The 2007 American Academy of Child and Adolescent Psychiatry ADHD Practice Parameter
by Richard Rubin, MD Clinical Associate Professor, University of Vermont College of Medicine

This practice parameter discusses the clinical evaluation for ADHD, associated comorbid conditions, research on etiology, and both psychopharmacologic and psychosocial interventions based on the current scientific evidence and clinical consensus of experts in the field. "While scientists and clinicians debate the best way to diagnose and treat ADHD, there is no debate among competent and well-informed health care professionals that ADHD is a valid neurobiological condition that causes significant impairment in those whom it afflicts. These guidelines seek to lay out the evidence basis for the effective diagnosis and treatment of ADHD." The 13 Recommendations are categorized as Minimal Standard (MS) applicable to almost all cases, Clinical Guideline (CG) applicable in most cases, Option (OP) based on emerging evidence or opinion, and Not Endorsed (NE) ineffective or contraindicated practices.

Recommendation 1: Screening for ADHD should be part of every patient's mental health assessment (MS).

Recommendation 2: Evaluation of the preschooler, child, or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient's school or day-care functioning, evaluation for comorbid psychiatric disorders, and review of the patient's medical, social, and family history (MS).

Recommendation 3:If the patient's medical history is unremarkable, laboratory or neurological testing is not indicated (NE).

Recommendation 4: Psychological and neuropsychological tests are not mandatory for the diagnosis of ADHD, but should be performed if the patient's history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient's intellectual ability (OP).

Recommendation 5: The clinician must evaluate the patient with ADHD for the presence of comorbid psychiatric disorders (MS).

Recommendation 6: A well thought-out and comprehensive treatment plan should be developed for the patient with ADHD (MS).

Recommendation 7: The initial psychopharmacological treatment of ADHD should be a trial with an agent approved by the Food and Drug Administration for the treatment of ADHD (MS).

Recommendation 8: If none of the approved agents results in satisfactory treatment of the patient with ADHD, the clinician should undertake a careful review of the diagnosis, and then consider behavior therapy and/or the use of medications not approved by the FDA for the treatment of ADHD (CG).

Recommendation 9: During a psychopharmacological intervention for ADHD, the patient should be monitored for treatment-emergent side effects (MS).

Recommendation 10: If a patient with ADHD has a robust response to psychopharmacological treatment and subsequently shows normative academic, family, and social functioning, the psychopharmacological treatment of the ADHD alone is satisfactory (OP).

Recommendation 11: If a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences stressors in family life, then psychosocial treatment in conjunction with medication treatment is often beneficial (CG).

Recommendation 12: Patients should be assessed periodically to determine if there is continued need for treatment or if symptoms have remitted. Treatment of ADHD should continue as long as symptoms remain present and cause impairment (MS).

Recommendation 13: Patients treated with medication for ADHD should have their height and weight monitored throughout treatment (MS).

The complete Practice Parameter text is available at www.aacap.org.

Disclosure: All of Dr. Rubin's Medical Practice Updates consist only of content certified by a Continuing Medical Education authority or peer reviewed publication.

Dr. Rubin practices Child and Adult Psychiatry, directs The Clinical Study Center in Burlington Vermont, and serves as Clinical Associate Professor at the University of Vermont College of Medicine.

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Reprinted with permission of Journal of Attention Disorders, this column contains abstracts of recent research studies provided by Sam Goldstein, Ph.D., University of Utah Medical School and editor of the Journal of Attention Disorders.

Amat, G.A., Bronen, R.A., Saluja, S., Satto, N., Zhu, H., and Gorman, D.A. (2006). Increased number of subcortical hyper-intensities on MRI in children and adolescents with Tourette's Syndrome, Obsessive Compulsive Disorder and ADHD. American Journal of Psychiatry, 163, 1106-1108

These authors sought to investigate whether cerebral hyper-intensities on T2 weighted MRI are associated with childhood neuropsychiatric disorders. The authors compared the frequency of cortical and subcortical cerebral hyper-intensities in 100 children and adolescents with Tourette's Syndrome, Obsessive Compulsive Disorder, ADHD and 32 healthy comparison subjects. The frequency of cerebral hyper-intensities was significantly higher in subjects with Tourette's Syndrome, OCD or ADHD versus the healthy comparisons. Each diagnostic group appeared to contribute to this effect. Among the patient groups, the likelihood of detecting cerebral hyper-intensities in the subcortex, primarily basal ganglia and thalamus, was significantly greater than in the cortex. The authors conclude that a childhood diagnosis of Tourette's Syndrome, OCD or ADHD significantly increases the likelihood of detecting cerebral hyper-intensities, particularly in the sub-cortex supporting the idea that subcortical injury may play a role in the pathophysiology of these conditions.

Barbaresi, W.J., Katusic, S.K., Colligan, R.C., Weaver, A.L., Leibson, C.L., & Jacobsen, S.J. (2006). Long-term stimulant medication treatment of ADHD: Results from a population based study. Journal of Developmental and Behavioral Pediatrics, 27, 1-10.

In an effort to provide detailed information about stimulant medication treatment throughout childhood nearly 400 children from a 1976-1982 Rochester, Minnesota birth cohort were evaluated. Subjects were retrospectively followed from birth until a mean age of 17.2 years. Overall, 77.8% of subjects were treated with stimulants. Boys were 1.8 times more likely than girls to be treated. The median age and initiation (9.8 years), median duration of treatment (33.8 months) and likelihood of developing at least one side effect (22.3%) were not significantly different by gender. Overall, 73.1% of episodes of stimulant treatment were associated with a favorable response. The likelihood of a favorable response was comparable across gender. Treatment was initiated earlier for children with either ADHD Combined Type of ADHD Hyperactive Impulsive Type than for those with the Predominantly Inattentive Type. Treatment was longer for the Combined Type as well. There was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response but dextroamphetamine was more likely to be associated with side effects. These results appear to demonstrate that the effectiveness of stimulant medication to treat ADHD is consistent throughout childhood and comparable to the efficacy of stimulant treatment demonstrated in clinical trials. For more information about the Journal of Attention Disorders

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