-
Implementing the Key Action Statements: AnAlgorithm and
Explanation for Process of Care for theEvaluation, Diagnosis,
Treatment, and Monitoring ofADHD in Children and Adolescents
Practice guidelines provide a broadoutline of the requirements
for high-quality evidence-based care. In sup-port of consistent and
comprehensivecare for children and adolescents withsymptoms of
attention and hyperactiv-ity disorders within a typical, busy
pe-diatric practice, the AAP has developedthe following suggested
process-of-care algorithm (see Supplemental Fig2) that provides
discrete and manage-able steps through which a primarycare
clinician can fulfill the key actionstatements offered in the
guideline.The algorithm is entirely consistentwith the practice
guideline and isbased on the practical experience andadvice of
clinicians experienced in thediagnosis and management of ADHD
inchildren and adolescents. Because ofthe detail provided, the
process algo-rithm does not have the same level ofevidence base as
the key action state-ments that are provided in the
practiceguideline. The steps of the algorithmare based primarily on
consensusamong expert clinicians.
This algorithm and each of its constit-uent steps is not
intended to be com-pleted in any single office visit or anyspecific
number of visits; the experi-ence of the clinician, the volume of
thepractice, the longevity of the relation-ship between the
clinician and family,the severity of the concerns, the avail-
ability of records and school input, thefamily’s schedule, and
the reimburse-ment structure will all play a role indetermining the
pace at which a familyand child/adolescent move throughthe process
of care.
Similarly, continued systematic moni-toring (to include
reconsideration ofthe diagnosis if improvements insymptoms are not
apparent) is an on-going process, to be addressedthroughout the
child’s/adolescent’scare within the practice, and in transi-tion
planning as the adolescent movesinto the adult care system.
The algorithm assumes that the pri-mary care practice has
adopted men-tal health surveillance and screeningas described by
the AAP Task Force onMental Health.1 In light of the preva-lence of
ADHD, the severity of the con-sequences of untreated ADHD, and
theavailability of effective treatments forADHD, the AAP recommends
that everychild/adolescent identified with signsor symptoms
suggestive of ADHD beevaluated for ADHD. It is important todocument
all aspects of the diagnosticand treatment procedures in
patients’records. Use of rating scales for thediagnosis of ADHD,
for assessment forcomorbid conditions, and as a methodfor
monitoring treatment and provid-ing information provided to
parents,such as management plans, can help
facilitate a clinician’s accurate docu-mentation of the
process.
SIGNS AND SYMPTOMS THATSUGGEST ADHD
4- to 18- y-old patient identified with signs or symptoms
suggesting ADHD. Symptoms can come from parents’ direct concerns or
the mental health screen
recommended by the TFOMHSee TFOMH Algorithms See action
statement 1
Many parents bring their child/adoles-cent to the primary care
clinician withspecific concerns about the child’s/ad-olescent’s
ability to sustain attention,curb activity level, and/or inhibit
im-pulsivity. In these cases, it is clear thatthe clinician should
initiate an evalua-tion for ADHD. However, in many in-stances, the
chief concern might in-clude behaviors and
characteristicsassociated with ADHD without mentionof the core ADHD
symptoms. For exam-ple, children/adolescents might havedifficulty
remaining organized, plan-ning activities, or inhibiting their
initialthoughts or actions, which are behav-iors that fall under
the umbrella of ex-ecutive functions or cognitive control.Problems
with executive functions arecorrelated with ADHD. Moreover,
chil-dren/adolescents might have difficultymaking or keeping
friends, followingthe rules of the classroom, or regulat-ing their
behavior. Problemswithin therealm of social relationships are
alsocorrelated with ADHD. In these cases,
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Supplemental Information
PEDIATRICS Volume , Number , SI1
pediatrics.aappublications.org/cgi/content/full/peds.2011-2654/DC1pediatrics.aappublications.org/cgi/content/full/peds.2011-2654/DC1pediatrics.aappublications.org/
-
Assess impact on treatment plan
Further evaluation/referral as needed
Exit this guideline.Evaluate or refer, as
appropriate.Iden�fy the child as
CYSHCN if appropriate.
Inattention and/or hyperactivity/impulsivity
problems not rising to DSM-IV diagnosisProvide educa�on of
family and child
re: concerns (eg, triggers for ina�en�on or hyperac�vity) and
behavior
management strategies or school-based strategies
Enhanced Surveillance
Coexisting disorders preclude primary care
management?
Follow-up and establish co-
management planSee TFOMH Algorithms
4- to 18- y-old patient identified with signs or symptoms
suggesting ADHD. Symptoms can come from parents’ direct concerns or
the mental health screen
recommended by the TFOMHSee TFOMH Algorithms See action
statement 1
Yes
1
2
4
6 7
5
Overview of the ADHD Care Process
See action statement 3
Provide educa�on to family and child re: concerns (eg, triggers
for
ina�en�on or hyperac�vity) and behavior-management strategies
or
school-based strategies
Provide educa�on addressing concern (eg,
expecta�ons for a�en�on as a func�on of age)
Enhanced Surveillance
No
Yes
8
9
10
12
DSM-IVdiagnosis of
ADHD?
Legend = Start
= Continued care
= Decision
= Action/process
Yes
13
Op�on: Medica�on(ADHD only and past medical or family history of
cardiovascular
disease considered) Ini�ate treatment
Titrate to maximum benefit, minimum adverse effectsMonitor
target outcomes
Op�on: Behavior management (developmental varia�on,
problem or ADHD)
Iden�fy service or approach
Monitor target outcomes
Op�on: Collaborate with school to enhance supports
and services (developmental varia�on, problem, or ADHD)
Iden�fy changes
Monitor target outcomes
See action statement 5
See action statement 6
BEGIN TREATMENT
Coexisting conditions?
14
15
16Do
symptoms improve?
Reevaluate to confirm diagnosis and/or provide education to
improve
adherence.
Reconsider treatment plan including changing of the medication
or dose, adding a medication approved for
adjuvant therapy, and/or changing behavioral therapy.
Yes
No
Follow-up for chronic care
management at least 2x/year for
ADHD issues
3
Perform Diagnostic Evaluation for ADHD and Evaluate or Screen
for Other/Coexisting Conditions:
Family(parents, guardian, other frequent caregivers):
Chief concerns
History of symptoms (eg, age of onset and course over �me)
Family history
Past medical history
Psychosocial history
Review of systems
Validated ADHD instrument
Evalua�on of coexis�ng condi�ons
Report of func�on, both strengths and weaknesses
School (and important community informants):
Concerns
Validated ADHD instrument
Evalua�on of coexis�ng condi�ons
Report on how well pa�ents func�on in academic, work, and social
interac�ons
Academic records (eg, report cards, standardized tes�ng,
psychoeduca�onal evalua�ons)
Administra�ve reports (eg, disciplinary ac�ons)
Child/adolescent (as appropriate for child’s age and
developmental status):
Interview, including concerns regarding behavior, family
rela�onships, peers, school
For adolescents: validated self-report instrument of ADHD and
coexis�ng condi�ons
Report of child’s self-iden�fied impression of func�on, both
strengths and weaknesses
Clinician’s observa�ons of child’s behavior
Physical and neurologic examina�on
See action statements 2–3
No
Other condition?
Yes
No
Apparently typical or
developmental variation?
Yes
No
No
11
17
18
ESTABLISH MANAGEMENT TEAM
Identify child as CYSHCN
Establish team including
coordination plan
Collaborate with family, school,
and child to identify target
goals.
See action statement 4
SUPPLEMENTAL APPENDIX FIGURE 2ADHD process-of-care algorithm.
TFOMH indicates Task Force on Mental Health; CYSHCN, child/youth
with special health care needs.1
SI2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
initiating the diagnostic evaluationmight be appropriate.
Perform Diagnostic Evaluation forADHD and Evaluate or Screen
for
Coexisting Disorders
Ideally, the primary care office staffcan ask the assistance of
the parent(s)in obtaining information on the pur-pose of a visit at
the time of scheduling.If possible, an extended visit is
oftendesirable for the evaluation of ADHD.As a general approach to
the initialevaluation, data on the child’s/adoles-cent’s symptoms
and functioning (eg,home or school questionnaires)should be
gathered from parents,school personnel, and other
sources,preferably before the visit. This strat-egy allows the
primary care pediatri-cian to focus on pertinent issues forthat
child/adolescent and family at thetime of the visit. Parental
consent toauthorize the release of school data to
pediatric providers is important to ob-tain. The process might
be facilitated ifthe family is given the responsibility toprovide
other informants with thequestionnaires or data-collection
forms to be used and to request otherrecords and reports.
To make a diagnosis of ADHD, the clini-cian needs to establish
that at least 6or more core symptoms per dimen-sion presented in
Supplemental Table2 are present in either or both of thedimensions
of inattention and/orhyperactivity/impulsivity.
Diagnostic criteria for ADHD in school-aged children and
adolescents includedocumentation of the following crite-ria:
● At least 6 of the 9 behaviors de-scribed in the inattentive
domainoccur often and to a degree incon-sistent with the child’s
developmen-tal age, and/or
● At least 6 of the 9 behaviors de-scribed in the
hyperactive/impul-sive domain occur often and to a de-gree
inconsistent with the child’sdevelopmental age.
● Presence of some impairment in 2or more major settings (eg,
homeand school) for at least 6 months.
● Presence of some symptoms ofADHD that caused impairment
(ac-cording to the history) before 7years of age.
● Symptoms have persisted for atleast 6 months.
● Evidence of significant clinical im-pairment in social,
academic, or oc-cupational functioning because ofthe behaviors.
● Symptoms are not attributable toanother physical, situational,
ormental health condition.
