or a secure electronic system. Inaddition to the ADHD rating scale,parents and teachers can be asked to
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review adverse effects and progresson target goals.
Follow-up Visits
A face-to face follow-up visit isrecommended at about the fourthweek after starting the medication. Atthis visit, the PCC reviews the child oradolescent’s responses to the varyingdoses and monitors adverse effects,pulse, BP, and weight. To promoteprogress in controlling symptoms ismaintained, PCCs will continue tomonitor levels of core symptoms andimprovement in specified targetgoals. ADHD rating scales should becompleted at each visit, particularlybefore any changes in medicationand/or dose.
In the first year of treatment, face-to-face visits to the PCC arerecommended to occur on a monthlybasis until consistent and optimalresponse has been achieved, thenthey should occur every 3 months.Subsequent face-to-face visits will bedependent on the response; theytypically occur quarterly but need tooccur at least twice annually until it isclear that target goals are progressingand that symptoms have stabilized.Thereafter, visits occur periodically asdetermined by the family and thePCC. After several years, if the child oradolescent is doing well and wants toattempt a trial off of the medication,this can be initiated.
Results from the MTA study suggestthat there are some children who,after 3 years of medication treatment,continue to improve even if themedication is discontinued.13 Thesefindings suggest that children whoare stable in their improvement ofADHD symptoms may be given a trialoff medication after extended periodsof use to determine if medication isstill needed. This process is bestundertaken with close monitoring ofthe child’s core symptoms andfunction at home, in school, and in thecommunity. If pharmacologicinterventions do not improve thechild or adolescent’s symptoms, the
diagnosis needs to be reassessed (seeTreatment Failure section).
Whenever possible, improvements incore symptoms and target goalsshould be monitored in an objectiveway (eg, an increase from 40% goalattainment to 80% per week; see theADHD Toolkit for more information).Core symptoms can be monitoredwith 1 of the DSM-5–based ADHDrating scales.
Pediatricians and other PCCs areencouraged to educate parents thatalthough medications can be effectivein facilitating schoolwork, they havenot been shown to be effective inaddressing learning disabilities ora child’s level of motivation. A child oradolescent who continues toexperience academicunderachievement after attainingsome control of his or her ADHDbehavioral symptoms needs to beassessed for a coexisting condition.Such coexisting conditions includelearning and language disabilities,other mental health disorders, andother psychosocial stressors. Thisassessment is part of the initialassessment in children who presentwith difficulties in keeping up withtheir schoolwork and grades and whoare rated as having problems in the 3academic areas (ie, reading, writing,and math).
Treatment: Psychosocial Treatment
Two types of psychosocial treatmentsare well established for children andadolescents with ADHD, includingsome behavioral treatments andtraining.25
Behavioral Treatments
There is a great deal of evidencesupporting the use of behavioraltreatments for preschool-aged andelementary and middle school–agedchildren, including several types ofPTBM and classroom interventions(see the clinical practice guideline formore information). There aremultiple PTBM programs available,
which are reviewed in the ADHDToolkit.225
Evidence-based PTBM trainingtypically begins with 7 to 12 weeklygroup or individual sessions witha trained or certified therapist.Although PTBM treatments differ, theprimary focus is on helping parentsimprove the methods they use toreward and motivate their child toreduce the behavioral difficultiesposed by ADHD and improve theirchild’s behavior. Therapists helpparents establish consistentrelationships or contingenciesbetween the child’s specific behaviorsand the parents’ use of rewards orlogical consequences for misbehavior.These treatments typically usespecific directed praise, pointsystems, time-outs, and privileges toshape behavior. Parents learn how toeffectively communicate expectationsand responses to desirable andundesirable behaviors.
PTBM programs offer specifictechniques for reinforcing adaptiveand positive behaviors anddecreasing or eliminatinginappropriate behaviors, which alterthe motivation of the child oradolescent to control attention,activity, and impulsivity. Theseprograms emphasize establishingpositive interactions between parentsand children, shaping children’sbehaviors through praising andstrengths spotting, giving successfulcommands, and reinforcing positivebehaviors. They help parents toextinguish inappropriate behaviorsthrough ignoring, to identifybehaviors that are most appropriatelyhandled through naturalconsequences, and to use naturalconsequences in in a responsible way.
These programs all emphasizeteaching self-control and buildingpositive family relationships. Ifparents strongly disagree aboutbehavior management or havecontentious relationships, parentingprograms will likely be unsuccessful.
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Depending on the severity of the childor adolescent’s behaviors and thecapabilities of the parents, group orindividual training programs will berequired. Programs may also includesupport for maintenance and relapseprevention.
