New Treatment Guidelines for ADHD From the
American Academy of Pediatrics  

In the October 2001 issue of Pediatrics, the American Academy of Pediatrics (AAP) published their evidence-based recommendations for the treatment of children diagnosed with ADHD.  The committee responsible for preparing these guidelines included general pediatricians, child psychiatrists, developmental pediatricians, family physicians, child psychologists, and child neurologists.  The committee devoted three years to reviewing the published literature on the treatment of children with ADHD. The resulting treatment guidelines are based on the best scientific evidence currently available.

The AAP guidelines are an extremely important resource for parents and practitioners..  Knowledge of these guidelines provides a basis for evaluating how the treatment being received by one's own child -- or the children one works with professionally -- compares to what has been recommended by an expert panel relying on state-of-the-art scientific evidence.  The recommendations listed below are taken directly from the AAP document.  The discussion of each recommendation represents my synthesis of how each recommendation was discussed along with ideas I have incorporated from other sources.

Recommendation 1: Primary care clinicians should establish a management program that recognizes ADHD as a chronic condition.

ADHD is a chronic condition with no known cure and many children with ADHD will manifest symptoms of the disorder into adolescence and beyond. Effective treatment thus requires that a long-term management plan.  The goal of this plan is to minimize the adverse impact of ADHD symptoms over the course of a child's development.

The AAP guidelines emphasize that educating parents and children about ADHD is critical in developing an effective management program.  Parents and children should be informed about the ways in which ADHD can affect learning, behavior, self-esteem, social skills, and family functioning. Initially, this information helps to demystify the diagnosis.  It also increases the likelihood that parents and children will participate in the development of a comprehensive treatment plan that can be sustained over time.

This patient education process is ongoing: families should be provided with important new information on ADHD as it becomes available. Clinicians should direct families to resources that provide families with ongoing current information  and the opportunity to develop supportive relationships with other families.

The importance of educating parents and children about ADHD cannot be over-emphasized.  Providing effective treatment/management for a child with ADHD can be an extremely difficult process that must be sustained over many years.  When families lack a solid understanding of how ADHD can affect children's development, sustaining the efforts required to effectively manage a child's symptoms over an extended time can be even more difficult.  

It is noteworthy that this guideline explicitly states that educating children about ADHD is an integral part of the treatment/management process. Children should be provided with an age-appropriate explanation of the condition and how it may affect them in school, at home, and with peers. They should be given the opportunity to ask questions about their condition. These questions may need to be addressed on multiple occasions, and the nature of their questions may change over time.  A child cannot be expected to be a cooperative partner in his/her treatment without a clear understanding of what he/she is being treated for and why treatment is necessary.

Recommendation 2: The treating clinician, the parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management.

This recommendation emphasizes that effective management of ADHD requires an ongoing collaborative effort that includes parents, the child, the school, and the health care provider.  This collaborative effort should be focused on maximizing the child's functioning in key social, academic, and behavioral areas, rather than on simply reducing the levels of core ADHD symptoms.  For example, desired results would include:

* improving the child's relationships with parents, siblings, teachers, and peers; * decreasing disruptive behaviors; * improving academic performance; * enhancing self-esteem; * enhancing safety in the community.

Treatment should begin with a clearly defined set of goals for the key areas in which a child is struggling.  These goals are based on input from children, parents, and school personnel.  (Once again, the value of including children as collaborative partners in the development of a treatment plan is emphasized.)  The treatment goals should be clearly specified (e.g. "John will complete his assigned work on time."), manageable in number (e.g. 3-6 key treatment targets), and realistic to attain.   A plan needs to be put into place for determining how success towards attaining each goal will be monitored and measured.   Without such a plan, it will be difficult to accurately evaluate the success of treatments that are implemented.

The recommendation that treatment focus on functional improvement in key areas (rather than on simply reducing/eliminating core ADHD symptoms) is important.  Parents and clinicians should recognize that symptomatic reduction and functional improvement do not always go hand-in-hand.  For example, some children can show clear reductions in inattention and/or hyperactivity but continue to struggle with schoolwork, peer relations, etc. By focusing on functional improvement rather than simple symptom reduction, parents and providers will be better able to identify such situations and make appropriate adjustments/modifications to a child's treatment.  

Recommendation 3: The clinician should recommend stimulant medication and/or behavior therapy as appropriate, to improve target outcomes in children with ADHD.

What treatment methods should be used to achieve the target outcomes developed as recommended above?  The AAP guidelines recommend stimulant medication treatment and/or behavior therapy.  The fact that these are the only 2 treatment options recommended does not mean that alternative treatments do not work.  It does indicate, however, that these were the only treatments for which the committee felt sufficient scientific evidence exists to justify their routine recommendation.

Beyond this generic recommendation, the guidelines contain important information about the use of each treatment.  It is noted that for most children "stimulant medication is highly effective in the management of the core symptoms of ADHD."  Research indicates that the most powerful effects are found on measures of observable social and classroom behaviors and on core symptoms of inattention, hyperactivity, and impulsivity.  The effects on academic achievement are more modest.

