2019 guidelines for ADHD: structure plus medication

Reference

Wolraich ML, Hagan JF, Allan C, et al, for the Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2019;144(4):e20192528.

Synopsis

The AAP's 2019 guideline for the evaluation and treatment of attention-deficit/hyperactivity disorder is largely the same as previous versions of the guideline. Evaluation can begin as early as age 4 years in children who present with inattention, hyperactivity, or impulsivity resulting in behavioral or academic problems. Diagnosis should take into account symptoms, along with evidence of social, academic, or occupational impairment, and other causes should be excluded. Preschool children should be treated with parent training in behavior management (strong recommendation); treatment with methylphenidate should be considered if training is not effective or is unavailable, weighing harms with benefits. Medication along with classroom interventions and parent training should be used for elementary school children. Adolescents should also be treated with a stimulant, behavior interventions, and school-based individualized education plans. The authors cite too little evidence to recommend mindfulness, cognitive training, diet modification, electroencephalogram biofeedback, supportive counseling, or cannabidiol oil. They do not provide guidance regarding what stimulant or nonstimulant medication to use first, though they cite evidence to suggest that stimulants may be more effective. An extensive list of medications is at http://www.adhdmedicationguide.com/. These guidelines were developed by an expert group composed of pediatricians, pediatric psychologists, pediatric psychiatrists, a family physician, and epidemiologists, with feedback from a patient group. The recommendations seem to be based on a systematic review, with the evidence graded and the recommendations ranked by strength. The guideline developers compared benefits and harms of treatments when making their recommendations. A number of the developers, including the workgroup chair, have financial conflicts of interests.