Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder

This clinical practice guideline provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline, the second in a set of policies on this condition, is intended for use by clinicians working in primary care settings. The initiation of treatment requires the accurate establishment of a diagnosis of ADHD; the American Academy of Pediatrics (AAP) clinical practice guideline on diagnosis of children with ADHD1 provides direction in appropriately diagnosing this disorder.

The AAP Committee on Quality Improvement selected a subcommittee composed of primary care and developmental-behavioral pediatricians and other experts in the fields of neurology, psychology, child psychiatry, education, family practice, and epidemiology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University, Ontario, Canada, to develop the evidence base of literature on this topic.2 The resulting systematic review, along with other major studies in this area, was used to formulate recommendations for treatment of children with ADHD. The subcommittee also reviewed the multimodal treatment study of children with ADHD3 and the Canadian Coordinating Office for Health Technology Assessment report (CCOHTA).4 Subcommittee decisions were made by consensus where definitive evidence was not available. The subcommittee report underwent extensive review by sections and committees of the AAP as well as by numerous external organizations before approval from the AAP Board of Directors.

The guideline contains the following recommendations for the treatment of a child diagnosed with ADHD:

Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition.

The treating clinician, parents, and child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.

The clinician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD.

When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions.

The clinician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.

This guideline is intended for use by primary care clinicians for the management of children between 6 and 12 years of age with ADHD. In light of the high prevalence of ADHD in pediatric practice, the guideline should assist primary care clinicians in treatment. Although many of the recommendations here also may apply to children with coexisting conditions, this guideline primarily addresses children with ADHD but without major coexisting conditions. The guideline is not intended for use in the treatment of children with mental retardation, pervasive developmental disorder, moderate to severe sensory deficits such as visual and hearing impairment, chronic disorders associated with medications that may affect behavior, and those who have experienced child abuse and sexual abuse. This guideline is not intended as a sole source of guidance for the treatment of children with ADHD. Rather, it is designed to assist the primary care clinician by providing a framework for decision-making. It is not intended to replace clinical judgment or to establish a protocol for all children with this condition, and may not provide the only appropriate approach to this problem.

The American Academy of Pediatrics (AAP) recognizes the importance of accurate diagnosis and management of children with attention-deficit/hyperactivity disorder (ADHD). The AAP developed a practice guideline for the diagnosis of ADHD among children from 6 to 12 years of age who are evaluated by primary care clinicians.1 The significant components of the diagnostic guideline include 1) the use of explicit criteria for the diagnosis using the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV) criteria5; 2) the importance of obtaining information about the child's symptoms in more than 1 setting (especially from schools); and 3) the search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

This guideline is based on an extensive review of the medical, psychological, and educational literature. The objectives of the literature review were to determine the long- and short-term effectiveness and safety of pharmacological and nonpharmacological interventions for ADHD in children from 6 to 12 years of age, and to compare single treatment methods (eg, medications alone) with combined management strategies. Two systematic, evidence-based reviews were used extensively in the development of this guideline.2,,4 In addition, other resources were used to gather more information.6,,7

Primary care clinicians cannot work alone in the treatment of school-aged children with ADHD. Ongoing communication with parents, teachers, and other school-based professionals is necessary to monitor the progress and effectiveness of specific interventions. Parents are key partners in the management plan as sources of information and as the child's primary caregiver. 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. Attention to the child's social development in community settings other than school requires clinical knowledge of a variety of activities and services in the community.

METHODOLOGY

The AAP collaborated with several organizations to develop a working subcommittee representing a wide range of primary care and subspecialty groups. The subcommittee, chaired by 2 general pediatricians, included representatives from the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, the Child Neurology Society, the Society for Pediatric Psychology, the Society for Developmental and Behavioral Pediatrics, and the Society for Developmental Pediatrics.

