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Clinical Practice Guideline for
the Diagnosis, Evaluation, and
Treatment of AttentionDeficit/Hyperactivity Disorder in
Children and Adolescents
Mark L. Wolraich, MD, FAAP
CMRI/Shaun Walters Professor of Pediatrics
University of Oklahoma
Health Sciences Center
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Disclaimers
 Statements and opinions expressed are those of the authors and not
necessarily those of the American Academy of Pediatrics.
 Mead Johnson sponsors programs such as this to give healthcare
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event that the presentation contains statements about uses of drugs that
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Disclosures
Consultant with:
 Lilly
 Shire
 Shinogi
 NextWave
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Learning Objectives
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Participants will be able to report on the major
changes in the revised attentiondeficit/hyperactivity disorder (ADHD) guideline.
Participants will be able to obtain and use
appropriate behavior rating scales.
Participants will be able to describe the importance
of considering ADHD as a chronic condition.
Participants will be aware of the variations in
treatment recommended for preschool age
children and adolescents.
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ADHD Guideline Recommendations
1. The primary care clinician should initiate an
evaluation for ADHD for any child 4 through 18
years of age who presents with academic or
behavioral problems and symptoms of
inattention, hyperactivity, or impulsivity. B/strong
recommendation
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Prevalence of ADHD in Children
Centers for Disease Control and Prevention/National Health Care Surveys, 1997–2006
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Prevalence and Medication Use
ADHD
prev
ADHD
on meds
ADHD not
on meds
ADHD
diagnosed
on meds
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ADHD Guideline Recommendations
2. To make a diagnosis of ADHD, the primary care
clinician should determine that Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) criteria have been met (including
documentation of impairment in more than 1
major setting) with information obtained primarily
from parents/guardians, teachers, and other school
and mental health clinicians involved in the child’s
care. The primary care clinician should also rule out
any alternative cause. B/strong recommendation
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Evaluation
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Identify core symptoms.
Assess impairment.
Identify possible underlying or alternative causes.
Identify co-occurring (co-morbid) conditions.
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DSM-IV Core Symptoms of Inattention
Manifestations of the following symptoms must occur often:*
 Inattention
 Careless
 Difficulty sustaining
attention in activity
 Doesn’t listen
 No follow-through
 Avoids/dislikes tasks requiring
sustained mental effort
 Can’t organize
 Loses important items
 Easily distractible
 Forgetful in daily activities
*Must have 6 or more symptoms for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA:
American Psychiatric Association; 2000
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DSM-IV Core Symptoms of HyperactivityImpulsivity
Manifestations of the following symptoms must occur often:*
Hyperactivity
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Squirms and fidgets
Can’t stay seated
Runs/climbs excessively
Can’t play/work quietly
“On the go”/“driven by a motor”
Talks excessively
Impulsivity
 Blurts out answers
 Can’t wait turn
 Intrudes/interrupts others
*Must have 6 or more symptoms for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA:
American Psychiatric Association; 2000
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Assess Function
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Academic performance
Peer relations
Sibling relations
Parent relations
Community activities
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Clinical Global Impression Scale
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DSM-IV ADHD Diagnostic Criteria
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List of core symptoms must be present for past 6
months.
Some symptoms need to be present before 7 years
of age.
Some impairment from symptoms must be present
in 2 or more settings (eg, school and home).
Significant impairment (social, academic, or
occupational) must be present.
Other mental disorders need to be excluded as the
cause of the core symptoms.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA:
American Psychiatric Association; 2000
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Inattention or Hyperactive/Impulsive
Problems
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Children who do not meet the criteria of ADHD
still may have some symptoms of inattention
and/or hyperactivity/impulsivity fitting the
category in the Diagnostic and Statistical Manual
for Primary Care (DSM-PC) of inattention and/or
hyperactivity/impulsivity. Use of the chronic
illness model and behavioral interventions are
appropriate, but medications are not.
American Academy of Pediatrics. In: Wolraich ML, Felice ME, Drotar D. The Classification of Child and Adolescent Mental
Diagnosis in Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 1996
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Preschool Age Diagnostic Issues
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The same criteria are pertinent for preschool age
children, but it is more difficult to find qualified
observers of these children.
Enroll the child in a program and/or have the
parents participate in a parent training program.
Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with
ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293
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Adolescent Diagnostic Issues
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It is much more difficult to get adequate observers,
as both parents and teachers have less opportunity
to observe.
The risk of substance abuse is higher and must be
ruled out before a diagnosis can be made.
The occurrence of co-morbid conditions,
particularly anxiety or depression, is more frequent.
Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder in adolescents: a review of the diagnosis,
treatment and clinical implications. Pediatrics. 2005;115:1734–1746
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Diagnostic Process
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Use of ADHD specific rating scales is a clinical
option in the evaluation of ADHD.
Use of broad-band rating scales is not
recommended in diagnosing ADHD although they
may be useful for evaluating for coexisting
conditions.
