October 2, 2019
The American Academy of Pediatrics (AAP) has updated its guidelines for the evaluation, treatment, and monitoring of children with attention deficit hyperactivity disorder (ADHD or ADD), in an announcement made this week that marks the first change to the guidelines since 2011.
The revised guidelines1, published on September 30 in Pediatrics, are based on the most recent ADHD research, with the majority of the changes relating to considerations for diagnosis and the need for continuous monitoring and care. The updates, however, are described as “only incremental” by AAP.
“Since 2011, much research has occurred, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has been released,” writes the AAP panel. “The new research and DSM-5 do not, however, support dramatic changes to the previous recommendations.”
One of the changes includes the addition of a key action statement (KAS) related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD, bringing the total number of KASs to seven since the 2011 revision. The new guidelines also come with a companion article that outlines systemic barriers in ADHD care as identified by AAP and recommendations on addressing the barriers. One such barrier involves the process of care algorithm (PoCA), which has also been updated to assist in implementing the guideline’s recommendations.
The additional KAS says that primary care clinicians can initiate treatment of ADHD comorbidities — like anxiety, depression, oppositional defiant disorder, autism spectrum disorders, and more — if experienced in diagnosing them, or make a referral to a sub-specialist for treatment.
“ADHD is a chronic illness that can have a devastating impact if left untreated,” said Mark L. Wolraich, MD, FAAP, lead author of the report and prominent clinician and researcher in ADHD in a release2. “A pediatrician can help families figure out what is going on and work with families to help children succeed in managing their symptoms and behavior.”
The AAP lists four barriers in its 10-page “Systemic Barriers to the Care of Children and Adolescents with ADHD” companion article: limited access to care because of inadequate training or shortage of specialists; payer coverage limitations for services; challenges in practice organization and staffing; and fragmentation of care and communication barriers. One strategy calls for clinicians to coordinate with patient communities.
“We know that a child diagnosed with ADHD will benefit most when there is a partnership between families, their doctors, and their teachers, who may need to create special instructional plans and support,” said Joseph F. Hagan, Jr., MD, FAAP, co-author of the guidelines.
Other strategies to address the barriers include promoting changes in pediatric residency curricula; supporting revisions to payment systems; and implementing team-based approaches to communication.
The guidelines, as in the previous version, continue to list areas for future research, like studies of medications and therapies that are used clinically for treating ADHD but are not FDA approved.
“Evidence is clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify comorbid conditions, and effectively treat with both psychosocial and pharmacologic interventions,” AAP writes. “The steps required to sustain appropriate treatments and achieve successful long-term outcomes remain challenging, however.”
National data from 2016, according to AAP, indicates that 9.4 percent of children in the United States between two to 17 years of age have been diagnosed at one point with ADHD. ADHD is also the most common childhood neurobehavioral disorder in the country, and the second most commonly diagnosed childhood condition.
The changes to the “Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” used to treat children from ages four to 18, come after the AAP subcommittee held review meetings between 2015 to 2018.
1 Wolraich, M. Hagan, J., et.al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics Oct. 2019, 144 (4) e20192528; DOI: 10.1542/peds.2019-2528
2 “AAP Updates Guidelineson Attention Deficit-Hyperactivity Disorder with Latest Research.” AAP.org, 30 Sept. 2019, www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Updates-Guidelines-on-Attention-Deficit-Hyperactivity-Disorder-with-Latest-Research.aspx.