cont. from

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

RECOMMENDATION 1: Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong).

Attention-deficit/hyperactivity disorder is one of the more common chronic conditions of childhood. Studies using parent reports indicate persistence of ADHD of 60% to 80% into adolescence.18-20 Given the high prevalence of ADHD among school-aged children (4% to 12%),1 primary care clinicians will encounter children with ADHD in their practices regularly and should have a strategy for diagnosis and long-term management of this condition. The primary care of children with ADHD includes attention to the main principles of care for children with any chronic condition, such as

• Providing information about the condition

• Updating and monitoring family knowledge and understanding on a periodic basis

• Counseling about family response to the condition

• Developmentally appropriate education of the child about ADHD, with updates as the child grows

• Availability to answer family questions

• Ensuring coordination of health and other services

• Helping families set specific goals in areas related to the child's condition and its effects on daily activities

• Linking families with other families with children who have similar chronic conditions as needed and available^21-26

As with other chronic conditions, treatment of ADHD requires the development of child-specific treatment plans that describe methods and goals of treatment and means of monitoring care over time, including specific plans for follow-up. (See Recommendation ⁵.)

Primary care clinicians should educate parents and children about the ways in which ADHD can affect learning, behavior, self-esteem, social skills, and family function. This initial phase of patient education is critical to demystifying the diagnosis and providing parents and children with knowledge about the condition. Education enables parents to work with clinicians, educators, and, in some cases, mental health professionals to develop an effective treatment plan. A therapeutic alliance among clinicians, parents, and the child is enhanced when attention is directed toward cultural values that affect the child's health and health care. The long-term care of a child with ADHD requires an ongoing partnership among clinicians, parents, teachers, and the child. Other school personnel—nurses, psychologists, and counselors—can also help with developing and monitoring plans.

Studies of children and adults with several chronic conditions indicate better adherence to treatment plans, improved health and disease status measures, and higher levels of satisfaction in the context of a comprehensive treatment plan with specific goals, follow-up activities, and monitoring.27-28 Thus, careful attention to the key elements of chronic care can lead to improved outcomes for children and families.

Activities specific to the care of children with ADHD include providing current information on the etiology of ADHD, its treatment, long-term outcomes, and effects on daily life and family activities. Thorough family understanding of the problem is essential before discussing treatment options and side effects. What distinguishes this condition from most other chronic conditions managed by primary care clinicians is the important role that the education system plays in the treatment and monitoring of children with ADHD.

Like other chronic conditions, new research on ADHD will change the information available to parents and clinicians over time and fill many gaps in diagnosing and understanding the etiology, treatment, long-term effects, and complications related to ADHD. Families should have access to this information. In addition, national, grassroots, parent-run associations provide support and/or education to caregivers and families of individuals with ADHD (eg, Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD]). The clinician should be aware of community resources that provide these services and know how to make referrals. Primary care providers may offer this information directly or collaborate with other providers, especially subspecialists and mental health providers, to ensure families' access to needed information.

RECOMMENDATION 2: The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong).

The core symptoms of ADHD (ie, inattention, impulsivity, hyperactivity) can result in multiple areas of dysfunction relating to a child's performance in the home, school, or community. The primary goal of treatment should be to maximize function. Desired results include

• improvements in relationships with parents, siblings, teachers, and peers

• decreased disruptive behaviors

• improved academic performance, particularly in volume of work, efficiency, completion, and accuracy

• increased independence in self-care or homework

• improved self-esteem

• enhanced safety in the community, such as in crossing streets or riding bicycles. Target outcomes should follow from the key symptoms the child manifests and the specific impairments these symptoms cause.

The process of developing target outcomes requires input from parents, children, and teachers, as well as other school personnel where available and appropriate.29 They should agree on at least 3 to 6 key targets and desired changes as prerequisites to constructing the treatment plan. The goals should be realistic, attainable, and measurable. The methods of treatment and of monitoring change will vary as a function of the target outcomes.

RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).

The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances.

