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## Complete Summary

#### GUIDELINE TITLE

Diagnosis and management of attention deficit hyperactivity disorder in
primary care for school age children and adolescents.

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of attention deficit hyperactivity disorder in primary care
for school-age children and adolescents. Bloomington (MN): Institute for
Clinical Systems Improvement (ICSI); 2007 Mar. 68 p. \[135 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of
attention deficit hyperactivity disorder in primary care for school age
children and adolescents. Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Jan. 69 p.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [August 21, 2006, Dexedrine (dextroamphetamine
    sulfate)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Dexedrine):
    Changes to the BOXED WARNING, WARNINGS and PRECAUTIONS sections of
    the prescribing information.

-   [September 29, 2005, Strattera
    (atomoxetine)](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Strattera):
    Manufacturer asked to revise the prescribing information to include
    a boxed warning and additional warning statements that alert health
    care providers of an increased risk of suicidal thinking in children
    and adolescents.

-   [August 2005,
    Adderall](http://www.fda.gov/cder/drug/infopage/adderall/default.htm):
    Return to Canadian market after February 2005 marketing suspension.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Attention deficit hyperactivity disorder (ADHD)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Public Health Departments\
Social Workers

#### GUIDELINE OBJECTIVE(S)

-   To increase the use of Diagnostic and Statistical Manual of Mental
    Disorders, Fourth Edition (DSM-IV) or Diagnostic and Statistical
    Manual for Primary Care (DSM-PC) criteria and screening for other
    primary conditions and comorbidities for patients newly diagnosed
    with attention deficit hyperactivity disorder (ADHD)

-   To improve the primary care use of first-line medications through a
    systematic, uniform approach

-   To increase the number of clinicians who are utilizing a
    multimodality approach in treatment planning for children with
    attention deficit hyperactivity disorder (ADHD)

-   To ensure that all patients diagnosed with ADHD are accurately
    evaluated and appropriately managed, whether by the primary
    clinician or through subspecialty consultation

#### TARGET POPULATION

Children and adolescents from kindergarten through 12th grade with
suspected or diagnosed attention deficit hyperactivity disorder (ADHD)
in the primary care setting

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Evaluation of key features of attention deficit hyperactivity
    disorder (ADHD) using Diagnostic and Statistical Manual of Mental
    Disorders, Fourth Edition/Diagnostic and Statistical Manual for
    Primary Care (DSM-IV/DSM-PC) criteria

2.  Assessment of and screening for other primary conditions and
    comorbidities

3.  Coordination of care with subspecialties as indicated for those
    patients with ADHD and a comorbid condition

**Management**

1.  Multimodal management of ADHD by the primary care physician

2.  Education of key individuals (parents/family, child, and school
    personnel)

3.  Non-pharmacological interventions including social skills training,
    cognitive-behavioral therapy, and study/organizational skills
    training

4.  First-line medications including psychostimulants (methylphenidate,
    dex-methylphenidate, dextroamphetamine, and amphetamine salts) and a
    norepinephrine reuptake inhibitor atomoxetine

5.  Second-line medications including tricyclic antidepressants
    (imipramine, desipramine), alpha adrenergic agonists (clonidine,
    guanfacine), and nontricyclic antidepressant (bupropion)

6.  Maintenance and continuing care

#### MAJOR OUTCOMES CONSIDERED

-   Prevalence of other primary conditions and comorbid conditions in
    children with attention deficit hyperactivity disorder (ADHD)

-   Academic and cognitive performance

-   Behavioral and symptom response to therapy

-   Development of compensation skills

-   Adverse effects of drug therapy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A literature search of clinical trials, meta-analysis, and systematic
reviews is performed.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Key conclusions (as determined by the work group) are supported by a
conclusion grading worksheet that summarizes the important studies
pertaining to the conclusion. Individual studies are classed according
to the system presented below, and are designated as positive, negative,
or neutral to reflect the study quality.

**Conclusion Grades**:

**Grade I**: The evidence consists of results from studies of strong
design for answering the question addressed. The results are both
clinically important and consistent with minor exceptions at most. The
results are free of any significant doubts about generalizability, bias,
and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.

**Grade II**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is some
uncertainty attached to the conclusion because of inconsistencies among
the results from the studies or because of minor doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from weaker
designs for the question addressed, but the results have been confirmed
in separate studies and are consistent with minor exceptions at most.

**Grade III**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is substantial
uncertainty attached to the conclusion because of inconsistencies among
the results of different studies or because of serious doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from a
limited number of studies of weak design for answering the question
addressed.

**Grade Not Assignable**: There is no evidence available that directly
supports or refutes the conclusion.

**Study Quality Designations**

The quality of the primary research reports and systematic reviews are
designated in the following ways on the conclusion grading worksheets:

**Positive**: indicates that the report or review has clearly addressed
issues of inclusion/exclusion, bias, generalizability, and data
collection and analysis.

**Negative**: indicates that these issues (inclusion/exclusion, bias,
generalizability, and data collection and analysis) have not been
adequately addressed.

**Neutral**: indicates that the report or review is neither
exceptionally strong nor exceptionally weak.

**Not Applicable**: indicates that the report is not a primary reference
or a systematic review and therefore the quality has not been assessed.

**Classes of Research Reports**:

A.  Primary Reports of New Data Collection:

> Class A:

-   Randomized, controlled trial

> Class B:

-   Cohort study

> Class C:

-   Nonrandomized trial with concurrent or historical controls

-   Case-control study

-   Study of sensitivity and specificity of a diagnostic test

-   Population-based descriptive study

> Class D:

-   Cross-sectional study

-   Case series

-   Case report

B.  Reports that Synthesize or Reflect upon Collections of Primary
    Reports:

> Class M:

-   Meta-analysis

-   Systematic review

-   Decision analysis

-   Cost-effectiveness analysis

> Class R:

-   Consensus statement

-   Consensus report

-   Narrative review

> Class X:

-   Medical opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

**New Guideline Development Process**

A new guideline, order set, and protocol is developed by a 6- to
12-member work group that includes physicians, nurses, pharmacists,
other healthcare professionals relevant to the topic, along with an
Institute for Clinical Systems Improvement (ICSI) staff facilitator.
Ordinarily, one of the physicians will be the leader. Most work group
members are recruited from ICSI member organizations, but if there is
expertise not represented by ICSI members, 1 or 2 members may be
recruited from medical groups or hospitals outside of ICSI.

The work group will meet for seven to eight three-hour meetings to
develop the guideline. A literature search and review is performed and
the work group members, under the coordination of the ICSI staff
facilitator, develop the algorithm and write the annotations and
footnotes and literature citations.

Once the final draft copy of the guideline is developed, the guideline
goes to the ICSI members for critical review.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Clinical Validation-Pilot Testing\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

**Critical Review Process**

Every newly developed guideline or a guideline with significant change
is sent to ICSI members for Critical Review.  The purpose of critical
review is to provide an opportunity for the clinicians in the member
groups to review the science behind the recommendations and focus on the
content of the guideline. Critical review also provides an opportunity
for clinicians in each group to come to consensus on feedback they wish
to give the work group and to consider changes necessary across systems
in their organization to implement the guideline.

All member organizations are expected to respond to critical review
guidelines. Critical review of guidelines is a criterion for continued
membership within the Institute for Clinical Systems Improvement (ICSI).

After the critical review period, the guideline work group reconvenes to
review the comments and make changes, as appropriate. The work group
prepares a written response to all comments.

**Approval**

Each guideline, order set, and protocol is approved by the appropriate
steering committee. There is one steering committee each for
Respiratory, Cardiovascular, OB/GYN, and Preventive Services. The
Committee for Evidence-based Practice approves guidelines, order sets,
and protocols not associated with a particular category. The steering
committees review and approve each guideline based on the following:

-   Member comments have been addressed reasonably.

-   There is consensus among all ICSI member organizations on the
    content of the document.

-   Within the knowledge of the reviewer, the scientific recommendations
    within the document are current.

-   Either a critical review has been carried out, or to the extent of
    the knowledge of the reviewer, the changes proposed are sufficiently
    familiar and sufficiently agreed upon by the users that a new round
    of critical review is not needed.

Once the guideline, order set, or protocol has been approved, it is
posted on the ICSI Web site and released to members for use. Guidelines,
order sets, and protocols are reviewed regularly and revised, if
warranted.

**Revision Process of Existing Guidelines**

ICSI scientific documents are revised every 12 to 36 months as indicated
by changes in clinical practice and literature. Every 6 months, ICSI
checks with the work group to determine if there have been changes in
the literature significant enough to cause the document to be revised
earlier than scheduled.

Prior to the work group convening to revise the document, ICSI members
are asked to review the document and submit comments. During revision, a
literature search of clinical trials, meta-analysis, and systematic
reviews is performed and reviewed by the work group. The work group will
meet for 1-2 three-hour meetings to review the literature, respond to
member organization comments, and revise the document as appropriate.

If there are changes or additions to the document that would be
unfamiliar or unacceptable to member organizations, it is sent to
members to review prior to going to the appropriate steering committee
for approval.

**Review and Comment Process**

ICSI members are asked to review and submit comments for every
guideline, order set, and protocol prior to the work group convening to
revise the document.

The purpose of the Review and Comment process is to provide an
opportunity for the clinicians in the member groups to review the
science behind the recommendations and focus on the content of the order
set and protocol. Review and Comment also provides an opportunity for
clinicians in each group to come to consensus on feedback they wish to
give the work group and to consider changes needed across systems in
their organization to implement the guideline.

All member organizations are encouraged to provide feedback on order
sets and protocol, however responding to Review and Comment is not a
criterion for continued membership within ICSI.

After the Review and Comment period, the work group reconvenes to review
the comments and make changes as appropriate. The work group prepares a
written response to all comments.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC) and the Institute
for Clinical Systems Improvement (ICSI)**: For a description of what has
changed since the previous version of this guidance, refer to \"[Summary
of Changes Report \-- March
2007](http://www.icsi.org/adhd/adhd__summary_of_changes_.html).\"

The recommendations for the diagnosis and management of attention
deficit hyperactivity disorder (ADHD) in primary care for children and
adolescents are presented in the form of two algorithms accompanied by
detailed annotations. The [Evaluation Algorithm for Attention Deficit
Hyperactivity
Disorder](http://www.guideline.gov/algorithm/5843/NGC-5843_1.html) has
12 components; the [Management Algorithm for Attention Deficit
Hyperactivity
Disorder](http://www.guideline.gov/algorithm/5843/NGC-5843_2.html) has
an additional 14 components (for a total of 26 components). Clinical
highlights and selected annotations (numbered to correspond with the
algorithm) follow.

Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not
Assignable) definitions are repeated at the end of the \"Major
Recommendations\" field.

**Clinical Highlights and Recommendations**

-   Evaluate children/adolescents suspected of having ADHD based on
    Diagnostic and Statistical Manual of Mental Disorders, Fourth
    Edition/Diagnostic and Statistical Manual for Primary Care
    (DSM-IV/DSM-PC) diagnostic criteria using consistent and appropriate
    diagnostic tools. (*Annotation #4*)

-   Screen all patients for other primary conditions or comorbidities
    and appropriately refer to subspecialty consultation for further
    evaluation. (*Annotation #5*)

-   Coordinate a simultaneous multimodal management plan that involves
    parent, child, and school-focused interventions. (*Annotation #14*)

-   Establish communication and intervention linkages with related
    systems (e.g. schools, mental health) (*Annotations #16, 17, 18*)

-   Establish appropriate use of medications in both initial and ongoing
    management of patients with ADHD. (*Annotation #20*)

-   Provide consistent and comprehensive monitoring and care
    coordination for all patients with ADHD including pharmacologic and
    non-pharmacologic interventions, identification and management of
    emerging comorbidities, and the impact of ADHD condition on
    patients, their families, and schools. (*Annotation #24*)

[**Evaluation Algorithm
Annotations**](http://www.guideline.gov/algorithm/5843/NGC-5843_1.html)

1.  **Learning/Behavior Problems (Suspect ADHD)**

> **Key Points**:

-   Children may be referred for evaluation of learning problems,
    behavior problems, or specifically ADHD.

