The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms

Abstract

IMPLEMENTING THE COMPLEX ATTENTION-DEFICIT/HYPERACTIVITY DISORDER GUIDELINE: PROCESS OF CARE ALGORITHMS To facilitate implementation of the Society for Developmental and Behavioral Pediatrics Complex Attention Deficit/Hyperactivity Disorder (ADHD) Guideline1 and its 5 Key Action Statements, the Guideline Panel developed the Process of Care Algorithms. As described in the Guideline, these algorithms reflect the consensus, expert opinion of the Panel, as well as a careful review of the existing literature and other available practice guidelines. Because there is insufficient evidence to allow for a prescriptive approach, each of the algorithms include suggested steps that are related to the Key Action Statements and that incorporate the key concepts from the Guideline (i.e., focus on functional impairment to improve long-term outcomes, psychosocial treatment as the foundation for treatment of complex ADHD, shared decision-making, interprofessional care, appropriate use of psychological testing and mental health diagnostic assessment, recognition and treatment of impairments due to coexisting conditions, and a life course perspective). The Society for Developmental and Behavioral Pediatrics (SDBP) Complex ADHD Practice Guideline was developed to improve the subspecialty level care of children and adolescents with “complex ADHD” by professionals with specialized training and/or experience. Therefore, the algorithms do not include basic information such as lists of diagnostic criteria. It is important to emphasize that the Process of Care Algorithms are to be used as companion documents to the Guideline. Key information and definitions in the Guideline are not repeated in the algorithms or in the following annotations to the algorithms. It is also beyond the scope of the algorithms to provide detailed recommendations about specific rating scales, questionnaires, pharmacological treatment selection, or medication dosing. The SDBP has convened a guideline implementation task force that will, over time, develop an online toolkit to further support implementation of the Guideline and Process of Care Algorithms. Algorithm titles are underlined and followed in parentheses by the Key Action Statement to which they correspond. Each algorithm includes numbered steps, using the following shapes: Numbering of Steps and Corresponding Annotations Comments on algorithm steps are numbered to match the corresponding step. The steps are presented in numerical order in the algorithms, with numbering from left to right as one moves from the top to the bottom of the algorithm. The steps are NOT always presented in numerical order in these annotations because at times it is more important to describe the likely path through as ection of the algorithm. Some steps do not have a corresponding annotation because the step is self-explanatory (e.g., a step that indicates that one should “exit” the algorithm). ANNOTATIONS FOR SPECIFIC ALGORITHMS Evaluation of a Child or Adolescent with Complex Attention-Deficit/Hyperactivity Disorder (Key Action Statements 1 and 2) Step 1: It is anticipated that children and adolescents with complex attention-deficit/hyperactivity disorder (ADHD), as defined in this guideline, will have been referred for subspecialty level assessment to be performed by a clinician with specialized training and/or expertise. Step 2: The clinician should obtain a comprehensive history, including the following: Attention-deficit/hyperactivity disorder symptoms and associated impairments Developmental, educational, and mental health history Review of systems with special attention to sleep, cardiac, and neurological history, as well as growth (height and weight) trajectory Medical history Family history, including family developmental, neurological, and mental health history Social history, including the history of adverse childhood experiences and peer victimization History of previous and current treatment and intervention for ADHD and/or previously identified coexisting conditions, including both psychosocial and pharmacological treatments, and assessment of response to previous and current treatments The assessment also includes review of supplemental information: Attention-deficit/hyperactivity disorder-specific questionnaires Other standardized questionnaires (focused on functional impairments in key domains and potential coexisting conditions) Previsit questionnaires, intake materials Report of previous psychological/educational testing School reports, report cards, Individualized Education Program (IEP) plans, 504 Plans Primary care and specialty care records Finally, the child or adolescent should be carefully observed and interviewed, followed by a comprehensive physical examination, considering the following: Age-appropriate interview/observation of child/adolescent Growth parameters (baseline height, weight, and head circumference) Vital signs (blood pressure, and pulse) General physical and neurological examination appropriate to age Signs of other disorders (e.g., dysmorphic features, skin lesions, thyroid dysfunction, and neurologic signs/deficits) Assessment of motor coordination (e.g., handwriting and balance) Steps 3 and 4: If ADHD is confirmed, the clinician should assess for coexisting conditions that are common among children and adolescents with ADHD. As described in the Guideline, the assessment