Postgraduate Medicine

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Clinical Practice Guidelines for Attention-Deficit/

Hyperactivity Disorder: A Review

Oscar G. Bukstein MD, MPH

To cite this article: Oscar G. Bukstein MD, MPH (2010) Clinical Practice Guidelines for
Attention-Deficit/Hyperactivity Disorder: A Review, Postgraduate Medicine, 122:5, 69-77

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CLINICAL FOCUS: ADHD, ALLERGIES, AND IMMUNIZATION
material will be used, the complete article citation, a copy of the figure or table of interest as it
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Clinical Practice Guidelines for Attention-Deficit/

Hyperactivity Disorder:  A Review

Oscar G. Bukstein, MD, MPH1 Abstract: The prevalence and public health importance of attention-deficit/hyperactivity
1
Western Psychiatric Institute and disorder (ADHD) as well as its impact on public health has led various groups to develop
Clinic, University of Pittsburgh School clinical practice guidelines (CPGs). Clinical practice guidelines are systematically developed
of Medicine, Pittsburgh, PA statements designed to assist practitioner and patient decisions about appropriate health care for
specific clinical circumstances. In this article, we review 9 CPGs, including their development
process, the recommendation of specific clinical actions, and advocacy of recommendations
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based on limited evidence. Despite the differences between these CPGs for ADHD, they appear
to be complementary and not inconsistent. The CPGs all recommend: a structured approach
to diagnosis and treatment; attention to psychiatric comorbidity and other ADHD-related
conflicts during an individual’s lifespan; consideration of medication (usually stimulants) and
psychosocial therapies; and follow-up and monitoring of patient response. A patient-centered
approach is also recommended in the evaluation and treatment of ADHD, although it is less
evidence based than recommended therapies.
Keywords: ADHD; clinical practice guidelines; treatment; stimulants

Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological
condition affecting 5% to 8% of school-aged children,1–4 with symptoms persisting
into adulthood.5,6 Psychiatrists, pediatricians, and other primary care physicians fre-
quently are asked by parents and teachers to evaluate children, adolescent, or adults for
ADHD. The prevalence and public health importance of ADHD has led various groups
to develop clinical practice guidelines (CPGs), which are systematically developed
statements designed to assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances.7 Clinical practice guidelines promote
evidence-based health care and provide support and resources to doctors and health
care professionals to help maintain the highest standards of medicine. The develop-
ment of CPGs requires a process of review of the literature, rating of evidence, and
review by experts and other stakeholders (ie, health care professionals, teachers, family
members, etc.). In this article, we describe several of these CPGs and use the common
elements to formulate a summary of common elements from the basic recommendations
resulting from these CPGs. The Appraisal of Guidelines for Research & Evaluation
(AGREE) collaboration is an international collaboration from researchers and policy
makers who have developed a framework for assessing the quality of CPGs.8 Using
Correspondence: Oscar G. Bukstein, MD,
MPH, an instrument, the ideal CPG can be graded in 6 domains (Table 1).
Western Psychiatric Institute and Clinic, We selected (not systematically) 9 CPGs that had a range of methodologies for
University of Pittsburgh School
of Medicine, diagnosing children, adults, or both (Table 2). The CPGs that we discuss are:
3811 O’Hara St.,
Pittsburgh, PA 15213.
Tel: 412-246-5114 1. American Academy of Pediatrics (AAP): Clinical Practice Guideline: Diagnosis
E-mail [email protected] and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder9

© Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260 69
71508e
 Oscar G. Bukstein

