Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline’s recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians’ ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.
Updates to the guidelines include:
- Changing the age at which symptoms need to have first started. Previously, symptoms needed to begin before age 7. That’s now been raised to age 12.
- In patients older than 17, fewer problem behaviors are needed to make an ADHD diagnosis. Wolraich said as children get older, symptoms can change and behaviors such as hyperactivity usually diminish.
- Emphasizing the need to rule out other causes of ADHD-like symptoms and to identify other conditions that may occur with ADHD, such as depression, anxiety, substance use, autism or trauma.
- Highlighting the need for ongoing medical care and coordination within the school and community.
- Recommending parent training in behavior management as a first-line treatment for preschoolers. Wolraich said behavior modification is an effective treatment that generally has two phases of treatment. The positive phase rewards a child for appropriate behavior, and the reward may just be praising, such as, “Johnny, I like the way you’re sitting in your chair.” The second phase includes consequences, such as “time-out.” But, he said, if you don’t have the positive side of treatment, time-out isn’t as helpful.
While the guidelines didn’t specifically recommend behavior management training for teachers and parents in high school students with ADHD, they noted that studies have found some value in this treatment for older kids.
