A direct comparison of recommendations presented in the above guidelines for the diagnosis and treatment of ADHD in children and adolescents is provided below.
Areas of Agreement
Evaluation and Diagnosis
AAP and KPCMI agree that children and adolescents presenting with symptoms (e.g., inattention, hyperactivity, impulsivity) or impairment (e.g., academic or behavioral problems) suggestive of ADHD should undergo a thorough evaluation, and that the diagnosis is established according to criteria outlined in the DSM-IV. AAP states that diagnostic information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child's care. KPCMI recommends the use of the Vanderbilt ADHD Rating Scales as part of the diagnosis and evaluation, and cites a number of behavioral rating scales (e.g., Conners' Rating Scales, Achenbach Scales) as options.
Treatment of Preschool-Aged Children
AAP recommends that the primary care clinician prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment for preschool-aged children (4-5 years of age), with the option of prescribing methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child's function. The KPCMI guideline does not address preschool-aged children.
Treatment of Children and Adolescents
AAP makes recommendations for the treatment of children and youth with ADHD according to age. For elementary school-aged children (6-11 years of age), AAP recommends that the primary care clinician prescribe FDA-approved medications for ADHD and/or evidence based parent- and/or teacher-administered behavior therapy, preferably both. For adolescents (12-18 years of age) with ADHD, AAP also recommends the use of FDA-approved medication (with the assent of the adolescent), noting that the primary care clinician may also prescribe behavior therapy, and that the use of both pharmacotherapy and behavior therapy is preferable.
KPCMI recommends pharmacological therapy as first-line treatment in children and adolescents with ADHD, citing behavioral therapies (CBT, family therapy, parent training, social skills training) as treatment options in patients for whom drug treatment is contraindicated or not tolerated, or for whom a decision has been made not to initiate drug therapy.
Selection of Pharmacological Agent(s)
AAP recommends the use of FDA-approved medications for the pharmacologic treatment of ADHD in both elementary-school aged children and adolescents, noting that the evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order). KPCMI similarly recommends the stimulant medications methylphenidate, amphetamine mixed salts, or dextroamphetamine as first-line pharmacological treatment options for children and adolescents diagnosed with ADHD. The specific medication should be collaboratively selected by clinicians, patients, parents and/or caregivers, KPCMI adds, and should be based on preferences, side effects and potential harms, pharmacokinetics, cost, and formulary availability. If the patient fails to adequately respond to, or is intolerant of the initial stimulant, KPCMI recommends an assessment of medication adherence and other conditions that might interfere with response, followed by a change in psychostimulant medication as needed (if not otherwise contraindicated). If two or more first-line stimulant formulations are contraindicated, not tolerated, or ineffective, second line pharmacologic treatment options cited by KPCMI are augmentation of stimulant treatment with guanfacine or clonidine, guanfacine or clonidine monotherapy, and atomoxetine. An appropriate second-line, non-pharmacological treatment option cited by KPCMI is referral or consultation with a specialist.
Pharmacological Therapy Considerations
KPCMI recommends that clinicians conduct a comprehensive baseline physical assessment prior to initiating pharmacological therapy, with an optional cardiac risk evaluation/consultation for children and adolescents with known cardiac abnormalities. With regard to dosage, AAP recommends that primary care clinicians titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects. KPCMI provides recommendations for the clinical follow-up of children and adolescents with ADHD after initiation of pharmacologic treatment. The developer recommends one in-person office visit in the first 30 days, a minimum of two follow-up visits in the following nine months, and at least one visit every six months thereafter. At these visits patients should be assessed for adverse effects, adherence to treatment, and response to treatment. If the benefits continue to outweigh the risks, KPCMI recommends that clinicians continue pharmacological treatment as long as it remains clinically effective, recommending against the use of routine drug holidays.
Areas of Difference
Recommendations offered by AAP and KPCMI for the use of behavioral therapies in addition to pharmacotherapy differ. According to AAP, the use of behavior therapy in addition to pharmacotherapy is preferable to pharmacotherapy alone in elementary school-aged children and adolescents. The developer makes a "strong recommendation" (Quality of Evidence B) for the addition of behavior therapy in 6-11 year olds, and a "recommendation" (Quality of Evidence C) for its use in 12-18 year olds.
KPCMI, in contrast, makes a "Weak" recommendation against the routine addition of non-drug interventions (CBT, family therapy, parent training, social skills training) for children and adolescents who are responding adequately to medication management. The developer cites non-drug interventions as options if drug treatment is contraindicated, not tolerated, or a decision has been made not to initiate drug therapy.