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Guideline Summary
Guideline Title
Diagnosis and treatment of attention deficit hyperactivity disorder in school-age children and adolescents 2012 clinical practice guideline.
Bibliographic Source(s)
Kaiser Permanente ADHD Guideline Development Team. Diagnosis and treatment of attention deficit hyperactivity disorder in school-age children and adolescents 2012 clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2012 Mar. 100 p. [58 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente ADHD Guideline Development Team. Child/adolescent attention deficit/hyperactivity disorder (ADHD) clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2009 Dec. 338 p. [123 references]

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • December 17, 2013 – Methylphenidate ADHD Medications External Web Site Policy: The U.S. Food and Drug Administration (FDA) is warning that methylphenidate products, one type of stimulant drug used to treat attention deficit hyperactivity disorder (ADHD), may in rare instances cause prolonged and sometimes painful erections known as priapism. Based on a recent review of methylphenidate products, FDA updated drug labels and patient Medication Guides to include information about the rare but serious risk of priapism. If not treated right away, priapism can lead to permanent damage to the penis.

Scope

Disease/Condition(s)

Attention deficit/hyperactivity disorder (ADHD)

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Managed Care Organizations
Nurses
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To assist Kaiser Permanente physicians, administrators, and other health care professionals in determining the most effective medical practices

Target Population

School-age children and adolescents with or at risk for attention deficit/hyperactivity disorder (ADHD)

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Evaluation of children and adolescents when they have signs and symptoms or impairment of attention deficit/hyperactive disorder (ADHD)
  2. Evaluation should include structured, validated rating scales, such as, Diagnostic and Statistical Manual-IV (DSM-IV) diagnostic criteria
  3. Baseline physical assessment, including cardiac risk evaluation

Treatment

  1. Drug treatments
    • First-line stimulant medication
      • Methylphenidate
      • Amphetamine preparations (amphetamine mixed salts, dextroamphetamine)
    • Second-line nonstimulant medication
      • Stimulant
      • Referral or consultation with a specialist
      • Stimulant treatment augmented with guanfacine or clonidine 
      • Guanfacine or clonidine monotherapy
      • Atomoxetine
  2. Cognitive behavioral therapy (CBT), family therapy, parent training, and social skills
  3. Additional educational services offered through the school system
  4. Follow-up visits
  5. Monitor adverse events, assessing benefits and risks of pharmacological treatment
  6. Referral to a specialist (including child psychiatry, behavioral health, a behavioral pediatrician, or ADHD champion) for certain comorbid conditions

Note: The following interventions and practices were considered but not routinely recommended:

  • Addition of a clinic-based, nondrug interventions
  • Dietary modifications and/or elimination diets
  • Referral for allergy evaluation
Major Outcomes Considered
  • Accuracy of diagnosis
  • Core symptoms (including measures of inattention, hyperactivity, impulsivity)
  • Stigma of attention deficit/hyperactivity disorder (ADHD) label
  • Inconvenience of tests
  • Anxiety associated with tests
  • False positives
  • False negatives
  • Important changes in weight, height, heart rate, and blood pressure
  • Morbidity, mortality (e.g., cardiac disease, sudden death, psychosis)
  • Reductions in core symptoms
  • Improvements in psychosocial and educational function
  • Core symptoms (including measures of inattention, hyperactivity, hyperactivity, impulsivity)
  • Quality of life (clinical global impression of overall severity indices as a proxy of quality of life)
  • Educational performance (e.g., volume of work, efficiency, completion, and accuracy)
  • Psychosocial function (relationships with parents, siblings, teachers, peers)
  • Cost-effectiveness

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A comprehensive literature search was performed in March to April 2011 to identify rigorous external attention deficit/hyperactivity disorder (ADHD) guidelines for children and adolescents. The Guidelines International Network (GIN) and Turning Research Into Practice (TRIP) databases were searched for full guidelines relating to ADHD in individuals ages 6 to 18 years. The inclusion criteria were full guidelines in English on children and adolescents, which were published from 2007 through the present. Of the 11 guidelines preliminarily identified as meeting the search parameters, four did not meet the preliminary inclusion criteria.