Although all effective parenting usesbehavioral techniques, applying thesestrategies to children or adolescentswith ADHD requires additional rigor,adherence, and persistence,compared with children without thedisorder. Some PTBM programsinclude additional components suchas education about ADHD,development and other related issues,motivational interviewing, andsupport for parents coping witha child with ADHD.
PTBM training has been modified foruse with adolescents to incorporatea family therapy approach thatincludes communication, problem-solving, and negotiation. Initiallydeveloped for adolescents witha wide range of problems,94,231 thisapproach has been modified foradolescents with ADHD.94,233 Theapproach’s effects are not as large aswith PTBM training with children, butclear benefits have been reported;this is a feasible clinic-basedapproach that warrants a referral, ifavailable.
Although PTBM training is typicallyeffective, such programs may not beavailable in many areas (see SystemicBarriers to the Care of Children andAdolescents with ADHD section in theSupplemental Information for furtherdiscussion of this issue153). Factorsthat may diminish PTBM’s effectsand/or render them ineffectiveinclude the time commitmentrequired to attend sessions andpractice the recommendations athome, particularly given othercompeting demands for the family’stime. Parental disagreements aboutimplementing the PTBM program,conflicts between parents, andseparated parents who share
caretaking responsibilities canadversely affect the results. Carefulmonitoring of progress and follow-upby the therapist or PCC can reducethe likelihood of these risks. PTBMtraining may not be covered by healthinsurance (insurance issues arediscussed in the Systemic Barriers tothe Care of Children and AdolescentsWith ADHD section).
Training Interventions
Training interventions are likely to beeffective with children andadolescents with ADHD. Theseinterventions involve targetingspecific deficiencies in skills such asstudy, organization, and interpersonalskills. Effective training approachesinvolve targeting a set of behaviorsthat are useful to the child in daily lifeand providing extensive training,practice, and coaching over anextended period of time. For somechildren, the combination ofbehavioral treatments and trainingmay be most effective. Psychosocialtreatments are applicable for childrenwho have problems with inattentiveor hyperactive/impulsive behaviorsbut do not meet the DSM-5 criteria fora diagnosis of ADHD.
Many of the behavioral and trainingtreatments described above can beprovided at school. Coaching, whichhas emerged as a treatment modalityover the last decade, can be a usefulalternative to clinic- or school-basedtreatments. There has yet to berigorous studies to support itsbenefits, although it has good facevalidity. Currently, there is nostandardized training or certificationfor coaches.
Other Considerations
PCCs can make recommendationsabout treatments that are most likelyto help a child or adolescent withADHD and discourage the use ofnonmedication treatments that areunlikely to be effective. Pediatriciansand other PCCs are encouraged todiscuss what parents have tried in the
past and what has been beneficial forthe child and his or her family.
Treatments for which there isinsufficient evidence include largedoses of vitamins and other dietaryalterations, vision and/or visualtraining, chelation, EEG biofeedback,and working memory (ie, cognitivetraining) programs.25 To date, there isinsufficient evidence to determinethat these therapies lead to changesin ADHD’s core symptoms orfunctioning. There is a lack ofinformation about the safety of manyof these alternative therapies.Although there is some minimalinformation that significant doses ofessential fatty acids may help withADHD symptoms, further study oneffectiveness, negative impacts, andadverse effects is needed before it canbe considered a recommendedtreatment.233
As noted, some therapies that areeffective for other disorders are notsupported for use with children oradolescents with ADHD. Theseinclude CBT (which has documentedeffectiveness for the treatment ofanxiety and depressive disorders),play therapy, social skills training, andinterpersonal talk therapy. Althoughit is possible that these treatmentsmay improve ADHD symptoms ina specific child or adolescent, they areless likely to do so compared toevidence-based treatments. Asa result, the PCC should discourageuse of these approaches. If theseineffective treatments are attemptedbefore evidence-based modalities,parents may erroneously concludethat all mental health treatments areineffective. For example, if CBT orplay therapy does not help theirchild’s ADHD, parents may dismissother treatments, like PTBM, whichcould be helpful. Parents also maydiscount CBT if it subsequently isrecommended for an emerginganxiety disorder.
Pediatricians and other PCCs areunlikely to be effective in providing
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psychosocial treatment unless theyare specifically trained, have trainedstaff, are colocated with a therapist,or dedicate multiple visits toproviding this treatment. Cliniciansmay have difficulty determining if thetherapists listed in the patient’shealth insurance plan have therequisite skills to provide evidence-based, psychosocial ADHD-relatedtreatment. This determination isimportant because many therapistsfocus on a play therapy orinterpersonal talk therapy, whichhave not been shown to be effectivein treating the impairmentsassociated with ADHD.
