cont. from

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

METHODOLOGY

The AAP collaborated with several organizations to develop a working subcommittee representing a wide range of primary care and subspecialty groups. The subcommittee, chaired by 2 general pediatricians, included representatives from the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, the Child Neurology Society, the Society for Pediatric Psychology, the Society for Developmental and Behavioral Pediatrics, and the Society for Developmental Pediatrics.

This subcommittee met over a period of 3 years, during which it reviewed basic literature on current practices in the treatment of children with ADHD. The subcommittee developed a series of research questions to direct an extensive evidence-based review, in partnership with the Agency for Healthcare Research and Quality.

In 1997, the McMaster University Evidence-based Practice Center received the contract for reviewing the literature related to treatment of children with ADHD. The McMaster report2 focused on the evidence from comparative studies on the effectiveness and safety of pharmacological and nonpharmacological interventions for ADHD in children and adults and whether combined interventions are more effective than individual interventions. This resulted in several questions in the following 7 areas: 1) studies with drug-to-drug comparisons of pharmacological interventions; 2) placebo-controlled studies evaluating the effect of tricyclic antidepressants; 3) studies comparing pharmacological and nonpharmacological interventions; 4) studies evaluating the effect of long-term therapies; 5) studies evaluating therapies for ADHD in adults (ie, those older than 18 years of age); 6) studies evaluating therapies given in combination; and 7) studies evaluating adverse effects of pharmacological interventions.

Several systematic reviews and meta-analyses have examined placebo-controlled trials of stimulant medication and have established the short-term efficacy of these agents for core symptoms. Placebo-controlled trials of stimulant medication were reviewed in the McMaster report only if they met the criteria for inclusion in any of the other 6 areas. The report also focused on head-to-head comparisons of pharmacological interventions and of pharmacological and nonpharmacological interventions because these were identified as of prime interest to clinicians.

The McMaster report of the literature on treatment of ADHD followed current standards for analyzing research evidence.2 Studies in this report were selected for evaluation if they were randomized, controlled trials that focused on the treatment of ADHD in humans and if they were published in peer-reviewed journals. Nonrandomized, controlled trials were included only if they provided data on adverse effects that were collected for more than 16 weeks. Studies of multiple conditions that included separate analyses for patients with ADHD were also included. The literature search was conducted using MEDLINE (from 1966), CINAHL (from 1982), HEALTHStar (from 1975), PsycINFO (from 1984), and EMBASE (from 1984). The Cochrane Library (issue 4, 1997) was also used in reviewing the literature. A total of 2405 citations were identified by the search strategies, and 92 reports, describing 78 different studies, were identified for further analysis.

In addition to the McMaster report, other sources of data were used to support clinical practice guideline recommendations. Although the McMaster report included results of the multimodal treatment study of children with ADHD (MTA),^3,7 the subcommittee also carefully evaluated the results of this large study separately.8-16 The subcommittee used data from the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) study.4 The CCOHTA review addressed the following 3 major issues related to treatment of children with ADHD: 1) a clinical evaluation of the use of methylphenidate for ADHD; 2) the efficacy of stimulant medications and other therapies; and 3) an economic evaluation of the pharmacological and behavioral therapies for ADHD. Many studies of behavioral interventions for ADHD use crossover techniques, where effects were determined on the same children when they did and did not receive treatment.⁶,¹⁷ The McMaster report excluded these crossover trials.2

The recommendations contained in this guideline (see Fig 1) are based on the best available data. For each recommendation, the subcommittee graded the quality of evidence on which the recommendation was based and the strength of the recommendation. Grades of evidence were grouped into 3 categories— good, fair, or poor. Recommendations were made at 3 levels. Strong recommendations were based on high-quality scientific evidence or, in the absence of high-quality data, strong expert consensus. Fair and weak recommendations were based on lesser quality or limited data and expert consensus. Clinical options are identified as interventions for which the subcommittee could not find compelling evidence for or against. Clinical options are defined as interventions that a reasonable health care provider might or might not wish to implement in his or her practice.

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Reviewed: 02/2006