Updates in Diagnostic and Treatment Guidelines for ADHD

Andrew J. Cutler, MD: There have been some recent updates to the guidelines for the assessment, evaluation, and treatment of attention-deficit/hyperactivity disorder [ADHD] in children and adolescents. The 2 main organizations that have published these guidelines are the American Academy of Pediatrics and the Society for Developmental and Behavioral Pediatrics [SDBP], which specialize in behavioral disorders in children.

In 2019, the American Academy of Pediatrics updated its guidelines. This was an update from the previous guidelines published in 2011. Since then, of course, the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th edition] criteria have been published. So they were updated to reflect the DSM-5 criteria. Many treatment recommendations stayed the same, including instituting a multimodal treatment plan with stimulants as first-line treatment. However, what was introduced was a new key action statement recognizing the importance of comorbidity and associated conditions.

What the key action statement refers to is, if the primary care provider is trained or experienced in diagnosing comorbid conditions, he or she may initiate treatment of such conditions or may make referral to an appropriate subspecialist. Also, after detecting possible comorbid conditions, if the primary care provider is not trained or experienced or comfortable making the diagnosis or initiating treatment, then the patient, of course, should be referred to an appropriate subspecialist.

The effect of comorbid conditions on ADHD is described as being variable, and the treatment of ADHD may resolve or improve the comorbid condition. They specifically mention, for instance, coexisting aggression, oppositional defiant disorder, depression, or anxiety. The comorbid condition, however, may require treatment, in addition to ADHD treatment.

The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline was published recently, in 2020. This recognizes the importance of diagnosing and treating comorbidities.

The SDBP guideline refers to this as complex ADHD. What they specify is the clinician, with specialized training or expertise, should initiate a comprehensive assessment and develop an interprofessional multimodal treatment plan for any child or adolescent with suspected or diagnosed complex ADHD upon referral from a primary care clinician. Treatment of complex ADHD should include evidence-based approaches that address ADHD and account for coexisting conditions, while respecting family background and preferences and cultural issues.

They define complex ADHD as including comorbid conditions, but also other complicating factors: moderate to severe functional impairment, diagnostic uncertainty on the part of the clinician, inadequate response to treatment, or uncertainty about treatment planning. Also, ages less than 4 years old or greater than 12 years old at initial presentation of symptoms.

These guideline updates are very helpful and important for clinicians. They raise consciousness on the importance of looking at the whole clinical picture of patients with ADHD. The majority of patients with ADHD have at least 1 comorbid condition. As a matter of fact, only 25% of patients with ADHD have just ADHD, or simple ADHD.

Transcript Edited for Clarity