Pediatricians and other PCCs maywant to develop a resource list of localtherapists, agencies, and other mentalhealth clinicians who can treat theseimpairments. Clinicians might requestreferences from other parents ofchildren with ADHD, professionalorganizations (eg, the Association forBehavioral and Cognitive Therapies),and ADHD advocacy organizations (eg,CHADD). Parents who have readauthoritatively written books aboutpsychosocial treatment may be ina better position to know what theyare looking for in a therapist. Some ofthese resources are available in theADHD Toolkit225 and in ADHD: WhatEvery Parent Needs to Know226 as wellas other online sources.226,234–236
Unfortunately, lack of insurancecoverage, availability, and accessibilityof effective services may limit theimplementation of this process (seeSystemic Barriers to the Care ofChildren and Adolescents with ADHDsection in the SupplementalInformation for further discussion).
Treatment: Collaborate With Schoolto Enhance Support and Services
School-based approaches havedemonstrated both short- andlong-term benefits for at least 1 yearbeyond treatment.95,97 Schools canimplement behavioral or traininginterventions that directly targetADHD symptoms and interventions to
enhance academic and socialfunctioning. Schools may usestrategies to enhance communicationwith families, such as daily behaviorreport cards. All schools should havespecialists (eg, school psychologists,counselors, special educators) whocan observe the child or adolescent,identify triggers and reinforcers, andsupport teachers in improving theclassroom environment. Schoolspecialists can recommendaccommodations to address ADHDsymptoms, such as untimed testing,testing in less distractingenvironments, and routine reminders.As children and adolescents get older,their executive functioning skillscontinue developing. Thus, theirdelays may decrease, and they may nolonger need the accommodations.Alternatively, further interventionmay be indicated to facilitate thedevelopment of these independentskills.
It is helpful for PCCs to be aware ofthe eligibility criteria for 504Rehabilitation Act and the IDEAsupport in their state and local schooldistricts.143 It is helpful tounderstand the process for referraland the specific individuals to contactabout these issues. Providing thisinformation to parents will supporttheir efforts to secure classroomadaptations for their child oradolescent, including the use ofempirically supported academicinterventions to address theachievement difficulties that are oftenassociated with ADHD symptoms.
Educate Parents About SchoolServices
School is often the place where manyproblems of a child or adolescentwith ADHD occur. Although servicesare available through specialeducation, IDEA, and Section 504plans, classroom teachers can helpstudents with ADHD. Students withADHD are most likely to succeed ineffectively managed classrooms inwhich teachers provide engaging
instruction, support their students,and implement rules consistently.School staff can sometimes consultwith classroom teachers to help themimprove their skills in these areas. Inmany schools, parents can ask theprincipal for a specific teacher fortheir child the followingacademic year.
In some schools, teachers mayimplement activities to help a studentbefore he or she is considered forspecial services, including a dailyreport card, organizationinterventions, behavioral pointsystems, and coordinating with theparents, such as using Web sites orportal systems for communication.Individualized behavioralinterventions, if implemented welland consistently, are some of the mosteffective interventions for childrenwith ADHD. In addition toindividualized interventions,encouraging parents to increasecommunication with the teacher canhelp parents reinforce desirablebehavior at school.
If these approaches are not adequateor teachers are unwilling to providethem, parents can be encouraged towrite to the principal or the directorof special education requesting anevaluation for special educationservices. An evaluation from a PCCcan help this evaluation process but isunlikely to replace it. A child who hasan ADHD diagnosis may be eligiblefor special education services in thecategory of “other health impaired.”Depending on the specific nature ofa child’s impairment at school, he orshe may be eligible for the categoriesof “emotional and behavioraldisorders” or “specific learningdisability.” The category of eligibilitydoes not affect the services availableto the child but usually reflect thenature of the problems that resultedin his or her eligibility for specialeducation services.
Although a PCC may recommend thata child is eligible for special education
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and specific services, these are onlyrecommendations, as specificevaluation procedures and criteria foreligibility are determined by eachschool district within federalguidelines. If the ADHD is severe andinterfering with school performance,services are usually provided underthe other health impaired category. Itis important for PCCs to avoid usinglanguage in the report that couldalienate people in the school or createconflict between the parents andschool staff. After school staffcomplete the evaluation, a meetingwill be held to review the results ofall evaluation information (includingthe PCC report) and determine thestudent’s eligibility for an IEP ora 504 plan. If they wish, the parentsmay invite others to attend themeeting. Some communities haveindividuals who are trained to helpparents effectively advocate forservices; being aware of existingresources, if they exist, can help thePCC refer parents to them. Additionaldetails about eligibility are usuallyavailable on the Web sites of theschool district and the statedepartment of education.
