AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder

Online version of this article contains a PDF file of "AAP Parent Pages," which can be used as a handout for patient education.

October 2001

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement

ABSTRACT. This clinical practice guideline provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline, the second in a set of policies on this condition, is intended for use by clinicians working in primary care settings. The initiation of treatment requires the accurate establishment of a diagnosis of ADHD; the American Academy of Pediatrics (AAP) clinical practice guideline on diagnosis of children with ADHD¹ provides direction in appropriately diagnosing this disorder.

The AAP Committee on Quality Improvement selected a subcommittee composed of primary care and developmental-behavioral pediatricians and other experts in the fields of neurology, psychology, child psychiatry, education, family practice, and epidemiology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University, Ontario, Canada, to develop the evidence base of literature on this topic.² The resulting systematic review, along with other major studies in this area, was used to formulate recommendations for treatment of children with ADHD. The subcommittee also reviewed the multimodal treatment study of children with ADHD³ and the Canadian Coordinating Office for Health Technology Assessment report (CCOHTA).⁴ Subcommittee decisions were made by consensus where definitive evidence was not available. The subcommittee report underwent extensive review by sections and committees of the AAP as well as by numerous external organizations before approval from the AAP Board of Directors.

The guideline contains the following recommendations for the treatment of a child diagnosed with ADHD:

• Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition.

• The treating clinician, parents, and child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.

• The clinician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD.

• 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.

• The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.

This guideline is intended for use by primary care clinicians for the management of children between 6 and 12 years of age with ADHD. In light of the high prevalence of ADHD in pediatric practice, the guideline should assist primary care clinicians in treatment. Although many of the recommendations here also may apply to children with coexisting conditions, this guideline primarily addresses children with ADHD but without major coexisting conditions. The guideline is not intended for use in the treatment of children with mental retardation, pervasive developmental disorder, moderate to severe sensory deficits such as visual and hearing impairment, chronic disorders associated with medications that may affect behavior, and those who have experienced child abuse and sexual abuse. This guideline is not intended as a sole source of guidance for the treatment of children with ADHD. Rather, it is designed to assist the primary care clinician by providing a framework for decision-making. It is not intended to replace clinical judgment or to establish a protocol for all children with this condition, and may not provide the only appropriate approach to this problem.

The American Academy of Pediatrics (AAP) recognizes the importance of accurate diagnosis and management of children with attention-deficit/hyperactivity disorder (ADHD). The AAP developed a practice guideline for the diagnosis of ADHD among children from 6 to 12 years of age who are evaluated by primary care clinicians.¹ The significant components of the diagnostic guideline include 1) the use of explicit criteria for the diagnosis using the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV) criteria⁵; ²) the importance of obtaining information about the child's symptoms in more than 1 setting (especially from schools); and 3) the search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

This guideline is based on an extensive review of the medical, psychological, and educational literature. The objectives of the literature review were to determine the long- and short-term effectiveness and safety of pharmacological and nonpharmacological interventions for ADHD in children from 6 to 12 years of age, and to compare single treatment methods (eg, medications alone) with combined management strategies. Two systematic, evidence-based reviews were used extensively in the development of this guideline.2,4 In addition, other resources were used to gather more information.^6,7

Primary care clinicians cannot work alone in the treatment of school-aged children with ADHD. Ongoing communication with parents, teachers, and other school-based professionals is necessary to monitor the progress and effectiveness of specific interventions. Parents are key partners in the management plan as sources of information and as the child's primary caregiver. Integration of services with psychologists, child psychiatrists, neurologists, educational specialists, developmental-behavioral pediatricians, and other mental health professionals may be appropriate for children with ADHD who have coexisting conditions and may continue to have problems in functioning despite treatment. Attention to the child's social development in community settings other than school requires clinical knowledge of a variety of activities and services in the community.

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Reviewed: 02/2006