The American Academy of Pediatrics issued guidelines for the treatment of ADHD based on evidence from research in the United States and Canada.  Last year guidelines were issued for the diagnosis of ADHD.  The guidelines issued last week are intended for use by the practicing clinician in primary care to help them provide the best possible care for these children.  The following recommendations for the treatment of the child with ADHD were made:

 

1.  Primary care physicians should establish a treatment program that recognizes ADHD as a chronic condition.  ADHD persists into adolescence 60-80% of the time. 

Approximately 4-12% of school age children have ADHD and physicians need to have a plan for long term management.

 

2.  The treating physician, parents, and the child in collaboration with school personnel, should specify appropriate target outcomes to guide the management of the child’s condition.  These outcomes could include improved relationships, decreased disruptive behaviors, improved academic performance, increased independence in homework or self care, improved self esteem, improved safety in the child’s environment, such as crossing streets and riding bikes.  These outcomes will allow the family and physician to monitor if the child is improving with treatment.

 

3.  The physician should recommend stimulant medication and/or behavior therapy to improve target outcomes in children with ADHD.  The evidence is actually better that stimulant medications alone works better than behavior therapy alone.  Multiple studies have shown that stimulants are safe when used as prescribed and that statistically there is no significant difference in the outcomes with different types of stimulants.  The two most commonly used medicines are methylphenidate (Ritalin) and a mixture of dextroamphetamine salts(Adderall).  All of the stimulants have similar side effects – loss of appetite, change in falling asleep, headache and stomachache, and occasional tics.  There is no long term effect on growth from any of the stimulants.  If one stimulant doesn’t work at a recommended dose, a second stimulant should be recommended and the first drug stopped.

4. When the target outcomes have not been met, physicians should evaluate the original diagnosis, adherence to the treatment plan and consider the presence of coexisting conditions such as depression, oppositional defiant disorder and learning disability.

5.  The physician should provide systematic follow up with the child with ADHD.  This will include assessment of meeting the target outcomes.  The first visit should be within the first month of treatment and after that, the child should be seen every 3-6 months to assure the best possible outcome.  This will allow follow up on side effects, school  performance, weight and growth evaluation, and compliance with the management plan.

More research is needed on the cause of ADHD and possible ways to prevent this common problem in childhood.  Until that is done, these guidelines give us an outline to follow to assure our children are getting the best care available.