Considered to be a position statement with a narrow focus on one first-line ADHD treatment, the guideline published by the Canadian Pediatric Society was excluded. Three additional guidelines - Sowerby Centre for Health Informatics at Newcastle (SCHIN) (2010), National Health and Medical Research Council (2009), and National Health and Medical Research Council (2011) - were also excluded. While only the draft version of the National Health and Medical Research Council (2009) could be located, its 2011 version is currently in development.

Three remaining full guidelines developed by the National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), and American Academy of Child and Adolescent Psychiatry (AACAP) were assessed, first for rigor of development. After evaluating the level of rigor, three assessors determined that two of the three guidelines were rigorous enough to proceed with the rest of the Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation.

Both guidelines (NICE and SIGN) were deemed acceptable after the three raters assessed the remaining domains: scope and purpose, stakeholder involvement, clarity of presentation, applicability, and editorial independence. The current Kaiser Permanente guideline was accepted by the guideline development team as a foundation for the update, and was not appraised using AGREE II.

Number of Source Documents

External Guidelines: 2

Internal Guidelines: 1 (2009 Kaiser Permanente attention deficit/hyperactivity disorder [ADHD] guideline)

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The overall quality of evidence for outcomes was assessed using a method developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. Refer to Appendix A in the original guideline document for the GRADE System of Evidence Rating.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The Project Management Team performed systematic reviews of the medical literature for each clinical question identified by the Guideline Development Team (GDT).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

To develop this guideline, Care Management Institute (CMI) consultants work with a multidisciplinary Guideline Development Team (GDT). Each GDT consists of a core group of physicians, representing primary care and the specialties most affected by the guideline topic, and, as appropriate, other content experts from disciplines such as pharmacy, nursing, and health education. The members of a GDT are nominated by the respective National Guideline Directors to represent their regions.

To develop the attention deficit/hyperactivity disorder (ADHD) guideline, released in February 2012, a multidisciplinary, interregional GDT met in April 2011 to define the scope of the guideline. The Project Management Team then performed systematic reviews of the medical literature for each clinical question identified by the GDT, assembled and presented the evidence, and developed draft recommendations for review by the GDT. The GDT then carefully reviewed the recommendations and supporting evidence in a series of meetings from August 2011 through November 2011.

Rating Scheme for the Strength of the Recommendations

To determine the overall strength of the recommendations, the Guideline Development Team (GDT) assigned equal weight to the four Grading of Recommendations Assessment, Development, and Evaluation (GRADE) domains* (for details, see the Attention Deficit Hyperactivity Disorder (ADHD) Rationale Decision Table in the original guideline document).

For example, when less uncertainty (in balance of harms to risks, differences in values and preferences, and net benefits and costs) and higher quality evidence were identified in three or four of the four domains, the GDT assigned a strong recommendation.

Otherwise, the GDT assigned a weak recommendation when uncertainty was greater in balance of harms to risks, patient values and preferences, and costs/resource implications.

When the quality of evidence was very low, the GDT considered the recommendation as weak (regardless of the weight of the other four domains).

* The Scottish Intercollegiate Guidelines Network (SIGN) ADHD guideline (2009) and Kaiser Permanente ADHD Clinical Practice Guideline (2009) did not use GRADE methodology to assess the overall quality of evidence across outcomes.

Cost Analysis

See the Attention Deficit Hyperactivity Disorder (ADHD) Rational Decision Table and Appendix B in the original guideline document for details on cost and resource implications of clinical questions.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The Guideline Quality Committee examined and approved the guideline in February 2012. The guideline was approved by the National Guideline Directors in March 2012.

Recommendations

Major Recommendations

The strength of recommendation (strong, weak) is defined at the end of the "Major Recommendations" field.