and Clinical Practice Guideline: Treatment of review, and development, whereas the TCMAP and ESCAP
the School-Aged Child With Attention-Deficit/ projects consist of a series of algorithms and broad subjec-
Hyperactivity Disorder10 tive recommendations, developed as a result of a consensus
2. American Academy of Child and Adolescent Psychiatry conference of experts. Finally, the Magellan guidelines are a
(AACAP): Practice Parameter for the Assessment very broad description of treatment practices. The guidelines
and Treatment of Children and Adolescents With differ in their development process, their recommendations of
Attention-Deficit/Hyperactivity Disorder11 specific clinical actions, and advocacy of recommendations
3. National Institute for Health and Clinical Excel- based on limited evidence.
lence (NICE; United Kingdom): Attention-Deficit/
Hyperactivity Disorder Diagnosis and Management Description of the Clinical Practice
of ADHD in Children, Young People, and Adults12 Guidelines for ADHD
4. Scottish Intercollegiate Guidelines Network: Manage- The AAP practice guidelines for ADHD are divided into
ment of Attention-Deficit and Hyperkinetic Disorders 2 documents–one for the evaluation and diagnosis9 and
in Children and Young People13 another for the treatment of ADHD10— and are focused on
5. Royal Australasian College of Physicians: Australian school-aged children (6–12 years). These guidelines are cur-
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Guidelines on Attention Deficit Hyperactivity Disor- rently being revised, with new documents to be published
der (ADHD)14 in 2011. The diagnosis/evaluation guidelines contain the
6. British Association for Psychopharmacology: following recommendations: 1) primary care physicians
Evidence-Based Guidelines for Management of should initiate an evaluation for ADHD in children present-
Attention-Deficit/Hyperactivity Disorder in Adoles- ing with inattention, hyperactivity, impulsivity, academic
cents in Transition to Adult Services and in Adults15 underachievement, or behavior problems; 2) the diagnosis of
7. European Society for Child and Adolescent Psychiatry ADHD requires that a child meet Diagnostic and Statistical
(ESCAP): European Clinical Guidelines for Hyperki- Manual of Mental Disorders, Fourth Edition, Text Revision
netic Disorder – First Upgrade16 (DSM-IV-TR) criteria; 3) the assessment of ADHD requires
8. The Texas Consensus Conference Panel on Medi- evidence directly obtained from parents or caregivers on
cation Treatment of Childhood Attention-Deficit/ the core symptoms of ADHD in various settings, the age
Hyperactivity Disorder: Texas Children’s Medication of onset, duration of symptoms, and extent of functional
Algorithm Project (TCMAP) (revised in 2007)17,18 impairment; 4) the assessment of ADHD requires evidence
9. Magellan Health Services, Clinical Practice Guideline directly obtained from the classroom teacher (or other school
Task Force, Clinical Practice Guideline for Patients professional) on the core symptoms of ADHD, duration of
with Attention-Deficit/Hyperactivity Disorder19 symptoms, extent of functional impairment, and associated
conditions; 5) evaluation of the child with ADHD should
Each of the first 6 guidelines were developed according include assessment for associated (coexisting) conditions;
to a defined process of research literature review, expert and 6) other diagnostic tests are not routinely indicated to
establish the diagnosis of ADHD but may be used for the
Table 1.  AGREE Domains for Assessing Clinical Practice Guidelines
assessment of other coexisting conditions (eg, learning dis-
1. Scope and purpose: overall aim of the guideline, specific clinical abilities and mental retardation).
questions, and the target patient population.
The treatment guidelines further recommend that primary
2. Stakeholder involvement: the extent to which the guideline repre-
care physicians should establish a treatment program that
sents the views of its intended users.
recognizes ADHD as a chronic condition. The treating
3. Rigor of development: the process used to gather and synthesize
the evidence, the methods to formulate the recommendations, and to physician, parents, and child, in collaboration with school
update them. personnel, should specify appropriate target outcomes to
4. Clarity and presentation: the language and format of the guideline. guide management. The physician should recommend
5.  Applicability: the likely organizational, behavioral, and cost implications stimulant medication and/or behavior therapy as appropriate
of applying the guideline. to improve target outcomes in children with ADHD. When
6. Editorial independence: the independence of the recommendations the selected management for a child with ADHD has not
and acknowledgment of possible conflicts of interest from the guideline
development group.
met target outcomes, physicians should evaluate the original
Abbreviation: AGREE, Appraisal of Guidelines for Research and Evaluation. diagnosis, appropriate treatments, adherence to the treatment

70 © Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260
 ADHD Clinical Practice Guidelines

Table 2.  Comparison of Clinical Practice Guidelines for ADHD

Guideline Methodologies Target Presence of Adult Child

Strength of
Recommendation

AAP Literature review Pediatricians and PCPs No X

Consensus recommendations dealing with children
AACAP Literature review Mental health professionals Yes X
Expert
consensus recommendations
NICE Literature review Health care professionals Yes X X
Evidenced-based
recommendations
British Association Literature review Health care professionals Yes X X
for Psychopharmacology Evidenced-based
recommendations
Scottish Intercollegiate Literature review Health care professionals Yes X
Guidelines Network Evidenced-based and expert
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consensus recommendations
Algorithms
Royal Australasian Literature review Health care professionals Yes X X
College of Physicians Evidenced-based and expert
consensus recommendations
ESCAP Consensus recommendations Health care professionals No X
Algorithms
TCMAP Consensus recommendations Health care professionals No X
Algorithms
Magellan Literature review Health care professionals No X X
Summary of other CGPs Other health care
organizations