-   The intensity and prominence of individual ADHD symptoms vary in
    relation to a child\'s age, developmental stage, and academic level.

> Children may be referred for an ADHD evaluation by a variety of
> individuals for a variety of reasons. ADHD can present in many
> fashions either at home or in the school setting. Furthermore,
> presenting symptoms may vary depending on the age of the child, evolve
> predictably with development, and change relative to academic demands
> at different grade levels. Although the core symptoms of inattention,
> impulsivity and hyperactivity are characteristic, their severity and
> pattern are highly variable across individuals.
>
> ***Evidence supporting these recommendations is of classes: B, C, R***

4.  **Evaluate for Key Features of ADHD Using DSM-IV/DSM-PC Criteria**

> **Key Points**:

-   Evaluation of primary symptoms should include information from
    multiple sources such as parents/caregivers, the child, and school
    personnel.

-   Three subtypes of ADHD are described based on the predominance of
    presenting symptoms: Predominantly Inattentive Type, Predominantly
    Hyperactive Impulsive Type, Combined Type.

-   Criteria related to age of onset, duration, pervasiveness of
    symptoms, and impairment should be considered in establishing the
    diagnosis of ADHD.

> The evaluation of primary symptoms should include information from
> multiple sources such as parents, the child, and school personnel. A
> comprehensive interview with parents or caregivers including current
> symptoms and their previous history, past medical and developmental
> history, school and educational history, family and psychosocial
> history is most important. There is no single evaluation tool
> available to make a definitive diagnosis of ADHD. The diagnosis is
> based on a clinical picture of early onset, significant duration and
> pervasiveness, and causing functional impairment within the life of
> the child or adolescent. This can be facilitated through the use of a
> semistructured interview or questionnaire with behavior rating scales
> completed by the parents, other caregivers, and school personnel.
>
> The American Academy of Pediatrics (AAP) has developed a tool kit to
> assist clinicians in providing quality care for children with ADHD.
> This resource provides a basis for a coordinated multidisciplinary
> system of care including primary care professionals, school personnel,
> parents, and children. Ordering information may be obtained by
> accessing their web site:
> [www.aap.org/bookstore](http://www.aap.org/bst/index.cfm?DID=15) or
> calling 1-888-227-1770. In addition, the NICHQ/Vanderbilt Assessment
> Scale is available as a non-normative referenced screening
> questionnaire.
>
> The *Diagnostic and Statistical Manual of Mental Disorders, Fourth
> Edition* (*DSM-IV*), is recognized as the most widely used resource
> for diagnosis of mental disorders, including ADHD. Alternatively, a
> manual designed for use in primary care practice, the *Diagnostic and
> Statistical Manual for Primary Care* (*DSM-PC*): *Child and Adolescent
> Version*, is now available. The DSM-PC is designed to bridge the gap
> between pediatric primary care and mental health services. It contains
> the DSM-IV criteria for childhood mental health disorders including
> ADHD and related conditions, but also contains useful information on
> the developmental continuum of behavior, from normal variations to
> mental disorders.
>
> **Note**: The DSM-IV TR (2000) is an updated version with no changes
> to ADHD criteria.
>
> Other components of the evaluation are described at subsequent points
> within the original guideline document.
>
> **Symptoms**
>
> ADHD is categorized by the following core symptoms:

-   Inattention

-   Hyperactivity

-   Impulsivity

> Refer to DSM-IV/DSM-PC criteria in the original guideline document for
> specific behavioral symptoms.
>
> There are 3 subtypes of the disorder based upon the \"often\"
> occurrence of at least six of nine behaviors within the inattention
> dimension, and six of nine behaviors within the combined
> hyperactivity/impulsivity dimension:

-   Predominantly inattentive type (meeting criteria for the inattention
    dimension)

-   Predominantly hyperactive/impulsive type (meeting criteria for the
    hyperactive/impulsive dimension)

-   Combined type (meeting criteria for both dimensions)

> **Onset**
>
> Some behavioral symptoms typically have begun prior to the age of
> seven years in most children (see DSM-IV/DSM-PC criteria in the
> original guideline document). These symptoms may not be obvious in
> children who are predominantly inattentive without significant
> hyperactivity or impulsivity. Previous history must be reviewed
> carefully, especially in older children and adolescents, for the
> presence of symptoms not previously recognized or identified.
>
> **Duration**
>
> The presence of behavioral symptoms is typically of long duration (at
> least six months - see DSM-IV/DSM-PC criteria in the original
> guideline document) and previously recognized by parents, teachers, or
> the patient. Careful review of previous symptoms is critical for
> evaluation of the presence or absence of symptoms not otherwise
> identified by parents, school personnel, or other caregivers. It is
> also helpful to assess the characteristics of previous observers with
> respect to the validity of information (e.g., specific teacher
> qualities, home and class room environment).
>
> **Pervasiveness**
>
> Due to the relationship of ADHD symptoms to the external environment,
> specific interest and motivation, individual demands on attention and
> focus, and day-to-day influences, there can be significant variability
> within a given child. Nevertheless, ADHD behaviors are typically
> present in more than one setting (e.g., home, school, play, or work --
> see the DSM-IV/DSM-PC criteria).
>
> **Impairment**
>
> ADHD symptoms present in varying degrees of severity and impairment,
> depending upon individual characteristics and demands. It is important
> to assess the degree of impairment as the ADHD symptoms relate to the
> child\'s or adolescent\'s social, academic, or family functioning (see
> DSM-IV/DSM-PC criteria in the original guideline document).
>
> A word about behavior rating scales:
>
> At least one standardized rating scale (see the original guideline
> document) is recommended for reviewing observations from those persons
> in direct contact with the child/adolescent (parents, day care
> providers, teachers, etc.) These observations/ratings should be used
> as part of the overall historical data base and should not be the sole
> criteria used to include or exclude the diagnosis of ADHD. Caution
> should be used in interpreting these due to observer bias, threshold
> of problem identification, and lack of observer knowledge (especially
> true of older children/adolescents in middle or upper grades). **The
> ADHD Rating Scale IV is normed based on DSM-IV/DSM-PC criteria and
> available for current use**. (Refer to the list of knowledge products
> in the Support for Implementation section of the original guideline
> document).
>
> A word about continuous performance tasks:
>
> Various continuous performance tasks (CPTs) have been developed to
> attempt to objectively measure sustained and selective attention: for
> example, Test of Variables of Attention (TOVA), Gordon Diagnostic
> System, Conners CPT, etc. These tasks involve the rapid presentation
> of stimuli where subjects are asked to respond to specific targets.
> The results measure certain variables of attention related to errors
> of omission and commission. Although these instruments appear to
> discriminate between children with ADHD and their normal counterparts
> at a group level, the usefulness of these measures in assessing
> individual children is limited. Due to significant false negative
> rates (estimated at 15-30%), these instruments are not considered
> pathognomonic of ADHD and are of limited utility in screening and
> evaluation. They are most useful in research settings and the complex
> individual patient where more extensive data may be useful.
>
> ***Evidence supporting this recommendation is of classes: C, R***

5.  **Screen for Other Primary Conditions and Assess for Comorbidities**

> **Key Points**:

-   Many children can exhibit symptoms of ADHD at some point in their
    development, but it is important to note that common symptoms
    (inattention, hyperactivity, disruptive behavior, academic
    difficulty) can be caused by a number of other difficulties.

-   One in every three to four children with ADHD has a learning
    disability.

-   Screen regarding academic functioning and refer for a formal
    psychoeducational assessment if warranted.

-   Assess ADHD symptoms in the context of a child\'s academic
    performance in order to determine if symptoms are related to
    learning abilities (i.e., learning problems, low IQ, high IQ), ADHD,
    or some combination.

> Many children can exhibit symptoms of ADHD at some point in their
> development, but it is important to note that common symptoms
> (inattention, hyperactivity, disruptive behavior, academic
> difficulty), can be caused by a number of other difficulties. At this
> stage of the process, the clinician must consider diagnoses other than
> ADHD in one of two paradigms. Some patients will meet the criteria for
> ADHD but will also have a **comorbid diagnosis or diagnoses (\"primary
> ADHD\" with comorbidity)**. Other patients will have a diagnosis other
> than ADHD that largely accounts for the behavioral symptoms of
> inattention, impulsivity, and/or hyperactivity. The latter instance
> can be conceptualized with an **alternative diagnosis as \"primary\"
> with secondary features that mimic ADHD**.
>
> Because of extensive comorbidity, the evaluation of children referred
> for problems with attention, impulse control or hyperactivity should
> include biobehavioral, developmental, psychological, psychosocial,
> educational and speech/language components.
>
> If issues comorbid to ADHD are not identified and addressed they may
> complicate and worsen the child\'s level of functional impairment and
> lead to higher morbidity with a poorer prognosis. Research suggests
> that ADHD subgroups might be delineated based on patterns of
> comorbidity. These distinct subgroups may have different clinical
> courses, pharmacologic responses and risk factors. Proper
> identification of comorbid conditions can lead to appropriate
> refinements in treatment planning.
>
> One way to get at comorbidity is by using standardized screening
> instruments such as the Child Behavior Checklist. It is important to
> note that this instrument serves a screening function and is not meant
> to be diagnostic for any specific condition. Training is recommended
> to effectively and appropriately score and interpret these
> instruments. Other, more specific, instruments including the
> Children\'s Depression Inventory, the Revised Children\'s Manifest
> Anxiety Scale and the Academic Performance Rating Scale may best be
> utilized in consultation with a qualified mental health professional.
>
> Differentiating ADHD from an alternative primary condition such as
> oppositional-defiant disorder, generalized anxiety disorder, or a
> specific learning disability can be difficult even for seasoned
> clinicians. Therefore the diagnosis of ADHD should be applied with
> care and caution, only after an appropriately thorough evaluation.
>
> In screening children and adolescents for other diagnoses, it is
> important to emphasize the need to include information from as many
> sources as possible: the patient, parents, teachers, coaches, and
> health care professionals.
>
> Screening patients for other diagnoses falls into the five basic
> domains defined in A-E of this annotation.
>
> There are a number of possible strategies to consider in the
> comprehensive screening of the ADHD patient for other problems. One is
> for the primary care provider to utilize his or her ongoing
> familiarity and relationship with the family and patient over time to
> get a sense of any primary or comorbid problems identifiable in the
> five areas defined in A-E of this annotation.
>
> A second strategy would be to use a semi-structured interview format
> with some \"key\" questions designed to get at the disorders
> identified in the five previously described domains.
>
> Another strategy includes the use of \"screening\" questionnaires
> which, although not diagnostic, can offer a general sense of potential
> areas for concern. Examples of utilized instruments are the
> **Achenbach Child Behavior Checklist (CBCL), Teacher Report Form
> (TRF), Youth Self-Report, Devereux Scales of Mental Disorders (DSMD),
> and the Behavioral Assessment System for Children (BASC)**. These
> forms are scored across a number of behavioral domains. Clients who
> receive scores above a certain cutoff point in any given domain might
> then be considered for more intensive evaluation around that problem
> area. Using the instrument properly requires some training.
> Consultation with a psychologist for assistance in interpretation may
> be helpful. For additional information, refer to Annotation #5 in the
> original guideline document.
>
> For those patients suspected of other conditions or comorbidities,
> continued assessment is necessary to confirm or exclude such
> conditions. In these cases further investigation, including
> subspecialty consultation, may be needed.
>
> ***Evidence supporting this recommendation is of classes: C, R***

A.  **Biomedical Conditions**

> **Key Points**:

-   A health history and a physical/neurological/developmental
    assessment are necessary to identify or rule out problems in the
    biomedical realm of the ADHD differential diagnosis.

