New Practice Parameter for ADHD

The following rating system was developed for the recommendations:

• Minimal standards are recommendations based on rigorous empirical evidence and overwhelming clinical consensus. These standards can be applied to patients more than 95% of the time.

• Clinical guidelines are recommendations based on strong empirical or clinical consensus.

• Options are recommendations based on emerging empirical evidence or clinical opinion, without current strong empirical evidence or clinical consensus.

• Not endorsed are practices that are known to be ineffective or that are contraindicated.

SCREENING AND EVALUATION
Minimal standards

During a mental health assessment, every child and adolescent patient should be screened for ADHD. Screening questions for ADHD that are related to inattention, impulsivity, and hyperactivity should be included, irrespective of the chief complaint.

The diagnostic evaluation of a child or adolescent for ADHD should include clinical interviews with the patient and parent, as well as obtaining information about the patient's functioning in the school or day care setting and a review of the patient's medical, social, and family histories.

The parameter suggests that parents complete a standardized behavioral rating scale to assess ADHD behaviors in their child as well as other psychiatric symptoms that may be comorbid with ADHD. With parental permission, the patient's teacher(s) should complete a similar scale. It was also recommended that older children and adolescents be interviewed separately from parents to increase the likelihood of obtaining additional important clinical information. For a preschool or young school-aged child, the interview may be done with the parents present, although in some clinical situations (eg, significant family dysfunction), the interview should be done separately.

Children and adolescents with ADHD should be evaluated for comorbid psychiatric disorders. Treatment plans need to address ADHD and any comorbid disorders. Some common comorbid disorders include oppositional defiant disorder, conduct disorder, mood disorders (major depressive disorder, bipolar disorder), anxiety disorders, and substance use disorders.

Options

Psychological and neuropsychological tests are not mandatory for the diagnosis of ADHD. These tests should be conducted if the patient's history suggests low general cognitive ability or low achievement in language or mathematics compared with his or her intellectual ability. It is important to determine whether low academic achievement is attributable to ADHD, a learning disorder, or both.

Not endorsed

Laboratory or neurological testing is not indicated if the patient's medical history is unremarkable. In the absence of significant factors in the patient's medical history, the following tests and procedures were not recommended for the evaluation of ADHD: thyroid and thyroid-stimulating hormone levels, serum lead level, electroencephalogram, MRI, single photon emission CT, and positron emission tomography.

TREATMENT
Minimal standards

A comprehensive treatment plan should be developed for patients with ADHD. The treatment plan should consist of psychopharmacological and/or behavioral therapy, parental and child psychoeducation on ADHD, connection with community supports, and additional school resources, if needed. The practice parameters note that the evidence base shows that pharmacological treatment for ADHD is more effective than behavioral treatment alone.

Initial medication should be an FDA-approved agent that is specific for the treatment of ADHD. FDA-approved medications for the treatment of ADHD are dextroamphetamine, d- and d,l-methylphenidate, mixed amphetamine salts, and atomoxetine. As per the practice parameter, the choice of which agent to use first is determined by the clinician and family. However, the Texas Children's Medication Algorithm Project recommended stimulants as first-line treatment because stimulant medication has the most evidence for efficacy and safety in the treatment of ADHD.²

Patients should be monitored for treatment-emergent adverse effects during medication treatment for ADHD in children and adolescents. Common adverse effects of stimulant medications include appetite decrease, weight loss, insomnia, and headache; other adverse effects include tics and emotional lability. With regard to possible cardiovascular events (eg, sudden death), it was not recommended that routine cardiac evaluation (eg, echocardiogram) be done before starting treatment in healthy children. Adverse effects of atomoxetine include GI distress, sedation, and decreased appetite. The FDA has issued black-box warnings for ato- moxetine, including hepatoxicity and suicidality.

Children and adolescents who are taking medication for the treatment of ADHD should have their height and weight monitored throughout treatment. It was suggested that serial plotting of height and weight on growth charts be used 1 or 2 times per year. If a patient has a change in weight or height that crosses 2 percentile lines, then either a drug holiday or switching to another medication should be considered.

Patients should be assessed periodically to determine whether there is a continued need for treatment or whether symptoms have remitted. Treatment should continue as long as symptoms remain and cause impairment. If a patient with ADHD has been symptom free for at least 1 year, then the clinician should discuss with the patient and family whether they believe the medication continues to be beneficial.

Clinical guidelines

The clinical guidelines for the treatment of ADHD in children and adolescents can be applied in about 75% of cases. If a patient does not respond to pharmacological treatment with an FDA-approved agent for ADHD, then after careful review of the diagnosis, behavior therapy or the use of non-FDA-approved medications for the treatment of ADHD in children should be considered.

The parameter notes that the evidence base for the use of other agents such as bupropion, tricyclic antidepressants, and a-agonists is much weaker than for FDA-approved medications. It was suggested that clinicians might want to recommend a trial of behavior- al therapy before using second-line agents.

Psychosocial treatment in conjunction with medication is often beneficial for a patient with ADHD who has had a less than optimal response to medication, has a comorbid disorder, or has stressors in family life.

Options

In patients with ADHD who have a robust response to medication treatment and have normative functioning in academic, family, and social spheres, psychopharmacological treatment alone is satisfactory.

CONCLUSION

The parameter notes that for patients with ADHD without comorbidity who have a positive response to medication, adjunctive psychosocial intervention may not provide increased benefit.

The practice parameter is not meant to set a standard of care but is intended to help clinicians in the assessment and treatment of children with ADHD.

References:

References

1.

Pliszka SR, AACAP Workgroup on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.

J Am Acad Child Adolesc Psychiatry.

2007; 46:894-921.

2.

Pliszka SR, Crismon ML, Hughes CW, et al. The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/ hyperactivity disorder.

J Am Acad Child Adolesc Psychiatry.

2006;45:642-657.