Abbreviations: AACAP, American Academy of Child and Adolescent Psychiatry; AAP, American Academy of Pediatrics; ADHD, attention-deficit/hyperactivity disorder; CGP,
clinical practice guidelines; ESCAP, European Society for Child and Adolescent Psychiatry; NICE, National Institute for Health and Clinical Excellence; PCP, primary care physi-
cian; TCMAP, Texas Children’s Medication Algorithm Project.

plan, and presence of coexisting conditions. The physician relative to the patient’s intellectual ability. The physician
should periodically provide a systematic follow-up for the child should evaluate the patient with ADHD for the presence of
with ADHD. Target outcomes and adverse effects shoudl be comorbid psychiatric disorders.
monitored, and information should be obtained from parents, Treatment should consist of a well-developed and
teachers, and the child. comprehensive treatment plan, with the initial psychophar-
The AACAP Practice Parameter for ADHD11 consists macological treatment of ADHD consisting of a trial with
of 13 recommendations covering the need for screening, an agent approved by the US Food and Drug Administration
comprehensive assessment, and treatment. Screening for (FDA). Treatment of ADHD should continue as long as
ADHD should be part of every mental health evaluation. symptoms remain present and cause impairment. Patients
Evaluation should consist of clinical interviews with the should be periodically assessed to determine whether there is
parent and patient, obtaining information about the patient’s continued need for treatment or if symptoms have remitted.
school or day-care functioning, evaluation for comorbid If none of the above agents result in satisfactory treatment of
psychiatric disorders, and review of the medical, social, and the patient with ADHD, the physician should carefully review
family history. If the patient’s medical history is unremark- the diagnosis and consider behavior therapy and/or the use
able, laboratory or neurological testing are not indicated. of medications not approved by the FDA. The patient should
Similarly, psychological and neuropsychological tests are be monitored for treatment-emergent side effects, including
not mandatory for the diagnosis of ADHD, but should be monitoring of height and weight throughout treatment. If a
performed if the patient’s history suggests low general cogni- patient with ADHD has a robust response to psychophar-
tive ability or low achievement in language or mathematics macological treatment and subsequently shows normative

© Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260 71
 Oscar G. Bukstein

functioning in academic, family, and social functioning, young adults with ADHD with medications, methylpheni-
then psychopharmacological treatment of the ADHD alone date should be considered for ADHD without significant
is satisfactory. If a patient has a less than optimal response to comorbidity or for ADHD with comorbid conduct disorder.
medication, has a comorbid disorder, or experiences stressors Atomoxetine should be considered for children/adolescents
in family life, then psychosocial treatment in conjunction if tics, Tourette’s syndrome, an anxiety disorder, stimulant
with medication treatment is often beneficial. The AACAP misuse, or risk of stimulant diversion are present, or if meth-
published a pocket card condensing the ADHD parameter ylphenidate has been ineffective at the maximum tolerated
into diagnostic and treatment algorithms, key points, and a dose, or the child/adolescent is intolerant to low or moderate
list of medications,20 providing a more practical application doses of methylphenidate. Medication treatment for adults
of the AACAP ADHD CPG. with ADHD should always form part of a comprehensive
In the United Kingdom, the NICE guidelines on the diag- treatment program that addresses psychological, behavioral,
nosis and management of ADHD12 focus more on parental and educational or occupational needs. Following a deci-
training and psychological interventions. For a diagnosis sion to start medication treatment in adults with ADHD,
of ADHD, symptoms should meet the diagnostic criteria methylphenidate should normally be tried first. Adults who
in DSM-IV-TR or International Classification of Diseases do not seek a medication treatment should be able to access
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10th Revision (ICD-10) (hyperkinetic disorder [HKD]) and psychological help instead.
be associated with at least moderate psychological, social, The Scottish Intercollegiate Guidelines Network13 for
and/or educational or occupational impairment based on children and adolescents with ADHD and HKD combine
interview and/or direct observation in multiple settings. evidenced-based recommendations with good practice
Symptoms should also be pervasive, occurring in $ 2 impor- points, which are based on the clinical experience of
tant settings, including social, familial, educational, and/or the guidelines development group. The principles of
occupational settings. intervention are the primary focus of the good practice points.
Treatment and care should take into account individuals’ Parents or caregivers of children with ADHD/HKD (and
needs and preferences, and (in children) those of their parents. older children with ADHD/HKD) should be given informa-
All individuals with ADHD, including children, should have tion about ADHD/HKD and about possible interventions,
the opportunity to be involved in decisions about their care including their potential risks and benefits, and health
and treatment in partnership with their health care profes- and education services communicate regularly to promote
sionals. Medication treatment is not recommended for pre- understanding of the difficulties of ADHD/HKD to ensure
school children with suspected ADHD or for older children a consistent approach to the individual across settings and
and adolescents with moderate ADHD. Instead, the parents to monitor effectiveness of intervention(s). Additionally, if
of children and adolescents with ADHD should be offered symptoms of ADHD are mild, physicians should consider
a group parental training program with the option of group behavioral approaches first. The remainder of the major
psychological treatment or social skills training for the child recommendations are evidenced-based, with the strength of
or young person, and individual psychological therapy for evidence ranging from A to D. Most of the medication rec-
older adolescents. The NICE guidelines recommend medi- ommendations are given an A rating: in school-aged children
cation treatment as the first-line intervention for children, and adolescents/young adults with HKD (severe ADHD),
adolescents, and young adults with severe ADHD as well medication is recommended. In school-aged children, ado-
as for adults with ADHD, and general practitioners should lescents, and young adults with ADHD/HKD, a combination
not initiate medication treatments for ADHD, although they of medication and behavioral treatments is recommended for
may continue prescribing and monitoring such treatment comorbid symptoms of oppositional defiant disorder and/or
once started by a qualified expert. aggressive behavior.
Medication treatment should always form part of a com- The recommendation for school-aged children, adoles-
prehensive care package that includes psychological and cents, and young adults with ADHD/HKD and comorbid
educational components. The NICE guidelines advocate the generalized anxiety disorders receiving a combination of
establishment of multidisciplinary specialist ADHD teams medication and behavioral treatments is given a B rating. The
and/or clinics and the provision of behavioral interventions recommendation for behavioral parent training for preschool
in the classroom by teachers with necessary training. When children with symptoms of ADHD/HKD is given a B rating.
a decision has been made to treat children or adolescents/ Assessment recommendations are given C and D ratings as

72 © Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260
 ADHD Clinical Practice Guidelines