of a child with complex ADHD requires an accurate assessment of the child or adolescent's development and cognitive status, as well as the degree of functional impairments. Physicians may perform developmental assessments and assessments of functional impairment. However, formal assessment of cognitive status can best be administered by a child clinical psychologist or school psychologist. Assessment for coexisting conditions should be informed by the following recommendations: Obtain psychological and educational testing (or review the results of testing completed within past 2–3 years for children >6 years old) Consider testing even for children with previous testing under the following circumstances: Deterioration in mental health or functional status Poor academic progress not explained by previous test results Suboptimal response to treatment for core ADHD symptoms History suggests an emerging language or learning disorder not identified in previous testing Younger age (<6 years) at the time of previous testing Patients preparing for a transition to college Step 5: If ADHD is not confirmed, consideration should be given to other conditions that may present with symptoms similar to ADHD. Identification of these other conditions may require psychological testing or mental health assessment. Less commonly, further neuropsychological testing may be required. Steps 6 to 9: If the child or adolescent is determined to have ADHD without any significant coexisting condition, treatment should be initiated using the approach described below (Behavioral/Educational Treatment for Complex ADHD). If a coexisting condition is identified, treatment should be guided by the relevant algorithms that address each major coexisting condition. Behavioral/Educational Treatment for Complex Attention-Deficit/Hyperactivity Disorder (Age ≥ 6 Years) (Key Action Statement 3) Psychosocial treatments, targeting areas of functional impairment, are the foundation of treatment for children and adolescents with complex ADHD. Therefore, the Behavioral/Educational Treatment algorithm should be considered as the starting place when planning treatment, although treatment decisions should be informed by family preferences and clinical judgment, taking into consideration available resources. Step 1: All parents and patients should be provided with psychoeducation about ADHD, including information about the benefits and risks of different treatment modalities. This step is especially important, given the availability of information about ADHD on the Internet that is often misleading or inaccurate. Evidence-based psychosocial treatment should be initiated for all children and adolescents with complex ADHD. Step 2: Ongoing assessment and monitoring should be conducted using tools such as patient and family interviews, standardized questionnaires and rating scales, and reports from school to determine the extent to which the child or adolescent is experiencing continued significant impairment in key domains of functioning. ADHD-specific rating scales are essential to monitoring core ADHD symptoms. Steps 3 and 4: If a child is experiencing continued significant functional impairment, ongoing treatment decisions should take into consideration the degree of impairment, parental preference, risk/benefit of treatment options and, at times, the availability of resources to support treatment decisions. The Panel would like to emphasize that it is essential for insurers to provide coverage for evidence-based treatment options and that further efforts are required to support the development of a workforce capable of delivering evidence-based treatments to children and adolescents with ADHD wherever they live. Treatment options to be considered at Step 4 include intensified behavioral treatment (Step 7) and/or medical (pharmacological) treatment (Step 8). Steps 5, 6 and 9: Once functional impairments are adequately addressed, the child or adolescent should have ongoing maintenance monitoring, consisting of in-person clinic visits approximately every 4 to 6 months. For patients who are treated with medication, visit frequency should be every 3 to 4 months, depending on the patient's response, occurrence of side effects, and coexisting conditions. Monitoring should include at least annual screening for coexisting conditions that may develop over time and, for adolescents, screening for substance use and abuse at every visit (see Substance Use Disorder Screening algorithm below for details). Steps 7, 8, and 11: Functional impairments are likely to change over time and are often related to the child's or adolescent's developmental stage. Therefore, monitoring visits should include an assessment of function, with consideration of earlier steps (Steps 6 and/or 9) to improve function. If coexisting conditions develop, further treatment should be guided by the relevant algorithm for ADHD with a coexisting condition (Step 11). This iterative approach—identification of treatment targets based on functional impairment, initiation of treatment, and assessment of response—is central to the treatment of complex ADHD. Complex Attention-Deficit/Hyperactivity Disorder General Medication Treatment of Core Attention-Deficit/Hyperactivity Disorder Symptoms (Age ≥ 6 Years) (Key Action Statement 4) This algorithm provides a suggested approach for initiation and maintenance of pharmacological treatment of core ADHD symptoms. The algorithm