Academy of Pediatrics Clinical Practice Guidelines


An expert in the management of ADHD (attention deficit hyperactivity disorder) discusses the most recent guidelines from the Academy of Pediatrics Clinical Practice regarding diagnosis and treatment.

Tim Wilens, MD: Welcome to this Psychiatric Times® and Contemporary Pediatrics® Viewpoints program titled “ADHD: Strategies for Developing a Further Dialogue.” My name is Dr Tim Wilens. I’m a child and adolescent psychiatrist from Massachusetts General Hospital in Boston.

Our discussion today focuses on multidisciplinary management of ADHD [attention-deficit/hyperactivity disorder]; challenges in the treatment of ADHD, especially during COVID-19 [coronavirus disease 2019]; and the impact of human abuse potential of ADHD medications.

Joining me today in this discussion are Dr Ann Childress, who is a practicing child and adolescent psychiatrist, a clinical trials researcher, and a clinical associate professor at the University of Nevada School of Medicine in Las Vegas. Also joining us is Dr Robert Findling, also a practicing child and adolescent psychiatrist, a clinical trials researcher, and chair of the Department of Psychiatry at the Virginia Commonwealth School of Medicine in Richmond; Dr Harlan Gephart, who is author of ADHD Complex: Practicing Mental Health in Primary Care, he’s also a pediatrician from Bellevue, Washington; and finally, Dr Mark Wolraich, who is a practicing developmental and behavioral pediatrician, a researcher, and a professor at the University of Oklahoma Health Sciences in Oklahoma City.

Let’s begin by getting a sense of ADHD and the multidisciplinary approach to both diagnosis and treatment. A lot of people ask why do we care so much about ADHD? First of all, ADHD is the most common presenting neurobehavioral disorder that pediatricians and child psychiatrists are going to see. In fact, it’s considered one of the top 3 chronic disorders that pediatricians deal with on a daily basis. The prevalence is around 6% to 9% of children. What’s interesting is that’s not just in the United States, that’s cross-cultural, that’s been found in almost every country where they’ve looked. There is formal meta-analysis that shows no differences between the rates of ADHD in the United States and regions and countries, in China, in middle and South America, throughout the world, the European Union, Scandinavian countries, etc.

We know that about 4% to 5% of adults have ADHD, it’s considered a chronic disease, where roughly 50% of kids diagnosed with ADHD will continue to have either full criteria or enough symptomatic difficulties to continue with the diagnosis into adults. Again, it’s been more or less reconsidered now a chronic disorder.

What I’d like to do now is shift and try to get a sense about a major renovation in the most recent American Academy of Pediatrics Clinical Practice Guidelines, and who better than Mark to walk us through that. Mark has been involved in the guidelines from the inception of contemporary ADHD to the most recent one. Mark, could you walk us through some of these guidelines say and what might be some poignant features of these guidelines of importance to our audience?

Mark Wolraich, MD: One comment on the prevalence you mentioned, we did a study in 5 school districts in Iowa and 1 in South Carolina, where we were essentially evaluating all the children in the school districts, and making pretty rigorous diagnoses with both teacher information and parent information. It was quite clear that about half of the kids who met the criteria had not been clinically diagnosed. Rather than being overdiagnosed, if anything, it probably weighs more on the area of being underdiagnosed.

As Tim was saying, it’s a very common condition seen in pediatrics. Its second to asthma in terms of the chronic illnesses seen. That spurred the academy in 2001 to come up with guidelines that were then revised in 2011, and then most recently revised in 2019, and you can find them in the October issue of Pediatrics. In 2011 we came out with both the guideline recommendations and a process of care algorithm to help physicians and to help in some of the continuing education courses on how to diagnose and manage the condition.

For this most recent change, we added a third paper. There are 3 papers; the guidelines, the process of care algorithm, and what we call a barriers paper. We got a lot of feedback from primary care pediatricians of how difficult it is to implement the guidelines to do the treatment the way it should be both in diagnosis and treatment. The barriers paper identifies what are the major barriers and makes some recommendations of how pediatricians or organizations can try to push to get better control on it. There is not a huge difference between the 2011 and 2019 revisions. We recommended utilizing DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th edition] criteria, but they’re not that much different than the DSM-4 criteria that we had recommended in the previous guidelines as part of it.

In 2011 was when we recommended that you could make the diagnosis down to age 4 using the same criteria, and that has remained the same. The treatments have been stable in terms of the stimulant medications as the first-line treatment and the behavioral interventions as also a treatment. We do divide it up by recommendations for preschoolers, school-age 6 to 11, and then adolescents, because there are some variations.

-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.

-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.

-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.

-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.

-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.

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