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Websites for the Vanderbilt Scales
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The University of Oklahoma College of Medicine
http://www.idi.ouhsc.edu/body.cfm?id=4779
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American Academy of Pediatrics - Pediatric Care Online
https://www.pediatriccareonline.org/pco/ub/index/FormsTools/Keywords/N/NICHQ
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ADHD Guideline Recommendations
3. Evaluation of a child for ADHD should include
assessment for coexisting conditions, including
emotional, developmental, and physical. B/strong
recommendation
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Co-morbidity:
Conditions Commonly Co-occurring with ADHD
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Disruptive behavior disorders
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Depressive disorders
Anxiety disorders
Cognitive disorders
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Oppositional defiant disorder
Conduct disorder
Learning disabilities
Language disorders
Motor disorders
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Developmental coordination disorder
Tic disorders (Tourette's)
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ADHD Guideline Recommendations
4. The primary care clinician should establish a
treatment program that recognizes ADHD as a
chronic condition and a child with ADHD as a
child/adolescent with special health care needs
who needs a medical home. B/strong
recommendation
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Methylphenidate therapy bout length by patient age
Miller AR, Lalonde CE, McGrail KM. Children’s persistence with methylphenidate therapy: a population-based study. Can J Psychiatry.
2004;49(11):761–768
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Treating ADHD as a Chronic Condition
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Educate parents and patients about ADHD.
Develop a partnership with the family.
Develop a management plan with specific
targeted goals.
Include the teachers if at all possible.
Requires ongoing monitoring and anticipation
of developmental changes.
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ADHD Guideline Recommendations
5. Recommendations for treatment of children and
youth with ADHD vary depending on the patient’s
age:
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Preschool-aged Children
(4–5 Years of Age)
A. Prescribe evidence-based parent- and/or
teacher-administered behavior therapy as the first
line of treatment. A/strong recommendation
and
May prescribe methylphenidate if the behavior
interventions do not provide significant
improvement and there is moderate-to-severe
continuing disturbance in the child’s function.
B/recommendation
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Preschool Age Treatment Issues
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While stimulant medications are appropriate for
preschool age children based on recent research,
given that a third of the children in a multi-site
study improved on behavioral interventions alone,
it is more appropriate to initiate a parent training
program first before utilizing medication and only
treat the more severe cases.
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Preschool age children frequently have a slower
metabolism of the medications and can start at a
lower dose and titrated at a slower rate.
Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with
ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293
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Elementary School-aged Children
(6–11 Years of Age)
B. Prescribe FDA-approved medications for ADHD.
A/strong recommendation
and/or
Evidence-based parent- and/or teacheradministered behavior therapy as treatment for
ADHD.
Preferably both. B/recommendation
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Adolescents (12–18 Years of Age)
C. Prescribe FDA-approved medications for ADHD
with the assent of the adolescent. A/strong
recommendation
and
May prescribe behavior therapy as treatment for
ADHD. C/recommendation
Preferably both.
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Non-Stimulants
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Atomoxetine is a highly specific norepinephrine
reuptake inhibitor.
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Extended release guanfacine and clonidine are
alpha 2 adrenergic agents.
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ADHD Guideline Recommendations
6. The primary care clinician should titrate doses of
medication for ADHD to achieve maximum benefit
with minimum adverse effects. B/strong
recommendation
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Summary
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Children from preschool age through adolescent
age can be diagnosed and treated for ADHD.
Both medications (stimulants, selective
norepinephrine reuptake inhibitors and alpha
adreneric agents) and behavior therapy are
effective and safe treatments for ADHD.
Effective treatments require appropriate titration
and ongoing monitoring to remain effective.
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Caring for Children With ADHD
A Resource Toolkit for Clinicians, 2nd Edition
This comprehensive ADHD resource provides a full
set of tools for assessment and diagnosis,
treatment and medication, monitoring and followup, parent education and support, and coding and
payment.
Included are more than 40 practice-tested tools—
many in English and Spanish—on one convenient
CD-ROM. The ADHD toolkit components have
been evaluated and refined based on input from
the American Academy of Pediatrics Quality
Improvement Innovation Network (QuIIN).
For more information or to order visit the AAP
bookstore at http://tinyurl.aap.org/pub169531.
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Additional ADHD Resources on
Pediatric Care Online (www.pediatriccareonline.org)
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Forms & Tools
https://www.pediatriccareonline.org/pco/ub/index/FormsTools/Keywords/A/ADHD
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Patient Handouts
https://www.pediatriccareonline.org/pco/ub/index/Patient_Handouts_
AAP/Keywords/A/ADHD
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AAP Textbook of Pediatric Care
https://www.pediatriccareonline.org/pco/ub/index/AAP-Textbook-ofPediatric-Care/Topics/A
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Point-of-Care Quick Reference
https://www.pediatriccareonline.org/pco/ub/index/Point-of-CareQuick-Reference/Topics/A
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For more information…
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On this topic and a host of other topics, visit:
www.pediatriccareonline.org
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help with virtually every pediatric clinical information need. Must-have resources
are included in a comprehensive reference library and time-saving clinical tools.
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