To access the document, click on “practice parameters” from AACAP's home Web page at www.aacap.org
The American Academy of Child and Adolescent Psychiatry has released an updated version of its 10-year-old practice parameter for the assessment and treatment of children and adolescents with attention-deficit hyperactivity disorder.
An underlying theme of the parameter, released last month, is the recognition that the diagnosis and treatment of ADHD are “in the mainstream of American medicine and American psychiatry,” lead author Dr. Steven R. Pliszka said in an interview.
“ADHD is an international phenomenon now. It's no different from screening for asthma or diabetes or treating those conditions,” he added.
“We have an equal degree of evidence of the biological causes and effective treatments,” said Dr. Pliszka, chief of adolescent psychiatry at the University of Texas, San Antonio. “We want everyone to recognize that and go forward and help their patients.”
In a process that began in late 2004, Dr. Pliszka and his associates assembled 13 recommendations based on a review of nearly 5,000 references related to the diagnosis and treatment of ADHD that were generated between 1996 and 2006. These included references from the 1997 version of the practice parameter, as well as those that appeared in the scientific medical literature, in book chapters, or at scientific meetings.
Two chief developments drove the need to update the parameter, Dr. Pliszka said. One is the proliferation of new treatments for ADHD that have emerged in the last 5–10 years.
Another is what he called “a growth of genetics and neuroimaging studies that are starting to point the way to the underlying causes and brain features of the disorder.”
One recommendation in the 44-page document that differs from the 1997 version is based in part on results from the National Institute of Mental Health-sponsored multimodal treatment study of children with ADHD, which examined different treatment options for the disorder (Arch. Gen. Psychiatry 1999;56:1073–86). It concluded that careful medication management alone was superior to behavioral therapy and to routine community care that included medication.
“While there's debate about exactly how to interpret that study, I think for the child who just has ADHD and no other complicating condition, medication treatment appears to be most effective by itself,” Dr. Pliszka said.
In contrast, if the child has ADHD in combination with other problems like learning disabilities, behavior disorders, or depression, then he or she needs a combined approach: the medication and some type of psychosocial intervention, he noted.
“We don't recommend behavioral intervention alone except in milder cases or in cases where the diagnosis is in question,” said Dr. Pliszka.
Other recommendations address medications used for ADHD. They conclude that stimulant medications are usually the best first-line treatment options.
The current stimulants on the market “tend to be equally efficacious, and it's largely a matter of family and physician preference as to which one you use,” Dr. Pliszka said.
The nonstimulant atomoxetine (Strattera) may be considered as a first-line treatment “in certain situations like co-occurring anxiety and tics,” he said.
Dr. Martin T. Stein, a developmental-behavioral pediatrician at Rady Children's Hospital in San Diego who was not involved in assembling the recommendations, called the new practice parameter a valuable reference for child psychiatrists and general pediatricians alike.
“I think it's quite good,” Dr. Stein, who is also a professor of pediatrics at the University of California, San Diego, said in an interview. “There are so many areas where psychiatric practice and pediatric practice overlap and complement each other in this document.” Any physician who treats children could read this and find it quite valuable for practice, he said.
The document notes that there may be a place in ADHD treatment for medications not approved by the Food and Drug Administration, but which have demonstrated efficacy in some studies. These include bupropion, tricyclic antidepressants, and αagonists.
“These should only be tried if the ones in the approved group have failed,” Dr. Pliszka said.
The document also addresses concerns about the potential for rare side effects from stimulant use, including aggression and mood lability.
“In controlled trials, there is no evidence that the stimulants produce these [side effects] in numbers greater than in the placebo groups,” Dr. Pliszka said. “We acknowledge that they've been reported in postmarketing studies and that physicians should be alert to them, but there's not any undue concern. They shouldn't be a reason that people would shy away from using the medication.”
As for concerns about possible cardiovascular side effects based on reports of sudden deaths in people taking certain agents used in ADHD treatment, Dr. Pliszka and his associates concluded in the document that the rates of sudden death of children on ADHD medications “do not appear to exceed the base rate of sudden death in the general population.”