Stimulant Medication

Many studies have documented the efficacy of stimulants in reducing the core symptoms of ADHD. In many cases, stimulant medication also improves the child's ability to follow rules and decreases emotional overreactivity, thereby leading to improved relationships with peers and parents. Three formal meta-analyses^30-32 and 1 review of reviews³³ support the short-term efficacy of stimulant medications in reducing core symptoms of ADHD as well as improving function in a number of domains. The most powerful effects4 are found on measures of observable social and classroom behaviors and on core symptoms of attention, hyperactivity, and impulsivity.* The effects on intelligence and achievement tests are more modest. Most studies of stimulants have been short-term, demonstrating efficacy over several days or weeks. The MTA study extends the demonstrated efficacy to 14 months.3 In that study, 579 children 7 to 9.9 years of age with ADHD were randomized to 4 treatment groups: medication management alone, medication and behavior management, behavior management alone, and a standard community care group. The medication management groups followed specific protocols and algorithms in distinction to routine community practice based on clinicians' best judgments. School-aged children with ADHD showed a marked reduction in core ADHD symptoms over a 14-month period when they were treated with medication management alone or a combination of medication and behavior management. Eighty-five percent of the children treated with medication received a stimulant medication.3 Despite the efficacy of stimulant medications in improving behaviors, many children who receive them do not demonstrate fully normal behavior (eg, only 38% of medically managed children in the MTA study received scores in the normal range at 1-year follow-up). Although the MTA study demonstrated that efficacy of stimulants lasts at least to 14 months, the longer term effects of stimulants remain unclear, attributable in part to methodologic difficulties in other studies.³⁵

Detailed instructions for determining the dose and schedule of stimulant medications are beyond the scope of this guideline. However, a few basic principles guide the available clinical options.

Unlike most other medications, stimulant dosages usually are not weight dependent. Clinicians should begin with a low dose of medication and titrate upward because of the marked individual variability in the dose-response relationship. The first dose that a child's symptoms respond to may not be the best dose to improve function. Clinicians should continue to use higher doses to achieve better responses.3 This strategy may require reducing the dose when a higher dose produces side effects or no further improvement. The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects. The dosing schedules vary depending on target outcomes, although no consistent controlled studies compare different dosing schedules. For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient. By contrast, a need for relief of symptoms at home and school suggests a 7-day schedule.

Stimulants are generally considered safe medications, with few contraindications to their use. Side effects occur early in treatment and tend to be mild and short-lived.35 The most common side effects are decreased appetite, stomachache or headache, delayed sleep onset, jitteriness, or social withdrawal. Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication. Approximately 15% to 30% of children experience motor tics, most of which are transient, while on stimulant medications. In addition, approximately half of children with Tourette syndrome have ADHD. The effects of medication on tics are unpredictable. The presence of tics before or during medical management of ADHD is not an absolute contraindication to the use of stimulant medications.^41,42 A review of 7 studies comparing stimulants with placebo or with other medications indicated no increase in tics in children treated with stimulants.2

According to the Physicians' Desk Reference⁴³ and medication package insert, methylphenidate is contraindicated in children with seizure disorders, a history of seizure disorder, or abnormal electroencephalograms. Studies of the use of methylphenidate have not, however, demonstrated an increase in seizure frequency or severity when it is added to appropriate anticonvulsant medications.^44-46

Children who receive too high a dose or who are overly sensitive may become overfocused on the medication or appear dull or overly restricted. Many times this side effect can be addressed by lowering the dose. Rarely, with high doses, some children experience psychotic reactions, mood disturbances, or hallucinations.

No consistent reports of behavioral rebound, motor tics, or dose-related growth delays have been found in controlled studies,47 although they are reported clinically.33 Appetite suppression and weight loss are common side effects of stimulant medication, with no apparent difference between methylphenidate and dextroamphetamine. Concern for growth delay has been raised, but a prospective follow-up study into adult life48 has found no significant impairment of height attained. Studies of stimulant use have found little or no decrease in expected height, with any decrease in growth early in treatment compensated for later on.^49,54 Many clinicians recommend drug holidays during summers, although no controlled trials exist to indicate whether holidays have gains or risks, especially related to weight gain.

3A: For children on stimulants, if one stimulant does not work at the highest feasible dose, the clinician should recommend another.

At least 80%³ of children will respond to one of the stimulants if they are tried in a systematic way. Children who fail to show positive effects or who experience intolerable side effects on one stimulant medication should be tried on another of the recommended stimulant medications. The reasons for this recommendation include the following:

• The finding that most children who fail to respond to one medication will have a positive response to an alternative stimulant

• The safety and efficacy of stimulants in the treatment of ADHD compared with nonstimulant medications

• The numerous crossover trials that indicate the efficacy of different stimulants in the same child^2,4

• The idiosyncratic responses to medication⁵⁵

Children who fail 2 stimulant medications can be tried on a third type or formulation of stimulant medication for the same reason. (As indicated in Recommendation 4, lack of response to treatment also should lead clinicians to assess the accuracy of the diagnosis and the possibility of undiagnosed coexisting conditions.)

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Reviewed: 02/2006