Guideline Summary

  1. Clinicians should not universally screen children and adolescents for attention deficit/hyperactivity disorder (ADHD). (Strong recommendation)
  2. Clinicians should evaluate children and adolescents for ADHD when they have signs, symptoms, or impairment suggestive of ADHD. (Strong recommendation)
  3. As part of the evaluation and diagnosis of ADHD in children and adolescents, clinicians should use structured, validated rating scales*, and refer to and follow the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria. (Strong recommendation)
  4. Clinicians should conduct a baseline physical assessment (including measurement of pulse, blood pressure, weight, and height with the appropriate use of percentile charts) prior to initiating pharmacological therapy. (Strong recommendation)
  5. Clinicians may recommend cardiac risk evaluation or consultations prior to prescribing psychostimulants for children and adolescents with ADHD with known cardiac abnormalities. (Weak recommendation)
  6. Clinicians should not perform psychodiagnostic tests as part of ADHD evaluation in the absence of other indications. (Strong recommendation)
  7. In the absence of signs or symptoms of atopy, clinicians should not refer children and adolescents with ADHD for allergy evaluation, as it is unlikely to change the diagnosis or treatment plan. (Weak recommendation)
  8. First-line pharmacological treatment
    • Clinicians should recommend stimulant medications methylphenidate, amphetamine mixed salts, or dextroamphetamine as first-line pharmacological treatment for children and adolescents diagnosed with ADHD (with or without comorbid conditions). (Strong recommendation)
    • Clinicians, patients, parents and/or caregivers should collaboratively select first-line pharmacological treatment based on preferences, side effects and potential harms, pharmacokinetics (rapidity of onset, duration of action), cost, and formulary availability. (Strong recommendation)
  9. Clinicians may recommend additional educational services offered outside of Kaiser Permanente (KP), such as through the school system, for children and adolescents diagnosed with ADHD. (Weak recommendation)
  10. Cognitive behavioral therapy (CBT), family therapy, parent training, and social skills training are options for children or adolescents diagnosed with ADHD, with or without comorbidities, for whom drug treatment is contraindicated, not tolerated, or a decision has been made not to initiate drug therapy. (Weak recommendation)
  11. For children and adolescents who are responding adequately to medication management, clinicians should not routinely add a clinic-based, non-drug intervention† for treating ADHD. (Weak recommendation)
  12. Clinicians should not recommend dietary modifications and/or elimination diets‡ for the treatment of ADHD. (Weak recommendation)
  13. Second-line pharmacological treatment options
    • After assessing for and addressing medication adherence and other conditions that might interfere with response, if not otherwise contraindicated, clinicians may recommend a different stimulant medication (in the same or different class) for patients who fail to adequately respond to or are intolerant of the initial stimulant. (Weak recommendation)
    • If two or more first-line stimulant formulations are contraindicated, not tolerated, or ineffective, treatment options include:
      1. Referral or consultation with a specialist, including child psychiatry, behavioral health, a behavioral pediatrician, or ADHD champion
      2. Stimulant treatment augmented with guanfacine or clonidine
      3. Guanfacine or clonidine monotherapy
      4. Atomoxetine (Kaiser Permanente non-formulary medication), (Weak recommendation)
  14. Clinical follow-up for children and adolescents with ADHD who start pharmacologic treatment
    • Clinicians should recommend one in-person office visit with a practitioner with prescriptive authority for children and adolescents during the 30-day initiation phase of drug treatment for ADHD.
    • Clinicians should recommend a minimum of two follow-up visits within 9 months after the 30-day initiation phase visit for children and adolescents continuing drug treatment for ADHD. One of the visits may be a telephone visit with a practitioner. More frequent follow-up visits may be conducted on a case-by-case basis.
    • At all follow-up visits, clinicians should assess patients for adverse effects, adherence to treatment, and response to treatment. Clinicians should monitor for changes in core symptoms of ADHD (hyperactivity, impulsivity, and inattention), educational function, psychosocial function, and potential side effects, such as headaches, abdominal pain, and changes in height, weight, blood pressure, pulse, or eating and sleeping patterns. (Weak recommendations)
  15. Monitoring for adverse events
    • Clinicians should instruct patients, parents, and/or other caregivers about cardiovascular signs and symptoms (for any stimulant), or liver dysfunction, and suicidality (for atomoxetine). Patients, parents, or caregivers should seek medical attention should any of these signs and symptoms occur. (Strong recommendation)
    • Clinicians may order liver function tests for patients prescribed atomoxetine. (Weak recommendation)
  16. Clinicians should not routinely recommend drug holidays for children and adolescents with ADHD. However, clinicians should consider the viewpoints of the patients, parents and/or other caregivers to identify the best pattern of use, which may include periods without drug treatment. (Weak recommendation)
  17. Clinicians should assess the continuing benefit and potential risk of pharmacological treatment at least every six months. (Weak recommendation)
  18. If the benefits continue to outweigh the risks, clinicians should prescribe pharmacological treatment for ADHD for as long as it remains clinically effective. (Weak recommendation)
  19. Clinicians may refer children and adolescents with ADHD and common comorbid conditions (e.g., oppositional defiant, conduct, anxiety, and tic disorders) for consultation with a specialist (e.g., a child psychiatrist, behavioral health specialist, behavioral pediatrician, or ADHD champion). (Weak recommendation)

