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The new attention deficit hyperactivity disorder clinical practice guidelines published by the American Academy of Pediatrics.

Mark L. Wolraich, MD In 2000 and 2001, the American Academy of Pediatrics (AAP) developed attention deficit hyperactivity disorder (ADHD) clinical practice guidelines1,2 to address the concerns about the quality of the services provided by primary care physicians including limited use of diagnostic instruments3,4 and difficulty collecting information from the school setting.5 In addition, the AAP developed a toolkit in conjunction with a quality improvement process in 2001–2003 and, in collaboration with the National Initiative for Children’s Healthcare Quality (NICHQ), pilot tested the toolkit. The AAP also developed an online CME activity (www.eqipp.org) for ADHD launched in 2003 and a modified quality improvement project, Partnership for Quality, in 10 state AAP chapters. The toolkits were distributed widely and were made available via the AAP and National Initiative for Children’s Healthcare Quality websites. Twenty-six practices completed the national collaborative, 186 physicians in 121 practices completed the Partnership for Quality, 386,525 toolkits were distributed, and 724 physicians subscribed to the eQIPP module. Additional AAP initiatives included CME programs on ADHD and a published book6 and pamphlets for parents and adolescents about ADHD. During this timeframe, there were a number of other CME courses and other training initiatives.7–9 Surveys conducted in 1999 and 2005 on random samples of AAP members found that the reported behaviors of practitioners moved in the direction of greater adherence with the recommended AAP ADHD guidelines, and there was a positive response to and a greater use of the materials developed to enhance practice.10 The original clinical practice guidelines, because of the large volume of literature and the complexities of diagnosis and treatment, were divided into a separate guideline for diagnosis and evaluation and a guideline for treatment. This division allowed room to provide more detail about how to implement the recommendations. The subcommittee revising the ADHD clinical practice guideline decided to combine the 2 guidelines because the 2 are intimately connected. To accomplish this goal, the guideline itself was limited to the broad recommendations where there was a predominance of evidence that could be graded. The more detailed information that enables clinicians to implement the guidelines and modify their practice to accommodate the changes was put together in a Process of Care Algorithm that accompanies the guidelines. The Process of Care Algorithm is a step-by-step process that provides more detail about how to implement the recommendations. It served as the basis for revising and field testing the AAP ADHD Toolkit with members of the AAP Quality Improvement Innovation Network. The Guidelines, Process of Care Algorithm, and toolkit were all unveiled at the AAP National Convention and Exhibition and were published in the November issue of Pediatrics. The revised guidelines expand the age range from 4 to 18 years of age. We receive a number of concerns with the initial guidelines because they did not provide any guidance for clinicians about preschoolers or adolescents. In our review now, there was more evidence for both ends of the age spectrum to allow the subcommittee to make evidence-based recommendations specific to preschoolers and adolescents. The most controversial recommendations in the popular press has been the use of methylphenidate in preschool-aged children, although the recommendation for its use was only after a trial of behavior therapy and only for children with moderate severe ADHD. As behavioral therapy does not require a diagnosis and the side effects are predominantly related to loss of time and money, behavioral therapy alone was recommended for children whose inattention and hyperactivity/impulsivity are at a problem level. The guidelines also encourage clinicians where possible to identify comorbid conditions. They also recommend more frequent monitoring (weekly when titrating stimulant medications and monthly until optimal treatment). The recommendations or evidence, where they differ by age, are grouped into preschool, elementary, and adolescent age groups. The guidelines continue to strongly emphasize the importance of considering ADHD to be a chronic illness using chronic illness and medical home principles in caring for children with this condition. This was an area that saw less improvement as a recommendation in the From the University of Oklahoma Health Sciences Center, Oklahoma City, OK.