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ADHD: A new practice guideline from the American Academy of Pediatrics
  1. H BAUCHNER MD, US Associate Editor

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Attention deficit hyperactive disorder (ADHD) is the most common neurobehavioural disorder of childhood. However, the prevalence of ADHD and its diagnosis and treatment remain controversial. There are persistent concerns that ADHD is overdiagnosed, with the diagnosis reflecting poorly validated diagnostic criteria. In addition, parents, educators, and health care professionals are also concerned that psychoactive medications are being used to “calm” children inappropriately. The American Academy of Pediatrics recently released an important practice parameter (guideline) about the diagnosis and evaluation of children with ADHD.1 Much of the parameter was based on an enlightening and exhaustive review of the medical literature on ADHD, which was performed by the McMaster group for the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Healthcare Policy and Research).2 ,3

Highlights of the guideline include the observations that:

  • The prevalence of ADHD in children from the US is between 7 and 10% and is diagnosed more often in boys than girls

  • Prevalence rates vary significantly depending on whether they reflect school samples (6.9%) or community samples (10.3%)

  • ADHD specific questionnaires, such as the Conners, are superior to non-specific questionnaires in differentiating children with ADHD from normal children

  • Non-specific questionnaires (broad band scales) should not be used to diagnose children with ADHD

  • In order to confirm the diagnosis, information is needed from various sources, usually from parents and the school

  • Co-existing conditions are common (1/3 of children with ADHD) and include conduct disorder (26%), depression (18%), and oppositional defiant disorder (35%); assessment for these conditions is recommended

  • Other diagnostic tests, such as EEG, brain imaging, and thyroid hormone levels are not recommended.

For clinicians, certainly those in the United States, who evaluate, diagnose, and treat children with ADHD, the AAP's practice parameter is valuable. The American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, Neurology Society, and Society for Pediatric Psychology have endorsed its recommendations. Other new literature that sheds light on this controversial topic includes the two reports from AHRQ2 ,3 on diagnosis and treatment, and the results from a multicentre National Institutes of Health supported randomised controlled trial on treatment, which compared 14 months of medication management to intensive behavioural therapy.4 ,5 The results of this important study suggest that medication is superior to behavioural treatment and to routine community care for children with ADHD. Sadly, medication and behavioural therapy did not yield greater benefits than medication alone.