*The publicly available Vanderbilt ADHD Rating Scales are recommended as part of the evaluation and diagnosis of ADHD in children and adolescents. The following behavioral rating scales are options to be used in addition to the initial evaluation: Conners' Rating Scales (the revised Conners' Parent Rating Scale [CPRS-R], the revised Conners' Teacher Rating Scale [CTRS-R], and the Conners'/Wells Self-Report of Symptoms rating scale [CASS]), Achenbach Scales: Child Behavioral Checklist (CBCL), Teacher Report Form (TRF), Youth Self Report (YSR), ADHD Rating Scale – IV (ADHD RS-IV) (DSM-IV-based), Swan, Nolan, and Pelham Questionnaire (SNAP) (DSM-IV-based), and Achenbach and Vanderbilt behavioral rating scales can be utilized to assess some comorbid disorders.

†Examples of clinic-based, non-drug interventions are CBT, family therapy, and parent and social skills training.

‡Elimination diets were introduced with the 'Feingold theory' and implicated artificial colorings, preservatives, and cross-reacting natural salicylates in a variety of illnesses, including ADHD.

Definitions:

Strength of Recommendations

To determine the overall strength of the recommendations, the Guideline Development Team assigned equal weight to the four Grading of Recommendations Assessment, Development and Evaluation (GRADE) domains (for details, see the Rationale Decision Table in the original guideline document).

For example, when less uncertainty (in balance of harms to risks, differences in values and preferences, and net benefits and costs) and higher quality evidence were identified in three or four of the four domains, the GDT assigned a strong recommendation.

Otherwise, the Guideline Development Team assigned a weak recommendation when uncertainty was greater in balance of harms to risks, patient values and preferences, and costs/resource implications.

When the quality of evidence was very low, the GDT considered the recommendation as weak (regardless of the weight of the other four domains).

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence for each recommendation is given in the Attention Deficit Hyperactivity Disorder (ADHD) Rationale Decision Table in the original guideline document.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis, treatment of attention deficit/hyperactivity disorder (ADHD) which may:

  • Create program-wide economies of scale
  • Support ongoing performance improvement activities
  • Consistently provide high quality resources for use in care delivery tools and systems
  • Increase Kaiser Permanente regions' abilities to leverage clinical guidelines to improve clinical outcomes
Potential Harms
  • Adverse effects of tests (e.g., stigma of attention deficit/hyperactivity [ADHD] label, inconvenience of tests, anxiety associated with tests, false positives, false negatives)
  • Adverse effects of drug treatment (e.g., important changes in weight, height, heart rate, and blood pressure; morbidity; mortality [e.g., cardiac disease, sudden death, psychosis])
  • See the ADHD Rationale Decision Table and Appendix B in the original guideline document for details on potential harms of tests and interventions.
  • Patients with a history of hypersensitivity to guanfacine: use guanfacine with caution in patients at risk for hypotension, bradycardia, heart block or syncope; measure heart rate and blood pressure periodically during treatment; advise patients to avoid becoming dehydrated or overheated.

Contraindications

Contraindications
  • Hypersensitivity to clonidine hydrochloride has been identified as a contraindication to clonidine.
  • Stimulant medication therapy for attention deficit/hyperactivity disorder (ADHD) has been traditionally contraindicated in patients with known cardiac abnormalities.