is intended for treatment of children whose core ADHD symptoms represent a significant source of functional impairment. Step 1: As described elsewhere, psychosocial treatment is the foundation of treatment for children and adolescents with complex ADHD, and it is anticipated that psychosocial treatment will generally already be in place for patients who are started on pharmacological treatment. However, the decision to implement pharmacological treatment and the timing of this decision are clinical judgments based on each patient's profile of symptoms, functional impairments, and response to previous treatment, respecting family background and preferences. Step 2: The clinician should provide the patient and family with psychoeducation about pharmacological treatment of ADHD, including the benefits, risks, and side effects. Baseline ADHD-specific rating scales should be obtained before initiation of treatment, along with a baseline assessment of functional impairment. In addition, a premedication baseline assessment of ADHD medication “side effects” should be performed because many potential “side effects” actually represent symptomatology that is present before initiation of pharmacological treatment (e.g., headache, poor appetite, poor sleep quality, and abdominal pain). It is important to identify specific target symptoms and treatment goals to inform ongoing assessment of treatment progress. Step 3: Initial pharmacological treatment should generally be with either of the 2 classes of stimulant medication (methylphenidate or amphetamine) at the lowest formulated dose. The following factors should be considered when selecting a medication: History of response to previous treatment with medication Duration of desired effect (length of school day, homework, and afterschool activities; intermediate-release preparations [6–8 hours] vs extended-release preparations [10–12 hours]) Ability to swallow pills Potential for abuse/misuse/diversion (tablet and beaded formulations have higher potential than osmotic-controlled release oral delivery system, prodrug, or dermal formulations) Step 4: Treatment effects should be assessed using ADHD-specific rating scales such as the Vanderbilt2 Assessment Scale to assess changes in core ADHD symptoms. Assessment of functional impairment should be based on information from parent/child interview, reports from school, and, where possible, ratings of functional impairment such as the Clinical Global Improvement3 or the Impairment Rating Scale.4 Significant improvement, by convention, may be represented by the following: >25% decrease in parent or teacher Vanderbilt total or relevant subscale score Patient no longer meets 6/9 positive items criteria on relevant Vanderbilt subscale, reported by the parent or teacher ≥1 category increase in parent-rated OR teacher-rated Clinical Global Improvement score Patient has met or maintained a satisfactory level of symptoms and functioning In addition, however, a general principle should be to titrate treatment to maximal effect with minimal side effects. There is no single optimal approach to initiation and titration of medication. In some situations, the initial choice of medication and dose may be effective. However, it is more typical for adjustments in medication dose or trials of a second or third medication option to be required before an optimal response is achieved. In general, treatment should be initiated with the lowest reasonable dose, with upward titration at approximately weekly intervals until target symptoms and function are maximally improved or intolerable side effects occur. Clinicians may wish to consider the following scheme as 1 possible option for initiation of medication: Attention-deficit/hyperactivity disorder rating scales and side effect rating scales administered at pretreatment baseline and weekly on Fridays for 4 weeks Parent to inform the teacher “We will be making frequent changes to student's treatment this month, so it will be important to get your feedback every week about student's performance” but otherwise keep the teacher blinded as to the child's medication condition Week 1: Start at the lowest dose on Saturday; follow up by phone or email at the end of week or if significant side effects are noted Week 2: Increase to next dose if equivocal effectiveness and minimal/tolerable side effects Week 3: Discontinue medication; keep the teacher blinded Week 4: Resume most recent dose and complete in-person follow-up visit Side effects should be characterized by type and severity: Minimal/Tolerable Side Effects Side effects rated as “mild” (e.g., appetite suppression and delayed sleep onset without significant reduction in duration of sleep; see exclusions) Side effects rated as “moderate” but are able to be mitigated by appropriate education and/or other strategies (e.g., increasing caloric density to manage decreased appetite; change in medication timing or formulation to manage sleep onset delay) Exclusions: any significant side effect Significant Side Effects Any suicidal ideation Any hallucinations or psychotic thoughts Moderate to severe aggression or irritability that is not associated with the medication wearing off Moderate to severe irritability, mood lability or mania Weight loss >2 graphed percentile categories since the start of medication treatment Atomoxetine: jaundice Alpha agonist: significant daytime sedation (unable to wake up, constantly falling