A PCC can help educate the parentsabout the types of services they canrequest at the meeting. There aregenerally 2 categories of services.Some of the most common servicesare often referred to asaccommodations, including extendingtime on tests, reducing homework, orproviding a child with class notesfrom the teacher or a peer. Theseservices reduce the expectations fora child and can quickly eliminateschool problems. For example, ifa child is failing classes because he orshe is not completing homework andthe teacher stops assigning the childhomework, then the child’s grade inthe class is likely to improve quickly.Similarly, parent-child conflictregarding homework will quicklycease. Although these outcomes aredesirable, if discontinuing theexpectation for completing
homework results does not helpimprove the student’s ability toindependently complete tasks outsideschool, which is an important lifeskill, it may not be beneficial.Although appealing, these servicesmay not improve and in some casesmay decrease the child’s long-termcompetencies. They need to beconsidered with this in mind.
The second set of services consists ofinterventions that enhance thestudent’s competencies. These takemuch more work to implement thanthe services described above and donot solve the problem nearly asquickly. Although appealing, theseservices may decrease the child’slong-term competencies if they are notcombined with interventions that areaimed at improving the student’s skillsand behaviors. Accommodations needto be considered with this broadercontext in mind. The advantage ofinterventions is that many studentsimprove their competencies andbecome able to independently meetage-appropriate expectations overtime (for more information on thisapproach, see information on the LifeCourse Model237).238 Interventionsinclude organization interventions,daily report cards, and training studyskills. The following school-basedinterventions have been found to beeffective in improving academic andinterpersonal skills for students withADHD: Challenging HorizonsProgram,95 Child Life and AttentionSkills Program,239 and Homework andOrganization Planning Skills.96 If theseare available in area schools, it isimportant to encourage their use.
V. AGE-RELATED ISSUES
V a. Preschool-Aged Children (Age4 Years to the Sixth Birthday)
Clinicians can initiate treatment ofpreschool-aged children with ADHD(ie, children age 4 years to the sixthbirthday) with PTBM training andassess for other developmentalproblems, especially with language. If
children continue to have moderate-to-severe dysfunction, the PCC needsto reevaluate the extent to which theparents can implement the therapy;the PCC can also consider prescribingmethylphenidate, as describedpreviously. Titration should start witha small dose of immediate-releasemethylphenidate becausepreschool-aged children metabolizemedication at a slower rate. Theyhave shown lower optimalmilligrams-per-kilogram daily dosesthan older children and may be moresensitive to emotional side effectssuch as irritability and crying.83,98
Currently, dextroamphetamine is theonly FDA-approved ADHD medicationto treat preschool-aged children.However, when dextroamphetaminereceived FDA approval, the criteriawere less stringent than they are now,so there is only sparse evidence tosupport its safety and efficacy in thisage group. There is more abundantevidence that methylphenidate is safeand efficacious for preschool-agedchildren with ADHD. For this reason,methylphenidate is the first-linerecommended ADHD medicationtreatment of this age group despitenot having FDA approval.28
The Preschool ADHD TreatmentStudy,83 the landmark trialdocumenting methylphenidate’ssafety and efficacy in this age group,included children with moderate-to-severe dysfunction. Therefore, therecommendation for methylphenidatetreatment is reserved for childrenwith significant, rather than mild,ADHD-related impairment. In thePreschool ADHD Treatment Studytrial, moderate-to-severe impairmentwas defined as having symptomspresent for at least 9 months andclear impairment in both the homeand child care and/or preschoolsettings that did not respond to anappropriate intervention.
There is limited published evidence ofthe safety and efficacy for thepreschool-aged group of atomoxetine,
22
extended-release guanfacine, orextended-release clonidine. None ofthese nonstimulant medications haveFDA approval for this age group.47
V b. Adolescents (Age 12 Years to the18th Birthday)
Pediatricians and other PCCs mayincrease medication adherence andengagement in the treatment processby closely involving adolescents (age12 years to the 18th birthday) inmedication treatment decisions.Collaborating with the adolescent todetermine if the medication isbeneficial can help align outcomemeasures with the adolescent’s owngoals. Special attention ought to bepaid to provide medication coverageat times when the adolescent mayexhibit risky behaviors, such as whenhe or she is driving or spendingunsupervised time with friends.Longer-acting or late-afternoonadministration of nonstimulantmedications or short-actingmedications may be helpful.