well as good practice points. Similar to previously discussed The British Association for Psychopharmacology guide-
guidelines, the Royal Australasian College of Physicians lines15 were developed for adolescents in transition to adult
Guidelines14 recommend that the diagnosis be based on services, and in adults. Each of the recommendations is
the DSM-IV-TR criteria and that the diagnosis of ADHD graded according to the supporting evidence. Diagnosing
should be made only after a comprehensive assessment. ADHD in adults requires a specialist (ie, a psychiatrist), but
This includes medical, developmental, and psychosocial should also involve primary care practitioners, who should
assessment, evidence of impairment in multiple settings, and be trained to be aware of the diagnosis. Assessment includes
information from multiple informants. identifying symptoms (past and present), impairments
For the management of ADHD, individuals with ADHD in different contexts, the influence of changing demands
and their families should be provided with information and throughout the patient’s lifespan, the exclusion of other
education about ADHD and its impact, as well as the advan- problems (including psychiatric disorders), and applica-
tages and disadvantages of potential treatment strategies. tion of clinical examination, rating scales, and other tools
Multimodal therapy is recommended for the treatment of as indicated. Diagnostic and assessment criteria should be
ADHD in all age groups, including psychosocial manage- based on checklists based on DSM-IV-TR and/or ICD-10
ment strategies, medication, and educational interventions. with adult symptoms as appropriate. Assessment needs to
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The individualized management plan should be developed confirm impairment in different domains, including: 1) a his-
in collaboration with the individuals with ADHD as well as tory of childhood ADHD or suggestive symptoms (impair-
his or her parents and teachers. Such a comprehensive plan ments/failure of attainment/demands and comorbidity), and
should take into account the specific needs and expressed 2) current evidence of symptoms leading to pervasive impair-
preferences of the patient, and the circumstances of his or ment in .  1 domain (given context demands and skills).
her family and culture; the associated psychosocial problems, Multiple informants need to be used where possible (at least
educational difficulties, and comorbid conditions; and the one contemporary and one developmental) with consent,
suitability of the plan for the individual and his or her family especially for younger patients. Neuropsychological tests
when considering factors such as affordability, accessibility, based solely on executive function are likely to be of limited
and acceptability. Physicians should be alert to the risk of diagnostic value, although test batteries that assess multiple
depression or other psychiatric disorders in parents/caregiv- domains of neuropsychological performance may be use-
ers of children or adolescents with ADHD, and should refer ful to determine individual deficits and to suggest tailored
them for support and treatment. management strategies. Treatment response cannot be used
The Australian guidelines state that not all individuals to make a diagnosis of ADHD. Physicians need to screen
with ADHD will require pharmacological management. for autistic spectrum, developmental disorders, communi-
Medications should be used only when symptoms are cation difficulties, learning disabilities, tics and Tourette’s
pervasive across settings (eg, school and home), cause signifi- syndrome, anxiety and affective disorders, substance use
cant academic, social, or behavioral impairments, and after disorders, and other conditions (eg, epilepsy, sleep disorders,
careful consideration of nonpharmacological approaches. sensory problems), but symptoms cannot be counted twice
Clearly defined goals should be identified prior to initiating a for ADHD and comorbid disorders. Further specialist input
trial of medication treatment. Medication should not be used or advice may be needed to confirm comorbidity (eg, learn-
as first-line treatment for ADHD in preschool-aged children. ing disability teams), because comorbidity can have a greater
Patients receiving treatment for ADHD should be reviewed impact on functioning than ADHD.
regularly (at least bi-annually) to ensure that the management In the United Kingdom, prescribing medication for
strategies remain appropriate and effective. adult patients with ADHD is off-label because no agent is
Other therapies, such as elimination and restriction diets, licensed there for this indication. However, atomoxetine is
are not supported as a general treatment for individuals with licensed for use in adults, but only when ADHD treatment
ADHD, although a subset of children who are sensitive to was initiated in childhood. Proven medication treatments in
certain foods or food additives may benefit from careful children include psychostimulants and atomoxetine as first-
exclusion diets. Other alternative treatments (including fatty line treatments, imipramine and bupropion as second-line
acid supplements, biofeedback, homeopathy, or sensory treatments, and clonidine and guanfacine as possible adjunc-
integration diets) are not currently supported as treatments tive treatment. Although adult patients with ADHD are most
for individuals with ADHD. likely to present to primary care, medication treatment is

© Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260 73
 Oscar G. Bukstein

best initiated and optimized by secondary/specialist services. provided a clinical consensus. The document consists of a
Medication treatment needs to be chosen and adapted to best chapter-like review of assessment and treatment options and
fit the individual, including the patient’s preferences and a subjective, general discussion of the supporting evidence
concerns. Medication treatment requires regular (preferably for a general scheme of clinical management. An algorithm
structured) monitoring and review (eg, for dose adjustment) for the initial treatment of children with activity/attention
at least (for uncomplicated cases) twice a year or annually. problems, and symptoms refractory to methylphenidate. There
These regular reviews include monitoring of ADHD and is an appendix with recommended assessment instruments.
other symptoms, global and specific functioning, adverse The TCMAP issued a revision of its 1998 recommenda-
effects, concordance of effects (eg, between patient, doc- tions for the medication treatment of children with ADHD
tor, informants), psychiatric side effects, cardiovascular with and without comorbid disorders.17 The TCMAP ADHD
effects, compliance, and tolerance (daily and long term). algorithm does not include psychosocial treatments or assess-
Medication treatment should not be initiated if the diag- ment of ADHD. Both the original and revised versions were
nosis is uncertain or benefit is unlikely. Abuse potential is based on a consensus conference of experts. The original
related to medication action and formulation. Slow-release version of this algorithm recommended a stimulant (meth-
preparations of these agents or atomoxetine are to be preferred ylphenidate or amphetamine) as the first stage of treatment.
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for patients with a history of, or who are at risk of, medication If one of these stimulants did not produce a satisfactory
misuse. While abuse by patients appears to be low, diversion result, then stage 2 would involve the patient receiving the
can occur with stimulants for performance enhancement or other stimulant not used in stage 1. Stage 3 was a trial of
weight loss. pemoline, and stage 4 was a trial of either bupropion or
Psychotherapeutic support to the individual, family, and a tricyclic antidepressant. Stage 5 was the agent not used
others is helpful to inform on the condition and prognosis, in stage 4, whereas stage 6 was treatment with an alpha
to prevent negative effects on self-esteem or unrealistic agonist. Subsequently, an open trial of the feasibility of the
expectations of treatment, to adapt positive and negative algorithm for the treatment of primary ADHD resulted in
coping strategies, and to give perspective to individual neu- the algorithm being well received by physicians, with good
rodevelopmental history. Structured adapted psychotherapies adherence through the first 2 stages but lower adherence in
may be useful to build confidence, develop executive skills, subsequent stages because of the small number of children
address anxiety and depression, and improve functioning, progressing to this point.18 The major changes in the revised
while group therapy may help to manage social isolation. algorithm included elimination of pemoline as a treatment
Evidence from the literature on children with ADHD suggests option, adding atomoxetine to the algorithm, and refining
that psychotherapies are beneficial for comorbid anxiety and guidelines for treating ADHD with comorbid depression,
for functional outcomes beyond the core symptoms, when aggressive behaviors, and tic disorders.
added to medication treatment. Involvement of educational/ Magellan Health Services is a diversified specialty health
occupational psychologists and other relevant personnel for care management organization whose behavioral health and
environmental restructuring can maximize functioning at employee assistance/work-life services cover more than
college or work. The guideline provides recommendations 40 million individuals. The Magellan guidelines19 were writ-
for individuals with specific problems such as learning dis- ten by Magellan to serve as an evidence-based framework for
abilities and juvenile delinquiency, as well as psychiatric practitioners’ clinical decision making with child, adolescent,
comorbidity, including anxiety, depression, bipolar disorder, and adult patients who have a diagnosis of ADHD. The 2010
autistic spectrum disorder, conduct and oppositional defiant revised guidelines were based on a review of the published
disorder, and substance use disorders. literature, along with reported practitioner input. There is no
The ESCAP revised guidelines16 were established from mention of expert review. The recommendations are quite
discussions between a group of child psychiatrists and psy- broad and are listed under the main areas of evaluation and
chologists from several European countries at the European treatment. Other guidelines, such as AAP and AACAP, are
Network for Hyperkinetic Disorders, in addition to an iterative referenced.
critique of each clinical analysis. The participants were guided
by evidence-based information, and the guidelines were based Comparison of the Guidelines
on evaluation (rather than meta-analysis) of the scientific In many respects the guidelines are quite different in
evidence. When reliable information was lacking, the group their development, scope, and targets. These CPGs were

74 © Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260
 ADHD Clinical Practice Guidelines

developed with different methodologies for different Research and Evaluation (AGREE) domains. The TCMAP
outcomes, and some were more focused on best cost out- algorithm, while admittedly not a CPF, is based only on
comes. For example, different medications are available limited expert consensus. The other CPGs include more
in Europe compared with the United States, and cultural or less the full range of the CPG procedures, including
differences would have influenced the development of rigorous literature review and grading of the evidence and
guidelines. As mentioned previously, each of the guide- expert and stakeholder review, although these procedures
lines involved one or more elements of proscribed CPG are variable across the CPGs and involve different grad-
elements from among the Appraisal of Guidelines for ing systems, review timeframes, and cross-disciplinary

