Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- March 2012 . In addition, ICSI has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This document is in transition to the GRADE methodology. Transition steps incorporating GRADE methodology for this document include the following:
- Priority placed upon available Systematic Reviews in literature searches.
- All existing Class A (randomized controlled trials [RCTs) studies have been considered as high quality evidence unless specified differently by a work group member.
- All existing Class B, C and D studies have been considered as low quality evidence unless specified differently by a work group member.
- All existing Class M and R studies are identified by study design versus assigning a quality of evidence (see Crosswalk between ICSI Evidence Grading System and GRADE in the "Definitions" sections at the end of the "Major Recommendations" field).
- All new literature considered by the work group for this revision has been assessed using GRADE methodology.
The recommendations for the diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for children and adolescents are presented in the form of two algorithms with 24 components accompanied by detailed annotations. Algorithms are provided in the original guideline document at the ICSI Web site for Evaluation of ADHD and Management of ADHD. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.
Class of evidence (Low Quality, Moderate Quality, High Quality, Meta-analysis, Systematic Review, Decision Analysis, Cost-Effectiveness Analysis, Guideline, and Reference) definitions are defined at the end of the "Major Recommendations" field.
- Evaluate children/adolescents suspected of having ADHD based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision/Diagnostic and Statistical Manual for Primary Care (DSM-IV-TR/DSM-PC) diagnostic criteria using consistent and appropriate diagnostic tools. (Annotation #4; Aim #1)
- Screen all patients for other primary conditions or comorbidities and appropriately refer to subspecialty consultation for further evaluation. (Annotation #5; Aim #2)
- Establish appropriate use of medications in both initial and ongoing management of patients with ADHD. (Annotation #14; Aim #3)
- As with many conditions, ADHD is rarely a singular diagnosis. Multimodal intervention is commonly needed for other concomitant conditions and comorbidities. (Annotation #18)
- Provide consistent and comprehensive monitoring and care coordination for all patients with ADHD including pharmacologic and non-pharmacologic interventions, identification and management of emerging comorbidities, and the impact of ADHD condition on patients, their families, and schools. (Annotation #22; Aims #3, 4)
Evaluation Algorithm Annotations
- Learning/Behavior Problems (Suspect ADHD)
- Consider ADHD evaluation if child presents with concerns regarding learning problems, behavior problems, or specifically ADHD.
- Recognize that the intensity and prominence of individual ADHD symptoms vary in relation to a child's age, developmental stage, and academic level.
Children may be referred for an ADHD evaluation by a variety of individuals for a variety of reasons. ADHD can present in many fashions either at home or in the school setting. Furthermore, presenting symptoms may vary depending on the age of the child, evolve predictably with development, and change relative to academic demands at different grade levels. Although the core symptoms of inattention, impulsivity and hyperactivity are characteristic, their severity and pattern are highly variable across individuals.
See the original guideline document for some possible presenting problems identified by parents, school personnel, and children/adolescents.
DSM-IV-TR/DSM-PC-based field trial data suggest that in the preschool age group, the hyperactive/impulsive subtype predominates, with the combined type being seen most often in the school-age child [Low Quality Evidence].
The impact of ADHD symptoms on functioning of individuals in the adolescent age group can be particularly confusing [Low Quality Evidence]. Not uncommonly, the hyperactivity/impulsivity dimension diminishes with age. Behavioral manifestations of ADHD in adolescence include insatiability and restlessness, behavioral impulsivity, risk-taking behaviors, low self-esteem, weak reinforcibility, loss of motivation, social failure, antisocial behavior, alcohol or drug abuse, motor vehicle accidents, and school dropout. ADHD may impact the academic performance of the adolescent, with associated difficulties such as memory problems, cognitive fatigue, fine motor dysfunction, or ineffective self-monitoring resulting in "careless" errors, performance inconsistency, task impersistence, and inattention to detail.
- Evaluate for Key Features of ADHD Using DSM-IV-TR/DSM-PC Criteria
- Incorporate information from multiple sources such as parents, other caregivers, the child, and school personnel in the evaluation of primary ADHD symptoms. Document this information in the patient medical record.
- Determine ADHD subtype (Predominantly Inattentive Type, Predominately Hyperactive-Impulsive Type, Combined Type) based on the criteria met by presenting symptoms.
- Criteria related to age of onset, duration, pervasiveness of symptoms, and impairment should be considered in establishing the diagnosis of ADHD.
The evaluation of primary symptoms should include information from multiple sources such as parents, the child, and school personnel. A comprehensive interview with parents or caregivers - including current symptoms and their previous history, past medical and developmental history, school and educational history, and family and psychosocial history - is most important. There is no single evaluation tool available to make a definitive diagnosis of ADHD. The diagnosis is based on a clinical picture of early onset, significant duration and pervasiveness, and causing functional impairment within the life of the child or adolescent. This can be facilitated through the use of a semistructured interview or questionnaire with behavior rating scales completed by the parents, other caregivers, and school personnel.
See the original guideline document for suggested behavior rating scales.
The DSM-IV-TR is recognized as the most widely used resource for diagnosis of mental disorders, including ADHD [Reference]. Alternatively, a manual designed for use in primary care practice, the Diagnostic and Statistical Manual for Primary Care (DSM-PC): Child and Adolescent Version, is now available. The DSM-PC is designed to bridge the gap between pediatric primary care and mental health services. It contains the DSM-IV-TR criteria for childhood mental health disorders including ADHD and related conditions, but also contains useful information on the developmental continuum of behavior, from normal variations to mental disorders.
Other components of the evaluation are described at subsequent points within the original guideline document.
ADHD is categorized by the following core symptoms:
Refer to DSM-IV-TR/DSM-PC criteria in the original guideline document for specific behavioral symptoms.
There are three subtypes of the disorder based upon the "often" occurrence of at least six of nine behaviors within the inattention dimension, and six of nine behaviors within the combined hyperactivity/impulsivity dimension:
- Predominantly inattentive type (meeting criteria for the inattention dimension)
- Predominantly hyperactive/impulsive type (meeting criteria for the hyperactive/impulsive dimension)
- Combined type (meeting criteria for both dimensions)
Some behavioral symptoms typically have begun prior to the age of seven years in most children (see DSM-IV-TR/DSM-PC criteria in the original guideline document). These symptoms may not be obvious in children who are predominantly inattentive without significant hyperactivity or impulsivity. Previous history must be reviewed carefully, especially in older children and adolescents, for the presence of symptoms not previously recognized or identified.
The presence of behavioral symptoms is typically of long duration (at least six months – see DSM-IV-TR/DSM-PC criteria in the original guideline document) and previously recognized by parents, teachers, or the patient. Careful review of previous symptoms is critical for evaluation of the presence or absence of symptoms not otherwise identified by parents, school personnel, or other caregivers. It is also helpful to assess the characteristics of previous observers with respect to the validity of information (e.g., specific teacher qualities, home and classroom environment).
Due to the relationship of ADHD symptoms to the external environment, specific interest and motivation, individual demands on attention and focus, and day-to-day influences, there can be significant variability within a given child. Nevertheless, ADHD behaviors are typically present in more than one setting (e.g., home, school, play, or work – see the DSM-IV-TR/DSM-PC criteria).
ADHD symptoms present in varying degrees of severity and impairment, depending upon individual characteristics and demands. It is important to assess the degree of impairment as the ADHD symptoms relate to the child's or adolescent's social, academic, or family functioning (see DSM-IV-TR/DSM-PC criteria in the original guideline document).