If pediatricians and other PCCs begintransitioning children to beincreasingly responsible for treatmentdecisions during early adolescence,then transitioning to a primary carephysician who specializes in care foradults will be a natural continuation ofthat process when the adolescentreaches the highest grades in highschool. Preparation for the transitionto adulthood is an important step thatincludes planning for transferring care,adapting treatment to new activitiesand schedules, and educating thepatient about effective ways to obtaininsurance and engage in services.
Counseling for adolescents aroundmedication issues needs to includedealing with resistance to treatmentand empowering the patient to takecharge of and own his or hermedication management as much aspossible. Techniques of motivationalinterviewing may be useful inimproving adherence.240
In addition to the numerousdevelopmental changes encountered
when working with adolescents, PCCsshould assess adolescent patientswith ADHD for symptoms ofsubstance use or abuse beforebeginning medication treatment. Ifsubstance use is revealed, the patientshould stop the use. Referral fortreatment of substance use must beprovided before beginning treatmentof ADHD (see the clinical practiceguideline). Pediatricians and otherPCCs should pay careful attention topotential substance use and misuseand diversion of medications.Screening for signs of substance useis important in the care of alladolescents and, depending on theamount of use, may lead a PCC torecommend treatment of substanceuse. Extensive use or abuse mayresult in concerns about continuingmedication treatment of ADHD untilthe abuse is resolved. Similarconcerns and consideration ofdiscontinuing medication treatmentof ADHD could emerge if there isevidence that the adolescent ismisusing or diverting medications forother than its intended medicalpurposes. Pediatricians and otherPCCs are encouraged to monitorsymptoms and prescription refills forsigns of misuse or diversion of ADHDmedication. Diversion of ADHDmedication is a special concernamong adolescents.132
When misuse or diversion isa concern, the PCC might considerprescribing nonstimulant medicationswith much less abuse potential, suchas atomoxetine, extended-releaseguanfacine, or extended-releaseclonidine. It is more difficult but notimpossible to extract themethylphenidate or amphetamine forabuse from the stimulant medicationslisdexamfetamine, dermalmethylphenidate, and osmotic-releaseoral system methylphenidate,although these preparations still havesome potential for abuse or misuse.
PCCs should be aware that short-acting, mixed amphetamine salts arethe most commonly misused or
diverted ADHD medication. It isimportant to note that diversion andmisuse of ADHD medications may becommitted by individuals who haveclose contact with or live in the samehouse as the adolescent, notnecessarily by the adolescent him- orherself; this is especially true forcollege-aged adolescents.Pediatricians and other PCCs areencouraged to discuss safe storagepractices, such as lockboxes forcontrolled substances, when used bycollege-aged adolescents.
VI. MONITORING
Pediatricians and other PCCs shouldregularly monitor all aspects of ADHDtreatment, including the following:
• systematic reassessment of coresymptoms and function;
• regular reassessment of targetgoals;
• family satisfaction with the care itis receiving from other cliniciansand therapists, if applicable;
• provision of anticipatory guidance,further child or adolescent andfamily education, and transitionplanning as needed andappropriate;
• occurrence and quality of carecoordination to meet the needs ofthe child or adolescent and family;
• confirmation of adherence to anyprescribed medication regimen,with adjustments made as needed;
• HR, BP, height, and weightmonitoring; and
• furthering the therapeuticrelationship with the child oradolescent and empoweringfamilies and children oradolescents to be strong, informedadvocates.
Some treatment monitoring can occurduring general health care visits if thePCC inquires about the child oradolescent’s progress toward targetgoals, adherence to medication andbehavior therapy, concerns, and
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changes. This extra time andevaluation effort may generate anevaluate and management (E/M)code along with the well-child carecode and may result in an additionalcost to the family (see the section onbarriers, specifically thecompensation section153). Monitoringof a child or adolescent withinattention or hyperactivity/impulsivity problems can help toensure prompt treatment shouldsymptoms worsen to the extent thata diagnosis of ADHD is warranted.
As treatment proceeds, in addition tousing a DSM-5–based ADHD ratingscale to monitor core symptomchanges, the PCC can make formaland informal queries in the areas offunction most commonly affected byADHD: academic achievement; peer,parent, or sibling relationships; andrisk-taking behavior. Progress can bemeasured by monitoring the targetgoals established in collaborationwith the child and family. Checklistscompleted by the school can facilitatemedication monitoring. Data from theschool, including ADHD symptomratings completed by the teacher aswell as grades and any other formaltesting, are helpful at these visits.Screening for substance use and sleepproblems is best continuedthroughout treatment because these
problems can emerge at any time. Atevery visit, it is helpful to graduallyfurther empower children to becomefull partners in their treatment planby adolescence.
