Latest Guidelines to Diagnose and Treat Kids with ADHD

ADHD Basics

Untreated ADHD can lead to other problems.
Untreated ADHD can lead to other problems. Charles Silvey

The American Academy of Pediatrics first released policy statements on the "Diagnosis and Evaluation of the Child With ADHD" and the "Treatment of the School-Aged Child With ADHD" in 2000 and 2001. Together, they offered physicians evidence-based recommendations to diagnose and treat their patients with ADHD.

They were finally replaced in 2011 with the policy statement,"ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents."

These ADHD guidelines now include recommendations for evaluating and treating children between the ages of 4 and 18 years, a more expanded scope than the more narrow focus of the previous guidelines that didn't include younger children or teens.

Diagnosing Kids with ADHD

Parents are sometimes surprised that diagnosing kids with ADHD is sometimes a little more subjective than they imagine. After all, there isn't a definitive blood test or x-ray that you can do that can say your child has ADD or ADHD.

Instead, pediatricians use questionnaires to check and make sure that a child meets the criteria of the "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition."

Who should they check?

Any child with "with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity."

In addition to meeting ADHD criteria, to be diagnosed with ADHD, their symptoms should be causing an impairment and shouldn't be caused by another condition, such as anxiety, sleep apnea, or a learning disorder, etc.

The Latest ADHD Treatment Guidelines

Among the conclusions and recommendations that are stated in this policy statement are that attention deficit hyperactivity disorder should be recognized as a chronic condition and that a child-specific, individualized treatment program should be developed for children with a goal of maximizing function to improve relationships and performance at school, decrease disruptive behaviors, promote safety, increase independence and improve self esteem.

Other recommendations include that stimulant medications and/or behavior therapy are appropriate and safe treatments for ADHD and that children should have regular and systematic follow-up to monitor goals and possible side effects. One of the strongest, and I think most helpful, recommendations in the policy statement is what to do with children who don't respond to standard treatments. Too often, if a child doesn't respond to a medication or continues to have problems, the treatment is stopped and he is left to continue to do poorly at school, have behavior problems and poor relationships with others. Instead, the AAP recommends that 'when the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions.'

For children with ADHD who continue to have problems with core symptoms, including inattention, hyperactivity, and impulsivity, if medication wasn't part of the initial treatment plan, then a stimulant medication should be considered and behavior therapy should be reinforced.

Children who are already on a stimulant medication and are doing poorly or having side effects, they may be changed to a different stimulant medication.

Many of the statements and conclusions of this policy statement should be reassuring to parents, including that:

  • review and analysis of several studies have shown that stimulant medications do work for the core symptoms of ADHD and in many cases 'improves the child's ability to follow rules and decreases emotional overactivity, thereby leading to improved relationships with peers and parents.'
  • side effects of stimulant medications are usually 'mild and short lived,' and for parents that worry about the effects of stimulant medications on their child's growth, that there is 'no significant impairment of height attained' in adult life.

ADHD Medications

The AAP policy statement also includes a brief review of medications used in the treatment of Attention Deficit Hyperactivity Disorder, including stimulants and non-stimulants.

Stimulants include different formulations of methylphenidate:

  • short acting, such as Ritalin and Focalin, with a duration of 3-5 hours
  • intermediate acting, such as Ritalin SR, Metadate ER, and Methylin ER, with a duration of 3-8 hours
  • long acting, such as Concerta, Daytrana, Metadate CD, Focalin XR, with a duration of 8-12 hours and which can be used just once a day

The other type of stimulant includes different formulations of amphetamine:

  • short acting, such as Dexedrine and Dextrostat, with a duration of 4-6 hours intermediate acting, such as Adderall and Dexedrine spansule, with a duration of 6-8 hours
  • long acting, such as Adderall XR and Vyvanse

Many non-stimulants are also now available, including Strattera, Intuniv, and Kapvay. In general, the AAP guideline states that the quality of evidence "is particularly strong for stimulant medications and sufficient but less strong." That typically leads many pediatricians and parents to try a stimulant as a first line treatment.

Choosing an ADHD Medication

With all of the different types of ADHD medications, and many new ones, how do you choose which one to use for your child? Which one works best? In general, there is no one 'best' medicine and the AAP states that 'each stimulant improved core symptoms equally.'

The other question is what dosage to use. Unlike most other medications, stimulants are not 'weight dependent,' so a 6 year old and 12 year old might be one the same dosage, or the younger child might need a higher dosage.

Because there are no standard dosages based on a child's weight, stimulants are usually started at a low dosage and gradually increased to find a child's best dose, which 'is the one that leads to optimal effects with minimal side effects.' These side effects can include a decreased appetite, headaches, stomachaches, trouble getting to sleep, jitteriness, and social withdrawal, and can usually be managed by adjusting the dosage or when the medication is given. Other side effects may occur in children on too high a dosage or those that are overly sensitive to stimulants and might cause them to be 'overfocused on the medication or appear dull or overly restricted.' Some parents are resistant to using a stimulant because they don't want their child to be a 'zombie,' but it is important to remember that these are unwanted side effects and can usually be treated by lowering the dosage of medication or changing to a different medication.

And because 'at least 80% of children will respond to one of the stimulants,' if 1 or 2 medications don't work or have unwanted side effects, then a third might be tried. If a child continues to respond poorly to treatment, then a reevaluation might be necessary to confirm the diagnosis of ADHD or look for coexisting conditions, such as oppositional defiant disorder, conduct disorder, anxiety, depression, and learning disabilities.

Other ADHD Treatments

In addition to stimulants, the policy statements recommends the use of behavior therapy, which might include parent training and '8-12 weekly group sessions with a trained therapist' to change the behavior at home and in the classroom for children with ADHD. Other psychological interventions, including play therapy, cognitive therapy or cognitive-behavior therapy, have not been proven to work as well as a treatment for ADHD.

Other interesting facts about ADHD mentioned in this policy statement include that:

  • 60-80% of children with ADHD continue to have symptoms in adolescence
  • 4-12% of school age children are thought to have ADHD
  • Commonly used stimulants do not require 'serologic, hematologic or electrocardiogram monitoring.' Although monitoring of liver function tests was required for children taking Cylert (which isn't commonly used anymore), the use of other stimulants doesn't require any routine blood tests.
  • Stimulants can cause unpredictable effects on motor tics, which transiently occur in 15-30% of children taking stimulants, but the 'presence of tics before or during medical management of ADHD is not an absolute contradindication to the use of stimulant medications.'

    The AAP "Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents" is very helpful for physcians taking care of children with this challenging and often controversial disorder. It can also help to educate parents about what treatment options are available, and when they should seek additional help.

     

    Sources:

    ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics Nov 2011, 128 (5) 1007-1022.

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