A word about behavior rating scales:
At least one standardized rating scale (see the original guideline document) is recommended for reviewing observations from those persons in direct contact with the child/adolescent (parents, day care providers, teachers, etc.) These observations/ratings should be used as part of the overall historical data base and should not be the sole criteria used to include or exclude the diagnosis of ADHD. Caution should be used in interpreting these due to observer bias, threshold of problem identification, and lack of observer knowledge (especially true of older children/adolescents in middle or upper grades).
A word about continuous performance tasks:
Various continuous performance tasks (CPTs) have been developed to attempt to objectively measure sustained and selective attention: for example, Test of Variables of Attention (TOVA), Gordon Diagnostic System and Conners CPT. These tasks involve the rapid presentation of stimuli where subjects are asked to respond to specific targets. The results measure certain variables of attention related to errors of omission and commission. Although these instruments appear to discriminate between children with ADHD and their normal counterparts at a group level, the usefulness of these measures in assessing individual children is limited. Due to significant false negative rates (estimated at 15%-30%), these instruments are not considered pathognomonic of ADHD and are of limited utility in screening and evaluation. They are most useful in research settings and the complex individual patient where more extensive data may be useful.
- Screen for Other Primary Conditions and Assess for Comorbidities
- Recognize that common ADHD symptoms (inattention, hyperactivity, disruptive behavior, academic difficulty) may result from a number of other difficulties.
- Acknowledge that children who have attention problems represent a very diverse, heterogeneous population and exhibit a broad range of symptom severity and a wide range of associated diagnoses.
Many children can exhibit symptoms of ADHD at some point in their development, but it is important to note that common symptoms (inattention, hyperactivity, disruptive behavior, academic difficulty), can be caused by a number of other difficulties. At this stage of the process, the clinician must consider diagnoses other than ADHD in one of two paradigms. Some patients will meet the criteria for ADHD but will also have a comorbid diagnosis or diagnoses ("primary ADHD" with comorbidity). Other patients will have a diagnosis other than ADHD that largely accounts for the behavioral symptoms of inattention, impulsivity, and/or hyperactivity. The latter instance can be conceptualized with an alternative diagnosis as "primary" with secondary features that mimic ADHD [Low Quality Evidence].
Because of extensive comorbidity, the evaluation of children referred for problems with attention, impulse control or hyperactivity should include biobehavioral, developmental, psychological, psychosocial, educational and speech/language components.
If issues comorbid to ADHD are not identified and addressed, they may complicate and worsen the child's level of functional impairment and lead to higher morbidity with a poorer prognosis. Research suggests that ADHD subgroups might be delineated based on patterns of comorbidity. These distinct subgroups may have different clinical courses, pharmacologic responses and risk factors. Proper identification of comorbid conditions can lead to appropriate refinements in treatment planning.
One way to get at comorbidity is by using standardized screening instruments such as the Child Behavior Checklist. It is important to note that this instrument serves a screening function and is not meant to be diagnostic for any specific condition. Training is recommended to effectively and appropriately score and interpret these instruments. Other, more specific, instruments including the Children's Depression Inventory, the Revised Children's Manifest Anxiety Scale and the Academic Performance Rating Scale may best be utilized in consultation with a qualified mental health professional.
Differentiating ADHD from an alternative primary condition such as oppositional-defiant disorder, generalized anxiety disorder, or a specific learning disability can be difficult even for seasoned clinicians [Low Quality Evidence]. Therefore the diagnosis of ADHD should be applied with care and caution, only after an appropriately thorough evaluation.
In screening children and adolescents for other diagnoses, it is important to emphasize the need to include information from as many sources as possible: the patient, parents, teachers, coaches, and health care professionals.
Screening patients for other diagnoses falls into the five basic domains defined in A-E of this annotation.
There are a number of possible strategies to consider in the comprehensive screening of the ADHD patient for other problems. One is for the primary care provider to utilize his or her ongoing familiarity and relationship with the family and patient over time to get a sense of any primary or comorbid problems identifiable in the five areas defined in A-E of this annotation.
A second strategy would be to use a semi-structured interview format with some "key" questions designed to get at the disorders identified in the five domains described in Annotation #4 (symptoms, onset, duration, pervasiveness, and impairment).
Another strategy includes the use of "screening" questionnaires that, although not diagnostic, can offer a general sense of potential areas for concern. Examples of utilized instruments are the Achenbach Child Behavior Checklist (CBCL), Achenbach Teacher Report Form (TRF), Achenbach Youth Self-Report, Devereux Scales of Mental Disorders (DSMD), and the Behavioral Assessment System for Children (BASC). These forms are scored across a number of behavioral domains. Clients who receive scores above a certain cutoff point in any given domain might then be considered for more intensive evaluation around that problem area. Using the instrument properly requires some training. Consultation with a psychologist for assistance in interpretation may be helpful. For additional information, refer to Annotation #4, "Evaluate for Key Features of ADHD Using DSM-IV-TR/DSM-PC Criteria" [Low Quality Evidence].
For those patients suspected of other conditions or comorbidities, continued assessment is necessary to confirm or exclude such conditions. In these cases further investigation, including subspecialty consultation, may be needed.
- Biomedical Conditions
- A health history and a physical/neurological/developmental assessment are necessary to identify or rule out problems in the biomedical realm of the ADHD differential diagnosis.
- Based on the history and physical examination, further work-up may be indicated in areas such as genetic or chromosomal, neurological, or biomedical conditions.
Note: The screening for the 5 domains (Annotation #5A-E) will provide data to suspect a differential diagnosis or data to suspect a diagnosis of ADHD.
A health history and a physical/neurological/developmental assessment are necessary to identify or rule out problems in the biomedical realm of the ADHD differential diagnosis. Deficits in sensory areas (e.g., hearing and vision) may result in classroom difficulties and produce restless or inattentive behaviors. Children with neuromaturational delays, or neurological "soft signs" are at risk for learning and behavioral disorders [Low Quality Evidence].
General Health History and Physical Examination, Including:
- Growth parameters: height, weight
- Vital signs: blood pressure, pulse
- Screening of vision and hearing
- History of prematurity [Low Quality Evidence]
Special emphasis on:
- Overall physical appearance
- Minor physical anomalies may signal genetic abnormalities (low-set ears, large or undescended testicles, high-arched palate, etc.)
Based on the history and physical examination, further work-up may be indicated. Refer to the original guideline document for information.
- Emotional/Psychiatric Problems
- Screen for comorbid conditions of depression, anxiety disorders, conduct disorder and substance abuse during the interview with the patient.
- Consider treating the ADHD symptoms presenting in children with autism spectrum disorders. (Autism treatment is out of guideline.)
The diagnosis of ADHD may be complicated by either the presence of another coexisting psychiatric condition or the existence of a psychiatric condition that has symptoms suggestive of the diagnosis of ADHD. It is clear that children with ADHD disorder are at risk for the coexistence of depression, anxiety disorders, conduct disorders, and substance abuse. The prevalence of these conditions in children with ADHD ranges from 15% to 30%. At the same time it is those same four diagnostic entities that may most often be misdiagnosed as ADHD due to the commonality of many of the symptoms. Therefore, it behooves the clinician to screen for those four conditions when evaluating a child for whom the diagnosis of ADHD is being considered [Low Quality Evidence], [R]. If the clinician identifies sufficient positive symptomology after completion of these screening questions to raise the clinical suspicion of a psychiatric diagnosis, referral to a mental health professional may be indicated.
The following may be considered as a starting point in evaluating the possible presence of depression, anxiety disorders, conduct disorders, and substance abuse.
