Updated Diagnosis and Treatment Recommendations for Childhood ADHD

 ADHD Weekly, December 5, 2019

Updated guidelines from the American Academy of Pediatrics places a greater emphasis on identifying ADHD in preschool-age children and on addressing co-occurring conditions in children and teens.

The guidelines are written for pediatricians and other medical professionals who treat children and teens. Parents will find them useful when working with the doctor during an evaluation and treatment.

“What the parents should do with this is make sure the pediatricians understand what the guidelines recommend,” says Max Wiznitzer, MD, a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio, and a member of CHADD’s professional advisory board. “There’s strong science that supports the use of these guidelines. Parents should be comfortable that these are well researched and science-based.”

Updates for preschool children

“There’s really a longer discussion on preschool ADHD” in the updates, says Dr. Wiznitzer. “And what you do when a preschooler has ADHD.”

The guidelines continue to recommend parent training and behavioral management as first-line treatment for children ages four and younger. The new guidelines also recognize that participating in behavioral interventions can lead to additional information about the child, which can later be used to refine a diagnosis of ADHD, ADHD with a co-occurring condition, or a diagnosis of different condition.

The changes also encourage medical professionals and parents to learn more about behavioral interventions as treatment for ADHD. Dr. Wiznitzer says he hopes these recommendations encourage more professionals to provide evidence-based parent training and behavioral management.

“There are two problems currently,” Dr. Wiznitzer says. “Do we have enough qualified practitioners to offer more programs, and do the families recognize the importance of using these programs? Families want a quick fix, and these programs are not a quick fix. But the results are more durable.”

Parent training has a documented effectiveness for behavioral problems in children, whether those challenges stem from ADHD or another condition, he says. By beginning with parent training and behavioral management, the child and family can receive those benefits even if further evaluation results in a diagnosis of something other than ADHD.

“If it’s not ADHD, hopefully intervention will be helpful in managing the kids,” says Dr. Wiznitzer. “If it is ADHD, then it provides additional information that this intervention is needed.”

If medication is needed as part of treatment in young children, the guidelines suggest methylphenidate. Dr. Wiznitzer says this is because there is “good data” showing its effectiveness and safety for this age group. Parents who are aware of the changes in the guidelines can better discuss possible medication management with their children’s doctors, if medication is needed—especially if a different ADHD medication is suggested.

“Parents need to ask if there are research studies showing that this [other] medication works, whether or not it’s approved for that age and diagnosis,” Dr. Wiznitzer says. Parents should continue to press for combination therapy if medication is suggested. “Combination therapy is not only medication, but behavioral interventions plus medication.”

Changes for teens regarding co-occurring conditions

The recommendations place an emphasis on identifying and treating co-occurring, or comorbid, conditions. Teens with ADHD frequently have at least one co-occurring condition, such as anxiety or depression, and this affects treatment plans and the outcomes of treatment.

“The failure to recognize that comorbidities are present, and can be more responsible for the behavior than the ADHD, will limit the clinicians’ ability to work with the family,” says Dr. Wiznitzer. “You have to know what you’re treating.”

Dr. Wiznitzer says professionals and families don’t want to manage the wrong condition, because it can lead to poor treatment or treatment with the wrong tools. For teens, it can add to the stresses they face with ADHD, the co-occurring condition, and academic and social life. Identifying the most pressing condition and addressing that can make a difference in a teen’s life.

Additionally, the updated recommendations require fewer behavioral problems for teens 17 and older when evaluating for ADHD and evidence of symptoms need to be present before age 12, rather than before 7 years old.

What the updates mean for parents

Dr. Wiznitzer says the updates add more nuance to the recommendations that can benefit families and children.

“The subtleties mean the authors of this paper are being more nuanced in their recommendations. It means you can fine-tune treatment better,” he says. “It recognizes there are differences between individuals and that you have to fine-tune treatment for those differences.”

Parents can also be reassured there is research and evidence that shows the recommended treatment approaches are successful.

“It’s something that provides really good guidance,” he says. “From a parent’s standpoint, you don’t develop guidelines unless you have good science to support the guidelines. It tells us there is strong science backing up the recommendations.”

Learn more about diagnosing and treating ADHD in children and teens:

Join the discussion: Have you been able to work with a parent trainer or behavioral therapist as part of your child’s treatment?