DSM-IV-TR2 criteria define 3 subtypesof ADHD:
● ADHD primarily of the inattentivetype (ADHD/I, having the
inappropri-ately often occurrence of at least 6of 9 inattention
behaviors and �6hyperactive-impulsive behaviors);
● ADHD primarily of the hyperactive-impulsive type (ADHD/HI,
having theinappropriately often occurrence ofat least 6 of 9
hyperactive-impulsivebehaviors and �6 inattention be-haviors);
and
● ADHD combined type (ADHD/C, hav-
Perform Diagnostic Evaluation for ADHD and Evaluate or Screen
for Other/Coexisting Conditions:
Family(parents, guardian, other frequent caregivers):
Chief concerns
History of symptoms (eg, age of onset and course over �me)
Family history
Past medical history
Psychosocial history
Review of systems
Validated ADHD instrument
Evalua�on of coexis�ng condi�ons
Report of func�on, both strengths and weaknesses
School (and important community informants):
Concerns
Validated ADHD instrument
Evalua�on of coexis�ng condi�ons
Report on how well pa�ents func�on in academic, work, and social
interac�ons
Academic records (eg, report cards, standardized tes�ng,
psychoeduca�onal evalua�ons)
Administra�ve reports (eg, disciplinary ac�ons)
Child/adolescent (as appropriate for child’s age and
developmental status):
Interview, including concerns regarding behavior, family
rela�onships, peers, school
For adolescents: validated self -report instrument of ADHD and
coexis�ng condi�ons
Report of child’s self-iden�fied impression of func�on, both
strengths and weaknesses
Clinician’s observa�ons of child’s behavior
Physical and neurologic examina�on
See action statements 2–3
SUPPLEMENTAL TABLE 2 Core Symptoms of ADHD (Adapted From the
DSM-IV-TR)
Inattention Dimension Hyperactivity-Impulsivity Dimension
Hyperactivity Impulsivity
Careless mistakes Fidgety Blurts answers before questions are
completedDifficulty sustaining attention Unable to stay seated
Difficulty awaiting turnSeems not to listen Moves excessively
(restless) Interrupts/intrudes on othersFails to finish tasks
Difficulty engaging in leisure activities quietlyDifficulty
organizing “On the go”
Talks excessivelyAvoids tasks that require sustained
attentionLoses thingsEasily distractedForgetful
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ing the inappropriately often occur-rence of at least 6 of 9
behaviors inboth the inattention andhyperactive-impulsive
dimensions).
There is also evidence that the criteriaare appropriate for
preschool-agedchildren3 and adolescents.4 The use ofspecific
DSM-IV-TR criteria decreasesvariation among clinicians in how
thediagnosis is made and will facilitatecommunication among
professionalsand patients.
DSM-IV-TR criteria require evidence ofimpairing symptoms before
7 years ofage. In some cases, the symptoms ofADHD might not be
recognized by par-ents or teachers until the child is olderthan 7
years, when school tasks be-comemore challenging. In children
forwhom the problems are identified af-ter 7 years of age, history
can oftenidentify an earlier age of onset of someof the symptoms.
Delayed recognitionmight be seen more often in the inat-tentive
subtype of ADHD.5
If symptoms arise suddenly, withoutprevious history, primary
care clini-cians should consider other condi-tions including head
trauma, physicalor sexual abuse, neurodegenerativedisorders, mood
or anxiety disorders,substance abuse, or a major psycho-logical
stress in the family or school.
The requirements that a child musthave significant impairment in
func-tion and some impairment in at least 2settings are the most
challenging as-pects of the DSM-IV-TR criteria for theclinician to
obtain accurate informa-tion. The presence of functional
im-pairments is often the most troublingissue for children,
families, and teach-ers and is a central requirement inmaking the
diagnosis of ADHD6 (alsosee Behavior Management”).
As was determined in the previousguideline, parent and teacher
ratingscales that use DSM-IV-TR criteria forADHD are helpful in
obtaining the infor-
mation required to make a diagnosison the basis of the DSM-IV-TR
criteria.Broad-band rating scales that assessmental health
functioning in generaldo not provide reliable and valid
indi-cations of ADHD diagnoses but mighthelp in screening for
co-occurring be-havioral conditions.7
No current instruments routinely usedin primary care practice
reliably as-sess the nature or degree of functionalimpairment in
children with ADHD, al-though parent-report instrumentsmight help.
Some measures that areavailable are limited, because theymostly
provide only a global rating (eg,the Strengths and Difficulties
Ques-tionnaire [SDQ] Impact Scale8 and theChildren’s Global
Assessment Scale[CGAS]9) or have more limited valida-tion (eg, the
performance componentof the Vanderbilt Scales10,11). Review
ofdocuments, such as report cards andresults of standardized
testing, and ev-idence of detention, suspensions, orexpulsions from
school can also serveas evidence of functional impairment.With
information obtained from theparent and school, the clinician
willneed to make a clinical judgmentabout the effect of the core
and asso-ciated symptoms of ADHD on academicachievement, classroom
performance,family and social relationships, inde-pendent
functioning and safety/acci-dental injuries, self-perception,
leisureactivities, and self-care (such as bath-ing, toileting,
dressing, and eating). Ad-ditional guidance regarding
functionalassessment is available through theAAP ADHD toolkit and
the Task Force onMental Health.15,16
In the absence of other concerns andfindings on medical history,
family andsocial history, and physical examina-tion of the child,
no further diagnostictestingwill help to reach the
diagnosis.Compared with clinical interviews,standardized
psychological tests, suchas computerized tests of attention,
have not been found to reliably differ-entiate between youth
with and with-out ADHD.14,15 Appropriate further as-sessment is
indicated if an underlyingetiology is suspected. Assessmentssuch as
screening for high lead levels,low iron or ferritin levels or
abnormalthyroid hormone levels or imagingstudies should be pursued
only if otherhistoric or physical information sug-gests their
presence. Conditions suchas sleep disorders, such as apnea,
ab-sence seizures, hyperthyroidism, ormood or anxiety disorders
might pres-ent with ADHD symptoms and might berelieved when the
primary condition istreated.
Current criteria do not describe gen-der or developmental
differences, al-though numerous studies have foundthat the
frequency of symptomatic be-haviors varies significantly
acrossgender and age groups (for a review,see Barkley16). Compared
with othergirls, girls with ADHD experience moredepression,
anxiety, distress, poorteacher relationships, stress, externallocus
of control, and impaired aca-demics. Compared with boys withADHD,
girls with ADHD experiencemore impairment in self-reported
anx-iety, distress, depression, and externallocus of control.
Furthermore, the be-havioral characteristics specified inthe
DSM-IV-TR, despite efforts to stan-dardize them, remain subjective,
to agreat extent, and may be interpreteddifferently by different
observers. Cul-tural norms and expectations of par-ents or teachers
may influence theperspectives of various informants.The rates of
ADHD and its treatmenthave been found to be different fordifferent
racial/ethnic groups.17,18 Theclinician must remain sensitive to
cul-tural differences in the appropriate-ness of behaviors and
perceptions ofmental health conditions. Other fac-tors, such as
poverty and access tocare, likely contribute to the cultural
SI4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
differences. These complexities in thediagnosis mean that
clinicians whouse DSM-IV-TR criteria must applythem in the context
of sound clinicaljudgment.
The DSM-IV-TR does include a categoryof “ADHD not otherwise
specified.” Thiscategory is meant for children whomeet many but not
the full criteria forADHD, such as children who meet allthe symptom
and impairment criteriabut whose age of onset is later than 7years
or children who have clinicallysignificant impairment but do
notmeet all the symptom requirements.Clinically significant
impairment is re-quired in diagnosing a child with ADHD.Children
with inattentive or hyperac-tive/impulsive symptoms but less
thansignificant impairment are character-ized as having
“problems.”
FAMILY
A comprehensive diagnostic evalua-tion typically begins with
identifyingthe family’s chief concerns. The clini-cian also needs
to have the familymembers complete a validated ADHDinstrument.
Family members shouldbe asked to provide a history of signsand
symptoms. This history includesdetermining the onset, frequency,
andduration of problem behaviors, situa-tions in which they
increase or de-crease, previous treatments and theirresults, and
the family’s understand-ing of the issues. The family historyshould
include any medical syn-dromes, developmental delays, cogni-tive
limitations, learning disorders, ormental illness in family
members, in-cluding ADHD and mood, anxiety, andbipolar disorders.
In addition, parentaltobacco and substance use is relevantto risk
factors for ADHD.17 Family mem-bers might not have been formally
di-agnosed with ADHD; asking about fam-ily members’ school
experience andproblems similar to those of the pa-
tient might suggest undiagnosedcases of ADHD.
Updating the medical history can fo-cus on factors associated
with ADHD,such as preterm delivery, neonatalproblems, congenital
infections, andhead trauma. The psychosocial his-tory should
include environmental fac-tors, such as family stress and
prob-lematic relationships that mightcontribute to the
child’s/adolescent’soverall functioning.
It is important to obtain history of con-ditions that might
mimic ADHD symp-toms or might co-occur with the condi-tion.
Co-occurring conditions arediscussed later in the process
algo-rithm. Several available question-naires also provide a screen
for coex-isting conditions and a report offunction. It is important
to obtain ahistory that would suggest lead expo-sure, absence
seizures, or other men-tal illnesses such as anxiety or
mooddisorders and Tourette disorder. A fullreview of systems might
also revealother symptoms, such as sleep distur-bances, that may
assist in formulatinga differential diagnosis and/or may
beconsidered in the development of man-agement plans. The patient
should alsobe screened for hearing and/or visualproblems.