- Consistent depressed or irritable mood for nearly every day that has lasted for at least two weeks
- Significantly diminished interest or pleasure in all or almost all activities
- Undeniable decline in school or work performance
- Recurrent suicidal ideation without a specific plan or recurrent thoughts of death
- Persistent depressed mood associated with almost daily insomnia or hypersomnia
Childhood Mania-Juvenile Bipolar Disorder
Recent experience suggests an overlap between ADHD and juvenile mania-bipolar disorder. Children with bipolar and comorbid ADHD presented with a predominantly irritable phenotype and predominately chronic course [Low Quality Evidence]. The following are characteristics of childhood mania that may aid the clinician in differentiating the 2 conditions:
- Childhood mania – juvenile bipolar disorder is episodic and extremely rare when compared to ADHD.
- Patient may experience pressured speech, racing thoughts, grandiosity, reduced need for sleep.
- Symptoms include rapid onset affective storms, prolonged severe temper outbursts, violent furious aggression, irritability, erratic interpersonal behavior.
- Usually mixed presentation with depression
- Strong family history of bipolar disorder
The diagnosis of post-traumatic stress disorder, which falls under the anxiety spectrum, may be the most common diagnosis that mimics ADHD. The most likely areas of post-traumatic stress disorder are those that fall in the spectrum of physical or sexual abuse. Those areas should have been screened by taking a psychosocial history as part of the overall assessment. The remaining diagnoses that are likely to present themselves in childhood include those of separation anxiety disorder and generalized anxiety disorder. Screening that may be useful in identifying those conditions is listed below:
- Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the child is attached
- Persistent and excessive worry about losing or about possible harm befalling major attachment figures
- Repeated complaints of physical symptoms when separation from major attachment figures occurs or is anticipated
- Consistent excessive dissatisfaction with less than perfect performances (e.g., school assignments)
- Difficulty in controlling or stopping his/her worrying/anxiety.
- Presence of negativistic, hostile, and defiant behaviors which may include losing temper, arguing with adults, refusing to comply with adults' requests, deliberately annoying people, consistent anger and resentment expressed toward others
- Presence of a history of physical aggression toward people or animals
- History of deliberate involvement in theft from others
- History of violation of rules with potential serious consequences (e.g., running away from home, truancy from school)
- History of use of alcohol or illicit drugs of any kind
- Use of alcohol or drugs to alter mood state or to escape a mood state
- Consequences at school, in the home, or with legal authorities related to the patient's use of alcohol or drugs
- History of a peer expressing concern regarding the patient's use of alcohol or drugs
- History of feeling guilty about use of alcohol or drugs
- Behaviors suggestive of drug or alcohol use (increasing isolation from family/friends, presence of drug paraphernalia)
Pervasive Developmental Disorders (e.g., autistic disorder, Asperger's syndrome)
Although it is uncommon for ADHD to be confused with autism spectrum disorders, it is not uncommon for children with autism spectrum disorders to present with ADHD features. Typical problem areas for these children include:
- Qualitative impairment in social interaction (e.g., reciprocity, non-verbal gesture, sharing, peer relationships)
- Qualitative impairment in communication (e.g., language delay, conversational speech, idiosyncratic/stereotyped language, symbolic/imitative play)
- Restrictive, repetitive patterns of behavior (e.g., preoccupations, rituals, self-stimulatory motor mannerisms)
- Family/Psychosocial Problems
- Evaluate chronic or acute stress that may cause changes in a child's academic or behavioral functioning.
- Assess family history of mental illness. Subtypes of ADHD vary with type of mental illness in families.
- Assess the family's functioning in terms of the nature of the caregiver-child interactions, impact of symptoms within the home, and family resources for coping.
In addition to the evaluation of comorbid psychiatric or learning conditions, it is important to consider the psychosocial context in which the child's symptoms and concerns arise. Identified below are factors to consider and some ideas for interview questions. A thorough assessment of the family's functioning will assist in understanding both the nature and severity of the child's symptoms and the family's ability to make use of education and treatment recommendations. If significant family pathology is present, then referral to a mental health professional, family therapist, or social services is appropriate.
The experience of chronic or acute stress may manifest in a child's functioning in a variety of ways; common symptoms include anxiety, dysphoria, and behavioral acting out. Any of these difficulties may result in changes in academic performance or behavior in the home environment.
Sample question: Has your family been coping with other difficulties or stressors during the past year or two?
Stressful life events may include:
- Major life transitions or changes (move, change of school)
- Loss (death of loved one, parental separation or divorce)
- Abuse (sexual or physical, domestic violence)
- Traumatic events (e.g., car accident)
There is increasing recognition that the subtypes of ADHD vary not only in patterns of comorbidity, but also with respect to genetic family history. Family history data suggests more ADHD, aggression, and substance abuse in families of children with ADHD hyperactive/impulsive subtype, whereas families of children with ADHD inattention subtype have more anxiety disorders and learning problems [Low Quality Evidence].
Sample question: Has anyone in your family (parents, siblings, and extended family) been treated for...?
- Anxiety disorder
- Depressive disorders (including bipolar disorder)
- Learning/attention problems
- Developmental delay, mental retardation, autism
- Chemical dependency
- Conduct problems
- Other mental health problems
Quality of Caregiving
Consider the family's strengths and resources for coping as well as their beliefs and attributions concerning their child's difficulties. Also examine the effects of the child's symptoms on the family as a whole.
Interview caregivers for evidence of family dysfunction or vulnerability. In particular, evaluate for problems which may affect the parents' ability to manage behavior consistently and appropriately, to provide adequate nurturance and structure, and to accurately (meaningfully) evaluate the child's functioning.
These problems may include:
- Parental psychiatric disorder or chemical abuse/dependency
- Cultural differences
- Lack of education or information
- Low intellectual functioning
- The absence of family/community supports
- Psychosocial stressors (see above)
- Limited nurturance of child
- What is a typical day like at your home?
- Do you feel supported by the child's school and the community?
- Who provides help with your child when you need it?
- Is there any use of alcohol or illicit drugs in your home?
- Can you tell me what you've heard or learned about ADHD?
- What kind of discipline works (or doesn't work) with your child?
- When do you enjoy being with your child?
- Speech/Language Problems
- If screening indicates concerns about a child's speech and/or language, including expressive and receptive language, speech fluency, pragmatic language, prosody, or phonology/articulation, a referral should be made to a pediatric speech and language pathologist.
- Parents may make a request for speech screening in writing to their child's school with a copy of the request kept by the parents. Alternatively, the family may seek a private speech and language evaluation. It is helpful for primary care providers to be familiar with speech and language pathology resources in their community in order to make appropriate referrals.
- If speech and language problems suggestive of a pervasive developmental disorder are present, refer the child to a diagnostic team including developmental or mental health professionals with a speech and language pathologist.
- Assess voice quality as children with ADHD are at higher risk for "vocal cord abuse." When a child is found to have a chronic raspy or hoarse vocal quality, refer to an otolaryngologist to look for vocal cord pathology such as vocal cord thickening or vocal cord nodules.
- If the child presents with symptoms of repetitive noises (throat clearing, sniffing, barking, or coprolalia) suggestive of Tourette's syndrome, consider consultation by a pediatric neurologist, developmental and behavioral pediatrician, or child psychiatrist.
Deficits in verbal functioning may be chronic and are particularly common in adolescents with antisocial behavior. Any history of speech or language delay or services should be discussed and reviewed [Low Quality Evidence]. Common difficulties include:
- Historical or current problems with dysfluencies
- Disorganized speech on tasks that require verbal explanations
- Excessive, tangential, or rapid speech
- Problems with volume modulation
- Fragmented sentences with pauses
Receptive language problems may also be present in children with ADHD or may be a comorbid condition. These children may mimic primary problems with attention and have problems following directions and retaining verbally presented material [Low Quality Evidence].
