Areas of Agreement and Difference
Areas of AgreementA direct comparison of recommendations presented in the above guidelines for the assessment and management of attention deficit hyperactivity disorder (ADHD) is provided below.
Assessment. The groups agree that comprehensive assessment of the child with suspected ADHD should include clinical interviews with the parent/carer as well as the patient. Focusing on diagnostic criteria for ADHD and associated, potentially comorbid disorders, there is agreement that during the parent interview clinicians should inquire about the patient's: symptoms (frequency, duration, severity, situational variation, age of onset, settings in which impairment occurs); academic functioning; medical history; mental health history (including any treatment received in the past); obstetric and perinatal history; developmental history/acquisition of developmental milestones; family history, including a history of ADHD (due to its heritability) and any other significant mental disorders/psychiatric illnesses; and family functioning. As children and young people may not always be reliable in reporting externalizing behavior, the groups agree that the primary purpose of the patient interview is not to confirm or refute the diagnosis, but rather to aid identification of internalizing signs or symptoms inconsistent with ADHD or suggestive of comorbid conditions (e.g., anxiety, depression).
Given that many children with ADHD experience academic difficulties, the groups agree that, in addition to inquiring about academic performance during the parent interview, a psychoeducational assessment should also be performed. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that the psychoeducational assessment is an opportunity for the clinician to review the patient's academic/intellectual progress and look for symptoms of learning disorders. According to the Scottish Intercollegiate Guidelines Network (SIGN), assessment of the child's presentation in their educational placement is important for confirming diagnosis and identifying educational underachievement. They add that psychoeducational assessment involves testing the child's level of attainment in basic skill areas such as reading, spelling and number work, and evaluating whether the child is achieving appropriately in terms of age and ability. Both groups recommend contacting the child's teacher(s)/school for details about academic performance as well as behavior during the school day to inform diagnosis and plan a management strategy.
The groups agree that laboratory or neurological testing is not indicated in the majority of patients with suspected ADHD. AACAP recommends considering measurement of thyroid levels and TSH only if symptoms of hyperthyroidism other than increased activity level are present, and measurement of serum lead levels only if a patient has been raised in an environment where exposure to lead paint or plumbing is probable. According to AACAP, unless there is strong evidence of certain risk factors in the medical history, neurological studies (EEG, MRI, SPECT, or PET) are not indicated for the evaluation of ADHD. SIGN similarly notes that neuroradiological, neurophysiological, neurochemical and chromosomal investigations are as yet unproven in the diagnosis of ADHD/HKD. They recommend certain physical investigations be carried out when thought to be important in the determination of an underlying medical problem, and might include: blood analyses (lead, chromosomes, Fragile X); electrophysiological studies (EEG); and CT (MRI for neurological disorders/ space occupying lesions).
With regard to psychological testing, AACAP states that psychological and neuropsychological tests are not mandatory for the diagnosis for ADHD, but should be performed if the patient's history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient's intellectual ability. AACAP adds that neuropsychological testing, speech-language assessments, and computerized testing of attention or inhibitory control are not required as part of a routine assessment for ADHD, but may be indicated by the findings of the standard psychological assessment. SIGN similarly states that laboratory assessment measures and psychological tests should not be regarded as a routine part of the diagnostic process, but rather used on the basis of a specific hypothesis in a specific case.
Psychostimulants and atomoxetine. AACAP recommends the initial pharmacological treatment of ADHD be a trial with an agent approved by the FDA for this purpose. U.S. FDA-approved agents include: the psychostimulants dextroamphetamine and methylphenidate; mixed salts amphetamine (e.g., Adderall); and atomoxetine. The same medications, with the exception of mixed salts amphetamine, are also licensed in the UK for the treatment of ADHD/HKD. While Adderall is not licensed in the UK, SIGN notes that a review of four studies found that Adderall showed a small advantage over immediate release methylphenidate and placebo when treatment response was measured by clinician and parent ratings/outcomes.
SIGN recommends psychostimulants as the first choice medication for the core symptoms of ADHD/HKD in children without known (or where there is no family history of) cardiac abnormalities. According to AACAP, the American Academy of Pediatrics, an international consensus statement, and the Texas Children's Medication Project have also recommended stimulants as the first line of treatment for ADHD, particularly when no comorbidity is present. They add that direct comparisons of the efficacy of atomoxetine with that of psychostimulants have shown a greater treatment effect of the stimulants.
With regard to medication use in preschoolers, SIGN provides no recommendations around the use of medications in children of preschool age. SIGN notes that in Scotland most clinicians would seldom confirm a diagnosis of ADHD/HKD in this age group. According to AACAP, stimulants have been widely prescribed by clinicians for preschoolers, although the number of published controlled trials is limited. They do not provide specific recommendations, but cite research findings which suggest that that the dose of MPH (or any stimulant) should be titrated more conservatively in preschoolers than in school-age patients, and that lower mean doses may be effective.