Primary sleep disorders, such as ob-structive sleep apnea
syndrome andrestless-leg syndrome/periodic limb-movement disorder,
might presentwith symptoms of inattention, hyper-activity, and
impulsivity or are fre-quently associated with ADHD.18–21
Allchildren being evaluated for ADHDshould be systematically
screened forsymptoms of (ie, frequent snoring, ob-served breathing
pauses; restlesssleep, urge to move their legs at night;daytime
sleepiness) and risk factorsfor (ie, adenotonsillar
hypertrophy,asthma/allergies, obesity; family his-tory of
restless-leg syndrome/periodiclimb-movement disorder, iron
defi-
ciency) primary sleep disorders.22
Sleep-assessment measures that havebeen shown to be useful in
the pediat-ric primary care practice setting in-clude brief
screening tools25 andparent-report surveys.26,27
Overnightpolysomnography should be stronglyconsidered for children
with symp-toms suggestive of and/or risk factorsfor obstructive
sleep apnea syndromeand restless-leg syndrome/periodiclimb-movement
disorder.28
In addition, even in the absence of pri-mary sleep disorders,
modest reduc-tions in sleep duration, such as thoseassociated with
environmentally re-lated insufficient sleep, might be asso-ciated
with detectable deterioration invigilance and attention in
childrenwithADHD and should be evaluated and ad-dressed.29 Common
clinical presenta-tions of insomnia in children withADHD include
bedtime resistance, de-layed sleep onset, night wakings,
andearly-morning awakening. Both a base-line assessment (ie, before
initiatingtreatment) and ongoing periodicscreening for sleep
problems shouldbe included in the management of allchildren with
ADHD. Sleep diaries areuseful adjuncts in quantifying sleep-onset
latency and night wakings andassessing variability in sleep
pat-terns.30 The differential diagnosis of in-somnia in
childrenwith ADHD includes:
● ADHD medication (stimulant andnonstimulant) effects:
● Direct effects on sleep architec-ture (ie, prolonged
sleep-onset la-tency and decreased sleep dura-tion, increased night
wakings)31–
33; and
● Indirect effects such as inade-quate control of ADHD
symptomsin the evening and medicationwithdrawal or
reboundsymptoms.23,34
● Sleep problems associated with co-existing psychiatric
conditions (ie,
Supplemental Appendix
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-
anxiety andmood disorders, disrup-tive behavior
disorders).34,35
● Circadian-based phase delay insleep-wake patterns, which
havebeen shown to occur in some chil-dren with ADHD, which results
inboth prolonged sleep onset and dif-ficulty waking in the
morning.36
● Inadequate sleep hygiene (ie, incon-sistent bedtimes and wake
times,absence of a bedtime routine, elec-tronics in the bedroom,
caffeineuse).37
● Intrinsic deficit associated withADHD. Numerous studies have
foundthat nonmedicated children withADHD and no comorbidmood or
anx-iety disorders have significantlygreater bedtime resistance,
moresleep-onset difficulties, and morefrequent night awakenings
whencompared with typically developingcontrol children.38 In
addition, somechildren with ADHD seem to have ev-idence of
increased daytime sleepi-ness even in the absence of a pri-mary
sleep disorder.39,40
A sound assessment of functioning inmajor areas can then be used
to con-struct an educational and behavioralprofile including not
only concerns butalso strengths or talents. The mostcommon areas of
functioning affectedby ADHD include academic achieve-ment; peer,
parent, sibling, and adultauthority-figure relationships;
partici-pation in recreation such as sports;and behavior and
emotional regula-tion, including risky behavior. One sys-tematic
approach to the assessment offunction can use the framework of
theInternational Classification of Func-tioning, Disability, and
Health.6,41
Suggestions and recommendationsfor scales such as the modified
PatientHealth Questionnaire-9 Modified forAdolescents (PHQ-A)42 and
Screen forChild Anxiety Related Emotional Disor-ders (SCARED)43
have been developed
by the AAP Task Force on MentalHealth.13 The situation might be
morecomplicated when parents disagree,particularly in divorce
situations whenparents with shared custody perceivethe child’s
problems and strengths dif-ferently. Under such circumstances,the
clinician must use communicationskills to find a consensus on the
diag-nosis and plan. Eliciting informationfrom extended family
members mighthelp clarify some of the differences.
SCHOOL AND/OR OTHERCOMMUNITY INFORMANTS
Multiple informants are required forclinicians to determine the
natureand severity of symptoms, impact ofthe symptoms on function
in 2 ormore settings, and whether thechild/adolescent meets
DSM-IV-TRcriteria for the diagnosis of ADHD. Inmost cases, the
teacher providesthose reports. The reports of parentsand teachers
are often sufficient forthe ADHD diagnosis, but informationfrom the
patient is essential for iden-tifying the internalizing conditions
ofmood and anxiety disorders. Ratingscales recommended by the
TaskForce on Mental Health may be help-ful. In some circumstances,
it mightbe desirable to solicit informationfrom additional sources.
School re-ports, for example, might be moredifficult to obtain—or
less compre-hensive—in cases that involvepreschool-aged children
and adoles-cents. Other adults who are active inthe life of an
adolescent, such ascoaches, pastors, or scout leaders,can be asked
to complete ratingscales to develop a full profile of
theadolescent, although the accuracy oftheir reporting has not been
studied
Teachers might indicate their majorconcerns by using
questionnairesor verbal input by telephone orthrough direct
conversation. An ap-propriate school representative
should be asked to complete a vali-dated ADHD instrument or
behav-ior scale based on DSM-IV-TR criteriafor ADHD and provide
observationsthat might suggest coexisting or al-ternative
conditions, including dis-ruptive behavior disorders, depres-sion
and anxiety disorders, tics, orlearning disabilities. Report
offunction, both strengths and weak-nesses, might be gleaned by
ques-tionnaires or academic recordsthat can include report cards;
stan-dardized testing in reading, mathe-matics, and written
expression; vali-dated functional assessment toolsmentioned
previously44; and previ-ous psychoeducational evaluations.These
records can help establish achild’s/adolescent’s profile of
aca-demic and behavioral performancein school, the presence of a
learningdisability, difficulty in followingschool rules, the
quality of peer in-teractions, and the extent of
schoolabsences.
If the records indicate that the childis having difficulty
learning aca-demic skills, the physician should de-termine if the
child has been as-sessed for a potential learningproblem by the
school, becausethere is a high comorbidity betweenlearning
disabilities and ADHD. Theschool assessment might use
aresponse-to-intervention model aspart of the diagnostic process
inwhich learning problems are evalu-ated on the basis of the
child’s re-sponse to evidence-based academicinterventions, or a
multidisciplinaryteam evaluation might be conductedby the school.
If the child has an Indi-vidualized Education Program, thisdocument
should be reviewed by theclinician.
If the child continues to struggle de-spite the school’s
interventions andtreatment for ADHD, further psychoe-ducational or
neuropsychological as-
SI6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
sessment is necessary. The clinicianmight want to recommend that
theevaluations be performed by an inde-pendent psychologist or
neuropsy-chologist. Despite the importance ofthe psychological
assessments, in-surance coverage is quite variable,and families
should be encouragedto investigate their coverage whenpursuing
independent psychologicalevaluations. Financing community-based
evaluations has been ad-dressed in a previous AAP state-ment.45
Children with intellectual orother developmental disabilitiesmight
also have ADHD, but the as-sessment in these cases is
morecomplicated, because one must en-sure that the academic
expectationsare matched to the child’s academicabilities and the
level of ADHD symp-toms exceeds what would be ex-pected for a
child’s developmentallevel. Primary care physicians in-volved in
assessing ADHD in childrenwith intellectual disabilities willneed
to collaborate closely with aschool psychologist or
independentpsychologist.
In addition to the academic informa-tion, information should be
re-quested that characterizes thechild’s/adolescent’s level of
func-tioning with regards to peer,teacher, and other authority
figurerelationships; ability to follow direc-tions; organizational
skills; history ofclassroom disruption; and assign-ment completion.
Administrativereports of disciplinary action, suchas suspensions
and expulsions, anddescriptions of behavior at schoolreflect social
function and behav-ioral regulation and suggest the pos-sibility of
coexisting conditions.
For adolescents who have multipleteachers, it is desirable to
obtain be-havior and impairment ratings from atleast 2 teachers in
academic subjects(eg, math and English teachers or, for
children/adolescents with learningdisabilities, a teacher in the
area ofstrong function and a teacher in thearea of weak function).
The ADHD tool-kit13 providesmaterials relevant to thisschool data
collection.
Teacher and parent reports frequentlydisagree,46 and there
alsomight be dis-agreement between parents. These ob-servations
might not be inaccurate,because parents and teachers ob-serve the
children under different cir-cumstances. When there is
disagree-ment, it is helpful to obtain moreinformation such as the
circumstanceunder which the individuals observedthe child, the
demands on the childduring those observations, the observ-ers’
understanding of the behaviorsand how to deal with them, and the
ob-servers’ understanding of ADHD andhow it is treated as well as
the rolethey play with the child. As noted pre-viously, obtaining
information from ad-ditional sources, such as grandpar-ents,
coaches, or Sunday schoolteachers, can be helpful. The clini-cian’s
decision about the diagnosis is aclinical judgment made on the
basis ofall the information that is available.
CHILD/ADOLESCENT
The clinician should conduct an age-appropriate interview,
including thechild’s/adolescent’s concern regardinghis or her own
behavior, and regardingfamily relationships, peers, andschool. Itis
important to include a discussion ofhis or her strengths, goals,
and difficul-ties. Along with the interview, the use ofan
appropriate validated self-reportinstrument of ADHD and
co-existingconditions, primarily for adolescents,canaid in
theassessmentof riskof ADHDand anxiety and mood disorders. It
isalso important to ask about delusionalthinking and suicidal
thoughts or ac-tions. This evaluation should also pro-vide a
baseline of the child’s/adoles-cent’s self-identified report of
function
at home, in school, at work, and amongpeers as well as validated
functional as-sessment tools.44 Whenever possible, theindividual
child’s or youth’s own view ofwhat heor shewould like to see
changedshould be considered primary targetsfor intervention,
because these goalsmight at times differ widely from parentor
school concerns.