-   Based on the history and physical examination, further work-up may
    be indicated in areas such as genetic or chromosomal, neurological,
    or biomedical conditions.

> Note: the screening for the 5 domains (Annotations #5A-E) will provide
> data to suspect a differential diagnosis or data to suspect a
> diagnosis of ADHD.
>
> A health history and a physical/neurological/developmental assessment
> are necessary to identify or rule out problems in the biomedical realm
> of the ADHD differential diagnosis. Deficits in sensory areas (i.e.,
> hearing and vision) may result in classroom difficulties and produce
> restless or inattentive behaviors. Children with neuromaturational
> delays, or neurological \"soft signs\" are at risk for learning and
> behavioral disorders.
>
> ***Evidence supporting this recommendation is of class: R***
>
> **General Health History and Physical Examination, including:**

-   Growth parameters: height, weight

-   Vital signs: blood pressure, pulse

-   Screening of vision and hearing

> Special emphasis on:

-   Overall physical appearance

    -   Minor physical anomalies may signal genetic abnormalities
        (low-set ears, large or undescended testicles, high-arched
        palate, etc.)

-   Signs and symptoms of abuse

-   Neurological examination

    -   Abnormalities (e.g., motor or vocal tics, asymmetry or
        abnormality of reflexes or motor tone, tremors)

    -   \"Soft signs\"

> Subtle neurological signs including difficulty with sequencing,
> dysrhythmia, mirroring, motor overflow, and clumsiness. \"Clumsiness\"
> refers to the performance of fine and/or gross motor tasks in an
> immature, slow, irregular, or inconsistent fashion. Skills are
> imprecise rather than grossly impaired. \"Soft\" neurological signs
> are present in many children with learning and behavioral disorders.

-   Assessment of developmental status

    -   Observation of child\'s activity level in examination room,
        ability to converse appropriately, ability to follow directions,
        and cooperativeness

-   History of delays or questionable areas:

    -   Auditory perception

    -   Expressive language

    -   Visual and sequential processing

    -   Memory

    -   Fine and gross motor function

-   Cognitive screening tools

> The provider may find the following helpful. Responses are age
> dependent.

-   Ask the child to tell about a recent event -- birthday, sports
    event, etc. (Note whether language is fluent, coherent, and
    organized.)

-   Ask parent if child has difficulty taking telephone messages or
    retaining classroom instructions, if age appropriate. (short-term
    memory)

-   Observe the child using a pencil to copy symbols and words. (visual
    perceptual-motor)

-   Ask the child to perform a three-step command. (sequencing)

-   Ask the child to repeat four words, remember them, and repeat them
    again when asked in 5 minutes or 10 minutes. (memory, attention)

-   Ask the child to repeat three, then four digits forward; then repeat
    three, then four digits backward. (concentration)

> Based on the history and physical examination, further work-up may be
> indicated. Refer to the original guideline document for information.
>
> ***Evidence supporting this recommendation is of classes: C, D***

B.  **Emotional/Psychiatric Problems**

> **Key Points**:

-   Children with ADHD have increased risk for depression, anxiety
    disorders, conduct disorder, and substance abuse.

-   Clinicians should screen for these comorbid conditions during the
    interview with all ADHD patients.

-   Children with autism spectrum disorders may present with ADHD
    symptom features but the autism spectrum symptoms will be primary.

> The diagnosis of ADHD may be complicated by either the presence of
> another coexisting psychiatric condition or the existence of a
> psychiatric condition that has symptoms suggestive of the diagnosis of
> attention deficit hyperactivity disorder. It is clear that children
> with attention deficit hyperactivity disorder are at risk for the
> coexistence of depression, anxiety disorders, conduct disorders, and
> substance abuse. The prevalence of these conditions in children with
> ADHD ranges from 15 to 30 percent. At the same time it is those same
> four diagnostic entities that may most often be misdiagnosed as ADHD
> due to the commonality of many of the symptoms. Therefore, it behooves
> the clinician to screen for those four conditions when evaluating a
> child for whom the diagnosis of ADHD is being considered. If the
> clinician identifies sufficient positive symptomology after completion
> of these screening questions to raise the clinical suspicion of a
> psychiatric diagnosis, then referral to a mental health professional
> is indicated.
>
> ***Evidence supporting this recommendation is of classes: C, R***
>
> The following may be considered as a starting point in evaluating the
> possible presence of depression, anxiety disorders, conduct disorders,
> and substance abuse.
>
> **Depression**

-   Consistent depressed or irritable mood for nearly every day which
    has lasted for at least two weeks

-   Significantly diminished interest or pleasure in all or almost all
    activities

-   Undeniable decline in school or work performance

-   Recurrent suicidal ideation without a specific plan or recurrent
    thoughts of death

-   Persistent depressed mood associated with almost daily insomnia or
    hypersomnia

> **Childhood Mania-Juvenile Bipolar Disorder**
>
> Recent experience suggests an overlap between ADHD and juvenile
> mania-bipolar disorder. The following are characteristics of childhood
> mania that may aid the clinician in differentiating the 2 conditions:

-   Mania-bipolar disorder is extremely rare when compared to ADHD.

-   Patient experiences pressured speech, racing thoughts, grandiosity,
    reduced need for sleep.

-   Symptoms include rapid onset affective storms, prolonged severe
    temper outbursts, violent furious aggression, irritability, erratic
    interpersonal behavior.

-   Usually mixed presentation with depression.

> **Anxiety Disorder**
>
> The diagnosis of post traumatic stress disorder, which falls under the
> anxiety spectrum, may be the most common diagnosis that mimics ADHD.
> The most likely areas of post traumatic stress disorder are those that
> fall in the spectrum of physical or sexual abuse. Those areas should
> have been screened by taking a psychosocial history as part of the
> overall assessment. The remaining diagnoses that are likely to present
> themselves in childhood include those of separation anxiety disorder
> and generalized anxiety disorder. Screening which may be useful in
> identifying those conditions is listed below:

-   Developmentally inappropriate and excessive anxiety concerning
    separation from home or from those to whom the child is attached

-   Persistent and excessive worry about losing or about possible harm
    befalling major attachment figures

-   Repeated complaints of physical symptoms when separation from major
    attachment figures occurs or is anticipated

-   Consistent excessive dissatisfaction with less than perfect
    performances (e.g., school assignments)

-   The child finds it difficult to control or stop his or her
    worrying/anxiety.

> **Conduct Disorder**

-   Presence of negativistic, hostile, and defiant behaviors which may
    include losing temper, arguing with adults, refusing to comply with
    adults\' requests, deliberately annoying people, consistent anger
    and resentment expressed toward others

-   Presence of a history of physical aggression toward people or
    animals

-   History of deliberate involvement in theft from others

-   History of violation of rules with potential serious consequences
    (e.g., running away from home, truancy from school)

> **Substance Abuse**

-   History of use of alcohol or illicit drugs of any kind

-   Use of alcohol or drugs to alter mood state or to escape a mood
    state

-   Consequences at school, in the home, or with legal authorities
    related to the patient\'s use of alcohol or drugs

-   History of a peer expressing concern regarding the patient\'s use of
    alcohol or drugs

-   History of feeling guilty about use of alcohol or drugs

-   Behaviors suggestive of drug or alcohol use (increasing isolation
    from family/friends, presence of drug paraphernalia)

> **Pervasive Developmental Disorders** (e.g., autistic disorder,
> Asperger\'s syndrome)
>
> Although it is uncommon for ADHD to be confused with autism spectrum
> disorders, it is not uncommon for children with autism spectrum
> disorders to present with ADHD features. Typical problem areas for
> these children include:

-   Qualitative impairment in social interaction (e.g., reciprocity,
    non-verbal gesture, sharing, peer relationships)

-   Qualitative impairment in communication (e.g., language delay,
    conversational speech, idiosyncratic/stereotyped language,
    symbolic/imitative play)

-   Restrictive, repetitive patterns of behavior (e.g., preoccupations,
    rituals, self-stimulatory motor mannerisms).

C.  **Family/Psychosocial Problems**

> **Key Points**:

-   Chronic or acute stress may cause changes in a child\'s academic or
    behavioral functioning, such as mimicking ADHD symptoms or
    exacerbating existing symptoms.

-   Assess family history of mental illness. Subtypes of ADHD vary with
    type of mental illness in families.

-   Assess the family\'s functioning in terms of the nature of the
    caregiver-child interactions, impact of symptoms within the home,
    and family resources for coping.

> In addition to the evaluation of comorbid psychiatric or learning
> conditions, it is important to consider the psychosocial context in
> which the child\'s symptoms and concerns arise. Identified below are
> factors to consider and some ideas for interview questions. A thorough
> assessment of the family\'s functioning will assist in understanding
> both the nature and severity of the child\'s symptoms and the
> family\'s ability to make use of education and treatment
> recommendations. If significant family pathology is present, then
> referral to a mental health professional, family therapist, or social
> services is appropriate.
>
> **Psychosocial Stressors**
>
> The experience of chronic or acute stress may manifest in a child\'s
> functioning in a variety of ways; common symptoms include anxiety,
> dysphoria, and behavioral acting out. Any of these difficulties may
> result in changes in academic performance or behavior in the home
> environment.
>
> Sample question: Has your family been coping with other difficulties
> or stressors during the past year or two?
>
> Stressful life events may include:

-   Major life transitions or changes (move, change of school)

-   Loss (death of loved one, parental separation or divorce)

-   Abuse (sexual or physical, domestic violence)

-   Traumatic events (e.g., car accident)

> **Family History**
>
> There is increasing recognition that the subtypes of ADHD vary not
> only in patterns of comorbidity, but also with respect to genetic
> family history. Family history data suggests more ADHD, aggression,
> and substance abuse in families of children with ADHD-Hyperactive
> Impulsive subtype, whereas families of children with ADHD-Inattention
> subtype have more anxiety disorders and learning problems.
>
> Sample question: Has anyone in your family (parents, siblings, and
> extended family) been treated for\...?

-   Anxiety disorder

-   Depressive disorders (including bipolar disorder)

-   Learning/attention problems

-   Developmental delay, mental retardation, autism

-   Chemical dependency

-   Conduct problems

-   Other mental health problems

> **Quality of Caregiving**
>
> Consider the family\'s strengths and resources for coping as well as
> their beliefs and attributions concerning their child\'s difficulties.
> Also examine the effects of the child\'s symptoms on the family as a
> whole.
>
> Interview caregivers for evidence of family dysfunction or
> vulnerability. In particular, evaluate for problems which may affect
> the parents\' ability to manage behavior consistently and
> appropriately, to provide adequate nurturance and structure, and to
> accurately (meaningfully) evaluate the child\'s functioning.
>
> These problems may include:

-   Parental psychiatric disorder or chemical abuse/dependency

-   Cultural differences

-   Lack of education or information

-   Low intellectual functioning

-   The absence of family/community supports

-   Psychosocial stressors (see above)

-   Limited nurturance of child

> Sample questions:

-   What is a typical day like at your home?