Qualifying Statements

Qualifying Statements
  • This guideline is informational only. It is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by practitioners, considering each patient's needs on an individual basis.
  • Guideline recommendations apply to populations of patients. Clinical judgment is necessary to design treatment plans for individual patients.

Implementation of the Guideline

Description of Implementation Strategy

Once approved, the Project Manager sends National Guideline Directors group-approved guidelines to the Regional guideline directors and managers for distribution within their respective regions. These eight regions may modify the guidelines to fit the Regional environment. The Regional guidelines are sent to clinicians, physician assistants, nurse practitioners, and other health care professionals in relevant specialty groups, as well as Health Plan and Hospital operations, administrative and education staff, providers by email, through regional physician portals and by U.S. mail for clinicians not connected to the Kaiser Permanente email system.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Kaiser Permanente ADHD Guideline Development Team. Diagnosis and treatment of attention deficit hyperactivity disorder in school-age children and adolescents 2012 clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2012 Mar. 100 p. [58 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Dec (revised 2012 Mar)
Guideline Developer(s)
Kaiser Permanente Care Management Institute - Managed Care Organization
Source(s) of Funding

Kaiser Permanente Care Management Institute

Guideline Committee

Kaiser Permanente Attention Deficit/Hyperactivity Disorder (ADHD) Guideline Development Team

Composition of Group That Authored the Guideline

Kaiser Permanente (KP) Attention Deficit/Hyperactivity Disorder (ADHD) Guideline Management Team: David Price, MD, FAAFP, Clinical Lead, KP Colorado; Angela Chen, MPH, Project Manager, Care Management Institute; Jill Haynes, MPH, Analyst, Care Management Institute; Erin Stone, MD, EBM Methodologist, KP Southern California; Tabitha Pousson, Staff Assistant, Care Management Institute

KP ADHD Guideline Development Team: Colorado: Bruce C. Doenecke, MD, Pediatrician; Kerri M. Gaughan, PharmD, Clinical Pharmacy Specialist, Behavioral Health; Edward Gibson, MD, Mental Health Pediatrician/Psychiatrist; Georgia: Catherine Dragstedt, MD, Chief of Pediatrics; Alice Heimberg-Funk, MD, Child and Adolescent Psychiatrist; Hawaii: John Draeger, MD, Chief BHS; Northern California: Anna O. Wong, PhD, Psychologist; Northwest: Heather N Block, MPH, Prevention Services Manager; Shannon Ann Brown, MD, Physician, Pediatrics; Corinne Gavrun, PharmD, MBA, Drug Information and Formulary Pharmacist; Heather Jones, MD, Child Psychiatrist, Team Leader; Lisa J. Nakashimada, RPh, Medication Management, Clinical Pharmacy Services; Ohio: Larissa Elgudin, MD, Child/Adolescent Psychiatrist; William Wieder, MD; Program Offices - CMI: Andrew Bertagnolli, PhD, Principal Consultant, Behavioral Health & Pain Management; Gladys I Tom, Principal Consultant, Evidence Services; Southern California: Debbie R. Kubota, PharmD, Pharmacist, Evidence Analyst; Jessica A. Lam, MPH, Consultant, Medical Technology Assessment and Guidelines; Robert A. Moss, MD, Pediatrician; David G. Reynolds, Chief of Psychiatry

Financial Disclosures/Conflicts of Interest

There were no conflicts of interest for any member of the Guideline Development Team (GDT).

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Kaiser Permanente ADHD Guideline Development Team. Child/adolescent attention deficit/hyperactivity disorder (ADHD) clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2009 Dec. 338 p. [123 references]

Guideline Availability

Electronic copies: None available

Print copies: Available from the Kaiser Permanente Care Management Institute, One Kaiser Plaza, 16th Floor, Oakland, CA 94612

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 22, 2011. This NGC summary was updated by ECRI Institute on December 19, 2012. This summary was updated by ECRI Institute on April 7, 2014 following the U.S. Food and Drug Administration advisory on Methylphenidate ADHD Medications.

Copyright Statement

For any questions regarding the content of Kaiser Permanente National Clinical Practice Guidelines, please contact Gladys Tom, MS, Manager, CMI at gladys.i.tom@kp.org or (510) 271-2620.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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