asleep); >10 point decrease in blood pressure or evidence of postural hypotension Steps 5 to 8: Steps 5 through 8 describe potential results of the assessment of response (progress toward treatment goals) and occurrence of side effects. Step 5 (inadequate progress toward treatment goals and targets, with minimal side effects) leads to an iterative process of adjustments in treatment, with the overall goal of achieving treatment goals with minimal side effects. During this process, an in-person assessment is recommended within the first 4 to 6 weeks of treatment to assess for side effects, to obtain vital signs and weight, and to perform a cardiac examination. When treatment is deemed to have achieved treatment goals/targets with minimal side effects (Step 6), treatment is continued with ongoing monitoring. Steps 7 and 8 represent distinct patterns of response to treatment and/or side effects, with subsequent treatment decisions as indicated in the algorithm. Step 9: While adjusting medication doses during the medication titration process, it is important to continue appropriate psychosocial treatment and to consider adjustments in psychosocial treatment. Steps 10 to 13: When treatment goals are achieved, medication and psychosocial interventions are continued, and the child or adolescent is seen for in-person clinic visits every 3 to 4 months to monitor response to treatment, occurrence of side effects, and, on at least an annual basis, to screen for development of coexisting conditions. For adolescents, monitoring visits should include screening for substance use. Steps 11 and 12: These steps highlight the importance of assessing for the occurrence of side effects to medication. Often, milder side effects can be managed or tolerated as described earlier. More severe or intolerable side effects require consideration of other medications and/or intensified psychosocial treatment. Step 13: If, in the course of maintenance monitoring, the patient's level of function deteriorates, treatment becomes ineffective, or new coexisting conditions are identified, treatment should be guided by earlier steps of the algorithm as appropriate (i.e., returning to Step 4). Steps 14 to 16: If the child or adolescent has stable symptoms and functional status with minimal side effects, maintenance monitoring continues. If the treatment targets and acceptable function are not maintained, special consideration should be given to a more detailed assessment for new coexisting conditions. If a coexisting condition is identified, treatment should proceed according to the relevant algorithm. If no coexisting condition is identified, medication treatment choices and psychosocial intervention and intensity should be reconsidered as described in earlier steps. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AND COEXISTING CONDITIONS In the following sections, we provide annotations for the algorithms describing the process of care for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and an identified coexisting condition. There are several general principles that should be considered when caring for patients with ADHD plus a coexisting condition: When a coexisting condition is identified, an assessment should be completed to determine whether the coexisting condition is equally, less, or more impairing than the impairment associated with ADHD itself. Treatment should target the major source of functional impairment (i.e., ADHD vs the coexisting condition) in specific domains (e.g., academic problems, difficulty getting along with peers, and noncompliance with teachers and parents). When both conditions are equally impairing, the decision of which condition to treat first should be made with the patient and family using principles of shared decision-making. An assessment of the degree of impairment attributable to ADHD versus impairment associated with the coexisting condition will be aided by the use of questionnaires specific to the coexisting condition. An analysis of the child's or adolescent's function in key domains (educational, behavioral, and social) may be needed to determine the most important source of functional impairment. This assessment is essential to identify treatment targets and goals. The overarching goal of the algorithms for the treatment of ADHD and coexisting conditions is to facilitate a systematic approach that focuses on improvement in function across domains. This is an iterative process that takes place over time, given that the source of functional impairment will inevitably change based on the unique profile and environment of the child or adolescent, including changes related to different developmental stages (preschool, school-age, and adolescence). When treatments are successful in addressing the primary source of a patient's impairment (e.g., core ADHD symptoms), there are often “residual” or novel impairments in other domains of functioning that may be attributable to a coexisting condition (e.g., aggression). These residual impairments will then become the targets of additional or modified treatment approaches. The algorithms for ADHD with coexisting conditions are not intended to be detailed comprehensive guidelines for the treatment of the specific coexisting condition (e.g., anxiety, depression). Rather, they are intended to help the clinician to identify treatment goals at a given point in the treatment process, based on the patient's most concerning