The American Academy of Pediatrics (AAP) has released guidelines for primary-care physicians on the treatment of attention deficit/hyperactivity disorder (ADHD).
The standards, developed by a panel of primary-care and developmental-behavioral pediatricians as well as experts in psychology, neurology, child psychiatry, education, family practice and epidemiology, are based on an analysis of scientific studies of the treatment of ADHD in school-age children. APA Div. 54 (Society of Pediatric Psychology) Past-president Ronald Brown, PhD, served as a liaison to the committee.
The recommendations call for:
Primary clinicians to establish a treatment program that recognizes ADHD as a chronic condition. Clinicians should continually educate parents, children and teachers about the condition, and establish a monitoring system to track the effects of treatment and developmental changes in behavior.
Clinicians, parents, school personnel and child to specify appropriate goals that relate to the specific problems of the child, such as school performance, difficulty finishing tasks or interactions with schoolmates.
Clinicians to recommend stimulant medication and/or behavior therapy to improve specific symptoms in children with ADHD, if appropriate. The guidelines include a review of the scientific evidence for medication and behavior therapy effectiveness.
Clinicians to re-evaluate the original diagnosis when the treatment for a child with ADHD had not met its goals.
Clinicians to conduct periodic, systematic follow-up with children. Gathering information from parents, teachers and the child, clinicians should monitor children's progress to their individual goals and any adverse effects of treatment.
The guidelines also recommend future research in treatment options, long-term outcomes and other domains.
The guidelines are particularly good for psychologists, says Mark Stein, PhD, director of the ADHD program at Children's National Medical Center in Washington, D.C. "They suggest that the treating clinician should suggest target behaviors in a collaborative effort with parents, children and teachers," says Stein. "That's not new to psychologists, but will be particularly helpful to pediatricians."
William E. Pelham Jr., PhD, a professor of psychology, pediatrics and psychiatry at the State University of New York at Buffalo and a consultant to the guidelines committee, says that among the guidelines' most important functions is the emphasis on the chronic nature of the disorder and "that the treatment plan needs to be a treatment plan for a chronic condition." In addition, he says, the guidelines focus on the problems of daily life, rather than just the clinical symptoms of ADHD, and recognize medication and behavioral therapy as the two most empirically validated treatments.
But some ADHD experts point out that no guidelines can substitute for the training that many physicians need to properly diagnose and treat the disorder. Others feel that the treatment guidelines offer little practical guidance.
"The guidelines are so vague and unrealistic as to provide no new guidance to primary-care providers," says psychologist Gretchen Lefever, PhD. Lefever, an associate professor at Eastern Virginia Medical School's Center for Pediatric Research, says the standards provide little specific information to help clinicians decide the appropriate approach for individual patients and do not pertain to children with co-occurring mental health conditions.
Meanwhile, many see the guidelines as an opportunity to develop collaborative relationships between pediatrics and psychology. Now that physicians are being encouraged to use behavioral treatments as well as medication, psychologists with ADHD training should make themselves known to physicians, says Pelham.
"Given that the guidelines emphasized careful titration of the child's medication to an optimal dose, there is also a clear role for psychologists to play in collaborating with physicians in optimizing children's medical treatment," Pelham adds, noting that in addition to performing assessments and diagnosing the disorder, psychologists also perform useful behavioral interventions with parents, teachers and children.
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