The clinician must keep in mind thetendency of many
children/adoles-cents to underreport their ADHD andother disruptive
behavior symptoms.However, the baseline impressions ofthe
child/adolescent can then be usedas the basis for shaping the
patient’sunderstanding of ADHD and coexistingsymptoms as well as
monitoring func-tion in social, behavioral, and aca-demic domains.
Active involvement ofthe children/adolescents might beuseful to
empower them to under-stand and participate in their own
di-agnostic formulation and, later, to ob-tain “buy in” to their
treatment planand improve adherence to treatment.Recommendations of
the AAP TaskForce on Mental Health and the Guide-lines for
Adolescent Depression in Pri-mary Care (GLAD-PC)47,48 include
usingvalidated diagnostic rating scales foradolescent mood and
anxiety disor-ders for clinicians whowish to use thisformat. In
addition, the CRAFFT (car, re-lax, alone, forget, friends, trouble)
isan available screen for substanceabuse.49
Clinical observations of the patientshould be recorded and
include his orher level of attention, activity, and im-pulsivity
during the encounter. An im-portant caveat is that the findings
seenin other settings, including core symp-toms, are often not
observed duringoffice visits.50
Special attention should be paid to lan-guage skills in
preschool-aged andyoung school-aged children, becausedifficulties
with language can be asymptom of a language disorder and
Supplemental Appendix
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-
predictor of subsequent reading prob-lems; such language
disorders mightpresent as problems with attentionand impulsivity.
Likewise, social inter-actions should be noted during the
ex-amination, because they are anotherpossible area of
deficiency.
The physical and neurologic exami-nation must be comprehensive.
Aphysical and neurologic examinationshould be conducted to
determine iffurther medical or developmental as-sessments are
indicated. Baselineheight, weight, blood pressure, andpulse
measurements should be taken.Among the signs to note are hearingand
visual acuity and cardiovascularstatus. Dysmorphic features
shouldalso be noted, because ADHD might beassociated with genetic
syndromes(eg, fetal alcohol syndrome and fragileX). The neurologic
evaluation shouldinclude developmental andmental sta-tus
observations including affect; com-munication skills, including
speechand language; tics; and gross and finemotor coordination.
Many childrenwith ADHD will have poor coordination,which might be
severe enough to war-rant a diagnosis of developmental
co-ordination disorder. The findings canaffect how well the child
can performin competitive sports and can also ad-versely affect his
or her writing skills.Through history and examination ofthe child’s
fine and gross motor skills,the clinician can identify these
deficitsand address them in the managementplan.
DSM-IVdiagnosis of
ADHD?
As a result of the diagnostic evalua-tion, a primary care
clinician should beable to answer the following ques-tions:
● How many inattentive and hyperac-tive/impulsive behavior
criteria forADHD does the child/adolescent
meet across the major settings ofhis or her life?
● Have these criteria been present for6 months or longer?
● Was the onset of these or similarbehaviors present before the
age of7 years?
● What functional impairments, if any,are caused by these
behaviors?
● Could any other condition be a bet-ter explanation for the
behaviors?
● Is there evidence of coexisting prob-lems or disorders?
On the basis of this information, theclinician should be able to
arrive at apreliminary diagnosis.
OTHER DISORDERS
If symptoms arise suddenly, with-out any previous history,
primarycare clinicians should considerother conditions, including
headtrauma, physical or sexual abuse,neurodegenerative
disorders,mood and anxiety disorders, sub-stance abuse, or a major
psycho-logical stress in the family or inschool, such as
bullying.
Exit this guideline.Evaluate or refer, as
appropriate.
appropriate.
Iden�fy the child as CYSHCN if
YesOther
condition?
If the evaluation identifies or sug-gests that another disorder
is thecause of the concerning signs andsymptoms, then it is
appropriate toexit this algorithm. The approach inthat case is
dictated by the results ofthe evaluation. If a referral is made,the
primary care clinician shouldframe the referral questions
clearlyand expect these referral questionsto be answered in a
manner that willensure that a comanagement planthat addresses the
families’ andchild’s/adolescent’s ongoing needsfor education and
general and spe-cialty health care is established. Re-
sources from the AAP Task Force onMental Health might be
helpful.
TYPICAL OR DEVELOPMENTALVARIATION:
Provide educa�on addressing concern (eg,
expecta�ons for a�en�on as a func�on of age)
Enhanced Surveillance
Apparently typical or
developmental variation?
Yes
Evaluation might reveal that thechild’s/adolescent’s
inattention, ac-tivity level, and impulsivity are withinthe normal
range of development;mildly or inconsistently elevated incomparison
to peers; or not associ-ated with any functional impairmentin
behavior, academics, social skills,or other domains. It is
important forthe clinician to probe further to de-termine if the
parental concerns re-garding the child/adolescent are at-tributable
to other issues in thefamily, such as parental tension ordrug abuse
in another family mem-ber; whether they are caused byother issues
in school, such as socialpressures or bullying; or whetherthey are
within the spectrum of typi-cal development. Parent educationabout
contributions to their con-cerns and to the spectrum of
devel-opmental variation might be helpful.Education about the range
of typicaldevelopment and strategies for im-proving a
child’s/adolescent’s be-haviors when they are problematicmight be
helpful. A schedule of en-hanced surveillance absolves thefamily of
the need to reinitiate con-tact if the situation deteriorates. If
arecommendation for continued rou-tine systematic surveillance is
made,then assurance that ongoing con-
SI8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
cerns can be revisited in future pri-mary care visits would be
important.
INATTENTION, HYPERACTIVITY, AND/OR IMPULSIVITY (PROBLEM
LEVEL):
Children/adolescents whose symptomsdo not meet the criteria for
diagnosis ofADHDmight still encounter difficulties orimpairment in
some settings, as de-scribed in the DSM-PC Child and Adoles-cent
Version.51
Professional consensus is that medica-tion is not an appropriate
treatment forchildren/adolescents with inattention,hyperactivity,
and/or impulsivity prob-lems that do not meet the DSM-IV-TR
cri-teria for ADHD. Children/adolescentswith these problems and
their familiesmight benefit from education, includingidentifying
and eliminating triggers thatprompt inattention, hyperactivity, or
im-
pulsivity; behavior-management options,including a
behavior-therapy or parent-ing program; strategies for
improvingschoolperformanceorbehavior; and therecommendations
provided in the inat-tention and hyperactivity/impulsivitycluster
guidance in the Task Force onMental Health ADHD toolkit.13
ATTENTION-DEFICIT/HYPERACTIVITYDISORDER:
If the child/adolescent is found to meetthe DSM-IV-TR criteria
for ADHD, includ-ing commensurate functional disabili-ties,
suchdiagnosis shouldbemade, andprogress through
theprocess-of-careal-gorithm continues as shown.
Provide Education to the Family andChild/Adolescent
Education for the family and child/adolescent about ADHD is an
impor-tant element in the care plan whenADHD is diagnosed or
inattention, hy-peractivity, and/or impulsivity (prob-lem level) is
identified. Family educa-tion continues throughout thecourse of
treatment. It includes an-ticipatory guidance in such areas
astransitions (eg, from elementary tomiddle and middle to high
schoolsand from high school to college oremployment) and working
withschools and developmental chal-lenges that might be affected
byADHD, including driving, gender, anddrugs.
Family education includes all mem-bers of the family, including
develop-mentally age-appropriate informationfor the affected
child/adolescent andany siblings. Topics include the disor-der; the
symptoms; the assessmentprocess; commonly coexisting disor-ders;
treatment choices and their ap-plication, likely effects, and
outcomes;long-term implications; impact onschool performance; and
socialparticipation.
A critical piece of the treatment planis to empower
children/adolescentsto understand their condition andthe degree of
impairment that it hason their daily life, including strate-gies
for addressing symptoms andimpairments. At every stage, this
ed-ucation must continue in a mannerconsistent with the
child’s/adoles-cent’s own level of understanding. Inaddition, it is
helpful for a child/ado-lescent with ADHD to know the nameof any
medication that he or she willbe using as well as common
adverseeffects.
The issue of how the patient thinks ofhimself or herself is
another area toaddress; it should be clarified thatthe condition
does not mean that he
Inattention and/or hyperactivity/impulsivity
problems not rising to DSM-IV DiagnosisProvide educa�on of
family and child
re: concerns (eg, triggers for ina�en�on or hyperac�vity) and
behavior
management strategies or schoolbased strategies
Enhanced Surveillance
Apparently typical or
developmental variation?
No
Provide educa�on to family and child re: concerns (eg, triggers
for
ina�en�on or hyperac�vity) and behavior-management strategies
or
based strategies
DSM-IVdiagnosis of
ADHD?Coexisting conditions?
No
Yes
Supplemental Appendix
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or she is less smart than other chil-dren/adolescents. It can
also behelpful to identify and support areasof strength and help
the child/ado-lescent with ADHD to learn how toidentify when he or
she needs helpand how to procure it.
Education for parents should includeproactive strategies that
can helpmake the home environment morefacilitative for their
child/adolescentwith ADHD. For example, making ad-aptations and
providing structurethat enables the child/adolescent tobest use his
or her strengths andcompensate for deficits can be help-ful to
parents. Such strategies in-clude providing greater consistencyin
the parents’ behavior toward theirchild/adolescent with ADHD,
formingdaily routines and schedules, anddisplaying house rules in
prominentplaces as visual reminders. It mayhelp parents to
communicate abouttheir child’s/adolescent’s behaviorand each
parent’s response as wellas the parental division of labor. It
isalso important to check on the par-ents’ well-being, because
parents ofchildren/adolescents with ADHD fre-quently are under
stress and mightnot take into consideration their ownwell-being or
that of other familymembers. These concerns are par-ticularly
relevant when a parent alsohas ADHD or associated conditions.