Table 3.  A Summary of Clinical Practice Guidelines for ADHD

1. Patient-Centered Care
  •  Treatment and care should consider an individual’s needs and preferences and (in children) those of their parents or caregivers.
  • All individuals with ADHD should be involved in decision making about their care and treatment in partnership with their health care professionals.
  •  Families and caregivers should be provided the information and support they need, and be encouraged to become involved in interventions.
2. Screening and Evaluation
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  •  Screening for ADHD should be a part of every mental health evaluation and developmental screening for children and adolescents.
  • Evaluation should consist of clinical interviews with the parent and patient, obtaining information about the patient’s school or day-care functioning,
assessment for comorbid psychiatric disorders, and review of the medical, social, and family history.
  • For a diagnosis of ADHD, symptoms should meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder) and be associated with at
least moderate psychological, social and/or educational, or occupational impairment based on interviews, instruments, and/or direct observation
in multiple settings.
  • Severity should be measured and based on the number and severity of ADHD symptoms/behaviors, presence of psychiatric comorbodity, level of
impairment, including pervasiveness (eg, occurrence in ≥ 2 important settings, including social, familial, educational, and/or occupational settings).
  •  The use of age-appropriate standardized instruments is suggested.
  • If the patient’s medical or educational history is unremarkable, laboratory testing, neurological testing, or psychological and neuropsychological
tests are not mandatory for the diagnosis of ADHD.
3. Comprehensive Treatment Planning
  • Patients, parents/caregivers, and educators should assist in the development of a comprehensive treatment program that addresses psychological,
behavioral, and educational/occupational needs.
  • Treatment selection (medication and/or psychosocial interventions) should consider severity, context of symptoms and impairment, patient age,
preferences, capabilities, and personal circumstances of the patients, parents/caregivers.
  • Medication trials should usually begin with stimulants (methylphenidate or amphetamine) and proceed to other stimulants and available FDA-approved
medications (long-acting guanfacine or atomoxetine) in the case of non- or poor response or intolerable adverse events.  Trials with off-label agents
such as bupropion, alpha-adrenergic agonist, modafinil, or tricyclic antidepressants should be reserved for individuals who are unable to tolerate
or respond to the FDA-approved agents listed previously.
  • Cardiovascular evaluation prior to a stimulant trial should be based on the presence of medical history risk factors (eg, structural cardiac
abnormalities, cardiovascular symptoms, family history of sudden death at an early age).
  • Clinicians should regularly monitor medication response to treatment and titrate doses to control symptoms, reduce impairment and other
behavioral targets, while minimizing adverse events.
  • Clinicians should regularly monitor for adverse events, blood pressure, heart rate, weight, and height.  Adolescents and adults should be monitored
for illicit substance use. Both patients and families should be monitored for possible diversion of medication.
  • Clinicians should treat comorbid psychiatric disorders or refer to specialists or other physicians for further evaluation and appropriate
treatment.
  • Psychosocial interventions should be considered for all patients with ADHD and their families, especially preschool children and those with coexist-
ing problems with behavior, emotions, family, or occupation. For children, such interventions include parent management training and other operant
behavioral interventions, and possibly social skills/problem-solving therapy and, for adults, cognitive behavioral therapies.
  • Modification of educational placements and accommodations should be considered for all students with ADHD. Teachers should be trained to
implement class or school-wide behavioral interventions and to assist in individual behavior management plans.
4. Follow-up
  • Clinicians should follow-up with patients on medications regularly to determine if continued treatment is warranted and if effectiveness continues
to be present.

© Postgraduate Medicine, Volume 122, Issue 5, September 2010, ISSN – 0032-5481, e-ISSN – 1941-9260 75
 Oscar G. Bukstein

review. For example, the British Psychopharmacology recommend a structured approach to diagnosis and treatment,
Guidelines include a very detailed indication of categories attention to psychiatric comorbidity and other problems asso-
of evidence (for both causal relationships and treatment and ciated with ADHD across the lifespan, consideration of both
observational relationships) and strength of recommendation medication (usually stimulants) and psychosocial therapies,
ratings (based on the level of evidence above). Similarly, the and follow-up and monitoring of response. Finally, although
Australian guidelines provide both categories of evidence less evidenced based than specific recommended therapies,
and strength of recommendations. The AACAP guidelines a patient-centered approach respecting the preferences and
do this as well but not as comprehensively. The AAP guide- decision-making capabilities of patients and their families in
lines do neither explicitly, although we expect this to change each of the tasks above is critical to acceptance of an ADHD
with the upcoming revision. The NICE guidelines were the diagnosis, adherence to treatment regimens, and optimal
result of a guideline development group, which reviewed the outcomes.
evidence and developed the recommendations. The guidelines
does not mention specific categories of evidence or strength Conflict of Interest Statement
of recommendations. The NICE guidelines do emphasize Oscar G. Bukstein, MD, MPH discloses no conflicts of
“person-centered care,” in which treatment and care take into interest.
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account the needs and preferences of the patient and their

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