-   Do you feel supported by the child\'s school and the community?

-   Who provides help with your child when you need it?

-   Is there any use of alcohol or illicit drugs in your home?

-   Tell me what you\'ve heard or learned about ADHD?

-   What kind of discipline works (or doesn\'t work) with your child?

-   When do you enjoy being with your child?

> ***Evidence supporting this recommendation is of classes: C, R***

D.  **Speech/Language Problems**

> **Key Points**:

-   If screening indicates concerns about a child\'s speech and/or
    language, including expressive and receptive language, speech
    fluency, pragmatic language, prosody, or phonology/articulation, a
    referral should be made to a pediatric speech and language
    pathologist.

-   Parents may make a request for speech screening in writing to their
    child\'s school with a copy of the request kept by the parents.
    Alternatively, the family may seek a private speech and language
    evaluation. It is helpful for primary care providers to be familiar
    with speech and language pathology resources in their community in
    order to make appropriate referrals.

-   If speech and language problems suggestive of a pervasive
    developmental disorder are present, referral should be made to
    developmental or mental health professionals with a speech and
    language pathologist as a part of the diagnostic team.

-   Children with ADHD are at higher risk for \"vocal chord abuse.\"
    When a child is found to have a chronic raspy or hoarse vocal
    quality, a referral to an otolaryngologist is recommended to look
    for vocal cord pathology such as vocal cord thickening or vocal cord
    nodules.

-   The presence of repetitive noises, throat clearing, sniffing,
    barking or coprolalia in a child with ADHD suggests comorbid
    Tourette\'s syndrome. A consultation by a pediatric neurologist,
    developmental and behavioral pediatrician, or child psychiatrist may
    be appropriate.

> Up to 50% of children with ADHD may show evidence of an expressive
> language problem. Deficits in verbal functioning may be chronic and
> are particularly common in adolescents with antisocial behavior. Any
> history of speech or language delay or services should be discussed
> and reviewed. Common difficulties include:

-   Historical or current problems with dysfluencies

-   Disorganized speech on tasks that require verbal explanations

-   Excessive, tangential, or rapid speech

-   Problems with volume modulation

-   Fragmented sentences with pauses

> Receptive language problems may also be present in children with ADHD
> or may be a comorbid condition. These children may mimic primary
> problems with attention and have problems following directions and
> retaining verbally presented material.
>
> Many children with ADHD manifest \"pragmatic language dysfunction\" in
> social situations - namely, an inability to read essential verbal,
> nonverbal, and situational cues. This can lead to a tendency to make
> socially unacceptable choices. Over 50% of children with ADHD are
> likely to have communication/interaction problems that manifest
> themselves as social skills deficits. The clinician should inquire
> about evidence of aggressive, domineering, and intrusive social
> interaction styles as well as difficulty in initiating and maintaining
> friendships, or even outright rejection by peers.
>
> If screening indicates concerns about a child\'s speech and/or
> language including expressive and receptive language, speech fluency,
> pragmatic language, prosody, or phonology/articulation, a referral
> should be made to a pediatric speech and language pathologist. Parents
> may make a request in writing to their child\'s school with a copy of
> the request kept by the parents. Alternatively, the family may seek a
> private speech and language evaluation. It is helpful for primary care
> providers to be familiar with speech and language pathology resources
> in their community in order to make appropriate referrals.
>
> Children with hearing impairments can also have ADHD exclusive of
> their hearing problems. This can be a complicated differential
> diagnosis, possibly requiring specialty referral. Children with
> hearing impairment may also present with symptoms of inattention,
> problems with task completion, disruptive behavior, noncompliance,
> speech and language problems, or a need for frequent repetition of
> information. All children being evaluated for ADHD should have had
> their hearing screened within the previous 12 months. If questions
> arise, they should be referred to an audiologist for formal
> evaluation.
>
> Children with difficulties in the pervasive developmental
> disorder/autism spectrum can sometimes present with symptoms similar
> to ADHD. Identifying features of PDD/autism from the speech/language
> standpoint include:

-   Excessive self-talk

-   Unusual intonation patterns or monotone

-   Echolalia

-   Acts as if didn\'t hear

-   Socially inappropriate behaviors (e.g., screaming, interrupting)

-   Loss of previously acquired language skills

> If speech and language problems suggestive of a pervasive
> developmental disorder are present, referral should be made to
> developmental or mental health professionals with a speech and
> language pathologist as a part of the diagnostic team.
>
> Children with ADHD are also at higher risk for \"vocal cord abuse\"
> and therefore voice quality (particularly \"hoarseness\") should be
> assessed. Children with evidence of vocal cord abuse (e.g., hoarseness
> of \> 6 months duration) may need referral to an otolaryngologist to
> evaluate for vocal cord pathology such as vocal cord thickening or
> vocal cord nodules.
>
> Patients with ADHD who have comorbid vocal tics or Tourette\'s may
> demonstrate speech patterns typical to this disorder including
> repetitive noises, throat clearing, barking or even coprolalia. A
> consultation by a pediatric neurologist, developmental and behavioral
> pediatrician, or child psychiatrist may be appropriate.
>
> ***Evidence supporting this recommendation is of classes: D, R***

E.  **Academic/Learning Problems**

> **Key Points**:

-   Approximately 25-30% of children with ADHD also have a specific
    academic skill deficit or \"learning disorder\" in achievement areas
    such as reading, written language, or mathematics.

-   Children with subnormal intelligence may appear inattentive due to a
    lack of understanding or comprehension of material; furthermore,
    these children are more likely than children of normal intelligence
    to have comorbid ADHD.

-   If history and screening indicate significant concerns with academic
    functioning, the child should undergo individual
    cognitive/psychoeducational assessment.

> Children with ADHD are at increased risk of struggling academically
> and are frequently reported as underachieving. The history should
> include information from parents and teachers to assess common
> performance areas of difficulty in children with ADHD, which include:

-   Completion of independent work in a timely fashion

-   Attention to detail

-   Studying for exams

-   Taking notes on classroom lectures

-   Organizational skills

-   Time management

-   Self-monitoring

> Empirical evidence indicates a consistent relationship between ADHD
> and learning disorders. One in every three to four children with ADHD
> has a specific academic skill deficit or \"learning disability\" in a
> traditionally defined area such as reading, written language, or
> mathematics. A learning disability is formally identified by comparing
> a student\'s IQ score to his or her scores in achievement areas and
> identifying a significant discrepancy (usually defined as 1.75 to 2
> standard deviations) between the two.
>
> Learning disabilities or disorders as currently defined in the
> DSM-IV/DSM-PC include:

-   Reading disorder

-   Mathematics disorder

-   Disorder of written expression

-   Developmental coordination disorder

> Children with subnormal intelligence may appear inattentive, due to
> their lack of understanding of and tracking with material that is too
> difficult for them. However, it is also important to note that
> children with cognitive impairment are three to four times more likely
> to have ADHD than children with intelligence scores in the normal
> range. Therefore, an IQ assessment and individual achievement testing
> may often be essential components of an ADHD evaluation. It is
> important to note that these children may be misdiagnosed as having a
> primary attention problem when in fact their symptoms are secondary to
> an inappropriate level of difficulty or stimulation in academic
> programming.
>
> It is important to review school concerns with the patient, parents,
> teachers, and other school professionals. \"Red-flags\" or common
> presenting symptoms of concern for children with learning disabilities
> or cognitive impairment could include:

-   Apparent apathy or hostility toward school

-   Avoidance of or failure in specific subject areas

-   Disruptive or negative behaviors in certain classes

-   Historical evidence of difficulty in specific skill areas

-   History of special educational services, \"Title 1\" assistance,
    etc.

-   History of early childhood service

> A sample of possible questions directed at children and their parents
> for assessing academic performance issues presenting in the context of
> an ADHD evaluation might include:

-   What subject is your favorite/easiest?

-   What subject is hardest/least favorite?

-   How do you get along with your teachers?

-   How much homework do you do on an average night? How does this
    compare to the amount of homework classmates are doing? How much do
    your parents help you with your homework?

-   What grades are you receiving in each of your classes? How does this
    compare to your grades in previous years? Have you ever failed or
    are you currently failing any classes?

-   Do you receive any special help in school?

-   What are your interests outside of school?

-   Does your son/daughter have any trouble with study/organizational
    skills?

-   What do you see as your son/daughter\'s learning style strengths?
    Weaknesses?

-   Do you think your child feels positively about school?

-   Has anyone from school ever contacted you with specific academic or
    behavioral concerns about your child?

-   Are you pleased with your child\'s grades?

-   Do you feel your son/daughter is working up to his/her potential?

> Students functioning at the \"gifted\" end of the cognitive spectrum
> may also manifest signs or symptoms of ADHD such as inattention,
> disruptive behavior, and apparent lack of motivation or engagement in
> classroom activities. It is important to note that these children can
> be misdiagnosed as having a primary attentional problem when in fact
> their symptoms are secondary to the lack of an appropriate level of
> challenge and stimulation in academic programming. Giftedness and ADHD
> may coexist, however.
>
> One of the goals of assessment is to determine whether a student\'s
> academic difficulties are due to ADHD, learning disabilities, or both.
> A second question would be whether a student presenting with symptoms
> of ADHD actually has ADHD as the primary condition or whether a
> learning style issue (e.g., learning disability) might be sufficient
> to account for the identified problem behaviors. There is a
> significant overlap between populations of students with ADHD and
> those with academic skills deficits.
>
> On average, students with ADHD do not differ substantially from the
> rest of the school age population in terms of overall intellectual
> functioning. Many of these children, however, show academic
> ***performance*** problems despite adequate ***abilities*** as
> measured by standardized tests. These children often exhibit less
> on-task behavior as compared to peers and have less opportunity to
> respond to and track with academic instruction. Growing evidence also
> suggests that the behavioral symptoms of ADHD disrupt academic skill
> acquisition and performance.
>
> One easy-to-use instrument for clinicians to screen academic
> functioning in students\' grades one through six is the Academic
> Performance Rating Scale. This instrument consists of 19
> teacher-completed items which are scored to yield four subscale
> scores: Learning Ability, Academic Performance, Impulse Control and
> Social Withdrawal. A total score of 1.5 standard deviations below the
> mean for age and gender are considered significant for screening
> purposes and warrant consideration of referral for formal educational
> assessment.
>
> If a child is referred to formal psychoeducational assessment, it is
> important to differentiate the need for IQ testing, achievement
> testing or both. IQ testing gives a general estimate of personal
> problem-solving ability based on age norms. It is important to note
> that verbal and performance (or nonverbal) abilities may differ, and
> that children with language-based disorders might be penalized for
> this on a standard IQ test such as the WISC-IV, resulting in an
> underestimation of their true ability. A less language-based
> instrument such as the Kaufman (K-ABC-II) may be preferable.
>
> Achievement testing, on the other hand, looks at a child\'s actual
> skill level in specific academic areas such as reading, spelling, or
> math as compared to either age norms or grade norms. Differences
> between predicted ability (based on IQ) and actual performance in
> specific academic skill areas (as defined by individual achievement
> test scores) are examined to identify learning disabilities, general
> underachievement, or giftedness.
>
> If screening indicates concerns about academic and/or cognitive
> functioning and appropriate testing has not been done, the patient
> should be referred for individual evaluation. Parents and primary care
> providers should communicate first with the classroom teacher and
> share concerns. Teachers often have similar concerns and welcome the
> opportunity to discuss these with the child\'s parents and physician.
> Testing and needs assessment are the responsibility of the special
> educational staff and/or school psychologist for each district.
> Parents may make a request for evaluation at any time. All requests
> for evaluations should be made in writing and dated with a copy of the
> request kept by the parent. Licensed child psychologists are also
> capable of providing this type of educational testing and cognitive
> assessment.
>
> ***Evidence supporting this recommendation is of class: R***