problems and impairments. Clinicians should consult primary sources and guidelines for these conditions. Attention-Deficit/Hyperactivity Disorder and Coexisting Autism Spectrum Disorder Step 1: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosing ADHD and coexisting autism disorder is It is important to the different that symptoms of and ADHD in the In general, of are made in and of ADHD are more made in it is more likely that symptoms of will be before of children for ADHD is symptoms of may be more or In with other health conditions (e.g., sleep and may to observed that may be with primary symptoms of ADHD. These conditions should be considered as potential for and in children and adolescents with Step 2: It is beyond the scope of this guideline to provide detailed information on the assessment and treatment of However, it is important for the clinician to that children and adolescents are appropriate treatment for in all before making a about the extent to which ADHD symptoms may represent a source of functional impairment. Steps 3 and 4 Steps 7, and 11: If impairing symptoms of ADHD do not implementation of treatment for further care is on maintenance monitoring of overall including assessment for of impairing symptoms of ADHD and/or other coexisting conditions. information about the ongoing monitoring of is beyond the scope of this Steps 5: The approach used in a functional behavioral analysis (i.e., of along with and to specific to an accurate of the factors that are to in function. To determine whether functional impairments are attributable to ADHD or to coexisting a formal may be required. In some it may be to determine which of symptoms are the primary source of functional impairment. In these situations, the clinician will to consider treatment of both the ADHD and symptoms. Step 8: When impairing symptoms of ADHD appropriate behavioral and other treatment for Step consideration should be given to pharmacological treatment for ADHD as the General Medication Treatment Steps 6 and with ADHD and coexisting may impairing symptoms of irritability, or other that require more behavioral treatment. When these symptoms are behavioral pharmacological treatment with may be of treatment with is beyond the scope of this Steps and 11: When impairing symptoms of other coexisting conditions are treatment should be guided by other algorithms as It is important to that other health conditions (e.g., sleep may to observed that may be with primary symptoms of ADHD. This guideline not include algorithms for treatment of these other conditions. Attention-Deficit/Hyperactivity Disorder and Coexisting Steps 1 and 2: This algorithm is intended for children and adolescents with or severe which are more likely to be associated with ADHD and with other coexisting It is important for the clinician to consider other or (e.g., and in the of It is also important to that are common in the general and are more common among with ADHD. may at the at which stimulant medications are and it should not be that onset of is by stimulant this is important information to with parents when ADHD pharmacological treatment is with ADHD and coexisting require careful consideration of treatment For children with ADHD and or severe it may be appropriate to consider doses of stimulant medication with of an Steps 4 to and adolescents with ADHD and coexisting are at a for disorders and the related For children with ADHD, and anxiety, treatment should be guided by the ADHD and Coexisting algorithm. It is also important to that insufficient sleep may anxiety, ADHD symptoms, and Step The clinician should determine whether or ADHD symptoms are functional impairment. This requires the of the child or adolescent and or parents because there may be in associated with may include poor functional because of and/or efforts to or Step 8: is among treatment strategies for ADHD with coexisting disorders because of the availability of Therefore, treatment recommendations in this algorithm reflect the opinion of the Treatment of should include Behavioral for at times with medications based on clinical about the and functional of the Treatment for is by the that and on its making it to the effectiveness of treatment. available treatments are so treatment goals for than of It is important to the development of and strategies in patients with ADHD and coexisting Step 9: When assessing response to pharmacological treatment of it is important to that response to may have a of weeks before a effect on suppression is Steps 10 to 13: When assessing the of treatment, the clinician consider both the response (i.e., progress toward treatment goals and and any side effects of treatment that Steps 10 to are to facilitate clinical about treatment response and of side effects in a systematic with Step 10 and to subsequent steps as indicated in the algorithm. Step This step titration of medication. Steps and Treatment is continued when deemed based on assessment of and related functional impairments. this the clinician should also determine whether residual ADHD symptoms are impairment and whether pharmacological treatment for ADHD should be Step When continue to be significant and impairing behavioral and pharmacological treatment with an consideration should be given to using an (e.g., if treatment has been with a to a When and related impairments are severe and have not to behavioral treatment and pharmacological treatment with an