Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents
Any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated for ADHD.
The diagnosis of ADHD should be based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, with information obtained from parents/guardians, teachers, and other school and mental health clinicians involved in the child’s care.
Alternative causes of the behavior should be ruled out.
A child being evaluated for ADHD should also be assessed for other conditions that might coexist with ADHD, including emotional, behavioral, developmental, and physical conditions.
Children with ADHD should be managed following the principles of the chronic care model and the Medical Home.
Preschool-aged children (4-5 years of age) should be treated with behavior therapy as the first line of treatment. Methylphenidate may be prescribed if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.
Elementary school-aged children (6-11 years of age) should be treated with FDA-approved medications for ADHD and /or behavioral therapy.
Adolescents (12-18 years of age) should be treated with FDA-approved medications, with assent, for ADHD and may be treated with behavioral therapy.
Medication doses should be titrated to achieve maximum benefit with minimum adverse effects.
Co-morbid conditions should be diagnosed and managed appropriately.
Key Action Statements
KAS 1: The pediatrician or other PCC should initiate an evaluation for ADHD for any child or adolescent age 4 years to the 18th birthday who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
KAS 2: To make a diagnosis of ADHD, the PCC should determine that DSM-5 criteria have been met, including documentation of symptoms and impairment in more than 1 major setting (ie, social, academic, or occupational), with information obtained primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescent’s care. The PCC should also rule out any alternative cause.
KAS 3: In the evaluation of a child or adolescent for ADHD, the PCC should include a process to at least screen for comorbid conditions, including emotional or behavioral conditions (eg, anxiety, depression, oppositional defiant disorder, conduct disorders, substance use), developmental conditions (eg, learning and language disorders, autism spectrum disorders), and physical conditions (eg, tics, sleep apnea).
KAS 4: ADHD is a chronic condition; therefore, the PCC should manage children and adolescents with ADHD in the same manner that they would children and youth with special health care needs, following the principles of the chronic care model and the medical home.
KAS 5a: For preschool-aged children (age 4 years to the sixth birthday) with ADHD, the PCC should prescribe evidence-based PTBM and/or behavioral classroom interventions as the first line of treatment, if available.
Methylphenidate may be considered if these behavioral interventions do not provide significant improvement and there is moderate-to-severe continued disturbance in the 4- through 5-year-old child’s functioning. In areas in which evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication before the age of 6 years against the harm of delaying treatment.
KAS 5b. For elementary and middle school-aged children (age 6 years to the 12th birthday) with ADHD, the PCC should prescribe FDA-approved medications for ADHD, along with PTBM and/or behavioral classroom intervention (preferably both PTBM and behavioral classroom interventions). Educational interventions and individualized instructional supports, including school environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include an IEP or a rehabilitation plan (504 plan).
KAS 5c. For adolescents (age 12 years to the 18th birthday) with ADHD, the PCC should prescribe FDA-approved medications for ADHD with the adolescent’s assent. The PCC is encouraged to prescribe evidence-based training interventions and/or behavioral interventions as treatment of ADHD, if available. Educational interventions and individualized instructional supports, including school environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include an IEP or a rehabilitation plan (504 plan).
KAS 6. The PCC should titrate doses of medication for ADHD to achieve maximum benefit with tolerable side effects.
KAS 7. The PCC, if trained or experienced in diagnosing comorbid conditions, may initiate treatment of such conditions or make a referral to an appropriate subspecialist for treatment. After detecting possible comorbid conditions, if the PCC is not trained or experienced in making the diagnosis or initiating treatment, the patient should be referred to an appropriate subspecialist to make the diagnosis and initiate treatment.