In the early stages of treatment, aftera successful titration period, thefrequency of follow-up visits willdepend on adherence, coexistingconditions, family willingness, andpersistence of symptoms. As noted,a general guide for visits to the PCC isfor these visits to occur initially ona monthly basis, then at least quarterlyfor the first year of treatment. Morefrequent visits may be necessary ifcomorbid conditions are present. Visitsthen need be held preferably quarterlybut at least twice each year, withadditional phone contact monitoring atthe time of medication refill requests.Ongoing communication with theschool regarding medication andservices is needed.
There is little evidence establishingthe optimal, practical follow-upregimen. It is likely that the regimenwill need to be tailored to theindividual child or adolescent andfamily needs on the basis of clinicaljudgment. Follow-up may incorporateelectronic collection of rating scales,telehealth, or use of remotemonitoring of symptoms andimpairment. The time-intensive
nature of this process, insurancerestrictions, and lack of payment maybe significant barriers to adoption(see Systemic Barriers to the Care ofChildren and Adolescents with ADHDsection in the SupplementalInformation for more information onthis issue).
(See the ADHD guideline’s KAS 4.)
VI A. TREATMENT FAILURE
ADHD treatment failure may be a signof inadequate dosing, lack of patientor family information or compliance,and/or incorrect or incompletediagnosis. Family conflict andparental psychopathology can alsocontribute to treatment failure.
In the event of treatment failure, thePCC is advised to repeat the fulldiagnostic evaluation with increasedattention to the possibility of anothercondition or comorbid conditions thatmimic or are associated with ADHD,such as sleep disorders, autismspectrum disorders, or epilepsy (eg,absence epilepsy or partial seizures).Treatment failure may also arise froma new acute stressor or from anunrecognized or underappreciatedtraumatic event. A coexisting learningdisability may cause an apparenttreatment failure. In the case ofa child or adolescent previously
SUPPLEMENTAL FIGURE 8Monitoring.
24
diagnosed with problem-levelinattention or hyperactivity, repeatingthe diagnostic evaluation may resultin a diagnosis of ADHD, which wouldallow for increased school supportand the inclusion of medication in thetreatment plan. A forthcomingcomplex ADHD guideline from theSDBP will provide additionalinformation on diagnostic evaluationand treatment of children andadolescents with ADHD treatmentfailure and/or ADHD that iscomplicated by coexistingdevelopmental or mental healthconditions.
Treatment failure could result frompoor adherence to the treatment plan.Increased monitoring and education,especially by including the patient,may increase adherence. It is helpfulto try to identify the issues restrictingadherence, including lack ofinformation about or understandingof the treatment plan. It is alsoimportant to recognize that culturalfactors may impact the patient’streatment and outcomes.
If the child continues to struggledespite the school’s interventions andtreatment of ADHD, furtherpsychoeducational,neuropsychological, and/or languageassessments are necessary toevaluate for a learning, language, orprocessing disorder. The clinicianmay recommend evaluation by anindependent psychologist orneuropsychologist.
VII. CHILDREN AND ADOLESCENTS FORWHOM AN ADHD DIAGNOSIS IS NOTMADE
If the evaluation identifies or suggestsanother disorder is the cause of theconcerning signs and symptoms, it isappropriate to exit this algorithm.
VII a. Other Condition
The subsequent approach is dictatedby the evaluation’s results. If the PCChas the expertise and ability toevaluate and treat the other or
comorbid condition, he or she may doso. Many collaborative care modelsexist to help facilitate a pediatrician’scomfort with comorbidity, as well asprograms that teach pediatricians tomanage comorbidities. It is importantfor the PCC to frame the referralquestions clearly if a referral is made.A comanagement plan must beestablished that addresses thefamily’s and child or adolescent’songoing needs for education andgeneral and specialty health care.Resources from the AAP MentalHealth Initiatives and the forthcomingcomplex ADHD clinical practiceguideline from the SDBP may behelpful.67,133,241
VII b. Apparently Typical orDevelopmental Variation
Evaluation may reveal that the childor adolescent’s inattention, activitylevel, and impulsivity are within thetypical range of development, mildlyor inconsistently elevated incomparison with his or her peers, oris not associated with any functionalimpairment in behavior, academics,social skills, or other domains. Theclinician can probe further todetermine if the parents’ concerns areattributable to other issues in thefamily, such as parental tension ordrug use by a family member;whether they are caused by otherissues in school, such as socialpressures or bullying; or whetherthey are within the spectrum oftypical development.