Many children with ADHD manifest "pragmatic language dysfunction" in social situations - namely, an inability to read essential verbal, nonverbal, and situational cues. This can lead to a tendency to make socially unacceptable choices. The clinician should inquire about evidence of aggressive, domineering, and intrusive social interaction styles as well as difficulty in initiating and maintaining friendships, or even outright rejection by peers.
If screening indicates concerns about a child's speech and/or language including expressive and receptive language, speech fluency, pragmatic language, prosody, or phonology/articulation, a referral should be made to a pediatric speech and language pathologist. Parents may make a request in writing to their child's school with a copy of the request kept by the parents. Alternatively, the family may seek a private speech and language evaluation. It is helpful for primary care providers to be familiar with speech and language pathology resources in their community in order to make appropriate referrals.
Children with hearing impairments can also have ADHD exclusive of their hearing problems. This can be a complicated differential diagnosis, possibly requiring specialty referral [Low Quality Evidence]. Children with hearing impairment may also present with symptoms of inattention, problems with task completion, disruptive behavior, noncompliance, speech and language problems, or a need for frequent repetition of information. If questions arise, they should be referred to an audiologist for formal evaluation.
Children with difficulties in the pervasive developmental disorder (PDD)/autism spectrum can sometimes present with symptoms similar to ADHD. Identifying features of PDD/autism from the speech/language standpoint include:
- Excessive self-talk
- Unusual intonation patterns or monotone
- Acts as if didn't hear
- Socially inappropriate behaviors (e.g., screaming, interrupting)
- Loss of previously acquired language skills
If speech and language problems suggestive of a pervasive developmental disorder are present, referral should be made to developmental or mental health professionals with a speech and language pathologist as a part of the diagnostic team.
Children with ADHD are also at higher risk for "vocal cord abuse" and therefore voice quality (particularly "hoarseness") should be assessed. Children with evidence of vocal cord abuse (e.g., hoarseness of more than six months' duration) may need referral to an otolaryngologist to evaluate for vocal cord pathology such as vocal cord thickening or vocal cord nodules.
Patients with ADHD who have comorbid vocal tics or Tourette's syndrome may demonstrate speech patterns typical to this disorder including repetitive noises, throat clearing, barking or even coprolalia. A consultation by a pediatric neurologist, developmental and behavioral pediatrician, or child psychiatrist may be appropriate.
- Academic/Learning Problems
- If history and screening indicate significant concerns with academic functioning, the child should undergo individual cognitive/psychoeducational assessment.
The history should include information from parents and teachers to assess executive function performance areas of difficulty in children with ADHD, which include:
- Completion of independent work in a timely fashion
- Attention to detail
- Studying for exams
- Taking notes on classroom lectures
- Organizational skills
- Time management
Empirical evidence indicates a consistent relationship between ADHD and learning disorders. One in every three to four children with ADHD has a specific academic skill deficit or "learning disability" in a traditionally defined area such as reading, written language, or mathematics. A learning disability is formally identified by comparing a student's IQ score to his or her scores in achievement areas and identifying a significant discrepancy (usually defined as 1.75 to 2 standard deviations) between the two.
Learning disabilities or disorders as currently defined in the DSM-IV-TR/DSM-PC include:
- Reading disorder
- Mathematics disorder
- Disorder of written expression
- Developmental coordination disorder
Children with subnormal intelligence may appear inattentive, due to their lack of understanding of and tracking with material that is too difficult for them. However, it is also important to note that children with cognitive impairment are three to four times more likely to have ADHD than children with intelligence scores in the normal range. Therefore, an IQ assessment and individual achievement testing may often be essential components of an ADHD evaluation. It is important to note that these children may be misdiagnosed as having a primary attention problem when in fact their symptoms are secondary to an inappropriate level of difficulty or stimulation in academic programming.
It is important to review school concerns with the patient, parents, teachers, and other school professionals. "Red-flags" or common presenting symptoms of concern for children with learning disabilities or cognitive impairment could include:
- Apparent apathy or hostility toward school
- Avoidance of or failure in specific subject areas
- Disruptive or negative behaviors in certain classes
- Historical evidence of difficulty in specific skill areas
- History of special educational services, "Title 1" assistance, etc.
- History of early childhood service
A sample of possible questions directed at children and their parents for assessing academic performance issues presenting in the context of an ADHD evaluation might include:
- What subject is your favorite/easiest?
- What subject is hardest/least favorite?
- How do you get along with your teachers?
- How much homework do you do on an average night? How does this compare to the amount of homework classmates are doing? How much do your parents help you with your homework?
- What grades are you receiving in each of your classes? How does this compare to your grades in previous years? Have you ever failed or are you currently failing any classes?
- Do you receive any special help in school?
- What are your interests outside of school?
- Does your son/daughter have any trouble with study/organizational skills?
- What do you see as your son/daughter's learning style strengths? Weaknesses?
- Do you think your child feels positively about school?
- Has anyone from school ever contacted you with specific academic or behavioral concerns about your child?
- Are you pleased with your child's grades?
- Do you feel your son/daughter is working up to his/her potential?
Students functioning at the "gifted" end of the cognitive spectrum may also manifest signs or symptoms of ADHD such as inattention, disruptive behavior, and apparent lack of motivation or engagement in classroom activities. It is important to note that these children can be misdiagnosed as having a primary attentional problem when in fact their symptoms are secondary to the lack of an appropriate level of challenge and stimulation in academic programming. Giftedness and ADHD may coexist, however.
One of the goals of assessment is to determine whether a student's academic difficulties are due to ADHD, learning disabilities, or both. A second question would be whether a student presenting with symptoms of ADHD actually has ADHD as the primary condition or whether a learning style issue (e.g., learning disability) might be sufficient to account for the identified problem behaviors. There is a significant overlap between populations of students with ADHD and those with academic skills deficits.
On average, students with ADHD do not differ substantially from the rest of the school age population in terms of overall intellectual functioning. Many of these children, however, show academic performance problems despite adequate abilities as measured by standardized tests. These children often exhibit less on-task behavior as compared to peers and have less opportunity to respond to and track with academic instruction. Growing evidence also suggests that the behavioral symptoms of ADHD disrupt academic skill acquisition and performance.
- Does ADHD Appear to Be the Primary Diagnosis?
- If ADHD is likely a primary diagnosis and a comorbid condition is suspected, consider moving to Annotation #10, confirming the DSM-IV-TR/DSM-PC criteria, but treat the comorbid condition as having equal importance with ADHD.
Suspected Alternative Primary Condition
If an alternative primary diagnosis is assessed through completion of an appropriate evaluation and an alternative primary diagnosis is identified that accounts for the presenting symptoms, the patient would be "out of guideline" and would be managed or referred as appropriate to the condition. Possible examples might include anxiety disorders, depression and cognitive impairment.
Patients undergoing further assessment for biomedical, emotional/psychiatric, family/psychosocial, speech/language and academic/learning problems may be identified as having a primary diagnosis other than ADHD that accounts for their symptoms. For these patients, symptoms are not due to ADHD; therefore, these patients do not fall within the scope of this guideline. The primary clinician is encouraged to coordinate care with multidisciplinary subspecialty consultation as indicated.
Suspected ADHD with Comorbid Condition
If ADHD is the likely primary diagnosis but a comorbid condition is also suspected, the clinician may choose to proceed to the Evaluation Algorithm while concurrent evaluation of the suspected comorbid problem is completed. This would allow the clinician to continue to move into appropriate management strategies in a time-efficient manner. It is important to consider some degree of caution here in that comorbid issues can be of equal importance to the diagnosis of ADHD. Therefore they must be fully evaluated and the overlapping nature of the conditions (e.g., ADHD and learning disabilities) must be considered prior to moving fully into the management plan. Possible examples might include oppositional defiant disorder and learning disability.