Parents will likely benefit if they learnabout optimal ways to
partner withschools such that teachers can be-come part of the
educational and inter-vention teams. Parents will benefitfrom being
informed about school ser-vices that are available to addresstheir
child’s/adolescent’s needs, in-cluding the Individuals With
Disabili-ties Education Act (IDEA) and the Reha-bilitation Act
(504) services providedby their state, and the eligibility
re-quirements for them. With a parent’spermission, the clinician
can provide
the school with information from theevaluation that will help
the school de-termine eligibility for special educa-tion services
and develop appropriateadaptations. Advocacy and supportgroups such
as CHADD (Children andAdults With Attention-Deficit/Hyperac-tivity
Disorder) can also provide infor-mation and support to
families.
The ADHD toolkit13 provides lists of ed-ucational resources
including Web-based resources, organizations, andbooks that might
be useful to parentsand students.
COEXISTING CONDITIONS:
If other disorders are suspected or de-tected during the
diagnostic evalua-tion, an assessment of the urgency ofthese
conditions and their impact onthe ADHD treatment plan needs to
bemade.
Urgent conditions, such as suicidalthoughts or acts or other
behaviorswith the potential to severely injurethe child/adolescent
or other peo-ple, such as severe temper out-bursts or child abuse,
should be ad-dressed immediately with servicescapable of handling
crisissituations.
The evidence shows that coexistingconditions, such as
oppositionality andanxiety, might improve with treatment
of ADHD.51 For example, children withADHD and coexisting anxiety
disordersmight find that ADHD medications de-crease anxiety
symptoms as well asADHD behaviors. In the cases of severelearning
disorders or oppositional de-fiant disorder, a trial of treatment
forADHD might indicate whether the ap-parent coexisting condition
can bemodulated with treatment of the ADHD.Other patients might
require addi-tional therapeutic treatments, such ascognitive
behavioral therapy or a dif-ferent or additional medication, to
ad-equately treat the ADHD and coexistingcondition.
Untreated substance use disorderneeds to be addressed first
beforefully addressing the patient’s ADHDtreatments.
If the primary care clinician requiresthe advice of another
subspecialist,then the clinician should considercarefully when to
initiate treatment forADHD. In some cases, it might be advis-able
to delay the start of medicationuntil the role of each member of
thetreatment team is established. For ex-ample, with some
coexisting psychiat-ric disorders, such as severe
anxiety,depression, and bipolar disorder, a co-managing
developmental behavioralpediatrician or psychiatrist might take
Assess impact on treatment plan
Further evaluation/referral as needed
Coexisting disorders preclude primary care
Follow-up and establish co-
management planSee TFOMH Algorithms
Yes
Provide educa�on to family and child re: concerns (eg, triggers
for
ina�en�on or hyperac�vity) and behavior-management strategies
or
No
Yes
DSM-IVdiagnosis of
ADHD?Coexisting conditions?
Yes
SI10 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
responsibility for treatment of boththe ADHD and the coexisting
illness.
At other times, such as in the case of achild or adolescent with
coexistingmild depression or obsessive-compulsive disorder, a
mental healthclinician, developmental-behavioralpediatrician,
neurodevelopmental dis-ability clinician, or child neurologistmay
treat the coexisting conditionwhile the primary care clinician
over-sees the treatment for ADHD, or theconsulting physician may
advise theprimary care physician about thetreatment of the
coexisting conditionto the extent that the primary care phy-sician
is comfortable treating both theADHD and coexisting problems.
ESTABLISH MANAGEMENT TEAM
Identify child as CYSHCN
Establish team including
coordination plan
Collaborate with family, school,
and child to identify target
goals.
IDENTIFY AS A CHILD/YOUTH WITHSPECIAL HEALTH CARE NEEDS:
Any child who meets the criteria forADHD should be considered a
child/youth with special health care needs.The AAP encourages
clinicians to de-velop systems that ensure that themedical home
needs of all children/youth with chronic illnesses are met.These
needs—and strategies formeeting them—are discussed in fur-ther
detail elsewhere in this guidelineand in other AAP resources such
asThe Building Your Medical Home Tool-kit and Addressing Mental
Health Con-cerns in Primary Care: A Clinician’sToolkit.43,53
Management Issues
Questions that are important to con-sider in developing a
managementplan include the following:
● Does the family need further assis-tance in understanding the
coresymptoms of ADHD and their child’s/adolescent’s target symptoms
andcoexisting conditions?
● Does the family need support inlearning how to establish,
measure,and monitor target goals?
● Have the family’s goals been identi-fied and addressed in the
care plan?
● Does the family have an understand-ing of effective
behavior-management techniques for re-sponding to tantrums,
oppositionalbehavior, or poor compliance to re-quests and
commands?
● Is help needed for normalizing peerand family
relationships?
● Does the child/adolescent need helpin academic areas? If so,
has a for-mal evaluation been performed andreviewed to distinguish
work pro-duction problems secondary toADHD from coexisting learning
orlanguage disabilities?
● Does the child/adolescent need helpin achieving independence
in self-help or schoolwork production?
● Does the child/adolescent or familyrequire help with
optimizing, orga-nizing, planning, or managingschoolwork flow?
● Does the family need help in recog-nition, understanding, or
manage-ment of coexisting conditions?
● Is there a plan in place to systemat-ically educate the
child/adolescentabout ADHD and its treatment aswell as the
child’s/adolescent’s ownstrengths and weaknesses?
● Is there a plan in place to empowerthe child/adolescent with
the knowl-edge and understanding that will in-crease his or her
adherence totreatments, and has that begun asearly as possible and
been ad-dressed at the child’s/adolescent’sdevelopmental level?
● Does the family have a copy of a careplan that summarizes
findings andtreatment recommendations thatcan be updated and used
in schoolsettings and other professional set-
tings so that the history and treat-ment plan does not need to
be con-stantly reinvented?
● Is the follow-up plan sufficient toprovide comprehensive,
coordi-nated, family-centered, culturallycompetent, ongoing
care?
COLLABORATE WITH THE FAMILY,SCHOOL, AND CHILD/ADOLESCENT
TOIDENTIFY TARGET GOALS:
Whereas an initial stimulant medica-tion trial might focus on
normalizingcore symptoms of ADHD, a longer-termcomprehensive plan
should focus onidentifying and addressing individual-ized and
specific behavioral, academic,and social target goals and
treat-ments. The clinician should assist par-ents, teachers, other
informants, andthe child/adolescent in developing tar-get goals in
the areas of function mostcommonly affected by ADHD: academ-ics;
peer, parent, or sibling relation-ships; and safety in the
community.Other goals might be identified by us-ing the
International Classification ofFunction (ICF) analysis conducted
inthe diagnostic phase of the clinicalpathway.6
It is not necessary to develop goals inevery area all at once.
Families mightbe encouraged to identify up to 3 of themost
impairing areas on which theywill initially work; parents and
thechild/adolescent can then add othertargets as indicated by their
relativeimportance. Such an exercisewill facil-itate greater
understanding of the ef-fects of the disorder on each memberof the
family and might lead to an im-proved collaboration in the
develop-ment of a few specific and measurableoutcomes. It is
helpful to incorporatethe child’s/adolescent’s strengths
andresilient factors in considering targetgoals and in generating a
treatmentplan. Goals for the school require inputfrom the teachers
in terms of bothidentification and measurement.
Supplemental Appendix
PEDIATRICS Volume , Number , SI11
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Establishing measurable goals in in-terpersonal domains and
behavior inunstructured settings might be partic-ularly important.
Whenever possible, itis important to make progress “count-able.”
For behaviors such as “fre-quency of yelling” or frequency
ofmissing assignments, charts may besuggested as strategies for
recordingthe event so that parents, teachers, thechild/adolescent,
and clinicians can allagree on howmuch progress has beenmade. In
this way, successes can bebuilt on in a systematic way.
Suchstrategies can help a family accuratelyassess and see progress
of behaviorchanges. A daily single-page reportcard can be used to
identify and moni-tor 4 or 5 behaviors that affect functionat
school, and these reports can beshared with the parents. Other
strate-gies and tools are available to clini-cians in the AAP ADHD
toolkit13 and toparents in the book ADHD: What EveryParent Needs to
Know.52
As treatment proceeds, in addition tousing a DSM-IV-TR–based
ADHD ratingscale to monitor core symptomchanges, formal and
informal queriescan be made in the areas of functionmost commonly
affected by ADHD (eg,academic achievement; peer, parent,or sibling
relationships; and safety inthe community). Progress can also
bemonitored by determining progress onthe target goals. At every
visit, it ishelpful to gradually empower chil-dren/adolescents to
become full part-ners in their treatment plan by adoles-cence.
Information from the school,including ADHD symptoms (ratingscale
completed by the teacher),grades, and any other formal
testingresults, are also helpful at these visits.
ESTABLISH TEAM ANDCOORDINATION PLAN:
It is best for the treatment team to in-clude everyone involved
in the care ofthe child/adolescent: the child/adoles-
cent, parents, teachers, the primarycare clinician, therapists,
subspecial-ists, and other adults (such as coachesor religious
leaders) who will be ac-tively engaged in supporting and
mon-itoring the treatment of ADHD. It ishelpful for the primary
care clinicianor an assigned “care coordinator” toensure that each
team member isaware of his or her role and that bothroutine and
as-needed communicationstrategies and expectations for re-ports
(frequency, scope) are clear. Col-laboration with the school goes
be-yond the initial report of diagnosis andis best facilitated by
agreement on astandardized, reliable system for ex-changing
communications.
TREATMENT:
Medication
This treatment option is restricted tochildren/adolescents who
meet the di-agnostic criteria for ADHD.