In talking with parents, it may help toexplain that ADHD differs froma condition like pregnancy, which isa “yes” or “no” condition. With ADHD,behaviors follow a spectrum fromvariations on typical behavior, toatypical behaviors that causeproblems but are not severe enoughto be considered a disorder, toconsistent behaviors that are severeenough to be considered a disorder.With problematic behaviors, it ishelpful for the PCC to provideeducation about both the range of
typical development and strategies toimprove the child or adolescent’sbehaviors. A schedule of enhancedsurveillance absolves the family of theneed to reinitiate contact if thesituation deteriorates. Ifa recommendation for continuedroutine systematic surveillance ismade by the PCC, it is important toprovide reassurance that ongoingconcerns can be revisited at futureprimary care visits.
VII c. Children and Adolescents WithInattention or Hyperactivity/Impulsivity(Problem Level)
Children and adolescents whosesymptoms do not meet the criteria fordiagnosis of ADHD may stillencounter some difficulties or mildimpairment in some settings, asdescribed in the DSM-PC, Child andAdolescent Version.49 For thesepatients, enhanced surveillance isrecommended. PCCs are encouragedto provide education for both thepatient and his or her family,specifically about triggers forinattention and/or hyperactivity aswell as behavior managementstrategies.
Medication is not appropriate forchildren and adolescents whosesymptoms do not meet DSM-5 criteriafor diagnosis of ADHD, but PTBMdoes not require a diagnosis of ADHDto be recommended.
VIII. COMPLEMENTARY ANDALTERNATIVE THERAPIES AND/ORINTEGRATIVE MEDICINE
Families of children and adolescentswith ADHD increasingly ask theirpediatrician and other PCCs aboutcomplementary and alternativetherapies. These includemegavitamins and other dietaryalterations, vision and/or visualtraining, chelation, EEG biofeedback,and working memory (eg, cognitivetraining) programs.242 As noted, thereis insufficient evidence to suggest thatthese therapies lead to changes inADHD’s core symptoms or function.
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For many complementary andalternative therapies, limitedinformation is available about theirsafety. Both chelation andmegavitamins have been proven tocause adverse effects and arecontraindicated.243,244 For these
reasons, complementary and alternativetherapies are not recommended.
Pediatricians and other PCCs can playa constructive role in helping familiesmake thoughtful treatment choices byreviewing the goals and/or effects
claimed for a given treatment, thestate of evidence to support ordiscourage use of the treatment, andknown or potential adverse effects. Iffamilies are interested in tryingcomplementary and alternativetreatments, it is helpful to have them
SUPPLEMENTAL FIGURE 9Children and adolescents for whom an ADHD diagnosis is not made. CYSHCN, children and youth with special health care needs.
26
define specific measurable goals tomonitor the treatment’s impact.Families also need to be stronglyencouraged to use evidence-basedinterventions while they explorecomplementary and alternativetreatments. PCCs have to respectfamilies’ interests and preferenceswhile they address and answerquestions about complementary andalternative therapies.
Pediatricians and other PCCs shouldask about additional therapies thatfamilies may be administering toadequately monitor for druginteractions. Parents and children oradolescents who do not feel that theirchoices in health care arerespected by their PCCs may be lesslikely to communicate aboutcomplementary or alternativetherapies and/or integrativemedicine.
IX. IMPLEMENTATION ISSUES:PREPARING THE PRACTICE
Implementation of the processdescribed in this algorithm can beenhanced with preparation of thepractice to meet the needs of childrenand adolescents with ADHD. Thispreparation includes both internalpractice characteristics andrelationships within the community.(More detail can be found in the AAPMental Health Initiatives’resources.133,245)
The following office procedures andresources will help practices facilitatethe steps in this algorithm:
• developing a packet of ADHDquestionnaires and rating scales forparents and teachers to completebefore a scheduled visit;
• allotting adequate time for ADHD-related visits;
• determining billing anddocumentation procedures andmonitoring insurance payments toappropriately capture the servicesrendered to the extent possible;
• implementing methods to track andfollow patients (see SystemicBarriers to the Care of Children andAdolescents with ADHD section inthe Supplemental Information formore information on this issue);
• asking questions during all clinicalencounters and promoting patienteducation materials (ie, brochuresand posters) that alert parents andpatients that appropriate issues todiscuss with the PCC includeproblem behaviors, schoolproblems, and concerns aboutattention and hyperactivity;
• developing an office system formonitoring and titratingmedication, includingcommunication with parents andteachers. For stimulantmedications, which are controlledsubstances requiring new, monthlyprescriptions, it is necessary todevelop a monitoring and refillprocess including periodic reviewof the state’s database of controlledsubstance prescriptions (any suchsystem is based on the PCC’sassessment of family organization,phone access, and parent-teachercommunication effectiveness); and
• using the ADHD Toolkit resources.
