AACAP guidelines for ADHD aim to guide clinicians toward best treatment practices

In July, the Journal for the American Academy of Child and Adolescent Psychiatry released a comprehensive document outlining the epidemiology, comorbidities, aetiology, screening practices and treatment for attention-deficit/hyperactivity disorder (ADHD) that are currently best supported by evidence. Pooling information gathered from over 5,000 articles published between 1996 and 2006, these practice parameters can be of invaluable assistance in setting out evidence-based guidelines for effective diagnosis and treatment of ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric conditions, and can cause significant impairment in those whom it afflicts. In July, the Journal for the Academy of Child and Adolescent Psychiatry published a practice parameter for the assessment and treatment of children and adolescents with ADHD, with the aim of providing evidence-based guidelines that can enable the most effective diagnosis and treatment possible.

Pooling research from over 5,000 articles, the most recent evidence regarding epidemiology and clinical course, co-morbidities, aetiology and the recent advances in treatment are discussed. This provides a background on which thirteen recommendations are made regarding screening, evaluation and treatment. These recommendations are each graded according to the strength of the evidence base, assessing the strength of underlying empirical and/or clinical support.

The recommendations made by the Academy are:

1. Screening for ADHD should be part of every patient’s mental health assessment.
2. Evaluation of the preschooler, child or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient’s school or day care functioning, evaluation for comorbid psychiatric disorders, and review of the patient’s medical, social and family histories.
3. If the patient’s medical history is unremarkable, laboratory or neurological testing is not indicated
4. Psychological and neuropsychological tests are not mandatory for the diagnosis of ADHD, but should be performed if the patient’s history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient’s intellectual ability.
5. The clinician must evaluate the patient with ADHD for the presence of comorbid psychiatric disorders
6. A well-thought-out and comprehensive treatment plan should be developed for patients with ADHD
7. The initial psychopharmacological treatment of ADHD should be a trial with an agent approved by the food and drug administration for the treatment of ADHD. These are:
   • Dexamphetamine
   • Methylphenidate (eg Concerta)
   • Mixed salts amphetamine and
   • Atomoxetine (Strattera)
8. If none of the above agents result in satisfactory treatment of the patient with ADHD, the clinician should undertake a careful review of the diagnosis and then consider cognitive behaviour therapy and/or use of medications not approved by the FDA for the treatment of ADHD. These agents include:
   • Bupropion
   • Tricyclic antidepressants
   • Alpha-agonists
9. During a psychopharmacological intervention for ADHD, the patient should be monitored for treatment-emergent side effects such as:
   • Weight loss
   • Insomnia
   • Headache
   • Tics
   • Emotional lability/irritability
10. If a patient with ADHD has a robust response to psychopharmacological treatment and subsequently shows normative functioning in academic, family and social functioning, then psychopharmacological treatment of the ADHD along is satisfactory.
11. If a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences stressors in family life, the psychosocial treatment in conjunction with medication treatment is often beneficial.
12. Patients should be assessed periodically to determine whether there is continued need for treatment of if symptoms have remitted. Treatment of ADHD should continue as long as symptoms remain present and cause impairment.
13. Patients treated with medication for ADHD should have their height and weight monitored throughout treatment.

These guidelines are discussed in a large amount of detail, as well as covering many of the other issues that currently surround ADHD evaluation and treatment. These guidelines should be of great help to anyone involved in the treatment of children with ADHD, and it is hoped that providing this solid evidence base will result in a better treatment outcome for the patient, their family and the clinician.

Reference:

1. Pliszka S, et al. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 2007; 46(7).