Although most studies examining the efficacy of stimulant medication have been short-term studies, recently published results from the MTA study indicated that school-aged children with ADHD showed a marked reduction in core ADHD symptoms over a 14-month period.  Despite these important gains, the majority of children treated with stimulant medication do not demonstrate fully normalized behavior, and many continue to show residual difficulties that need to be addressed via other means.

Other important aspects of medication treatment noted in the guidelines included the following:

* The longer term effects of stimulant medication treatment remain unclear and the data required to evaluate long-term impact are not currently available;

* There is currently no basis for recommending one brand/type of stimulant over another and each stimulant improves core symptoms equally; (Note: The use of Pemoline/Cylert is not recommended because of potential complications with liver functioning);

* The optimum stimulant dosages for a child are not weight dependent and it is not possible to predict in advance what the best dose -- or most effective stimulant -- will be for an individual child.  Clinicians should begin with a low dose and gradually increase it across the full range of recommended dosages to determine the best fit for each child.

(Note:  The key point here is that the first dose to which a child shows some response may not be the best dose to improve function.  It is only by testing a child on a full range of doses and obtaining systematic feedback from parents and teachers about the child's functioning on each dose that the best recommended starting dosage for treatment can be determined.)

* Children may respond favorably to one stimulant, but not another.  For this reason, physicians should not switch to a non-stimulant medication for treating ADHD until a child has been tested on at least 2-3 different stimulants across a full range of doses, without showing a significantly positive response.

* Available evidence indicates that stimulant medications are safe and well tolerated by most children.  Most side effects occur early in treatment, are short-lived, and can often be successfully managed through dosage adjustment or a change in medication.  No adverse effects of long-term use of stimulant medication are currently known, although the need for long-term safety studies is well documented.

* The only medications other than stimulants for which efficacy in treating ADHD in children has been demonstrated are tricyclic antidepressants, bupropion, and clonidine.  As noted above, these should only be considered after a child has not responded to a careful trial of 2-3 different stimulants.

Behavior Therapy

Behavior therapy is the other treatment specifically recommended for school-aged children with ADHD.  Behavior therapy is usually implemented by training parents and teachers to consistently reward the child for demonstrating desired behavior and providing negative consequences for failure to meet behavioral goals.  Several different techniques and strategies (e.g. behavioral parent training, classroom management) can be utilized, and in those with demonstrated efficacy, the focus is on structuring a child's environment to provide consistent consequences for desired and undesired behaviors rather than trying to teach the child new behavioral and/or cognitive skills.  These skills training approaches -- although intuitively appealing -- have not yet been shown to be clearly effective for treating the core symptoms of ADHD.

(Note:  I think it is important to emphasize that the above recommendation does not necessarily mean there is no place for skills training in the treatment of some children with ADHD.  For example, some children with ADHD may lack the social and problem-solving skills required to establish and maintain good peer relationships. When these skills are poorly developed, skill-building approaches can be helpful.  The point to keep in mind, however, is that skills training approaches are unlikely to help with core ADHD symptoms.  And, effectively treating core symptoms via medication and/or behavior therapy may obviate the need for skills training approaches. For example, this would be the case for a child who has the skills to interact effectively with peers, but who is unable to use these skills consistently without medication treatment because he/she is too impulsive. When a child continues to display skill-related deficits even after core ADHD symptoms are being effectively managed, these adjunctive skill building therapeutic approaches should be considered.)

The AAP guidelines note that, although positive effects for well-conducted behavior therapy have been clearly demonstrated, there are important limitations associated with this treatment.  First, almost all studies comparing behavior therapy with stimulants indicate a much stronger effect from stimulants on the core symptoms of ADHD.  Second, as with stimulant medication treatment, behavior therapy often does not bring an ADHD child's behavior into the normal range.  Finally, behavior therapy does not generally yield positive changes that persist beyond the time when it is being implemented.  Parents using this approach thus need to be prepared to sustain the treatment over the entire course of their child's development. This necessity is consistent with the notion of ADHD as a chronic condition rather than something that can be "cured" by treatment.

Recent data from the MTA study  indicate that the combination of careful medication treatment and behavior therapy provides some significant benefits relative to medication treatment alone.  For example, on an overall measure of treatment outcome, children receiving combined treatment showed greater improvement than children treated with medication alone.  In addition, children receiving combined treatment required a significantly lower dose of medication over the 14-month study.  Finally, parents and teachers of children receiving combined treatment were significantly more satisfied with the treatment plan.

Recommendation 4 - When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions.

This recommendation is based on the premise that well-conducted medication and/or behavior therapy should yield clinically significant benefits for the vast majority of children with ADHD.  When such benefits fail to occur, this guideline identifies several prominent reasons that should be considered.

First, the original diagnosis of ADHD may be incorrect and the basis upon which the diagnosis was made should be reevaluated.  Unfortunately, prior research has shown that many children are incorrectly diagnosed with ADHD and then treated inappropriately with stimulant medication.  (Note:  An equally important problem is the probably far greater number of children with ADHD who are never identified or treated.)