The groups agree that the noradrenergic reuptake inhibitor atomoxetine is superior to placebo, but inferior to stimulants, in treating core symptoms of ADHD. SIGN recommends atomoxetine in children where psychostimulant medication is not appropriate, not tolerated, or is ineffective. AACAP similarly states that atomoxetine may be considered as the first medication for ADHD in individuals with an active substance abuse problem, comorbid anxiety, or who experience severe side effects of stimulants such as mood lability or tics. The groups agree that patients taking atomoxetine should be monitored for suicidal ideation, clinical worsening of mood, and unusual changes in behavior.
Unlicensed medications. The groups agree that, in children who have not responded to licensed medications, unlicensed medications may be appropriate in selected circumstances. Both groups address the alpha agonists clonidine and guanfacine. Concerning clonidine, AACAP states it is effective for impulsivity and hyperactivity; modulating mood level; tics worsening from stimulants; and sleep disturbances, and that clinical consensus has led to its use as adjunctive therapy to treat tics or stimulant-induced insomnia rather than as a primary treatment for ADHD. SIGN recommends consideration of clonidine in children unresponsive to or unable to tolerate psychostimulants or atomoxetine on an individual case basis. The groups agree that clinicians should periodically assess pulse and blood pressure, and monitor for cardiac symptoms and over-sedation in patients prescribed clonidine. There is also agreement that clonidine may be used alone or in combination with another ADHD medication (SIGN specifies methylphenidate on an individual case basis). Concerning guanfacine, SIGN found insufficient evidence on which to base a recommendation. AACAP cites a small double-blind trial that showed its superiority over placebo in the treatment of children with ADHD and comorbid tics, and recommends reviewing personal and family cardiovascular history before prescribing. The groups agree that alpha-agonist discontinuation should be carried out gradually to avoid rebound hypertension.
With regard to tricyclic antidepressants (TCAs), AACAP states that they are the most studied of the non-FDA-approved medications for the treatment of ADHD, and that imipramine and nortriptyline have been most commonly used in recent years. They add that desipramine should be used only if other TCAs have not proven effective or have caused the patient to suffer excessive side effects, and should be used with extreme caution in children and adolescents due to reports of sudden death. According to SIGN, the TCAs are more effective in addressing the behavioral symptoms than attention/concentration deficits. The groups agree that for TCAs, caution is warranted in patients with a history of cardiac problems, and that electrocardiographic monitoring should be performed at baseline and during treatment.
With regard to antidepressants other than TCAs, SIGN did not identify any contemporary evidence on the use of bupropion in ADHD/HKD, but cites an older study which suggested symptom reduction comparable with methylphenidate using several measures. AACAP states that bupropion showed modest efficacy in the treatment of ADHD in one double-blind, placebo-controlled trial, and is contraindicated in patients with a current seizure disorder. SIGN also addresses reboxetine and selegiline, for which they found insufficient evidence on which to base a recommendation.
Psychological interventions. While there is overall agreement that, generally speaking, pharmacological intervention for ADHD is more effective than psychological intervention, the groups agree that behavior therapy is appropriate in certain situations, one of which is as initial treatment for mild ADHD. Circumstances also cited by AACAP include when the diagnosis of ADHD is uncertain, parents reject medication treatment, or there is marked disagreement about the diagnosis between parents or between parents and teachers.
According to AACAP, if a patient has a robust response to medication and subsequently shows normative functioning in academic, family, and social settings, then pharmacological treatment alone is satisfactory. If, however, a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences stressors in family life, then psychosocial treatment in conjunction with pharmacologic treatment is often beneficial.
Both groups address behavioral parent training, the short-term effectiveness of which has been demonstrated in a number of controlled studies according to AACAP. SIGN recommends behavioral parent training for parents of pre-school children with symptoms of ADHD/HKD. In pre-adolescent children with ADHD/HKD and symptoms of comorbid generalized anxiety, ODD, or aggressive behavior, SIGN recommends behavioral programs to treat the comorbid problems (in conjunction with medication to treat the core symptoms). SIGN found insufficient evidence to make a recommendation for psychological interventions for adolescents. SIGN also addresses school-based interventions, recommending an individualized school intervention program including behavioral and educational interventions for children with ADHD/HKD.
Areas of DifferenceAtomoxetine. Recommendations differ slightly with regards to dosing of atomoxetine. Both groups agree that children who weigh <70 kg should be initiated at 0.5 mg/kg/day. SIGN recommends maintaining this dose for at least 7 days before being increased to a maintenance dose of 1.2 mg/kg/day. AACAP, in contrast, recommends maintaining the initial dosage for four days, followed by 1 mg/kg/day for four days, then increasing to 1.2 mg/kg/day. Both groups note that the manufacturer does not recommend the opening of capsules.