- Any Additional Related Comorbidities Identified?
- Screen for comorbid conditions that occur commonly with ADHD.
Patients undergoing assessment for biomedical, emotional/psychiatric, family/psychosocial, speech/language, and academic/learning problems may be identified as having a related comorbidity to the primary ADHD condition.
- Desire Subspecialty Consultation for ADHD Management?
- ADHD with comorbidities may need appropriate subspecialty consultation.
For those patients with ADHD and a comorbid condition identified, the primary clinician is faced with the option of medically managing the ADHD component or utilizing medical subspecialty consultation. This decision depends on the complexity of the comorbid condition and its relationship to the ADHD symptoms, as well as on the individual clinician's own threshold of expertise and knowledge.
The type of medical subspecialty consultation may include the following:
- Child-Adolescent Psychiatry
- Developmental-Behavioral Pediatrics
- Pediatric Neurology
The primary care clinician is encouraged to coordinate care between medical and non-medical (e.g., mental health, school/educational, speech/language) subspecialty consultation as indicated.
- DSM-IV/DSM-PC Criteria Confirmed?
- Accurate diagnosis requires confirmation of DSM-IV-TR/DSM-PC criteria.
Only after careful evaluation of the patient's primary symptoms and complete screening for any comorbidity or other primary condition is the clinician able to confirm the diagnosis of ADHD.
- ADHD Diagnostic Formulation Completed
- Discuss the diagnosis with family in detail, including the child's functioning at school, home and in the community.
A comprehensive diagnostic formulation for a child with ADHD is critical so that parents clearly understand their child's attentional difficulties as part of an inclusive picture of his or her functioning. Findings should be presented to families within a biopsychosocial framework. Discussion of the ADHD diagnosis should be presented within the context of associated comorbid mental health diagnoses and issues, academic performance issues, learning disabilities, developmental concerns, medical diagnoses, social concerns, family issues, and stressors [Low Quality Evidence]. It is crucial to discuss the child's and the family's strengths as well as their vulnerabilities.
Adequate and appropriate treatment planning should then follow from a comprehensive and accurate diagnostic formulation.
Management Algorithm Annotations
- Education of Key Individuals
- Provide appropriate information about the new ADHD diagnosis for the child, the family and his/her educators.
Upon initial diagnosis of ADHD, education of key individuals including the parents, the child, and school personnel is imperative.
For the parents, this should include information on neurologic mechanisms, common features of ADHD and how they relate to the child's previous and current problems, and future expectations of clinical course and intervention strategies. The importance of individual teacher selection each year should be emphasized.
For the child, a developmentally appropriate explanation and demystification of ADHD using specific metaphors and examples is especially helpful. This should include not only explanation of related difficulties, but also discussion of the child's strengths and attributes.
For school personnel in contact with the child, one should not assume teacher knowledge of ADHD. It is important to provide specific teacher-focused information for the parents to share with all appropriate individuals. This information not only should explain ADHD related to the child's classroom difficulties, but also should address appropriate intervention strategies and modifications as described in Annotation # 21, "School Interventions."
Please refer to the "Quality Improvement Support" section of the original guideline document for specific recommended educational materials and resources directed to parents, children and adolescents, and teachers.
- Medication Trial(s)
- Prescribe U.S. Food and Drug Administration (FDA)-approved treatments for ADHD in children, including psychostimulants and/or non-stimulants.
- Obtain cardiology consultation for patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems that could place patients at an increased risk to the sympathomimetic effects of central nervous system (CNS) stimulants and/or atomoxetine.
- Review the personal and family cardiovascular history, and complete a physical examination of each patient prior to starting stimulant therapy and/or atomoxetine. Medication history or physical exam changes consistent with possible cardiac disease during treatment with stimulant medication and/or atomoxetine may require additional evaluation by a cardiologist.
The decision to use medication should be made in conjunction with parents following a thorough discussion of expected benefits and potential risks. Factors such as the child's age, severity of symptoms and presence of comorbidity should also be considered and may involve decision-making regarding choice of medication [Low Quality Evidence].
Optimal medication management alone is superior to other modalities for the core symptoms of ADHD.
Occasionally a comorbid condition may warrant the consideration of alternative medications. In the presence of comorbidity, the primary symptoms of concern should influence the medication decision.
Psychostimulant and Non-Stimulant Medications
Response to one stimulant does not predict response to the others. If a child is a non-responder to one stimulant, it is advisable to attempt a second or third trial with other stimulants.
Treatment with psychostimulants is often safe and effective in managing many children with ADHD with mild to moderate tics. Nevertheless, frequency and severity of tics should be carefully monitored in these patients. No routine blood work is necessary before or during psychostimulant therapy.
Dosages should be adjusted for each child depending on body weight, degree of impairment, and specific symptoms targeted for improvement. Children with ADHD of the predominantly inattentive type have been shown to respond well to low doses of methylphenidate. Children with ADHD, combined-type or predominantly hyperactive, have shown more positive response at moderate to high doses of methylphenidate. Refer to Table 2, "Summary of FDA-Approved ADHD Medications for Use in Children and Adolescents," in the original guideline document for information on dosing, titration and adverse effects of specific medications, and Annotation #22, "Maintenance and Continuing Care."
Each of these stimulant medications has the common adverse effects of decreased appetite, insomnia, headache, stomachache and irritability. If sleep problems are reported, determine factors that may influence response to stimulant treatment [Low Quality Evidence].
Absolute contraindications to the use of psychostimulants include psychosis, certain cardiovascular conditions, or previous untoward reactions to stimulant medication.
Current evidence does not support a higher risk of sudden cardiac death with stimulant medication compared to the general population [High Quality Evidence]. However, certain conditions may place a patient at higher risk for such an outcome. All patients should receive a thorough cardiovascular personal/family history and physical exam before initiating stimulant medication and/or atomoxetine, with an emphasis on identifying risk factors for sudden death. A routine electrocardiogram (ECG) on all patients is not recommended [Meta-analysis]. See Appendix A, "Screening Tool for Sudden Death Cardiac Risk Factors among Children Starting Stimulant Medication," in the original guideline document.
Cardiology consultation should be obtained prior to the use of stimulant medication and/or atomoxetine in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac problems.
Atomoxetine has demonstrated efficacy over placebo in two placebo-controlled trials [High Quality Evidence].
Atomoxetine is a good option for patients with comorbid anxiety, sleep initiation disorder, substance abuse, or tics, or if initially preferred by parents and/or physician. Atomoxetine is a non-controlled substance that may make it preferable in certain clinical situations. Potential adverse effects include somnolence, nausea, anorexia, mild increase in blood pressure or heart rate, and skin rash.
Extended-release guanfacine demonstrated a statistically significant 50% decrease in baseline ADHD Rating Scale Version IV (ADHD-RS-IV) scores in one large clinical trial [Low Quality Evidence]. Side effects of guanfacine include somnolence, headache, fatigue and sedation [Low Quality Evidence].
Extended-release guanfacine (Intuniv®) and extended-release clonidine (Kapvay®) are the first ADHD medications to achieve FDA approval as adjunctive therapy with stimulant medications. A randomized control trial in 2011 looked at placebo versus extended-release clonidine as adjunctive therapy in patients currently taking stimulant medication. They found clinically significant improvement of overall ADHD symptoms (total ADHD-RS-IV score) in clonidine XR group versus placebo that started in week two and continued into week eight [High Quality Evidence].