Second, clinicians and parents should examine whether the goals being targeted can be realistically accomplished or whether they have been set "too high".  Care must be taken to set behavioral and academic goals that are within a child's reach.

Third, the treatment plan should be reevaluated to determine whether it is comprehensive enough to address a child's difficulties.  For example, although medication and behavioral intervention have both been shown to be effective treatments for ADHD, limiting a child's treatment to one of these options alone may not be adequate in many instances.

Fourth, adherence to the treatment plan should be looked at carefully.  If a child fails to consistently receive medication as prescribed, such treatment is not likely to provide meaningful benefits.  Behavioral interventions are also unlikely to yield any substantial benefits unless they are faithfully implemented over a sustained time period.  If a well-designed treatment plan is not providing desired results because it is not being adhered to, reasons for non-adherence to the treatment plan need to be identified and addressed. Abandoning such a plan before it has been given a fair test would not be advisable.

Finally, careful consideration needs to be given to whether co-existing conditions are present that may complicate the treatment of ADHD.  Children with ADHD are at increased risk for a variety of other disorders, including learning disabilities, mood and anxiety disorders, oppositional defiant disorder (ODD), and conduct disorder (CD).  When one or more of these disorders co-occur with ADHD, interventions in addition to standard ADHD treatments are often required.  Although a thorough evaluation for ADHD should include assessment for co-occurring conditions so that treatment plans can be developed accordingly, this may not have occurred.  Thus, when ADHD treatment is not yielding desired results, the possibility that an important co-occurring condition has been missed should be carefully considered.  

Recommendation 5: The clinician should periodically provide a systematic follow-up for the child with ADHD.  Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.

The importance of this recommendation cannot be overemphasized.  A significant limitation in the treatment received by many children with ADHD is the lack of adequate follow-up and monitoring.  When careful monitoring of treatment success is lacking, an ineffective treatment regimen may continue without the necessary adjustments or modifications being made.

In the MTA study, an important treatment feature was that monthly follow-ups were scheduled for children treated with medication.  At these follow-ups, direct information on the child's functioning was obtained from parents and teachers.  Problems that may have emerged were thus identified quickly and appropriate modifications to the medication treatment were made.

It is important to note that, even though an extremely rigorous procedure was used in the MTA study to identify the optimum dose of medication for each child, dosage adjustments over the next 13 months were common and some children were even switched to new medications.  For example, three months into the maintenance period for children receiving medication in the MTA study, 56% had already had their medication or dosage changed.  The average amount of time to the first dose change was between 4 and 5 months.

Across the entire maintenance period, the average number of changes required for each child was just over 2, but some children required as many as 10 medication adjustments.  Of the total medication changes made, 62% involved increasing the dosage of the current medication, 31% involved decreasing dosage, and 7% involved changing types of medication.  These changes were required in order to maintain adequate management of children's symptoms.

The AAP guidelines state that the frequency of monitoring will depend on the "...degree of dysfunction, complications, and adherence" and there is no research that specifies the appropriate frequency of follow-up visits.  The guidelines state that once a child is stable, an office visit every 3-6 months is necessary to allow for the assessment of learning and behavior. It is also noted, however, that additional communication should occur at more frequent visits to refill medication, and that parents should be asked about functioning at home, school, and in interpersonal relationships.  Any apparent decrease in the child's functioning should be carefully evaluated to determine whether treatment modifications should be implemented.

Providing systematic monitoring for a child being treated for ADHD does not have to be a difficult task.  If a systematic procedure for tracking how well treatment outcome targets are being met is implemented, failure to consistently achieve target outcomes will be readily apparent.  For a school-aged child, a reasonable set of parameters to monitor at school would include:

• how well core ADHD symptoms are being managed;

• the child's ability to follow classroom rules;

• the quality of peer interactions;

• general mood;

• the quality of academic performance.

Summary and Conclusion

The AAP treatment guidelines will hopefully spur significant improvements in the quality of care received by children with ADHD from primary care physicians.  Based on the best evidence currently available, they present a clear set of principals that should be incorporated into each child's treatment.  In summary, the elements of optimum treatment should include: 1) a management plan that is consistent with the chronic nature of ADHD and which educates parents and children about the condition; 2) a clear set of treatment goals that focus on functional improvement and which are developed in collaboration with parents, children, school personnel, and providers; 3) the use of empirically based treatments including stimulant medication and/or behavior therapy; and 4) close monitoring of treatment outcomes and failures.

Because research on the long-term impact of treatment that carefully adheres to these treatment guidelines is not currently available, the ultimate impact of such treatment on children with ADHD is not known.  The key to promoting the long-term success of a child with ADHD, however, is to make each day as successful as possible for that child.  It is through stringing together successful days into successful weeks, successful weeks into successful months, and successful months into successful years, that favorable long-term outcomes will be achieved.

Based on the current state of our knowledge, careful adherence to the AAP guidelines is the best way to accomplish this, and one hopes that primary care physicians will make the necessary adjustments in their practice to make sure this occurs.