Professional Documents
Culture Documents
ABSTRACT. This clinical practice guideline provides should be directed to target outcomes and adverse
evidence-based recommendations for the treatment of effects, with information gathered from parents, teach-
children diagnosed with attention-deficit/hyperactivity ers, and the child.
disorder (ADHD). This guideline, the second in a set of
policies on this condition, is intended for use by clini- This guideline is intended for use by primary care
cians working in primary care settings. The initiation of clinicians for the management of children between 6 and
treatment requires the accurate establishment of a diag- 12 years of age with ADHD. In light of the high preva-
nosis of ADHD; the American Academy of Pediatrics lence of ADHD in pediatric practice, the guideline
(AAP) clinical practice guideline on diagnosis of children should assist primary care clinicians in treatment. Al-
with ADHD1 provides direction in appropriately diag- though many of the recommendations here also may
nosing this disorder. apply to children with coexisting conditions, this guide-
The AAP Committee on Quality Improvement selec- line primarily addresses children with ADHD but with-
ted a subcommittee composed of primary care and out major coexisting conditions. The guideline is not
developmental-behavioral pediatricians and other ex- intended for use in the treatment of children with mental
perts in the fields of neurology, psychology, child psy- retardation, pervasive developmental disorder, moderate
chiatry, education, family practice, and epidemiology. to severe sensory deficits such as visual and hearing
The subcommittee partnered with the Agency for Health- impairment, chronic disorders associated with medica-
care Research and Quality and the Evidence-based Prac- tions that may affect behavior, and those who have ex-
tice Center at McMaster University, Ontario, Canada, to perienced child abuse and sexual abuse. This guideline is
develop the evidence base of literature on this topic.2 The not intended as a sole source of guidance for the treat-
resulting systematic review, along with other major stud- ment of children with ADHD. Rather, it is designed to
ies in this area, was used to formulate recommendations assist the primary care clinician by providing a frame-
for treatment of children with ADHD. The subcommittee work for decision-making. It is not intended to replace
also reviewed the multimodal treatment study of chil- clinical judgment or to establish a protocol for all chil-
dren with ADHD3 and the Canadian Coordinating Office dren with this condition, and may not provide the only
for Health Technology Assessment report (CCOHTA).4 appropriate approach to this problem.
Subcommittee decisions were made by consensus where
definitive evidence was not available. The subcommittee ABBREVIATIONS. AAP, American Academy of Pediatrics; ADHD,
report underwent extensive review by sections and com- attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and
mittees of the AAP as well as by numerous external Statistical Manual of Mental Disorders, Fourth Edition; MTA, multi-
organizations before approval from the AAP Board of modal treatment study of children with ADHD; CCOHTA, Cana-
Directors. dian Coordinating Office for Health Technology Assessment.
The guideline contains the following recommenda-
tions for the treatment of a child diagnosed with ADHD:
T
he American Academy of Pediatrics (AAP) rec-
• Primary care clinicians should establish a treatment ognizes the importance of accurate diagnosis
program that recognizes ADHD as a chronic condition. and management of children with attention-
• The treating clinician, parents, and child, in collabora- deficit/hyperactivity disorder (ADHD). The AAP
tion with school personnel, should specify appropriate
target outcomes to guide management.
developed a practice guideline for the diagnosis of
• The clinician should recommend stimulant medication ADHD among children from 6 to 12 years of age who
and/or behavior therapy as appropriate to improve are evaluated by primary care clinicians.1 The signif-
target outcomes in children with ADHD. icant components of the diagnostic guideline include
• When the selected management for a child with 1) the use of explicit criteria for the diagnosis using
ADHD has not met target outcomes, clinicians should the Diagnostic and Statistical Manual of Mental Health
evaluate the original diagnosis, use of all appropriate Disorders, Fourth Edition (DSM-IV) criteria5; 2) the
treatments, adherence to the treatment plan, and pres- importance of obtaining information about the
ence of coexisting conditions. child’s symptoms in more than 1 setting (especially
• The clinician should periodically provide a systematic from schools); and 3) the search for coexisting con-
follow-up for the child with ADHD. Monitoring
ditions that may make the diagnosis more difficult or
complicate treatment planning.
The recommendations in this statement do not indicate an exclusive course This guideline is based on an extensive review of
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
the medical, psychological, and educational litera-
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- ture. The objectives of the literature review were to
emy of Pediatrics. determine the long- and short-term effectiveness and
Unlike most other medications, stimulant dosages According to the Physicians’ Desk Reference43 and
usually are not weight dependent. Clinicians should medication package insert, methylphenidate is con-
begin with a low dose of medication and titrate traindicated in children with seizure disorders, a
upward because of the marked individual variability history of seizure disorder, or abnormal electroen-
in the dose-response relationship. The first dose that cephalograms. Studies of the use of methylphenidate
a child’s symptoms respond to may not be the best have not, however, demonstrated an increase in sei-
dose to improve function. Clinicians should continue zure frequency or severity when it is added to ap-
to use higher doses to achieve better responses.3 This propriate anticonvulsant medications.44 – 46
strategy may require reducing the dose when a Children who receive too high a dose or who are
higher dose produces side effects or no further im- overly sensitive may become overfocused on the
provement. The best dose of medication for a given medication or appear dull or overly restricted. Many
child is the one that leads to optimal effects with times this side effect can be addressed by lowering
minimal side effects. The dosing schedules vary de- the dose. Rarely, with high doses, some children
pending on target outcomes, although no consistent experience psychotic reactions, mood disturbances,
controlled studies compare different dosing sched- or hallucinations.
ules. For example, if there is a need for relief of No consistent reports of behavioral rebound, mo-
symptoms only during school, a 5-day schedule may tor tics, or dose-related growth delays have been
be sufficient. By contrast, a need for relief of symp- found in controlled studies,47 although they are re-
toms at home and school suggests a 7-day schedule.
ported clinically.33 Appetite suppression and weight
Stimulants are generally considered safe medica-
loss are common side effects of stimulant medica-
tions, with few contraindications to their use. Side
tion, with no apparent difference between methyl-
effects occur early in treatment and tend to be mild
phenidate and dextroamphetamine. Concern for
and short-lived.35 The most common side effects are
decreased appetite, stomachache or headache, de- growth delay has been raised, but a prospective fol-
layed sleep onset, jitteriness, or social withdrawal. low-up study into adult life48 has found no signifi-
Most of these symptoms can be successfully man- cant impairment of height attained. Studies of stim-
aged through adjustments in the dosage or schedule ulant use have found little or no decrease in expected
of medication. Approximately 15% to 30% of chil- height, with any decrease in growth early in treat-
dren experience motor tics, most of which are tran- ment compensated for later on.49 –54 Many clinicians
sient, while on stimulant medications. In addition, recommend drug holidays during summers, al-
approximately half of children with Tourette syn- though no controlled trials exist to indicate whether
drome have ADHD. The effects of medication on holidays have gains or risks, especially related to
tics are unpredictable. The presence of tics before weight gain.
or during medical management of ADHD is not an 3A: For children on stimulants, if one stimulant does
absolute contraindication to the use of stimulant not work at the highest feasible dose, the clinician
medications.41,42 A review of 7 studies comparing should recommend another.
stimulants with placebo or with other medications
indicated no increase in tics in children treated with At least 80%3 of children will respond to one of the
stimulants.2 stimulants if they are tried in a systematic way. Chil-