Extended-release guanfacine is the first ADHD medication to look for improvement of oppositional symptoms in addition to ADHD core symptoms. A randomized, double-blind placebo controlled trial, in 2010, using extended-release guanfacine as monotherapy for nine weeks showed clinically significant reduction of ADHD-RS-IV total score beginning in week two. They also found clinically significant reduction in the Connors' Parent Rating Scale oppositional subscale beginning in week three [High Quality Evidence]. It is the ICSI work group's consensus that other alpha agonists would likely have the similar effects upon oppositional symptoms; however, they have not been specifically studied to date.
In 2004 the FDA issued a paper advising health professionals about a warning regarding atomoxetine. The labeling has been updated with a bolded warning about the potential for severe liver injury, following two reports. The warning indicates that the medication should be discontinued in patients who develop jaundice or laboratory evidence of liver injury. Currently, routine liver function tests are not being recommended for those taking this medication.
In September 2005, the FDA issued an alert advising health professionals about an increased risk of suicidal thinking in children and adolescents being treated with atomoxetine. The labeling has been updated with a boxed warning.
- Successful Alternative Medication(s) Trial(s)?
When adequate stimulant, atomoxetine or alpha adrenergic trials are unsuccessful due to either poor response or adverse effects, or if associated comorbidity is present, alternative medication trials may be considered (see Table 3, "Summary of Alternative Medications That May be Considered for Children and Adolescents," in the original guideline document).
Fewer studies are available documenting the benefit and safety of alternate agents in children or adolescents compared to the stimulants. The primary clinician may decide to continue management based on individual knowledge and expertise or may refer for subspecialty consultation. In either case, the patient would no longer be within the scope of this guideline.
- Multimodal Management Coordinated by Primary Clinician
- In addition to primary medication treatment, multimodal intervention is commonly needed for management of ADHD and other concomitant conditions and comorbidities.
As with many conditions, ADHD is rarely a singular diagnosis. In addition to medication, multimodal intervention is commonly needed for the management of ADHD and other concomitant conditions and comorbidities. The primary care physician is in a unique position to coordinate care.
A 1992 large-scale randomized clinical trial sponsored by the National Institute of Mental Health and the U.S. Department of Education examined the efficacy of medication management, intensive behavioral treatment, the two combined, and standard community care for the treatment of children with ADHD Combined Type [High Quality Evidence]. Results indicated that for the core symptoms of ADHD, intensive medication management was superior to results of the behavioral treatment only and to the routine community care groups studied. Combined treatment of medication management and intensive behavioral treatment did not yield significantly greater benefits than medication management alone [High Quality Evidence].
In young children (ages 7-9), no benefit was found for clinic-based social skills training over stimulant use [Moderate Quality Evidence]. Another analysis of this study population found no support for adding long-term psychosocial interventions but found benefits from stimulant medication over two years [Moderate Quality Evidence]. Children without learning or conduct disorders who responded to stimulants did not further benefit from therapy or academic assistance [High Quality Evidence].
- Parents/Family Focused Strategies
- Recognize that parents have a unique role in ADHD management for their children.
- Support parents learning management skills through ADHD support groups, advocacy groups, and parenting skills training.
- Offer specific intervention strategies to parents, as they find them to be helpful.
ADHD Support Groups
These groups help parents learn more about ADHD through lectures or reading material and can help parents cope emotionally by communicating with other parents of ADHD children in a supportive setting. The Attention Deficit Disorder Association (ADDA) and Children and Adults with Attention Deficit Disorder (CHADD) are two such groups and have local chapters in many areas. A children's or community hospital in the area or the child's school or school district may also have a support group.
Groups exist to help parents learn about what rights their children have in the educational setting and what special services are available for their needs. These groups can also aid in parent interactions with the school system and can give parents some direction in finding services for their children. One such group is Parent Advocacy for Children's Educational Rights (PACER). Additional resources are listed in the Implementation Tools and Resources section of the original guideline document.
Parenting Skills Training
One of the most useful strategies a parent can undertake to improve harmony in the home is to learn ways to set children up for success by providing a structured home environment, clear expectations, consistent responding, positive attention for appropriate behaviors and appropriate consequences for maladaptive behaviors. Learning the above methods serves to give the child direction, goals and limits in hopes of improving compliance, increasing self-esteem, enhancing positive aspects of the parent-child relationship, and reducing tension and struggles within the home. Although this training can be obtained through formal classes and books, research demonstrates that changes in parenting knowledge do not necessarily translate into changes in parenting behavior. A recent meta-analysis [Meta-analysis] that reviewed effects of parenting training programs on childhood externalizing behaviors including ADHD found that increasing positive parent-child interactions, practicing with one's own child, and learning time-out/disciplinary consistency (responding the same way every time to a misbehavior) were essential components of parent training programs. Moreover, less active involvement (modeling, homework, etc.) were not found to be effective components of parenting training programs.
Suggestions for Parents
Many of these suggestions are best executed when parents are consulting with a specialist in behavioral therapy.
- Note problem behaviors and make notations of frequency and severity to help make the problems more objective and to aid in monitoring improvements as behavioral changes are made.
- Provide consistent schedules and routines with forewarning of any upcoming changes.
- One or two simple, clear instructions should be given at a time. The child should repeat the instructions back to ensure comprehension.
- Clear, concise rules should be provided for the behavior of all family members, with consistent follow-through of appropriate consequences and rewards.
- Decrease inappropriate behavior by allowing:
- Natural consequences to the child's actions
- Logical consequences linked to the offending behavior
- Create consistent sleep habits and a restful sleep environment.
- Have a special quiet spot with few distracting influences for doing homework or working on projects.
- Allow the child choices within set limits so that the child has a sense of some control.
- Make sure the child knows his or her behavior is the issue or problem, not the child himself or herself.
- Try to spend 10-15 minutes daily focusing on this child alone to listen and let them know they are important. Parents should avoid giving commands, choosing the activity, criticizing behaviors, or asking questions. As much as possible, rather, the time should be spent actively listening and attending to your child's activity.
- Utilize differential social attention to decrease ADHD behaviors that are not aggressive or dangerous to self, others or property. You can do this by ignoring behaviors like interrupting others, wherein you provide no attention (e.g., eye contact, verbal, smiling at them, etc.) to the problem behavior (e.g., "Thanks for being quiet while I finished talking to my friend"). This strategy is often taught in parent training programs.
- Incorporate prevention strategies such as visuals (e.g., timers, posted hour rules, etc.) to promote on-task and adaptive behaviors.
- Create a sticker, point or token system to track and reward specific behaviors that you want to increase (e.g., working on homework for 15 minutes without getting up from table). Behaviors should be stated positively and be something that the child can obtain. Expectations can increase (e.g., 20 minutes instead of 15) as children demonstrate success with initial goals.
- Parents serve as models for their children. It is important to demonstrate appropriate coping methods in front of children so they can learn positive methods to channel their frustrations. Hence, it is important for parents to take a break or a time-out from the child if he or she is becoming too frustrated or angry. Ensure that you have access to immediate social supports (e.g., friends or relatives whom you can reach quickly if you need someone to talk to about your child's behaviors).
Complementary Alternative Medicine (CAM)
Given concerns regarding side effects and potential long-term adverse effects of medication, parents often seek alternative treatment modalities that are safe and potentially useful. Examples of common complementary alternative medicine therapies investigated for ADHD are herbal remedies, nutritional supplements, biofeedback, massage, acupuncture, meditation and dietary changes.
Most CAM modalities have not been subjected to systematic precise studies to determine efficacy in treating ADHD symptoms. A few CAM treatments (meditation, acupuncture) have been investigated and have not shown documented effectiveness [Systematic Review]. Studies of other CAM modalities (iron supplements, elimination diets) indicate positive benefits [High Quality Evidence]. However, due to small sample size or limited number of studies, they fail to qualify as evidence-based criteria influencing ICSI guideline recommendations. These are areas to monitor the literature for future research.