Although it is a rare occurrence55
and more evidence is required toidentify whether it is an
increasedrisk, it is important to obtain acareful history of
cardiac symp-toms; a cardiac family history, par-ticularly of
arrhythmias, suddendeath, and death at a young agefrom cardiac
conditions; and vitalsigns, cardiac physical examina-tion, and
further evaluation on thebasis of clinical judgment.
Stimulant medications and severalnonstimulant medications are
nowavailable, as outlined in SupplementalTable 3. The presence of a
tic disordermight affect the decision about which
medication to initiate for ADHD ther-apy. With the greater
availability ofmedications approved by the FDA
forchildren/adolescents with ADHD, it hasbecome increasingly
unlikely that clini-cians need to consider the off-label useof
othermedications. The choice of for-mulation depends on factors
such asthe efficacy of each agent for a givenchild/adolescent, the
preferred lengthof coverage time, whether a child canswallow pills
or capsules, and ex-pense. The extended-release formula-tions are
generally more expensivethan the immediate-release formula-tions
but might be preferred by manyfamilies and children/adolescents,
be-cause they provide the benefits of con-sistent and sustained
coverage withfewer administrations per day. Long-acting
formulations usually precludethe need for school-based
administra-tion of ADHD medication. Better cover-age with fewer
administrations leadsto greater convenience for the familyand,
therefore, might also lead to bet-ter adherence to the medication
man-agement plan. Some patients, particu-larly some adolescents,
might requiremore than 12 hours of coverage to en-sure adequate
focus and concentra-tion during evening study time anddriving; in
these cases, a short-actingpreparation might be used in additionto
a long-acting preparation.
The ease with which preparations canbe administered and the
minimizationof adverse effects are important forthe quality-of-life
concerns that chil-dren, youth, and parents expressaround the
decision to usemedication.
Op�on: Medica�on(ADHD only and past medical or family history of
cardiovascular
disease considered) Ini�ate treatment
Titrate to maximum benefit, minimum adverse effectsMonitor
target outcomes
Op�on: Behavior management (developmental varia�on,
problem or ADHD)
Iden�fy service or approach
Monitor target outcomes
Op�on: Collaborate with school to enhance supports
and services (developmental varia�on, problem, or ADHD)
Iden�fy changes
Monitor target outcomes
See action statement 5
See action statement 6
BEGIN TREATMENT
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-
Other context issues that should alsobe considered in deciding
which med-ication to recommend include the timeof day when the
targeted symptomsoccur, when homework is usuallydone, whether
medication remains ac-tive when teenagers are driving,whether
medication alters sleep initia-tion, and risk status for drug
use.
All approved stimulant medicationsare methylphenidate or
amphetaminecompounds, which have similar effectsand adverse
effects. Given the exten-sive evidence of efficacy and safety,they
remain the first choice of medica-tion treatment. Thus, the
decision re-garding which compound a clinicianfirst prescribes
should bemade on the
basis of individual preferences of theclinician and family. Some
children/ad-olescents will respond better to or dis-play more
adverse effects with 1 com-pound group or the other. Becausethese
effects cannot be determined inadvance, if a trial with 1 group is
un-successful (poor efficacy or adverseeffects), a trial on a
medication fromthe other group should be undertaken.For cases in
which there is concernabout possible abuse or diversion ofthe
medication or there is a strongfamily preference against
stimulantmedication, an FDA-approved non-stimulant medication may
be consid-ered as the first choice of medication.The medications
that use a microbead
technology can be opened and sprin-kled on food for patients who
have dif-ficulty swallowing tablets or capsules.Immediate-release
methylphenidate,which comes in liquid and chewableforms, and a
methylphenidate trans-dermal patch are also available as
al-ternatives to tablets or capsules.
It is helpful to prepare families for theinitial medication
(titration) process,including what it will entail and howlong
itmight take. The usual procedureis to begin with a low dose of
medica-tion and titrate to the dose that pro-vides maximum benefit
and minimaladverse effects. Initially, core symp-tom reduction
ismore likely to indicatemedication effects; the effects of im-
SUPPLEMENTAL TABLE 3 FDA-Approved Medications: Dosing and
Pharmacokinetics
Medication Brand Initial Titration Dose Frequency Time toInitial
Effect
Duration, h Maximum Dose Available Doses
Mixed amphetaminesalts
Adderalla 2.5–5.0 mg QD–BID 20–60 min 6 40 mg 5.0-, 7.5-, 10.0-,
12.5-, 15.0-,20.0-, and 30.0-mg tablets
Adderall XRa 5 mg QD 20–60 min 10 40 mg 5-, 10-, 15-, 20-, 25-,
and 30-mgcapsules
Dextroamphetamine Dexedrinea/Dextrostat
2.5 mg BID–TID 20–60 min 4–6 40 mg 5- and 10-mg (Dextrostat
only)tablets
DexedrineSpansulea
5 mg QD–BID �60 min �6 40 mg 5-, 10-, and 15-mg capsules
Lisdexamfetamine Vyvanse 20 mg QD 60 min 10–12 70 mg 20-, 30-,
40-, 50-, 60-, and 70-mg capsules
Methylphenidate Concerta 18 mg QD 20–60 min 12 54 mg (�13 y);
72mg (�13 y)
18-, 27-, 36-, and 54-mgcapsules
Methyl ER 10 mg QD 20–60 min 8 60 mg 10- and 20-mg
tabletsMethylin 5 mg BID–TID 20–60 min 3–5 60 mg 5-, 10-, and 20-mg
tablets and
liquid and chewable formsDaytrana 10 mgb Apply for 9 h 60 min
11–12 30 mg 10-, 15-, 20-, and 30-mg
patchesRitalina 5 mg BID–TID 20–60 min 3–5 60 mg 5-, 10-, and
20-mg tabletsRitalin LA 20 mg QD 20–60 min 6–8 60 mg 20-, 30-, and
40-mg capsulesRitalin SRa 20 mg QD–BID 1–3 h 2–6 60 mg 20-mg
capsulesMetadate CD 20 mg QD 20–60 min 6–8 60 mg 10-, 20-, 30-,
40-, 50-, and 60-
mg capsulesDexmethylphenidate Focalina 2.5 mg BID 20–60 min 3–5
20 mg 2.5-, 5.0-, and 10.0-mg tablets
Focalin XR 5 mg QD 20–60 min 8–12 30 mg 5-, 10-, 15-, and
20-mgcapsules
Atomoxetine Strattera 0.5 mg/kg per d, then increaseto 1.2 mg/kg
per d; 40 mg/dfor adults and children at�154 lb, up to 100 mg/d
QD–BID 1–2 wk At least 10–12 h 1.4 mg/kg 10-, 18-, 25-, 40-,
60-, 80-, and100-mg capsules
Extended-releaseguanfacine
Intuniv 1 mg/d QD 1–2 wk At least 10–12 h 4 mg/d 1-, 2-, 3-, and
4-mg tablets
Extended-releaseclonidine
Kapvay 0.1 mg/d QD–BID 1–2 wk At least 10–12 h 0.4 mg/d 0.1- and
0.2-mg tablets
QD indicates daily; BID, twice daily; TID, three times daily.a
Available in a generic form.b Dosages for the dermal patch are not
equivalent to those of the oral preparations.
Supplemental Appendix
PEDIATRICS Volume , Number , SI13
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provement in function require a moreextended time period.
Stimulant medi-cations can be effectively titrated on a3- to 7-day
basis. During the firstmonthof treatment, medication dose may
betitrated with a weekly or biweekly tele-phone call to the family.
The increasingdoses can be provided either by pre-scriptions that
allow dose adjust-ments upward or, for some of themed-ications, by
1 prescription of tablets/capsules of the same strength
withinstructions to administer progres-sively higher amounts by
doubling ortripling the initial dose. Another ap-proach similar to
that used in the MTAstudy56 is for parents to be directed
toadminister different doses of the samepreparation, each for 1
week at a time(eg, Saturday through Friday). At theend of each
week, teacher and parentfeedback and/or DSM-IV-TR–basedADHD rating
scales can be completedthrough a telephone interview, fax, orsecure
electronic system. In additionto the ADHD rating scale, parents
andteachers should be asked to review ad-verse effects and target
goals.
A face-to face follow-up visit is recom-mended by the fourth
week of medica-tion, during which clinicians reviewthe responses to
the varying doses andmonitor adverse effects, pulse, bloodpressure,
and weight. To ensure thatprogress in symptom control is
beingmaintained, clinicians should continueto monitor levels of
core symptomsand improvement in specified targetgoals. A general
guide for visits to theprimary care clinician is for the face
toface visits to occur initially on amonthly basis, until there is
a consis-tent optimal response, and then every3 months in the first
year of treatment.Subsequent visits will depend on theresponse but
should occur at least 2times per year, until it is clear that
tar-get goals are progressing and stable,and then periodically as
determined bythe family and the clinician. Recent re-
sults from the MTA study indicate thatthere are a number of
children/adoles-cents who, by 3 years after startingmedication,
continue to improve evenif the medication has been discontin-ued.57
The findings suggest that chil-dren/adolescents who are stable
intheir improvement of ADHD symptomsmay be given a trial off
medication af-ter several years to determine if med-ication is
still needed. This process isbest undertakenwith closemonitoringof
the child’s/adolescent’s core symp-toms and function at home, in
school,and in the community.
Whenever possible, improvements incore symptoms and target
goalsshould be monitored in an objectiveway (eg, going from 60% to
20%miss-ing assignments per week [see theADHD toolkit13]), and the
core symp-toms can be monitored by use of oneof the DSM-IV-TR–based
ADHD ratingscales such as the Vanderbilt ADHDfollow-up scales.
