AAP Updates Guidelines for ADHD Treatment in Children
The “incremental” revisions to the American Academy of Pediatrics’ (AAP) guidelines for ADHD diagnosis and treatment in children, the first in eight years, focus on comorbid conditions and comprehensive care.
October 2, 2019
The American Academy of Pediatrics (AAP) has updated its guidelines for the evaluation, treatment, and monitoring of children with attention deficit hyperactivity disorder (ADHD or ADD) in a series of revisions that most notably underscore systemic barriers to care and call on pediatricians to screen and initiate treatment for comorbidities.
The revised guidelines1, published on September 30 in Pediatrics, mark the first change to the guidelines since 2011. The recent updates, however, are described as “only incremental” by AAP.
“Since 2011, much research has occurred, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has been released,” writes the AAP panel. The new guidelines clearly state that the DSM-5, released in 2013, is now the standard used for diagnosis as opposed to the DSM-IV. The changes between the manuals are minimal, but do include some notable differences – children over 17 are required to show fewer problem behaviors required to meet criteria for ADHD, for example.
A major change in the new guidelines, however, includes the addition of a key action statement (KAS), which says that primary care clinicians can initiate treatment of ADHD comorbidities — like anxiety, mood disorder, oppositional defiant disorder, autism spectrum disorders, and more — if experienced in diagnosing them, or make a referral to a sub-specialist for treatment. The new KAS brings the total number of KASs to seven since the 2011 revision.
“ADHD is a chronic illness that can have a devastating impact if left untreated,” said Mark L. Wolraich, MD, FAAP, lead author of the report and prominent clinician and researcher in ADHD in a release2. “A pediatrician can help families figure out what is going on and work with families to help children succeed in managing their symptoms and behavior.”
The new guidelines also come with a new 10-page companion article, “Systemic Barriers to the Care of Children and Adolescents with ADHD,” that features four barriers as identified by AAP and recommendations on addressing them. The barriers include: limited access to care because of inadequate training or shortage of specialists; payer coverage limitations for services; challenges in practice organization and staffing; and fragmentation of care and communication barriers. One strategy calls for clinicians to coordinate with patient communities.
“We know that a child diagnosed with ADHD will benefit most when there is a partnership between families, their doctors, and their teachers, who may need to create special instructional plans and support,” said Joseph F. Hagan, Jr., MD, FAAP, co-author of the guidelines.
Other strategies to address the barriers include promoting changes in pediatric residency curricula; supporting revisions to payment systems; and implementing team-based approaches to communication. The barriers were determined, in part, as AAP reviewed the process of care algorithm (PoCA), which has also been updated to assist in implementing the guideline’s recommendations.
The guidelines, as in the previous version, continue to list areas for future research, like studies of medications and therapies that are used clinically for treating ADHD but are not FDA approved.
“Evidence is clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify comorbid conditions, and effectively treat with both psychosocial and pharmacologic interventions,” AAP writes. “The steps required to sustain appropriate treatments and achieve successful long-term outcomes remain challenging, however.”
National data from 2016, according to AAP, indicates that 9.4 percent of children in the United States between two to 17 years of age have been diagnosed at one point with ADHD. ADHD is also the most common childhood neurobehavioral disorder in the country, and the second most commonly diagnosed childhood condition.
The changes to the “Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” used to treat children from ages four to 18, come after the AAP subcommittee held review meetings between 2015 to 2018.
1 Wolraich, M. Hagan, J., et.al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics Oct. 2019, 144 (4) e20192528; DOI: 10.1542/peds.2019-2528
2 “AAP Updates Guidelines on Attention Deficit-Hyperactivity Disorder with Latest Research.” AAP.org, 30 Sept. 2019, www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Updates-Guidelines-on-Attention-Deficit-Hyperactivity-Disorder-with-Latest-Research.aspx.