New AAP ADHD Guideline Expands Age Range, Scope

The expansion of the AAP ADHD clinical practice guideline to include recommendations for preschool-age children is one of a number of welcome and beneficial changes to help guide the management of patients with ADHD, according to Dr. David O. Childers.

"I’m really glad to see that they are endorsing identification and intervention in 4- to 5-year-olds. That has been practiced, but it really hasn’t been endorsed or considered an official standard of care," he said.

Furthermore, the recommendation to start with behavior therapy in this age group, moving to treatment with methylphenidate only if necessary, is a good strategy, he said, noting that the updated guideline recognizes – importantly – that while methylphenidate is off label for this indication, strong evidence exists showing that it has a better safety and efficacy profile for younger children than the only FDA-approved medication (dextroamphetamine) for ADHD in children under age 6 years.

Dr. Childers also praised the subcommittee’s decision to highlight the potential for substance abuse in adolescents with ADHD as well as the importance of obtaining assent in the adolescent population, the comorbidities associated with ADHD, the importance of evaluating younger children in more than one setting to assess symptoms, the value of behavior therapy strategies, the strength of the evidence for stimulant versus other types of medications in 6- to 11-year-olds, the chronic nature of ADHD, and the need for medication dose titration to "best effect – not first effect."

One thing he said he would have liked to have seen included is a greater emphasis on the DSM-IV’s requirement that children be assessed based on their developmental level. A child with language delay, for example, will have an attention level commensurate with their language skills rather than their age, therefore an assessment that doesn’t take this into consideration could lead to a misdiagnosis, he explained.

Dr. Childers is assistant professor of pediatrics and chief of the division of developmental pediatrics at the University of Florida, Jacksonville. He said he had no relevant financial disclosures.