6.  **Does ADHD Appear to Be the Primary Diagnosis?**

> **Suspected Alternative Primary Condition**
>
> If an alternative primary diagnosis is suspected through completion of
> an appropriate evaluation and an alternative primary diagnosis is
> identified that accounts for the presenting symptoms, the patient
> would be \"out of guideline\" and would be managed or referred as
> appropriate to the condition. Possible examples might include anxiety
> disorders, depression and cognitive impairment.
>
> Patients undergoing further assessment for biomedical,
> emotional/psychiatric, family/psychosocial, speech/language and
> academic/learning problems may be identified as having a primary
> diagnosis other than ADHD that accounts for their symptoms. For these
> patients, symptoms are not due to ADHD; therefore, these patients do
> not fall within the scope of this guideline. The primary clinician is
> encouraged to coordinate care with multidisciplinary subspecialty
> consultation as indicated.
>
> **Suspected ADHD with Comorbid Condition**
>
> If ADHD is the likely primary diagnosis but a comorbid condition is
> also suspected, the clinician may choose to proceed to step 10 while
> concurrent evaluation of the suspected comorbid problem is completed.
> This would allow the clinician to continue to move into appropriate
> management strategies in a time-efficient manner. It is important to
> consider some degree of caution here in that comorbid issues can be of
> equal importance to the diagnosis of ADHD. Therefore they must be
> fully evaluated and the overlapping nature of the conditions (e.g.,
> ADHD and learning disabilities) must be considered prior to moving
> fully into the management plan. Possible examples might include
> oppositional defiant disorder, learning disability.

8.  **Any Additional Related Comorbidities Identified?**

> Patients undergoing further assessment for biomedical,
> emotional/psychiatric, family/psychosocial, speech/language, and
> academic/learning problems may be identified as having a related
> comorbidity to the primary ADHD condition.

9.  **Desire Subspecialty Consultation for ADHD Management?**

> For those patients with ADHD and a comorbid condition identified, the
> primary clinician is faced with the option of medically managing the
> ADHD component or utilizing medical subspecialty consultation. This
> decision depends on the complexity of the comorbid condition and its
> relationship to the ADHD symptoms, as well as on the individual
> clinician\'s own threshold of expertise and knowledge.
>
> The type of medical subspecialty consultation may include the
> following:

-   Child-Adolescent Psychiatry

-   Developmental-Behavioral Pediatrics

-   Pediatric Neurology

> The primary care clinician is encouraged to coordinate care between
> medical and non-medical (e.g., mental health, school/educational,
> speech/language) subspecialty consultation as indicated.

10. **DSM-IV/DSM-PC Criteria Confirmed?**

> Only after careful evaluation of the patient\'s primary symptoms and
> complete screening for any comorbidity or other primary condition is
> the clinician able to confirm the diagnosis of ADHD.

12. **ADHD Diagnostic Formulation**

> A comprehensive diagnostic formulation for a child with ADHD is
> critical so that parents clearly understand their child\'s attentional
> difficulties as part of an inclusive picture of his or her
> functioning. Findings should be presented to families within a
> biopsychosocial framework. Discussion of the ADHD diagnosis should be
> presented within the context of associated comorbid mental health
> diagnoses and issues, academic performance issues, learning
> disabilities, developmental concerns, medical diagnoses, social
> concerns, family issues, and stressors. It is crucial to discuss the
> child\'s and the family\'s strengths as well as their vulnerabilities.
>
> Adequate and appropriate treatment planning should then follow from a
> comprehensive and accurate diagnostic formulation.

[**Management Algorithm
Annotations**](http://www.guideline.gov/algorithm/5843/NGC-5843_2.html)

14. **Multimodal Management Coordinated by Primary Clinician**

> **Key Points**:

-   Refer and coordinate interventions (medication, education, behavior
    management, skills training) to address core symptoms of ADHD and
    problems that develop secondarily to ADHD symptoms.

> After accurate diagnosis of attention deficit hyperactivity disorder,
> the underlying principle of successful management includes multiple
> treatment modalities to address the multidimensional nature and
> secondary effects of the disorder and its impact on child\'s
> functioning. The primary clinician is in a unique position to
> coordinate these interventions from initial diagnosis through ongoing
> monitoring and continuing care. Subspecialty consultation at any point
> along this continuum may occur depending on the knowledge and
> expertise of the primary clinician as well as the complexity of the
> patient. Despite the need for individualized approaches, there are
> several general interventions and strategies which effectively address
> many of the common primary features of ADHD.
>
> The multimodal treatment model for ADHD allows for simultaneous
> interventions resulting in effective management for the range of
> problems children with ADHD experience. A management plan might
> include proven treatments such as parent-child education, medication,
> behavior management training, cognitive training, social skill
> training, and academic support.
>
> For core symptoms of ADHD, use of medication management alone is
> superior to behavioral treatment and to combined intervention of
> routine community care and medication. *\[Conclusion Grade I: See
> Conclusion Grading Worksheet A - Annotation #14 - (Multimodal
> Management)* in the original guideline document\].
>
> ***Evidence supporting this recommendation is of classes: A, C, M***

15. **Education of Key Individuals**

> Upon initial diagnosis of ADHD, education of key individuals including
> the parents, the child, and school personnel is imperative.
>
> For the parents, this should include information on neurologic
> mechanisms, common features of ADHD and how they relate to the
> child\'s previous and current problems, and future expectations of
> clinical course and intervention strategies. The importance of
> individual teacher selection each year should be emphasized.
>
> For the child, a developmentally appropriate explanation and
> demystification of ADHD using specific metaphors and examples is
> especially helpful. This should include not only explanation of
> related difficulties, but also discussion of the child\'s strengths
> and attributes.
>
> For school personnel in contact with the child, one should not assume
> teacher knowledge of ADHD. It is important to provide specific
> teacher-focused information for the parents to share with all
> appropriate individuals. This information not only should explain ADHD
> related to the child\'s classroom difficulties, but also should
> address appropriate intervention strategies and modifications as
> described in Annotation \# 18, \"School Interventions\"

16. **Parents/Family Focused Strategies**

> **Key Points**:

-   Parents have a unique role in ADHD management as they see their
    children in all areas of life, and have the long-term goal of seeing
    their children become successful, well-adjusted members of society.

-   Parents learn management skills through ADHD support groups,
    advocacy groups, and parenting skills training.

-   Parents find specific intervention strategies to be helpful.

> **ADHD Support Groups**
>
> These groups help parents learn more about ADHD through lectures or
> reading material and can help parents cope emotionally by
> communicating with other parents of ADHD children in a supportive
> setting. The Attention Deficit Disorder Association (ADDA) and
> Children and Adults with Attention Deficit Disorder (CHADD) are two
> such groups and have local chapters in many areas. A children\'s or
> community hospital in the area or the child\'s school or school
> district may also have a support group.
>
> **Advocacy Groups**
>
> Groups exist to help parents learn about what rights their children
> have in the educational setting and what special services are
> available for their needs. These groups can also aid in parent
> interactions with the school system and can give parents some
> direction in finding services for their children. One such group is
> Parent Advocacy for Children\'s Educational Rights (PACER). Additional
> resources are listed in the Support for Implementation/Health
> Education Resources section of the original guideline document.
>
> **Parenting Skills Training**
>
> One of the most useful strategies a parent can undertake to improve
> harmony in the home is to learn ways to modify the child\'s behavior
> in a manner consistent with school-focused behavior modification. This
> serves to give the child direction, goals and limits in hopes of
> improving compliance, behavior, self-esteem, etc. This training can be
> obtained through formal classes, books, or counseling.
>
> **Suggestions for Parents**

-   Note problem behaviors and make notations of frequency and severity
    to help make the problems more objective and to aid in monitoring
    improvements as behavioral changes are made.

-   Try to spend 10 to 15 minutes daily focusing on this child alone to
    listen and let them know they are important.

-   Set consistent schedules and routines with forewarning of any
    upcoming changes.

-   One or two simple, clear instructions should be given at a time. The
    child should repeat the instructions back to ensure comprehension.

-   Clear, concise rules should be provided for the behavior of all
    family members, with consistent follow-through of appropriate
    consequences and rewards.

-   Decrease inappropriate behavior by allowing:

    -   Natural consequences to the child\'s actions

    -   Logical consequences linked to the offending behavior

    -   Time-outs

-   Create consistent sleep habits and a restful sleep environment

-   Have a special quiet spot with few distracting influences for doing
    homework or working on projects.

-   Allow the child choices within set limits so that the child has a
    sense of some control.

-   Have the parent take a break or time-out from the child if he or she
    is becoming too frustrated or angry.

-   Make sure the child knows his or her behavior is the issue or
    problem, not the child himself or herself.

> **Comorbidity Present**
>
> In cases with significant family dysfunction or other stresses (e.g.,
> financial, health problems, chemical dependency issues) individualized
> family therapy may be more appropriate. In-home counseling may be
> available through county services.
>
> ***Evidence supporting this recommendation is of classes: A, R***

17. **Child Interventions**

> **Key Points**:

-   Consider the need for social skills training to improve peer
    relationships that are often negatively affected by ADHD symptoms
    (i.e., impulsivity).

-   Cognitive-behavioral therapy may be warranted to teach children how
    to be more reflective in problem solving.

-   Study skills and organizational skills are additional areas to
    target.

