Recommendations for Treatment of AD/HD from the American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder
By Bob Seay
Children who have AD/HD should receive medication and/or behavioral treatments for their disorder with continued treatment of AD/HD as a chronic condition, according to guidelines published by the American Academy of Pediatrics (AAP) on October 1, 2001.
The recommendations were compiled by a committee that included representatives from the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry and other mental health groups from the United States and Canada which met over a three year period. The final document was reviewed by several organizations before receiving approval from the AAP Board of Directors.
"The AAP Clinical Practice Guidelines for ADHD succinctly summarize decades of clinical research in a set of cogent, practical, evidence-basedrecommendations," said Arthur Robin, Ph.D., Professor of Psychiatry and Behavioral Neurosciences at Wayne State University. In a conversation with ADDitudemag.com, he expressed optimism that the AAP recommendations will help put an end to many of the unfortunate myths which have prevented children and adolescents with AD/HD from receiving optimal treatment. Dr. Robin, a licensed psychologist, believes that clinicians will benefit from the newly published guide. "Practitioners of all disciplines- physicians, psychologists, social workers, and educators- will find these guidelines to be very useful," he said.
The full Guidelines for Treatment are available from the American Academy of Pediatrics .
Before Treatment Begins
The new guidelines stress the importance of an accurate diagnosis for patients suspected to have AD/HD and the consideration of other factors in the life of the child. Specifically, these recommendations are not for children who have developmental disorders, hearing problems, or who have been the victims of abuse. The authors also remind clinicians and parents that symptoms must occur in more than one setting and must meet other criteria presented in the AAP <a href="/medical.asp?DEPT_NO=501&ARTICLE_NO=5&ARCV=1"> Guidelines for Pediatricians Diagnosing AD/HD</a> and the <a href="/medical.asp?DEPT_NO=201&ARTICLE_NO=1&ARCV=1"> list of symptoms of AD/HD</a> found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
An Outline for Treatment
Following an accurate diagnosis, the panel recommends establishing specific goals for treatment. Such goals, or target outcomes, might include improvements in relationships with parents, siblings, teachers, and peers; decreased disruptive behaviors and/or improved academic performance. The AAP panel recommends setting 3 to 6 goals and stresses that they should be ''realistic, attainable, and measurable.'' These goals should be decided by the child and his or her parents, teachers and doctor(s).
Goals should be reviewed and progress noted throughout treatment. Lack of improvement could mean a change in treatment plan, a reconsideration of goals, or in some instances, the possibility of a change in diagnosis.
Building Teams for Treatment
The panel concluded that "primary care clinicians cannot work alone in the treatment of school-aged children with ADHD." Rather than relying solely on the doctor, the AAP recommends a team approach with continued communication between parents, teachers, and other school-based professionals as they monitor the effectiveness of treatment.
Research indicates that as many as 80% of children diagnosed with AD/HD will continue to present symptoms of the disorder during their teenage years. This chronic nature of AD/HD requires continued education and support for parents and children who have AD/HD. Explanations of AD/HD, how it is treated and why treatment is important should be modified as the child matures and is capable of better understanding the diagnosis. Parents should be informed of new developments in research and treatment.
More complicated cases involving co-existing disorders and conditions may require greater resources. The panel's recommendations echo the findings of the multi-modal treatment study of children with AD/HD (MTA) published in late 1999: "Integration of services with psychologists, child psychiatrists, neurologists, educational specialists, developmental-behavioral pediatricians, and other mental health professionals may be appropriate for children with ADHD who have coexisting conditions and may continue to have problems in functioning despite treatment."
Medication and Behavior Therapies
Stimulant medications (Ritalin, Adderall and others) and/or behavioral therapy are recommended to help improve target outcomes. While recommending both, the panel seems to be of the opinion that the evidence for medication treatment is stronger than that of behavior therapy:
" The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong). - (NOTE: Italics, boldface and parentheses are used in the original text.)
The panel continues the comparison: "For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances."
With either approach, the chronic nature of AD/HD requires continued treatment. Medication appears to be effective only when it is being used. According to the authors of the guidelines, the same is true of behavior therapies: "Studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy; however, behavior therapy has been demonstrated to be effective only while it is implemented and maintained."
Patients begin with a low dose of medication which is may be increased as needed. The panel reiterates that stimulant medications used to treat AD/HD are generally considered safe medications with few side effects which can usually be easily controlled.
Rather than a one-size-fits-all approach to medication, the panel recognizes individual differences in medication response, concluding that "the best dose of medication for a given child is the one that leads to optimal effects with minimal side effects." Dosing schedules for stimulant medications may also vary depending on target outcomes. "For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient. By contrast, a need for relief of symptoms at home and school suggests a 7-day schedule."
In the event that the first choice of medication does not work, the panel recommends that other stimulants be considered. Children who fail 2 stimulant medications can be tried on a third type of stimulant medication, however, the panel notes that "lack of response to treatment also should lead clinicians to assess the accuracy of the diagnosis and the possibility of undiagnosed co-existing conditions."
As was mentioned above, behavior therapy is recommended as a treatment option, either alone or in combination with medication.
Successful behavior therapy involves not only the child but includes parents, teachers and other influential adults who must be trained in specific techniques of improving behavior. The panel recommends providing rewards (extended play time, tokens, or other incentives) and consequences such as "time outs" or loss of privileges for specific behaviors.
AAP cites research which shows that parent training in behavior therapy and classroom behavior interventions can successfully change the behavior of children with ADHD. According to the panel, parent training typically begins with 8 to 12 weekly group sessions with a trained therapist.
The focus is on the child's behavior problems and difficulties in family relationships. The panel also warns that there is no guarantee of success: "Parent training improves the child's functioning and decreases disruptive behavior but does not necessarily bring the behavior of a child with ADHD into the normal range on parent rating scales."
Plan For Long Term Treatment
Because ADHD is a chronic condition, the panel recommends re-evaluation of the child and continuing education about how AD/HD may affect the individual as he or she matures. "The clinician should periodically provide a systematic follow-up for the child with ADHD," notes the panel. "Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child." Support for parents is also recommended.
Treatment for AD/HD requires time and effort from the child, his or her parents and others. However, with proper treatment, AD/HD is manageable. The full Guidelines for Treatment are available from the American Academy of Pediatrics .