ADHD – Diagnosis, Evaluation, and Treatment
Featured Reading 3: Diagnosis, Evaluation, and Treatment of ADHD in children aged 4-18 years old
Wolraich ML, Hagan JF Jr, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019 Oct;144(4). doi: 10.1542/peds.2019-2528. PubMed PMID: 31570648.
This clinical guideline from the AAP updates the 2011 one and addresses the evaluation, diagnosis, and treatment of ADHD in children aged 4-18 years old.ADHD is best managed in a patient-centered medical home setting. In the supplemental section of the article there isa process of care algorithm (PoCA) for the diagnosis and treatment of ADHD and an article on systemic barriers to the care of children and adolescents with ADHD.
EVALUATION AND DIAGNOSIS OF ADHD
The DSM-5 criteria are similar to the 2011 guidelines except for two important changes.
- For those ≥ 17 years, fewer problem behaviors are required for diagnosis.
- Symptoms of ADHD must begin before the age of 12, rather than the old guidelines at age 7.
Also, rule out other causes of ADHD-like symptoms and identify co-morbid conditions such as:
- Emotional or behavioral conditions (anxiety, depression, oppositional defiant disorder, conduct disorder, and substance use)
- Developmental conditions (learning and language disorders, autism spectrum disorders)
- Physical conditions (tics and sleep apnea)
THERAPIES AND TOOLS FOR TREATMENT OF ADHD
Recommended treatments are unchanged. Use methylphenidate and amphetamine medications as first line treatment. Secondary medications include atomoxetine, guanfacine, and clonidine. Behavioral therapy is also recommended as a first line treatment for preschoolers and should include parent training in behavior management. For high school students, some studies show value in behavior management training forthe parents and teachers.
PROCESS OF CARE ALGORITHM (PoCA)
The guidelines and algorithm emphasize that ADHD is a chronic illness with effective treatments, but no cure. It also includes additional assessment tools with rating scales for anxiety, depression, substance abuse, and trauma. Some children with ADHD learn to compensate as they mature but will always have ADHD symptoms.
SYSTEMIC BARRIERS TO CARE
Clinicians experience significant barriers when trying to implement ADHD guidelines. These include inadequate payment for services, inadequate pediatric training in mental health, limited consultants (medical and behavioral), and barriers to communicate with schools and consultants.