New Guidelines Expand the Scope of ADHD

Children as young as 4 years old and as old as 18 years old can now be diagnosed with attention-deficit/hyperactivity disorder (ADHD), according to updated guidelines from the American Academy of Pediatrics that focus on the diagnosis and treatment of the disorder in young children and adolescents.

The previous AAP guidelines from 2000-2001 included children aged 6 to 12 years; however, emerging evidence makes it possible to diagnose and manage ADHD in children aged 4 to 18 years. The new guidelines, which are published in the November 2011 issue of Pediatrics, also discuss the special considerations involved in diagnosing and treating preschool children and adolescents, and include interventions to help children with hyperactive/impulsive behaviors that do not meet the full diagnostic criteria for ADHD.

“Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school,” said Mark Wolraich, MD, lead author of the report. “Because of greater awareness about ADHD and better ways of diagnosing and treating this disorder, more children are being helped.”

There is some concern, however, that the updated recommendation may further fuel the debate over medication use for ADHD, which is already the most common neurobehavioral disorder in children, occurring in about 8% of pediatric patients. A study conducted by the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ) found that trends in both prescribed stimulant use and reported cases of ADHD continued to climb during the past decade. According to a report published in the American Journal of Psychiatry, the percentage of children aged 4-17 diagnosed with ADHD increased from 7.8% in 2003 to 9.5% in 2007.

In terms of prescription use, researchers noted a slow but steady rise from 2.4% in 1996 to 3.5% in 2008, marking a 3.4% annual growth rate, which is substantially less than the growth rate of 17% between 1987 and 1996. Overall, prescription use among children aged 6 to 12 years was highest, and the fastest growth in prescribed stimulant use occurred among adolescents aged 13 to 18.

More adolescents are taking medications for ADHD than ever before, according to the study’s co-author, Benedetto Vitiello, MD, who estimates that 60% of children with ADHD are treated with drugs. “Stimulant medications work well to control ADHD symptoms, but they are only one method of treatment for the condition,” he said in a statement.

A multifaceted treatment approach

In addition to providing guidance on the use of stimulant drugs such as methylphenidate (Ritalin) and amphetamines such as Adderall, which are commonly used to treat ADHD, the AAP guidelines also stress the importance of behavioral therapies in managing the symptoms of the disorder.

Clinicians, according to one of the key action statements in the report, “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.” A diagnosis should be made using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, with information obtained from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care.

Treatment recommendations, the report states, vary depending on the patient’s age. In children aged 4 to 5, physicians should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool-aged children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose. For elementary school children and adolescents, the AAP recommends both FDA-approved medications and behavior therapy. Evidence is particularly strong for stimulant medications and sufficient, but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine, the guidelines stated.

Finally, the guidelines emphasize the fact that ADHD is a chronic condition that may last into adulthood, and should be treated as such.

“Because ADHD is a chronic condition, it requires a team approach, including the patients, their parents, the pediatrician, therapists, and teachers,” Dr. Wolraich said.

For more information on ADHD:

• Attention-Deficit/Hyperactivity Disorder and Treatment
• Let’s Focus on ADHD
• Addressing challenging situations in the management of ADHD