This subcommittee met over a period of 3 years, during which it reviewed basic literature on current practices in the treatment of children with ADHD. The subcommittee developed a series of research questions to direct an extensive evidence-based review, in partnership with the Agency for Healthcare Research and Quality.

In 1997, the McMaster University Evidence-based Practice Center received the contract for reviewing the literature related to treatment of children with ADHD. The McMaster report2 focused on the evidence from comparative studies on the effectiveness and safety of pharmacological and nonpharmacological interventions for ADHD in children and adults and whether combined interventions are more effective than individual interventions. This resulted in several questions in the following 7 areas: 1) studies with drug-to-drug comparisons of pharmacological interventions; 2) placebo-controlled studies evaluating the effect of tricyclic antidepressants; 3) studies comparing pharmacological and nonpharmacological interventions; 4) studies evaluating the effect of long-term therapies; 5) studies evaluating therapies for ADHD in adults (ie, those older than 18 years of age); 6) studies evaluating therapies given in combination; and 7) studies evaluating adverse effects of pharmacological interventions.

Several systematic reviews and meta-analyses have examined placebo-controlled trials of stimulant medication and have established the short-term efficacy of these agents for core symptoms. Placebo-controlled trials of stimulant medication were reviewed in the McMaster report only if they met the criteria for inclusion in any of the other 6 areas. The report also focused on head-to-head comparisons of pharmacological interventions and of pharmacological and nonpharmacological interventions because these were identified as of prime interest to clinicians.

The McMaster report of the literature on treatment of ADHD followed current standards for analyzing research evidence.2Studies in this report were selected for evaluation if they were randomized, controlled trials that focused on the treatment of ADHD in humans and if they were published in peer-reviewed journals. Nonrandomized, controlled trials were included only if they provided data on adverse effects that were collected for more than 16 weeks. Studies of multiple conditions that included separate analyses for patients with ADHD were also included. The literature search was conducted using MEDLINE (from 1966), CINAHL (from 1982), HEALTHStar (from 1975), PsycINFO (from 1984), and EMBASE (from 1984). The Cochrane Library (issue 4, 1997) was also used in reviewing the literature. A total of 2405 citations were identified by the search strategies, and 92 reports, describing 78 different studies, were identified for further analysis.

In addition to the McMaster report, other sources of data were used to support clinical practice guideline recommendations. Although the McMaster report included results of the multimodal treatment study of children with ADHD (MTA),3,,7 the subcommittee also carefully evaluated the results of this large study separately.8–16 The subcommittee used data from the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) study.4 The CCOHTA review addressed the following 3 major issues related to treatment of children with ADHD: 1) a clinical evaluation of the use of methylphenidate for ADHD; 2) the efficacy of stimulant medications and other therapies; and 3) an economic evaluation of the pharmacological and behavioral therapies for ADHD. Many studies of behavioral interventions for ADHD use crossover techniques, where effects were determined on the same children when they did and did not receive treatment.6,,17 The McMaster report excluded these crossover trials.2

The draft clinical practice guideline underwent extensive peer review by committees and sections within the AAP, numerous outside organizations, and other individuals identified by the subcommittee. Liaisons to the subcommittee were also invited to distribute the draft to entities within their organizations. Comments were compiled and reviewed by the subcommittee cochairpersons, and relevant changes were incorporated into the guideline.

The recommendations contained in this guideline (see Fig 1) are based on the best available data. For each recommendation, the subcommittee graded the quality of evidence on which the recommendation was based and thestrength of the recommendation. Grades of evidence were grouped into 3 categories— good, fair, or poor. Recommendations were made at 3 levels. Strong recommendations were based on high-quality scientific evidence or, in the absence of high-quality data, strong expert consensus. Fair and weak recommendations were based on lesser quality or limited data and expert consensus. Clinical options are identified as interventions for which the subcommittee could not find compelling evidence for or against. Clinical options are defined as interventions that a reasonable health care provider might or might not wish to implement in his or her practice.