> To date, no well-designed studies have been empirically validated to
> support the use of social skills training, problem--solving training,
> or study/organizational skills training in the direct treatment of
> ADHD. Anecdotal endorsement of these interventions does exist. Using
> the same criteria for acceptance of psychosocial treatments for ADHD
> and those used for acceptance of medication treatments for ADHD is
> difficult, given the methodological limits and complexities of
> psychosocial research. Thus, the following interventions may be
> understood and most appropriate for implementation with individuals
> with ADHD when problems with social skills, problem solving, or
> organization co-occur with or develop secondarily to ADHD symptoms.
>
> The purpose of education of the child is to provide the basis for
> further independence. The person with ADHD will be managing their own
> environment and interpersonal relationships and choosing a vocation.
> Without insight and specific strategies to address this impairment,
> long-term consequences may include decreased self-esteem and poor
> problem solving. Loss of social support from peers has long-lasting
> consequences. Early intervention can avert the resulting loss of
> self-esteem and productivity.
>
> **Social Skills Training**
>
> The child\'s social skills are resources for solving the specific
> problems that arise from ADHD. Interpersonal problems and difficulties
> with peers may occur secondary to impulsivity (i.e., unpredictable
> behavior). As a child gets older, unpredictable behavior is less
> tolerated by peers and within the family.
>
> Social skills building is meant to offer immediate practical skills in
> a safe setting. Sometimes this can be a way to have several people
> (family, school, friends) offering the same message about appropriate
> behavior and may have a better chance of being generalized to a larger
> setting.
>
> Social skills training (group or individual) instructs children in the
> execution of specific prosocial behaviors. It is appropriate for
> children who exhibit difficulties in initiating and maintaining
> positive peer interactions. Children with ADHD often show deficient
> use of functional, pragmatic language in social situations. This type
> of training is designed to increase knowledge about appropriate and
> inappropriate social behaviors. The various target skills may include
> maintaining eye contact, initiating and maintaining conversation,
> sharing, and cooperating. Role-playing exercises with group feedback
> are commonly used.
>
> Social skills building groups may be available through the school.
> These may be recognized as \"friendship groups\" or \"social skills
> groups.\" Early childhood family education, which may include children
> older than the preschool aged child, is also available. Some other
> community resources may include the YMCA, Community Education, or
> local health organizations.
>
> ***Evidence supporting this recommendation is of classes: A, D, R***
>
> **Problem Solving Strategies/Cognitive Behavioral Therapy**
>
> The goal of self-instructional problem solving training is to help
> children who have ADHD \"stop and think\" before acting. This
> therapeutic modality falls under the general category of
> cognitive-behavioral therapies. Designed to facilitate self-control
> and reflective problem solving, it is appropriate for children who
> exhibit impulsive, non-self-controlled behavior and/or manifest
> deficits in problem solving. This can be accomplished through the use
> of various resources: family therapy, in-home therapy, an individual
> therapist, or county services (if available). All options should be
> coordinated with school efforts.
>
> ***Evidence supporting this recommendation is of classes: A, R***
>
> **Study/Organizational Skills Training**
>
> Study and organizational skills building should be offered in
> conjunction with curriculum intervention. The curriculum should be
> concrete and sequential with only essential information as a
> requirement. Specific interventions can address issues, such as:
>
> *Behavior*: Difficulty sequencing and completing steps to accomplish
> specific tasks (e.g., writing a book report or term paper, organizing
> paragraphs; solving division problems)
>
> *Accommodation*: Break task into workable and manageable component
> tasks. Provide examples to accomplish task.
>
> *Behavior*: Difficulty prioritizing from most to least important.
>
> *Accommodation*: Prioritize assignments and activities. Provide a
> model to help students. Post the model and refer to it often.
>
> ***Evidence supporting this recommendation is of class: R***
>
> **Comorbidity Present**
>
> In children or adolescents with comorbid anxiety,
> depression/dysthymia, chemical abuse, oppositional or conduct
> disorder, medical comorbidity appropriate medical management should be
> implemented.

18. **School Interventions**

> **Key Points**:

-   Primary care providers for children with ADHD should explore with
    school personnel and parents opportunities for services and supports
    for the child which are available within their school.

-   Physicians and other primary health care providers are often in a
    good position to assist parents in advocating for appropriate school
    programming for children with ADHD.

-   If the primary care provider or parents decide not to use
    medications to treat ADHD, despite its overwhelming effectiveness,
    it is still appropriate to implement the psychosocial interventions.

> Even at optimal doses of medication, most children with ADHD have
> residual difficulties at school. Physicians and other primary health
> care providers are often in a good position to assist parents in
> advocating for appropriate school programming for children with ADHD.
> Several classroom strategies are listed below. Although it is not
> expected that the primary care provider will act as an expert
> \"consultant\" in this area, it is important for him or her to have
> enough background familiarity with these issues to be an effective
> advocate and to be able to educate and empower parents on these
> issues.
>
> Studies demonstrate that medication is superior to non-pharmacological
> interventions when delivered alone. Non-pharmacological interventions
> such as behavioral management and educational
> accommodations/modifications in the classroom have been found to
> assist children with ADHD in coping with and compensating for the
> academic and social difficulties associated with this disability. If
> the primary care provider or parents decide not to use medications to
> treat ADHD, despite its overwhelming effectiveness, it is still
> appropriate to implement the psychosocial intervention.
>
> **Classroom Strategies for Children with ADHD**

-   A high degree of order and predictability to the classroom

-   Clear and consistent rules and expectations

-   Classroom organizational strategies such as a posted daily work
    schedule, written notices for homework assignments, quiet work
    areas, seating close to teacher and near positive peer models

-   Training for students in study skills and time management

-   Regularly scheduled, frequent breaks

-   Creation of multisensory learning activities that are engaging and
    use various attention-getting devices

-   Reduction of the amount of work assigned or other modifications of
    assignments

-   Liberal use of positive reinforcers immediately and continually for
    desired behaviors

-   Establishment of a school-home daily note card system to maintain
    parent-teacher contact with regard to academic and behavioral
    progress and problem areas

-   Working with the student on self-monitoring, self-reinforcement and
    development of compensatory/adaptive strategies

> Ongoing collaboration and communication between teachers and primary
> care providers is desirable in order to discuss and implement
> effective treatment strategies for each child. It is also important
> for the primary care provider to communicate with school staff about
> their perceptions of the child\'s diagnosis (or diagnoses) with
> particular attention to any medical/neurologic problems (e.g.,
> Tourette\'s Syndrome, mental retardation, seizures, hearing
> impairment, chronic medical conditions) that might be important for
> the teachers to understand. They may also want to discuss the
> perceived role of psychotropic medication and answer any questions
> about expected benefits, side effects, etc.
>
> The severity of the child\'s ADHD and its adverse impact on academic
> performance will determine whether the child qualifies for special
> education services. The three educational service categories most
> commonly identified for children with ADHD (in school terminology) are
> Learning Disability (LD), Emotional/Behavioral Disorder (EBD), and
> Other Health Disability (OHD). Students with ADHD who do not meet
> eligibility criteria for the specific programs described (LD, EBD,
> OHI) may still need some level of assistance to be successful and may
> still receive specialized instruction and accommodations in the
> regular classroom. This is stated in section 504 of the Rehabilitation
> Act of 1973 and is intended to insure a \"free and appropriate
> education in the least restrictive environment\" for all students
> including those with a physical or mental impairment that limits
> learning. **In these cases, parents should be encouraged to formally
> request a \"Section 504 plan\" for their child from school
> administration. Adequate documentation of the child\'s impairment
> (e.g., ADHD or other diagnosis) will be required from the physician.**
>
> **Comorbidity Present**
>
> Specific learning disabilities comorbid to ADHD must be treated
> concurrently with appropriate special educational programming. Primary
> care providers should develop a basic understanding of the
> Individualized Educational Plan (IEP), the document which details the
> student\'s direct and indirect special educational services.
>
> Speech- and language-related difficulties must also be treated and
> supported across the curriculum and can have an impact on a number of
> subject areas and tasks. Children with ADHD who are also hearing
> impaired may require special assistance such as an \"auditory
> trainer\" device and other classroom accommodations. Most districts
> have the availability of a hearing impairment specialist to consult on
> these clients.
>
> ***Evidence supporting this recommendation is of classes: A, R***

19. **Medications Warranted and Desired?**

> Medication is an effective treatment for ADHD. Medication is superior
> to non-pharmacological interventions when delivered alone. The
> decision to use medication should be made in conjunction with parents
> following a thorough discussion of expected benefits and potential
> risks. Factors such as the child\'s age, severity of symptoms, and
> presence of comorbidity should also be considered and may involve
> decision making regarding choice of medication.
>
> ***Evidence supporting this recommendation is of classes: A, M, R***

20. **First Line Medication(s) Trial(s)**

> **Key Points**:

-   Psychostimulant medications are considered first-line therapy in
    children with ADHD: the four types of psychostimulant medications
    are methylphenidate, dex-methylphenidate, dextroamphetamine and
    amphetamine salts.

-   Absolute contraindications to the use of psychostimulants include
    psychosis, certain cardiovascular conditions, or previous untoward
    reactions to psychostimulant medications.

-   Treatment with psychostimulants is often safe and effective in
    managing children with ADHD with mild to moderate tics.

-   Response to one psychostimulant does not predict response to the
    others.

-   Atomoxetine, a norepinephrine reuptake inhibitor, has been found
    effective in the treatment of ADHD and may also be considered a
    first-line agent.

> Psychostimulant medications are considered first-line therapy as they
> are effective in 70--80% of children with ADHD. It is theorized that
> stimulants increase the availability of neurotransmitters at the
> presynaptic terminals. This allows the child to exhibit more
> purposeful, goal-oriented behavior by focusing attention, lessening
> impulsiveness, and decreasing motor activity.
>
> Absolute contraindications to the use of psychostimulants include
> psychosis, certain cardiovascular conditions, or previous untoward
> reactions to stimulant medication. Occasionally a comorbid condition
> may warrant the consideration of alternative medications. In the
> presence of comorbidity, the primary symptoms of concern should
> influence the medication decision.
>
> Treatment with psychostimulants is often safe and effective in
> managing many children with ADHD with mild to moderate tics.
> Nevertheless, frequency and severity of tics should be carefully
> monitored in these patients. No routine blood work is necessary before
> or during psychostimulant therapy.
>
> The four types of stimulant medication most commonly used are:

-   Methylphenidate (MPH)

-   Dex-methylphenidate

-   Dextroamphetamine

-   Amphetamine salts

> Response to one stimulant does not predict response to the others.
> Studies indicate a 70 to 80% response rate to each stimulant
> independent of one another; therefore, if a child is a non-responder
> to one stimulant, it is advisable to attempt a second or third trial
> with other stimulants.
>
> Each of these stimulant medications has the common adverse effects of
> decreased appetite, insomnia, headache, stomachaches, and
> irritability. If sleep problems are reported, determine factors that
> may influence response to stimulant treatment.
>
> Dosages should be adjusted for each child depending on body weight,
> degree of impairment, and specific symptoms targeted for improvement.
> Children with ADHD of the predominantly inattentive type have been
> shown to respond well to low doses of methylphenidate. Children with
> ADHD, combined-type or predominantly hyperactive, have shown more
> positive response at moderate to high doses of methylphenidate.
>
> Refer to Table 3 in the original guideline document for information on
> dosing, titration, and adverse effects of first line ADHD medications.
>
> Atomoxetine (Strattera), an inhibitor of the presynaptic
> norepinephrine transporter, has been found effective in the treatment
> of ADHD. It now may be considered as a first-line agent in patients
> for whom psychostimulants may not be an option, for patients with
> comorbid anxiety, sleep initiation disorder, substance abuse, or tics,
> or if initially preferred by parents and/or physician. Atomoxetine is
> a non-controlled substance that may make it preferable in certain
> clinical situations. Potential adverse effects include somnolence,
> nausea, anorexia, mild increase in blood pressure or heart rate and
> skin rash.
>
> In 2004 the Food and Drug Administration (FDA) issued a paper advising
> health professionals about a new warning regarding Strattera. The
> labeling has been updated with a bolded warning about the potential
> for severe liver injury following two reports. The warning indicates
> that the medication should be discontinued in patients who develop
> jaundice or laboratory evidence of liver injury. Currently, routine
> liver function tests are not being recommended for those taking this
> medication.
>
> In September 2005, the FDA issued an alert advising health
> professionals about an increased risk of suicidal thinking in children
> and adolescents being treated with Strattera. The labeling has been
> updated with a boxed warning.
>
> In February 2006, the FDA ordered labeling changes of all stimulants
> to include the following: \"Sudden death has been reported in
> association with central nervous system (CNS) stimulant treatment at
> usual doses in children and adolescents with structural cardiac
> abnormalities or other serious heart problems.\" In general,
> stimulants should not be used in such patients. A careful history and
> physical examination is recommended before prescribing the medication.
> Particular attention to family history of sudden death prior to age
> 50, and individual history of unexplained syncope or chest pain are
> suggested. If potential risk is identified, further cardiology
> evaluation is recommended. In the absence of risk, there is no
> recommendation for further evaluation, including electrocardiogram
> (EKG) or cardiac ECHO.
>
> Pharmacological treatment should be initiated by means of a trial that
> should incorporate teacher and parent rating scales of performance.
> Refer to Appendix A in the original guideline document for information
> on open label and placebo-controlled trials.
>
> ***Evidence supporting this recommendation is of classes: A, C, D,
> R***

22. **Alternative Medication(s) Trial(s)?**

> When adequate stimulant and atomoxetine trial are unsuccessful due to
> either poor response or side effects in spite of adjustment, or if
> associated comorbidity, alternative medication trials may be
> considered. Second line medications for ADHD therapy in these
> situations commonly include tricyclic antidepressants (imipramine,
> desipramine), alpha adrenergic agonist (clonidine), and a nontricyclic
> antidepressant (bupropion).
>
> At this point, due to increased side effects and more intense
> monitoring, the primary clinician is directed out of guideline and may
> consider subspecialty consultation depending upon individual knowledge
> and expertise.
>
> ***Evidence supporting this recommendation is of classes: A, C, D,
> R***
>
> For information on second-line ADHD medications refer to Table 4 in
> the original guideline document.