Clinicians are en-couraged to educate parents that al-though
medication can be effectivein facilitating schoolwork produc-tion,
it has not been shown to be ef-fective in addressing learning
dis-abilities. A child/adolescent whocontinues to experience
academicunderachievement after attainingsome control of ADHD
behavioralsymptoms should be assessed for acoexisting condition,
including learn-ing and language disabilities, othermental health
disorders, or otherpsychosocial stressors. Noncompli-ance with the
treatment plan shouldalso be assessed.
If the maximum dose of a stimulantpreparation is reached and
less-than-satisfactory results have beenachieved or intolerable
adverse ef-fects occur before adequate efficacywith a medication
from one of thestimulant groups (methylphenidateor amphetamine), a
medication fromthe other stimulant group should be
recommended with a similar titra-tion plan. At least half of the
chil-dren/adolescents whose symptomsfail to respond to 1 stimulant
medi-cation may have a positive responseto the alternative
medication.56
Families concerned about the use ofstimulants or with concerns
aboutabuse or diversion may choose tostart with atomoxetine or
extended-release guanfacine or extended-release clonidine. In
addition, thosewhose symptoms do not respond toeither stimulant
group might still re-spond to atomoxetine or extended-release
guanfacine or extended-release clonidine. Extended
releaseguanfacine or extended release clo-nidine also may be added
as an ad-junctive therapy in children who par-tially respond to
stimulantmedication.
There is a block-box warning onatomoxetine of the possibility
ofsuicidal ideation when initiatingmedication management.
Earlysymptoms of suicidal ideationmight include thinking about
self-harm and increasing agitation. Ifthere are any concerns about
sui-cidal ideation in children pre-scribed atomoxetine, further
evalu-ation, reconsideration about theuse of atomoxetine, and more
fre-quent monitoring should be consid-ered, and if necessary,
referral to amental health clinician should bemade.
Atomoxetine is a selectivenorepinephrine-reuptake inhibitorand
might result in maximum re-sponse only after approximately 4 to
6weeks. Extended-release guanfacineand extended-release clonidine
are�2A-adrenergic agonists and might re-sult in maximum response in
approxi-mately 2 to 4 weeks. Parents may beencouraged to complete
weekly symp-tom and adverse-effect monitoring, as
SI14 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
described previously, as an objectivemeasure to monitor
efficacy. Becausesymptom change is more gradual withatomoxetine and
�2A-adrenergic ago-nists than with stimulant medications,families
who have had previous expe-rience with stimulants should
bemadeaware of this fact. In some patients, amodest effect of
atomoxetine might beseen in 1 week. Atomoxetine mightcause
gastrointestinal tract symptomsand sedation early in treatment, so
it isrecommended to prescribe half thetreatment dose (0.5 mg/kg)
for thefirst week. Appetite suppression canalso occur. Both �2A
agonists cancause the adverse effect of somno-lence. In addition,
it is recommendedthat the medications be tapered whendiscontinued
to prevent a possible re-bound in blood pressure.
Special Circumstances: Preschool-Aged Children
Clinicians should initiate ADHD treat-ment of preschool-aged
children(4 –5 years of age) with behaviortherapy and should also
assess forother developmental problems, es-pecially with language.
If children donot experience adequate symptomand functional
improvement with be-havior therapy (most programs are10–14 weeks
long, but the clinicianshould check with the therapistsabout their
usual length of interven-tion), the clinician should first
evalu-ate the adequacy and parental ac-ceptance of the therapy. If
thesymptoms and/or functioning havenot improved and the child is at
sig-nificant behavioral or developmentalrisk because of ADHD,
medicationcan be prescribed, as described pre-viously. It must be
noted that, cur-rently, the FDA has only approveddextroamphetamine
for ADHD in chil-dren in this age group, althoughthere is little
evidence to support itssafety and efficacy. There is, how-ever,
evidence that methylphenidate
is safe and efficacious for children inthis age group.58
Evidence58 suggeststhat the rate of metabolizing methyl-phenidate
is slower in children 4 and5 years of age, so they should bestarted
at a lower dose that is in-creased in smaller increments. In
ad-dition, the preschool-aged childrenstudied in the multisite
study58 hadmore severe dysfunction, whichshould be considered in
the decisionto try treatment with methylpheni-date. The additional
criteria for de-fining moderate-to-severe impair-ment include
symptoms present forat least 9 months and clear impair-ment in both
the home and day care/preschool settings that has not re-sponded to
an appropriatebehavioral intervention. Limited evi-dence59 and no
FDA approval for chil-dren in this age group are availablefor
atomoxetine, and no evidence orapproval for extended-release
guan-facine or extended-release clonidineare available.
Special Circumstances: Adolescents
Clinicians should assess adolescentpatients with ADHD for
symptoms ofsubstance use or abuse before begin-ning medication
treatment. If sub-stance abuse is revealed, they shouldhave the
patient stop the use, and theyshould provide treatment or refer
fortreatment for substance abuse beforebeginning treatment for
ADHD. Clini-cians are also encouraged to monitorsymptoms and
prescription refills forsigns of misuse or diversion of
ADHDmedication.
Special concern should be taken toprovide medication coverage
forADHD symptom control while driving.Longer-acting or
late-afternoon/short-acting medications might behelpful in this
regard. Counseling foradolescents around medication is-sues should
include dealing with re-sistance to treatment and empower-
ing children/adolescents to takecharge of and own their
medicationmanagement as much as possible.Techniques of motivational
inter-viewing might be useful in improvingadherence.60
Special Circumstances: Families andChildren/Adolescents Who
DeclineMedication
The decision about what is the mostacceptable treatment for
their child/adolescent rests with the family, andthe clinician must
respect that deci-sion. The clinician should, however, ad-dress any
misinformation or concernsabout medication shared by the
family,encourage all other dimensions oftreatment, and provide
appropriatemonitoring.
Special Circumstances: Inattention orHyperactivity/Impulsivity
(ProblemLevel)
Medication is not appropriate for chil-dren/adolescents whose
symptoms donot meet DSM-IV-TR criteria for diagno-sis of ADHD.
Behavior Management
Evidence-based parent training typi-cally begins with 7 to 12
weekly groupsessions with a trained therapist orcertified
instructor. The focus is onparent education about ADHD,
thechild’s/adolescent’s behavior prob-lems, and difficulties in
family relation-ships. A typical program aims to im-prove the
parents’/caregivers’understanding of the child’s/adoles-cent’s
behavior and to teach themskills to help the child/adolescent
toreduce the behavioral difficultiesposed by ADHD.
Programs offer specific techniques forreinforcing adaptive and
positive be-haviors and decreasing or eliminatinginappropriate
behaviors, both ofwhich alter the motivation of the
child/adolescent to control attention, activ-ity, and impulsivity.
These programs
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PEDIATRICS Volume , Number , SI15
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emphasize establishing positive inter-actions between parents
and children;learning how to shape children’s be-haviors through
combinations ofpraising and ignoring; how to give suc-cessful
commands; how to reinforcepositive behaviors; how to
extinguishinappropriate behaviors through ig-noring; how to
identify which behav-iors are handled most appropriatelythrough
punishment; and determininghow to carry punishments out in a
re-sponsible way. These programs all em-phasize teaching
self-control andbuilding positive family relationships.If parents
strongly disagree about be-havior management or have conten-tious
relationships, parenting pro-grams will likely be unsuccessful.
Other strategies, such as changing thephysical environment to
reduce stim-uli to overactivity, are also effective bychanging the
stimuli that trigger prob-lem behaviors. Depending on the se-verity
of the child’s/adolescent’s be-haviors and the capabilities of
theparents, group or individual trainingprograms will be required.
Programstypically include support for mainte-nance and relapse
prevention.
Behavior therapy should be differenti-ated from psychological
interventionsdirected to the child/adolescent anddesigned to change
the child’s/adoles-cent’s emotional status (eg, play ther-apy) or
thought patterns (eg, interper-sonal talk therapy).
Thesepsychological interventions do nothave a demonstrated efficacy
for theADHD core symptoms, and gainsachieved in the treatment
setting usu-ally do not transfer into the classroomor home. By
contrast, parent trainingin behavior therapy and classroom
be-havior interventions have successfullychanged the behavior of
children/ado-lescents with ADHD.61 Behavior therapyis also
applicable for children/adoles-cents who have problems in the
do-mains of inattention or hypersensitivi-
ty/impulsivity but do notmeet the DSM-IV-TR criteria and for
those children/adolescents with a developmentalvariation.
Unless primary care clinicians arespecifically trained, have
trained staffor a colocated therapist, or dedicatemany visits to
providing the ongoingtreatment, they might not be effectivein
providing behavior therapy.62 Clini-cians might also have
difficulties de-termining the skills of behavior thera-pists listed
in the behavioral healthinsurance plan. This determination
isimportant, because many therapistsfocus on a play or
interpersonal-talktherapy that has not been shown to beeffective in
treating the core symp-toms of ADHD. Telephone inquiries
oftherapists, agencies, and mentalhealth clinicians regarding their
ap-proach to behavior therapy might al-low clinicians to develop a
resourcelist for parents. Clinicians might alsorequest references
from other par-ents of children/adolescents withADHD, professional
organizations(eg, Association for Behavior andCognitive Therapies),
and ADHD advo-cacy organizations (eg, CHADD). Par-ents who have
read authoritativelywritten books about behavior thera-py/behavior
parent training might bein a better position to know whatthey are
looking for in a therapistand ask the salient questions whenseeking
appropriate therapists.Some of these resources are avail-able in
the ADHD toolkit13 and thebook ADHD: What Every Parent Needsto
Know.54
Classroom behavior management alsofocuses on shaping the
child’s/adoles-cent’s behaviors and may be inte-grated into
classroom routines for allstudents or targeted for a
selectedchild/adolescent in the classroom.Classroom management
often beginswith increasing the structure of activi-ties. Token
economy refers to using
points or tokens that are given for pos-itive behaviors, and
response cost re-fers to points or tokens subtracted
forinappropriate behaviors. The tokensor points can then be cashed
in after adefined period for rewards or privi-leges. Systematic
rewards (eg, use of atoken economy) are included to in-crease
appropriate behavior and elim-inate inappropriate behavior. A
peri-odic (often daily) behavior report cardcan record the
child’s/adolescent’sprogress or performance with regardto goals and
communicate the child’s/adolescent’s progress to the parents,who
then provide reinforcers or con-sequences based on that day’s
perfor-mance. Such programs are also usefulfor the purpose of
monitoring medica-tion effects.
