New Guidelines for ADHD and Complex ADHD
Karen Sampson Hoffman and Robert J. Cattoi
AAP Revises ADHD Guidelines
by Karen Sampson Hoffman, MA
The American Academy of Pediatrics recently released its updated guidelines for the evaluation, diagnosis, and treatment of ADHD. The updates place a greater emphasis on identifying ADHD in preschool-aged children and on addressing co-occurring conditions in children and teens.
The guidelines are written for pediatricians and other medical professionals. Parents will find them useful when working with their child’s doctor during an evaluation and treatment.
“There’s really a longer discussion on preschool ADHD” in the updates, says Max Wiznitzer, MD, “and what you do when a preschooler has ADHD.” A pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio, Wiznitzer is also a member of CHADD’s professional advisory board and Attention’s editorial advisory board.
The guidelines continue to recommend parent training and behavioral management as first-line treatment for children ages four and younger. They 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 comorbid 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. Wiznitzer says he hopes these recommendations encourage more professionals to provide evidence-based parent training and behavioral management.
“There are two problems currently,” he 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. 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 Wiznitzer. “If it is ADHD, then it provides additional information that this intervention is needed.”
Medications and co-occurring conditions
If medication is needed as part of treatment in young children, the guidelines suggest methylphenidate. Wiznitzer said 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,” Wiznitzer says. And parents should continue to press for combination therapy if medication is suggested. “Combination therapy is not only medication, but behavioral interventions plus medication.”
The recommendations place an emphasis on identifying and treating co-occurring conditions. Teens with ADHD frequently have at least one additional 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 clinician’s ability to work with the family,” says Wiznitzer. “You have to know what you’re treating.”
Professionals and families don’t want to manage the wrong condition, he says, 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, when the clinician is evaluating for ADHD, the updated guidelines require fewer behavioral problems in teens age 17 and older; evidence of symptoms needs to be present before age twelve, rather than before age seven.
What parents need to know and do
The AAP’s revised guidelines can help parents know their children are receiving the right care following a diagnosis, says former CHADD board member Eva O’Malley, who assisted the Society for Developmental & Behavioral Pediatrics in creating a separate set of guidelines for complex ADHD.
Other professional and medical organizations are inclined to adopt the AAP or SDBP guidelines when they don’t yet have their own set of guidelines for ADHD diagnosis, says O’Malley. This can lead to a better standardization of care for children.
Parents should be aware that the guidelines are written for medical professionals, however, rather than for parents. “Most of people who will be reading these guidelines will be family doctors and internists, your child’s pediatrician or therapist,” says O’Malley. But they can serve as an important conversation starter between parents and medical professionals. “The guidelines bring everybody up to speed for what is available as treatment.”
Parents can learn more about the guidelines, bring them to an appointment, and discuss how they could be helpful for their child. “I think doctors appreciate it when parents are informed,” says O’Malley. “I think it will help them have a better conversation with the doctor. Instead of just describing symptoms, you’ll be a little bit more focused on particular things you’re seeing in your child.”
“What the parents should do with this is make sure the pediatricians understand what the guidelines recommend,” says Wiznitzer. “There’s strong science that supports the use of these guidelines. Parents should be comfortable that these are well researched and science-based.”
Karen Sampson Hoffman, MA, is the senior health information specialist, webinar coordinator, and ADHD Weekly editor for CHADD’s National Resource Center on ADHD. This is an expanded version of an article that appeared in ADHD Weekly.
SDBP Releases New Guideline for Complex ADHD
by Robert J. Cattoi
CHADD is pleased to announce the newly released guidelines for complex ADHD in children and adolescents. The Society for Developmental and Behavioral Pediatrics (SDBP) guidelines were written with input from former CHADD board member Eva O’Malley. As part of our mission to provide evidence-based information to parents and to all individuals affected by ADHD, CHADD worked with the SDBP by providing not only scientific information, but also the experiences of a real-world parent dealing with the myriad issues raised by complex ADHD.
In addition to addressing the specialized evaluation and multimodal treatment of ADHD in children and adolescents, this guideline further addresses the many systemic barriers to delivering optimal care for complex ADHD. This important addition further highlights the important work that CHADD does to advocate on behalf of people with ADHD and related disorders. CHADD’s public policy committee educates legislative and regulatory agencies in regard to ADHD, particularly in the educational systems, justice and civil rights, employment and healthcare. CHADD is specifically addressing the issues of primary care education, financial impact of ADHD, and the limited resources within the education system as described in this report.
According to their website, SDBP “developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with ‘complex ADHD’”:
“Complex ADHD” is defined as ADHD co-occurring with one or more learning, neurodevelopmental, or psychiatric disorders. Approximately 60% of children diagnosed with ADHD fit into the complex category, and these are the first guidelines to address this population in a systematic and evidence-based manner.
This guideline consists of five evidence-based key action statements that support clinicians in their assessment of ADHD, evaluation of coexisting conditions, implementation of behavioral and educational interventions, consideration of pharmacologic treatment, and recognition of ADHD as a chronic condition.
A complementary section of the guideline contains process-of-care algorithms for managing the most common conditions that coexist with ADHD, including, autism spectrum disorder, tic disorders, substance use disorders, anxiety, depression, disruptive behavior disorders; and the special consideration of preschoolers with complex ADHD.