24. **Maintenance and Continuing Care**

> **Key Points**:

-   ADHD has an impact in all domains of a child\'s life. The child
    usually does not outgrow ADHD but instead learns to cope and
    compensate for this chronic condition. All measures are aimed at
    building successes for the child in day-to-day life.

-   Evaluation and management visits of these patients should take into
    consideration medical, psychosocial, and educational aspects.

-   Anticipatory guidance is given at each visit; this can touch on
    points such as immediate and long-term expectations, study and
    organizational skills, guidance on behavior management or updating
    reading material. Advocacy issues are stressed and revising
    multimodal care management is often needed.

-   The transition to adulthood is the last step in the child\'s
    journey. Consideration of these points is often helpful during that
    time.

> Attention Deficit Hyperactivity Disorder may have an evolving impact
> on a child\'s or adolescent\'s learning or behavioral success. It is a
> condition that is significantly related to each child\'s environment
> (home, school, etc.) as well as to the specific demands placed upon
> the child or adolescent. The ability of the individual to develop
> compensation skills and success over time is related to these factors,
> as well as the presence or absence of comorbid conditions.
>
> Recent evidence suggests that worsening clinical status during
> adolescence may more likely be due to environmental and/or comorbid
> causes, instead of inadequate psychostimulant medication dosage. The
> clinician should evaluate these possibilities before prescribing
> higher doses of stimulants to adolescents. For these reasons, close
> monitoring and follow-up is recommended for all children and
> adolescents diagnosed with ADHD, whether or not medication is
> utilized.
>
> **Frequency**

-   Closely by phone during trial and first several weeks

-   Clinic visit after trial to review care plan

-   Once patient is stable, clinic visits every 3 to 6 months depending
    on individual case; more frequent with significant comorbidity

> **These visits allow for review and management of the following
> areas:**
>
> **Psychosocial**

-   Family functioning

-   Home behavior management

-   Peer relationships

-   Outside activities

> **Educational**

-   ADHD symptoms

-   Child-teacher relationships, social functioning, general attitude

-   Academic performance, homework and study skills

-   Current interventions and supports

-   Review Individualized Educational Plan (IEP) or section 504 plan if
    appropriate

> **Psychological**

-   Perception of ADHD and treatment

-   Self esteem issues

-   Personal strengths and successes

> **Anticipatory Guidance**

-   Immediate and long-term expectations

-   Study/organizational skills

-   Behavior management

-   Updated reading materials and advocacy issues

> **Transitioning to Adulthood**

-   Identify adult health care provider for care transfer (this may
    require coordination with college health service).

-   Prioritize treatment to address target symptoms, level of
    impairment, and available resources (multiple modalities frequently
    useful), patient participation necessary.

-   Emphasize vocational evaluation, counseling, and training as well as
    time management skills, organization, and study skills.

-   Discuss relationship issues.

-   High index of suspicion for comorbidity

-   Address risk of medication abuse by patient and peers.

-   Stimulants may be less effective; consider alternative medications
    if indicated.

> **Medical**

-   Measurement

    -   Height, weight, blood pressure, pulse

-   Medication

    -   Dosage, timing, coverage priorities, duration

    -   Before making dosage adjustments or switching medications, the
        patient\'s adherence to current regimen should be addressed.

-   Positive attributes of medication

-   Side effects and their management (see Table 6 in the original
    guideline document)

-   Laboratory as indicated

-   Behavior rating scales (especially if problems and anticipated
    medication adjustment)

-   Alternative/complimentary medicine

> Increasingly, parents are considering the use of
> alternative/complimentary therapies for children with ADHD. Certain
> therapeutic interventions, such as the use of herbal, botanical, and
> other nutraceutical agents, have the capacity to interact with
> psychotropic medications including stimulants, selective serotonin
> reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs),
> among others. Therefore, it is important for pediatric health care
> providers to inquire in a non-judgmental fashion about the use of
> these agents by children under their care. Parents can then be
> educated appropriately about potential risks, benefits, side effects,
> and drug interaction possibilities associated with a certain therapy.
> Such interventions are not supported by evidence-based research at
> this time.
>
> Revise multimodal care management plan as needed.
>
> ***Evidence supporting this recommendation is of class: R***
>
> Adherence to current regimen may be assessed by asking open-ended
> non-threatening questions at each office visit. If adherence to
> medication regimen appears to be lacking, the patient may benefit from
> adherence interventions. Such interventions include re-educating the
> patient and family about medications and how they fit into the
> treatment plan (including side effects and how they may be prevented.)
> Other ways to help adherence include regimen simplification (e.g.,
> less frequent dosing), use of patient adherence aids (e.g., tablet
> boxes, alarms), suggesting support group sessions, sending appointment
> reminders, cueing medication administration to daily activities (e.g.,
> breakfast) and giving positive reinforcement for adherence efforts.
> Adverse effects of stimulants are not uncommon, but can generally be
> managed in most cases. The more common side effects include anorexia,
> insomnia, stomachaches, and headaches and, less commonly, rebound
> irritability, dysphoria, agitation, tics, and growth impairment are
> seen.
>
> It is generally felt that, in individual patients, psychostimulants
> may unmask or exacerbate tics. However, in two recent studies evidence
> suggests that psychostimulants may not be associated with tic
> frequency or severity.
>
> Growth suppression has been a concern with long-term use of
> stimulants. It seems to occur rarely and is likely secondary to
> reduced caloric intake. Upon discontinuing the stimulant, growth
> rebound occurs with no significant compromise of ultimate height
> attained.
>
> ADHD is a lifelong chronic condition. While it is common for the
> hyperactivity part of the condition to ameliorate throughout
> adolescence, there often remains (in 50 to 60% of patients)
> significant inattentiveness, restlessness, and impulsivity.
>
> As expected, patients will be able to discontinue medication variably,
> depending on the severity of ADHD symptoms and their ability to
> compensate relative to environmental demands. (e.g., school, work,
> family).
>
> Poor prognostic indicators have included low intelligence, poor
> academic achievement, early conduct problems, poor social
> relationships, and family psychopathology. Many individuals, however,
> learn to compensate well as they rely on their significant strengths
> to overcome any persisting ADHD symptoms.
>
> ***Evidence supporting this recommendation is of classes: A, C, D, M,
> R***

**Definitions**:

**Conclusion Grades**:

**Grade I**: The evidence consists of results from studies of strong
design for answering the question addressed. The results are both
clinically important and consistent with minor exceptions at most. The
results are free of any significant doubts about generalizability, bias,
and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.

**Grade II**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is some
uncertainty attached to the conclusion because of inconsistencies among
the results from the studies or because of minor doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from weaker
designs for the question addressed, but the results have been confirmed
in separate studies and are consistent with minor exceptions at most.

**Grade III**: The evidence consists of results from studies of strong
design for answering the question addressed, but there is substantial
uncertainty attached to the conclusion because of inconsistencies among
the results of different studies or because of serious doubts about
generalizability, bias, research design flaws, or adequacy of sample
size. Alternatively, the evidence consists solely of results from a
limited number of studies of weak design for answering the question
addressed.

**Grade Not Assignable**: There is no evidence available that directly
supports or refutes the conclusion.

**Classes of Research Reports**:

A.  Primary Reports of New Data Collection:

> Class A:

-   Randomized, controlled trial

> Class B:

-   Cohort study

> Class C:

-   Nonrandomized trial with concurrent or historical controls

-   Case-control study

-   Study of sensitivity and specificity of a diagnostic test

-   Population-based descriptive study

> Class D:

-   Cross-sectional study

-   Case series

-   Case report

B.  Reports that Synthesize or Reflect upon Collections of Primary
    Reports:

> Class M:

-   Meta-analysis

-   Systematic review

-   Decision analysis

-   Cost-effectiveness analysis

> Class R:

-   Consensus statement

-   Consensus report

-   Narrative review

> Class X:

-   Medical opinion

#### CLINICAL ALGORITHM(S)

Detailed and annotated clinical algorithms are provided for:

-   [Evaluation of Attention Deficit Hyperactivity
    Disorder](http://www.guideline.gov/algorithm/5843/NGC-5843_1.html)

-   [Management of Attention Deficit Hyperactivity
    Disorder](http://www.guideline.gov/algorithm/5843/NGC-5843_2.html)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is classified for selected
recommendations (see \"Major Recommendations\").

In addition, key conclusions contained in the Work Group\'s algorithm
are supported by a grading worksheet that summarizes the important
studies pertaining to the conclusion. The type and quality of the
evidence supporting these key recommendations (i.e., choice among
alternative therapeutic approaches) is graded for each study.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**General Benefits**

Accurate diagnosis and effective management of patients presenting with
learning or behavior problems and suspected of attention deficit
hyperactivity disorder (ADHD) in the primary care setting

#### POTENTIAL HARMS

-   The most common side effects of stimulant medication include
    anorexia, insomnia, headache, stomach ache, increased heart rate;
    less commonly rebound irritability, dysphoria, agitation, tics, and
    growth impairment are seen. Growth suppression occurs only rarely,
    and is likely secondary to reduced calorie intake.

-   In addition, it is generally felt that, in individual patients,
    psychostimulants may unmask or exacerbate tics. However, evidence
    from two recent studies suggests that psychostimulants may not be
    associated with tic frequency or severity.

-   In February 2006, the FDA ordered labeling changes of all stimulants
    to include the following: \"Sudden death has been reported in
    association with central nervous system (CNS) stimulant treatment at
    usual doses in children and adolescents with structural cardiac
    abnormalities or other serious heart problems.\" In general,
    stimulants should not be used in such patients.

-   Second line medications used in the treatment of attention deficit
    hyperactivity disorder (ADHD), such as tricyclic antidepressants
    (imipramine, desipramine), alpha adrenergic agonists (clonidine,
    guanfacine) and nontricyclic antidepressant (bupropion) have the
    following possible predominant adverse effects:

    -   *Tricyclic antidepressants*: Cardiac conduction disturbances,
        dry mouth, urinary retention, and headache. Cases of sudden
        death have been reported with desipramine, but a cause and
        effect relationship has not been established. It is prudent to
        exercise a heightened level of caution when instituting and
        monitoring desipramine therapy.