Establishing relations with schools andother agencies can facilitatecommunication and establish clearexpectations when collaborating oncare for a child. A community-levelsystem that reflects consensus amongdistrict school staff and local PCCs forkey elements of diagnosis,interventions, and ongoingcommunication can help to provideconsistent, well-coordinated, and cost-effective care. A community-basedsystem with schools relieves theindividual PCC from negotiating witheach school about care andcommunication regarding each patient.Offices that have incorporated medicalhome principles are ideal forestablishing this kind of community-level system. Although achieving thelevel of coordination described below
is ideal and takes consistent effort overthe years, especially in areas withmultiple separate school systems,some aspects may be achievedrelatively quickly and will enhanceservices for children.
The key elements for a community-based collaborative system includeconsensus on the following:
• a clear and organized process bywhich an evaluation can beinitiated when concerns areidentified either by parents orschool personnel;
• a packet of information completedby parents and teachers about eachchild and/or adolescent referred tothe PCC;
• a contact person at the practice toreceive information from parentsand teachers at the time ofevaluation and during follow-up;
• an assessment process toinvestigate coexisting conditions;
• a directory of evidence-basedinterventions available in thecommunity;
• an ongoing process for follow-upvisits, phone calls, teacher reports,and medication refills;
• availability of forms for collectingand exchanging information;
• a plan for keeping school staffand PCCs up to date on theprocess; and
• awareness of the network of mentalhealth providers in your area andestablishments of collaborativerelationships with them.
The PCC may face challenges todeveloping such a collaborativeprocess. For example, a PCC istypically caring for children frommore than 1 school system, a schoolsystem may be large and not easilyaccessed, schools may have limitedstaff and resources to completeassessments, or scheduling may makeit difficult for the PCC tocommunicate with school personnel.Further complicating these efforts is
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the fact that many providersencounter a lack of recognition andpayment for the time involved incoordinating care. These barriers mayhamper efforts to provide the internalresources within a practice andcoordination across schools and otherproviders that are described above;nevertheless, some pediatricians andother PCCs have found ways to lessensome of these obstacles (see SystemicBarriers to the Care of Children andAdolescents with ADHD section in theSupplemental Information for moreinformation on overcomingchallenges).
In the case of multiple or large schoolsystems in a community, the PCC maywant to begin with 1 schoolpsychologist or principal, or severalpractices can initiate contactcollectively with a community schoolsystem. Agreement among theclinicians on the components of a goodevaluation process facilitatescooperation and communication withthe school toward common goals.Agreement on behavior rating scalesused can facilitate completion byschool personnel. Standardcommunication forms that monitorprogress and specific interventions can
be exchanged among the school andthe pediatric office to shareinformation. Collaborative systems canextend to other providers who maycomanage care with a PCC. Suchproviders may include a mental healthprofessional who sees the child oradolescent for psychosocialinterventions or a specialist to addressdifficult cases, such asa developmental-behavioralpediatrician, child and adolescentpsychiatrist, child neurologist,neurodevelopmental disabilityphysician, or psychologist. The AAPMental Health Initiatives provide a fulldiscussion of collaborativerelationships with mental healthprofessionals, including colocation andintegrated models, in its ChapterAction Kit and PediaLinkModule.133,241
Achieving this infrastructure in thepractice and the coordination acrossschools and other providers willenhance the PCC’s ability toimplement the treatment guidelinesand this algorithm. Achievingthese ideals is not necessary forproviding care consistent with thesepractices, however.
X. CONCLUSIONS
ADHD is the most commonneurobiological disorder of childrenand adolescents. Untreated orundertreated ADHD can have far-reaching and serious consequencesfor the child or adolescent’s healthand well-being. Fortunately, effectivetreatments are available, as aremethods for assessing and diagnosingADHD in children and adolescents.The AAP is committed to supportingprimary care physicians in providingquality care to children andadolescents with ADHD and theirfamilies. This algorithm representsa portion of that commitment and aneffort to assist pediatricians and otherPCCs to deliver care that meets thequality goals of the practiceguideline. This PoCA, in combinationwith the guideline and SystemicBarriers to the Care of Children andAdolescents With ADHD sectionbelow, is intended to provide supportand guidance in what is currently thebest evidence-based care for theirpatients with ADHD. Additionalsupport and guidance can beobtained through the work andpublications of the AAP Mental HealthInitiatives.133,241