Neurofeedback has been demonstrated in one randomized, controlled clinical trial [High Quality Evidence] to be significantly better than a computerized attention skills training control. ADHD symptoms were moderately improved. Long-term benefits have not been definitively proven. The cost and time involved in treatment need to be taken into account. Neurofeedback for ADHD lacks sufficient research support. Treatment response rates have not reached the level shown with psychostimulant medications; therefore neurofeedback cannot be recommended as an alternative to medication use in ADHD.
In cases with significant family dysfunction or other stresses (e.g., financial, health problems, chemical dependency issues) individualized family therapy may be more appropriate. In-home counseling may be available through county services.
- Child Interventions
- Consider the need for social skills training to improve peer relationships that are often negatively affected by ADHD symptoms (e.g., impulsivity).
- Cognitive-behavioral therapy may be warranted to teach children how to be more reflective in problem solving.
- Study skills and organizational skills are often helpful to address common educational and executive function deficits.
To date, no well-designed studies have been empirically validated to support the use of social skills training, problem–solving training, or study/organizational skills training in the direct treatment of ADHD. Anecdotal endorsement of these interventions does exist. Using the same criteria for acceptance of psychosocial treatments for ADHD and those used for acceptance of medication treatments for ADHD is difficult, given the methodological limits and complexities of psychosocial research. Thus, the following interventions may be understood and most appropriate for implementation with individuals with ADHD when problems with social skills, problem solving, or organization co-occur with or develop secondarily to ADHD symptoms.
The purpose of education of the child is to provide the basis for further independence. The person with ADHD will be managing his/her own environment and interpersonal relationships and choosing a vocation [Low Quality Evidence, Reference]. Without insight and specific strategies to address this impairment, long-term consequences may include decreased self-esteem and poor problem solving. Loss of social support from peers has long-lasting consequences. Early intervention can avert the resulting loss of self-esteem and productivity.
Social Skills Training
The child's social skills are resources for solving the specific problems that arise from ADHD. Interpersonal problems and difficulties with peers may occur secondary to impulsivity (e.g., unpredictable behavior). As a child gets older, unpredictable behavior is less tolerated by peers and within the family.
Social skills building is meant to offer immediate practical skills in a safe setting. Sometimes this can be a way to have several people (family, school, friends) offering the same message about appropriate behavior and may have a better chance of being generalized to a larger setting.
Social skills training (group or individual) instructs children in the execution of specific prosocial behaviors [Low Quality Evidence], [High Quality Evidence]. It is appropriate for children who exhibit difficulties in initiating and maintaining positive peer interactions. Children with ADHD often show deficient use of functional, pragmatic language in social situations. This type of training is designed to increase knowledge about appropriate and inappropriate social behaviors. The various target skills may include maintaining eye contact, initiating and maintaining conversation, sharing, and cooperating. Role-playing exercises with group feedback are commonly used.
Social skills building groups may be available through the school [Low Quality Evidence]. These may be recognized as "friendship groups" or "social skills groups." Early childhood family education, which may include children older than the preschool aged child, is also available. Some other community resources may include the YMCA, community education, or local health organizations.
Problem Solving Strategies/Cognitive Behavioral Therapy
The goal of self-instructional problem solving training is to help children who have ADHD "stop and think" before acting. This therapeutic modality falls under the general category of cognitive-behavioral therapies. Designed to facilitate self-control and reflective problem solving, it is appropriate for children who exhibit impulsive, non-self-controlled behavior and/or manifest deficits in problem solving. This can be accomplished through the use of various resources: family therapy, in-home therapy, an individual therapist, or county services (if available). All options should be coordinated with school efforts [High Quality Evidence], [Low Quality Evidence].
Study/Organizational Skills Training
Study and organizational skills building should be offered in conjunction with curriculum intervention [Reference]. The curriculum should be concrete and sequential with only essential information as a requirement. Specific interventions can address issues, such as:
Behavior: Difficulty sequencing and completing steps to accomplish specific tasks (e.g., writing a book report or term paper, organizing paragraphs; solving division problems)
Accommodation: Break task into workable and manageable component tasks. Provide examples to accomplish task.
Behavior: Difficulty prioritizing from most to least important.
Accommodation: Prioritize assignments and activities. Provide a model to help students. Post the model and refer to it often.
- School Interventions
- Primary care providers for children with ADHD should advocate and assist parents in appropriate school programming, services, and supports.
- If medication is not tolerated or effective for the patient, or not desired by the parents after shared decision-making with the primary physician, family-focused strategies as well as child and school interventions should be emphasized.
Even at optimal doses of medication, most children with ADHD have residual difficulties at school. Physicians and other primary health care providers are often in a good position to assist parents in advocating for appropriate school programming for children with ADHD. Several classroom strategies are listed below. Although it is not expected that the primary care provider will act as an expert "consultant" in this area, it is important for him or her to have enough background familiarity with these issues to be an effective advocate and to be able to educate and empower parents on these issues.
Non-pharmacological interventions such as behavioral management and educational accommodations/modifications in the classroom have been found to assist children with ADHD in coping with and compensating for the academic and social difficulties associated with this disability [Reference], [Moderate Quality Evidence], [High Quality Evidence], [Low Quality Evidence]. If the primary care provider or parents decide not to use medications to treat ADHD, despite its overwhelming effectiveness, it is still appropriate to implement the psychosocial intervention.
Classroom Strategies for Children with ADHD
- A high degree of order and predictability to the classroom
- Clear and consistent rules and expectations
- Classroom organizational strategies such as a posted daily work schedule, written notices for homework assignments, quiet work areas, seating close to teacher and near positive peer models
- Training for students in study skills and time management
- Regularly scheduled, frequent breaks
- Creation of multisensory learning activities that are engaging and use various attention-getting devices
- Reduction of the amount of work assigned or other modifications of assignments
- Liberal use of positive reinforcers immediately and continually for desired behaviors
- Establishment of a school-home daily note card system to maintain parent-teacher contact with regard to academic and behavioral progress and problem areas
- Working with the student on self-monitoring, self-reinforcement and development of compensatory/adaptive strategies
Ongoing collaboration and communication between teachers and primary care providers is desirable in order to discuss and implement effective treatment strategies for each child. It is also important for the primary care provider to communicate with school staff about his/her perceptions of the child's diagnosis (or diagnoses) with particular attention to any medical/neurologic problems (e.g., Tourette's syndrome, mental retardation, seizures, hearing impairment, chronic medical conditions) that might be important for the teachers to understand. They may also want to discuss the perceived role of psychotropic medication and answer any questions about expected benefits, side effects, etc.
The severity of the child's ADHD and its adverse impact on academic performance will determine whether the child qualifies for special education services. The three educational service categories most commonly identified for children with ADHD (in school terminology) are Learning Disability (LD), Emotional/Behavioral Disorder (EBD), and Other Health Disability (OHD). Students with ADHD who do not meet eligibility criteria for the specific programs described (LD, EBD, OHD) may still need some level of assistance to be successful and may still receive specialized instruction and accommodations in the regular classroom. This is stated in section 504 of the Rehabilitation Act of 1973 and is intended to insure a "free and appropriate education in the least restrictive environment" for all students including those with a physical or mental impairment that limits learning. In these cases, parents should be encouraged to formally request a Section 504 plan for their child from school administration. Adequate documentation of the child's impairment (e.g., ADHD or other diagnosis) will be required from the physician.