    -   *Alpha adrenergic agonists*: Sedation, rashes with skin patches,
        orthostatic hypotension in less than 5% of those treated,
        fatigue, headache, and insomnia

    -   *Nontricyclic antidepressant (bupropion)*: Sedation,
        constipation, dryness of mouth, may lower seizure threshold

-   Potential adverse effects of atomoxetine (Strattera) include
    somnolence, nausea, vomiting, gastrointestinal pain, anorexia,
    dizziness, mild increase in blood pressure or heart rate, and skin
    rash. In 2004 the U.S. Food and Drug Administration (FDA) issued a
    paper advising health professionals about a new warning regarding
    Strattera. The labeling has been updated with a bolded warning about
    the potential for severe liver injury following two reports. The
    warning indicates that the medication should be discontinued in
    patients who developed jaundice or laboratory evidence of liver
    injury. Currently, routine liver function tests are not being
    recommended for those taking this medication.

> In September 2005, the FDA issued an alert advising health
> professionals about an increased risk of suicidal thinking in children
> and adolescents being treated with Strattera. The labeling has been
> updated with a boxed warning.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Absolute contraindications to the use of psychostimulants include
    psychosis, certain cardiovascular conditions, or previous untoward
    reactions to stimulant medication.

-   Atomoxetine should not be used concurrently or within two weeks of
    monoamine oxidase (MAO) inhibitors as it may significantly increase
    atomoxetine concentrations, requiring atomoxetine dose reduction.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These clinical guidelines are designed to assist clinicians by
    providing an analytical framework for the evaluation and treatment
    of patients, and are not intended either to replace a clinician\'s
    judgment or to establish a protocol for all patients with a
    particular condition. A guideline will rarely establish the only
    approach to a problem.

-   This clinical guideline should not be construed as medical advice or
    medical opinion related to any specific facts or circumstances.
    Patients are urged to consult a health care professional regarding
    their own situation and any specific medical questions they may
    have.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Once a guideline is approved for general implementation, a medical group
can choose to concentrate on the implementation of that guideline. An
action group is formed when a topic is selected as an initiative.  In
addition to the action group goals and measures, each medical group sets
specific goals they plan to achieve in improving patient care based on
the particular guideline(s).Each medical group shares its experiences
and supporting measurement results within the action group. This sharing
facilitates a collaborative learning environment. Action group learnings
are also documented and shared with interested medical groups within the
collaborative.

Currently action groups may focus on one guideline or a set of
guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented in the original guideline
document to help close the gap between clinical practice and the
guideline recommendations. Summaries of the measures are provided in the
National Quality Measures Clearinghouse (NQMC).

**Key Implementation Recommendations**

The following system changes were identified by the guideline work group
as key strategies for health care systems to incorporate in support of
the implementation of this guideline.

1.  Evaluation for key features of attention deficit hyperactivity
    disorder (ADHD) using the Diagnostic and Statistical Manual of
    Mental Disorders, Fourth Edition/ Diagnostic and Statistical Manual
    for Primary Care (DSM-IV/DSM-PC) criteria should include information
    from multiple sources such as parents/caregivers, the child and
    school personnel and should be documented in the patient medical
    record.

2.  Results of this evaluation (#1) are used to identify treatment
    options/resources.

3.  Develop processes that allow for consistent documentation and
    monitoring of diagnosis and management of ADHD.

4.  Develop a process for follow-up assessment and success in management
    of ADHD for primary care provider, parents and school.

5.  Develop a process for consistent documentation and monitoring of
    medication.

6.  Develop a process to key the primary care physician at the time of
    or near puberty, that anticipatory guidance and transition into
    adulthood discussion should take place.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Pocket Guide/Reference Cards\
Quality Measures

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

#### RELATED NQMC MEASURES

-   [Diagnosis and management of attention deficit hyperactivity
    disorder (ADHD) in primary care for school age children and
    adolescents: percentage of patients newly diagnosed with ADHD whose
    medical record contains documentation of DSM-IV or DSM-PC criteria
    being
    addressed.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=11145)

-   [Diagnosis and management of attention deficit hyperactivity
    disorder (ADHD) in primary care for school age children and
    adolescents: percentage of patients treated with medication for the
    diagnosis of ADHD whose medical record contains documentation of a
    follow-up visit twice a
    year.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=11146)

-   [Diagnosis and management of attention deficit hyperactivity
    disorder (ADHD) in primary care for school age children and
    adolescents: percentage of patients diagnosed with ADHD whose
    medical record contains documentation that the clinician discussed
    the need for school-based supports and educational service options
    for children with
    ADHD.](http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=11147)

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of attention deficit hyperactivity disorder in primary care
for school-age children and adolescents. Bloomington (MN): Institute for
Clinical Systems Improvement (ICSI); 2007 Mar. 68 p. \[135 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1997 Oct (revised 2007 Mar)

#### GUIDELINE DEVELOPER(S)

Institute for Clinical Systems Improvement - Private Nonprofit
Organization

#### GUIDELINE DEVELOPER COMMENT

Organizations participating in the Institute for Clinical Systems
Improvement (ICSI): Affiliated Community Medical Centers, Allina Medical
Clinic, Altru Health System, Aspen Medical Group, Avera Health,
CentraCare, Columbia Park Medical Group, Community-University Health
Care Center, Dakota Clinic, ENT Specialty Care, Fairview Health
Services, Family HealthServices Minnesota, Family Practice Medical
Center, Gateway Family Health Clinic, Gillette Children\'s Specialty
Healthcare, Grand Itasca Clinic and Hospital, HealthEast Care System,
HealthPartners Central Minnesota Clinics, HealthPartners Medical Group
and Clinics, Hutchinson Area Health Care, Hutchinson Medical Center,
Lakeview Clinic, Mayo Clinic, Mercy Hospital and Health Care Center,
MeritCare, Mille Lacs Health System, Minnesota Gastroenterology,
Montevideo Clinic, North Clinic, North Memorial Care System, North
Suburban Family Physicians, Northwest Family Physicians, Olmsted Medical
Center, Park Nicollet Health Services, Pilot City Health Center, Quello
Clinic, Ridgeview Medical Center, River Falls Medical Clinic, Saint
Mary\'s/Duluth Clinic Health System, St. Paul Heart Clinic, Sioux Valley
Hospitals and Health System, Southside Community Health Services,
Stillwater Medical Group, SuperiorHealth Medical Group, University of
Minnesota Physicians, Winona Clinic, Ltd., Winona Health

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425;
telephone, (952) 814-7060; fax, (952) 858-9675; e-mail:
<icsi.info@icsi.org>; Web site: [www.icsi.org](http://www.icsi.org/).

#### SOURCE(S) OF FUNDING

The following Minnesota health plans provide direct financial support:
Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica,
Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind
support is provided by the Institute for Clinical Systems Improvement\'s
(ICSI) members.

#### GUIDELINE COMMITTEE

Committee on Evidence-Based Practice

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Work Group Members*: Kathy Moore, PhD (Work Group Leader) (Allina
Medical Clinic) (Psychology); W. Brooks Donald, MD, MPH (HealthPartners
Medical Group) (Behavioral Pediatrician); Judson B. Reaney, MD (Park
Nicollet Health Services) (Behavioral Pediatrician); Michael Crandell,
MD (Sioux Valley Hospitals & Health System) (Family Practice); Bruce
Kuhlmann, DO (CentraCare Health System) (Family Practice); John Huxsahl,
MD (Mayo Clinic) (Psychiatry); Colleen Dobie, RN, CNP, MS (Allina
Medical Clinic) (Pediatrics); Steve Elias, MD (Columbia Park Medical
Group) (Pediatrics); Bernadine Lee, RN (Olmsted Medical Center)
(Nursing); Laura Hay, PharmD (Gillette Childrens Specialty Healthcare)
(Pharmacy); Penny Fredrickson (Institute for Clinical Systems
Improvement) (Measurement Advisor); Pam Pietruszewski, MA (Institute for
Clinical Systems Improvement) (Facilitator)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

In the interest of full disclosure, the Institute for Clinical Systems
Improvement (ICSI) has adopted a policy of revealing relationships work
group members have with companies that sell products or services that
are relevant to this guideline topic.  The reader should not assume that
these financial interests will have an adverse impact on guideline
content.  Readers of the guideline may assume that only work group
members listed below have potential conflicts of interest to disclose.

Judson Reaney, MD received consulting, speaker fees or honoraria from
UCB Pharma, Shire, McNeil, Eli Lilly and Novartis.

No other work group members have potential conflicts of interest to
disclose.

ICSI\'s conflict of interest policy and procedures are available for
review on ICSI\'s website at [www.icsi.org](http://www.icsi.org/).

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of
attention deficit hyperactivity disorder in primary care for school age
children and adolescents. Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Jan. 69 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Institute for Clinical Systems
Improvement (ICSI) Web
site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/).

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Diagnosis and management of attention deficit hyperactivity disorder
    in primary care for school age children and adolescents. Executive
    summary. Bloomington (MN): Institute for Clinical Systems
    Improvement, 2007 Mar. 2 p. Electronic copies: Available from the
    [Institute for Clinical Systems Improvement (ICSI) Web
    site](http://www.icsi.org/adhd/adhd__executive_summary_.html).

-   ICSI pocket guidelines. April 2006 edition. Bloomington (MN):
    Institute for Clinical Systems Improvement, 2006. 298 p.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200,
Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
Web site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### PATIENT RESOURCES

The following is available:

-   Diagnosis and management of attention deficit hyperactivity disorder
    in primary care for school age children and adolescents. Health care
    guideline for patients and families.  Bloomington (MN): Institute
    for Clinical Systems Improvement, 2007 Mar.

Electronic copies: Available in Portable Document Format from the
[Institute for Clinical Systems Improvement (ICSI) Web
site](http://www.icsi.org/for_patients_families/attention_deficit_hyperactivity_disorder_in_primary_care__diagnosis_and_management_of__for_patients___families_.html).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on June 30, 1999. The information was
verified by the guideline developer on August 4, 1999. This summary was
updated by ECRI on May 15, 2000, December 30, 2003, and March 14, 2005.
This summary was updated by ECRI on August 15, 2005, following the U.S.
Food and Drug Administration advisory on antidepressant medications.
This summary was updated by ECRI on October 3, 2005, following the U.S.
Food and Drug Administration advisory on Strattera (atomoxetine). This
summary was updated by ECRI on August 28, 2006 following the updated
U.S. Food and Drug Administration advisory on Adderall. This summary was
updated by ECRI on September 7, 2006 following the updated U.S. Food and
Drug Administration advisory on Dexedrine. This NGC summary was updated
by ECRI Institute on Sept 14, 2007. This summary was updated by ECRI
Institute on November 9, 2007, following the U.S. Food and Drug
Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

This NGC summary (abstracted ICSI Guideline) is based on the original
guideline, which is subject to the guideline developer\'s copyright
restriction.

The abstracted ICSI Guidelines contained in this Web site may be
downloaded by any individual or organization. If the abstracted ICSI
Guidelines are downloaded by an individual, the individual may not
distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization,
copies may be distributed to the organization\'s employees but may not
be distributed outside of the organization without the prior written
consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are
reserved by the Institute for Clinical Systems Improvement, Inc. The
Institute for Clinical Systems Improvement, Inc. assumes no liability
for any adaptations or revisions or modifications made to the abstracts
of the ICSI Guidelines.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

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Date Modified: 11/10/2008