COLLABORATE WITH THE SCHOOL TOENHANCE SUPPORTS AND SERVICES
Many teachers and schools have effec-tive strategies for
supporting andserving children/adolescents withADHD. Schools can
implementbehavior-management programs thatdirectly target ADHD
symptoms as wellas interventions to enhance academicand social
functioning. Schools mayalso use strategies (eg, daily
behaviorreport cards) to enhance communica-tion with families. All
schools shouldhave specialists (eg, school psycholo-gists,
counselors, special educators)who observe the
child/adolescent,identify triggers and reinforcers, andsupport
teachers in changing the cir-cumstances of the classroom andmaking
accommodations to addressADHD symptoms, such as written-output
bypass strategies, untimedtesting, testing in less distracting
envi-ronments, preferential seating, androutine reminders.
Clinicians should be aware of the eligi-bility criteria for the
504 RehabilitationAct and the IndividualsWith DisabilitiesEducation
Act supports in their state
SI16 FROM THE AMERICAN ACADEMY OF PEDIATRICS
-
and local school district(s)63 andshould understand the process
for re-ferral as well as the individuals withwhom the physician or
parent shouldmake contact. This information can beprovided to
parents to support theirefforts to request classroom adapta-tions
for their child/adolescent withADHD, including the use of
empiricallysupported academic interventions toaddress achievement
difficulties asso-ciated with ADHD symptoms.
Do symptoms improve?
In providing a medical home, primarycare clinicians should
regularly moni-tor all aspects of ADHD treatment, toinclude:
● systematic reassessment of coresymptoms and function;
● regular reassessment of targetgoals;
● assurance that the family is satis-fied with the care they are
receiv-ing from other clinicians and thera-pists, if
applicable;
● provision of anticipatory guid-ance, further
child/adolescentand family education, and transi-tion planning as
needed andappropriate;
● assurance that care coordinationis occurring and meeting the
needsof the child/adolescent and family;
● confirmation of adherence to anyprescribed medication
regimen,with adjustments made as needed;
● heart rate, blood pressure, height,and weight monitoring;
and
● continuing to form a therapeutic re-lationship with the
child/adolescentand empower families and chil-dren/adolescents to
be strong, in-formed advocates.
Some treatment monitoring can occurduring general health care
visits if theclinician inquires about progress to-
ward target goals, adherence to medi-cation and behavior
therapy, con-cerns, or changes.
Monitoring of children/adolescentswith inattention or
hyperactivity/im-pulsivity problems can help to ensureprompt
treatment, should their symp-toms worsen to the extent that a
diag-nosis of ADHD is warranted.
Reevaluate to confirm diagnosis and/or provide education to
improve
adherence.
Reconsider treatment plan including changing of the medication
or dose, adding a medication approved for
adjuvant therapy, and/or changing behavioral therapy.
No
ADHD treatment failuremight be a signof incorrect or incomplete
diagnosis.Clinicians are advised to repeat the fulldiagnostic
evaluation and pay in-creased attention to the possibility
ofcoexisting conditions that mimic orare associated with ADHD, such
assleep disorders, Asperger syndrome,or epilepsy (eg, absence
epilepsy orpartial seizures). A coexisting learningdisordermight
also cause an apparenttreatment failure. In the case of
achild/adolescent previously diagnosedwith problem-level
inattention or hy-peractivity, repeating the diagnosticevaluation
might result in a diagnosisof ADHD, which would allow for
in-creased school supports and the inclu-sion of medication in the
treatmentplan.
Treatment failure could also signalpoor adherence to the
treatment plan.Increased monitoring and education,especially by
including the patientearly in his or her treatment, might in-crease
treatment adherence. It is help-ful to try to identify the issues
that re-strict adherence.
Yes
Follow-up for chronic care
management at least 2x/year for
ADHD issues
In the early stages of treatment, after asuccessful titration
period, the fre-quency of follow-up visits will dependon adherence,
coexisting conditions,and persistence of symptoms. Asnoted
previously, a general guide forvisits to the primary care clinician
isfor these visits to occur initially on amonthly basis, then every
3 months inthe first year of treatment. More fre-quent visits might
be necessary if co-morbid conditions are present. Visitsshould then
be held at least twice eachyear with additional telephone
moni-toring at the time of medication-refillrequests. Ongoing
communicationwith the school regarding medicationand services is
also needed.
It should be noted that at this point,there is little evidence
to establish theoptimal, yet practical, follow-up regi-men. It is
likely that the regimen willneed to be tailored to the
individualchild/adolescent and family needs onthe basis of clinical
judgment.
PREPARING THE PRACTICE
Specific office practice proceduresthat facilitate the optimal
and efficientdiagnosis and treatment process arecritical for
successful management ofchildren/adolescents with ADHD. Moredetail
can also be found in the report ofthe AAP Task Force on Mental
Health.1
The office process can include:
● developing a packet of ADHD ques-tionnaires and rating scales
for par-ents and teachers to complete be-fore a scheduled
visit;
● allotting adequate time for ADHD-related visits;
● determining appropriate billing,documentation, and monitoring
ofinsurance payments to ensure thatthey adequately cover the
servicesrendered;
● implementing methods to track and
Supplemental Appendix
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follow-up patients (refer to medicalhome procedures for more
detail);
● asking questions during all clinicalencounters and placing
brochuresand posters in the office to alert par-ents and
children/adolescents thatbehavior and school problems andADHD are
appropriate issues to dis-cuss with the clinician;
● developing an office system formonitoring and titrating
medication(a follow-up system should includethe clinician’s
assessment of familyorganization, telephone access,
andparent-teacher communication ef-fectiveness); and
● collaborating with schools andother involved community
providersand resources that can enhance theprocess for ADHD
diagnosis andmanagement, which can beachieved on a case-by-case
basisthrough coordination of the diagno-sis and treatment plan
amongschool staff, the clinician, parents,and other involved
professionals(note that this less-systematic ap-proach carries
significant chal-lenges, including ensuring consis-tent care for
all children/adolescents with ADHD).
A community-level system that reflectsconsensus among district
school staffand local primary care clinicians forkey elements of
diagnosis, interven-tions, and ongoing communication canhelp to
ensure consistent, well-coordinated, and cost-effective care.
Acommunity-based systemwith schoolsrelieves the individual primary
careclinician from negotiating with eachschool about care and
communicationregarding each patient. Offices thathave incorporated
medical home prin-ciples are ideal for establishing thiskind of
community-level system. Thekey elements for a
community-basedcollaborative system include consen-sus on:
● a clear and organized process bywhich an evaluation can be
initiatedwhen concerns are identified by ei-ther parents or school
personnel;
● a packet of information completedby parents and a teacher
abouteach child/adolescent referred tothe primary care
clinician;
● a contact person at the practice toreceive information from
parentsand teachers at the time of evalua-tion and during
follow-up;
● an assessment process to investi-gate coexisting
conditions;
● a directory of evidence-based inter-ventions available in
thecommunity;
● an ongoing process for follow-upvisits, telephone calls,
teacher re-ports, and medication refills;
● availability of forms for collectingand exchanging
information; and
● a plan for keeping school staff andprimary care clinicians
up-to-dateon the process.
The clinician might face challenges todeveloping such a
collaborative pro-cess. As examples, the primary careprovider might
be caring for children/adolescents from more than 1 schoolsystem; a
school systemmight be quitelarge and not easily accessed;
schoolsmight have limited staff and resourcesto complete
assessments; or it mightbe difficult for the physician andteacher
or other school personnel tocommunicate by telephone becausetheir
schedules differ. There are work-able strategies for addressing
each ofthese challenges.
In the case of multiple or large schoolsystems in a community,
the primarycare clinician might want to begin with1 school
psychologist or principal, orseveral practices can initiate
contactcollectively with a community schoolsystem. Agreement among
the clini-cians on the components of a good
evaluation process facilitates cooper-ation and communication
with theschool toward common goals. For ex-ample, agreement on the
behavior rat-ing scales used can facilitate comple-tion by school
personnel. Standardcommunication forms that monitorprogress and
specific interventionscan be faxed between the school andthe
pediatric office to shareinformation.
Collaborative systems also extend toother providers who may
comanagecare with the primary care clinician.Providers may include
a mental healthprofessional who sees the child/ado-lescent for
psychosocial interventionsor a specialist who addresses
difficultcases, such as a developmental-behavioral pediatrician,
child psychia-trist, child neurologist, neurodevelop-mental
disability physician, orpsychologist. Agreed-on processes
forroutine communication can also beused in these relationships.
The AAPTask Force onMental Health provides afull discussion of
collaborative rela-tionships with mental health profes-sionals,
including colocation and inte-grated models, in its Chapter
ActionKit64 and Pedialink Module.
It is important to note that good carefrequently requires
activities that cur-rently are not reimbursed. These activ-ities
include contacts with teachersand mental health consultants
andnon–face-to-face contact with parentsand patients. It would be
helpful for cli-nicians to document the nonreim-bursed efforts and
for the nationalAAP, state chapters, and clinicians tocontinue to
try tomake third-party pay-ers understand the need for these
ef-forts and provide compensation forthis appropriate care.
COMPLEMENTARY AND UNPROVENTHERAP