Specific learning disabilities comorbid to ADHD must be treated concurrently with appropriate special educational programming. Primary care providers should develop a basic understanding of the Individualized Educational Plan (IEP), the document that details the student's direct and indirect special educational services.
Speech- and language-related difficulties must also be treated and supported across the curriculum and can have an impact on a number of subject areas and tasks. Children with ADHD who are also hearing impaired may require special assistance such as an "auditory trainer" device and other classroom accommodations. Most districts have the availability of a hearing impairment specialist to consult on these clients.
- Maintenance and Continuing Care
- Direct all management goals at building success for the child in his/her daily life skills and for their future.
- During evaluation and management visits, take into consideration medical, psychosocial and educational factors.
- Give anticipatory guidance at each visit; this can include immediate and long-term expectations, study and organizational skills, guidance on behavior management, adolescent concerns and updating resources.
- Consider advocacy issues and revise multimodal care management as needed.
- Recognize in the transition to adulthood the need for careful planning for post-secondary education or vocational needs.
ADHD may have an evolving impact on a child's or adolescent's learning or behavioral success. It is a condition that is significantly related to each child's environment (home, school, etc.) as well as to the specific demands placed upon the child or adolescent. The ability of the individual to develop compensation skills and success over time is related to these factors, as well as the presence or absence of comorbid conditions.
Recent evidence suggests that worsening clinical status during adolescence may more likely be due to environmental and/or comorbid causes, instead of inadequate psychostimulant medication dosage. The clinician should evaluate these possibilities before prescribing higher doses of stimulants to adolescents. For these reasons, close monitoring and follow-up is recommended for all children and adolescents diagnosed with ADHD, whether or not medication is utilized.
- Follow closely during initial medication trial by phone or clinical visit for first several weeks. Titration of dose every one to three weeks is suggested until target ADHD symptoms remit, adverse effects prevent further dose increase, or maximum dose for the stimulant medication is reached. Atomoxetine may take up to four weeks at target dose for observed response.
- Schedule a clinic visit after the initial medication trial to review care plan. The work group reviewed consensus guidelines from the American Academy of Child and Adolescent Psychiatry (2007) [Guideline] and the American Academy of Pediatrics (2001) [Guideline]. Because of very little evidence, work group consensus based on community standards of care is to recommend for stimulant medications a follow-up visit within six weeks of initiation of therapy.
- Once the patient is stable, schedule a clinic visit every three to six months, depending on the individual case – more frequent with significant comorbidity [R], [Guideline].
These visits allow for review and management of the following areas:
- Height, weight, blood pressure, pulse
- Dosage, timing, coverage priorities, duration
- Before making dosage adjustments or switching medications, the patient's adherence to current regimen should be addressed
- Positive attributes of medication
- Side effects and their management (see Table 5 in the original guideline document)
- Parent and teacher observations or behavior rating scales may be helpful
- Alternative/complementary medicine
Increasingly, parents are considering the use of alternative/complementary therapies for children with ADHD. Certain therapeutic interventions, such as the use of herbal, botanical and other nutraceutical agents, have the capacity to interact with psychotropic medications including stimulants, selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), among others. Therefore, it is important for pediatric health care providers to inquire in a non-judgmental fashion about the use of these agents by children under their care. Parents can then be educated appropriately about potential risks, benefits, side effects and drug interaction possibilities associated with a certain therapy. Such interventions are not supported by evidence-based research at this time.
- Family functioning
- Home behavior management
- Peer relationships
- Outside activities
- ADHD symptoms
- Child-teacher relationships, social functioning, general attitude
- Academic performance, homework and study skills
- Current interventions and supports
- Review IEP or Section 504 plan if appropriate
- Perception of ADHD and treatment
- Self-esteem issues
- Personal strengths and successes
- Immediate and long-term expectations
- Study/organizational skills
- Behavior management
- Updated resources and need for advocacy
- Adolescent considerations:
- Drug use
- Substance use
- Misuse and diversion of stimulant medications
Transitioning to Adulthood
- Despite growing interest in adult ADHD, little is known about predictors of persistence of childhood cases into adulthood. One recent retrospective study screened for adult ADHD 3,197 18-44 year olds diagnosed with ADHD in childhood. "Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence" [Low Quality Evidence].
- Another recent study showed, "An average of 50% of children with ADHD (range: 32.8%-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults" [Low Quality Evidence].
- Identify post-secondary education or vocational plans, and counsel patient regarding availability of academic support services.
- Identify adult health care provider to care transfer if necessary.
- Prioritize treatment to address target symptoms, level of impairment, and available resources (multiple modalities frequently useful); patient participation is necessary.
- Emphasize vocational evaluation, counseling, and training as well as time management skills, organization, and study skills.
- Discuss relationship issues.
- Monitor because comorbidities are common.
- Address risk of medication abuse by patient and peers.
Adherence to current regimen may be assessed by asking open-ended non-threatening questions at each office visit. If adherence to medication regimen appears to be lacking, the patient may benefit from adherence interventions. Such interventions include re-educating the patient and family about medications and how they fit into the treatment plan (including side effects and how they may be prevented). Other ways to help adherence include regimen simplification (e.g., less frequent dosing), use of patient adherence aids (e.g., tablet boxes, alarms), suggesting support group sessions, sending appointment reminders, cueing medication administration to daily activities (e.g., breakfast) and giving positive reinforcement for adherence efforts. Adverse effects of stimulants are not uncommon, but can generally be managed in most cases. The more common side effects include anorexia, insomnia, stomachaches, and headaches and, less commonly, rebound irritability, dysphoria, agitation, tics, and growth impairment are seen.
It is generally felt that, in individual patients, psychostimulants may unmask or exacerbate tics. However, in two recent studies evidence suggests that psychostimulants may not be associated with tic frequency or severity.
Growth suppression has been a concern with long-term use of stimulants. Recent observations/data suggest that reduced growth rates in ADHD patients treated with stimulants may occur in the first two years of treatment; however, the significance of effect on adult height acquisition is not known [High Quality Evidence], [Low Quality Evidence].
ADHD is a lifelong chronic condition. While it is common for the hyperactivity part of the condition to ameliorate throughout adolescence, there often remains (in 50%-60% of patients) significant inattentiveness, restlessness, and impulsivity.
As expected, patients will be able to discontinue medication variably, depending on the severity of ADHD symptoms and their ability to compensate relative to environmental demands. (e.g., school, work, family).
Poor prognostic indicators have included low intelligence, poor academic achievement, early conduct problems, poor social relationships, and family psychopathology. Many individuals, however, learn to compensate well as they rely on their significant strengths to overcome any persisting ADHD symptoms [Reference], [Low Quality Evidence].
Following a review of several evidence rating and recommendation writing systems, the Institute for Clinical System Improvement (ICSI) has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Crosswalk between ICSI Evidence Grading System and GRADE
|Design of Study Current ICSI System
||ICSI GRADE System
||Randomized, controlled trial
||High, if no limitation
|Moderate, if some limitations
|Low, if serious limitations
||High, if well done with large effect
|Moderate, if well done with effect
|Low, most studies
|Non-randomized trial with concurrent or historical controls
|Population-based descriptive study
|Study of sensitivity and specificity of a diagnostic test
|*Following individual study review, may be elevated to Moderate or High depending upon study design.
|Class Not Assignable
High Quality Evidence = Further research is very unlikely to change confidence in the estimate of effect.
Moderate Quality Evidence = Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
Low Quality Evidence = Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.
In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to inform the reader of other topics of interest. This literature is not given an evidence grade and is instead identified as a Reference throughout the document.
Detailed and annotated clinical algorithms for evaluation and management of attention deficit hyperactivity disorder are provided in the original guideline document .