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

IMPLEMENTING THE COMPLEX ATTENTION-DEFICIT/HYPERACTIVITY DISORDER GUIDELINE: PROCESS OF CARE ALGORITHMS

To facilitate implementation of the Society for Developmental and Behavioral Pediatrics Complex Attention Deficit/Hyperactivity Disorder (ADHD) Guideline¹ and its 5 Key Action Statements, the Guideline Panel developed the Process of Care Algorithms. As described in the Guideline, these algorithms reflect the consensus, expert opinion of the Panel, as well as a careful review of the existing literature and other available practice guidelines. Because there is insufficient evidence to allow for a prescriptive approach, each of the algorithms include suggested steps that are related to the Key Action Statements and that incorporate the key concepts from the Guideline (i.e., focus on functional impairment to improve long-term outcomes, psychosocial treatment as the foundation for treatment of complex ADHD, shared decision-making, interprofessional care, appropriate use of psychological testing and mental health diagnostic assessment, recognition and treatment of impairments due to coexisting conditions, and a life course perspective).

The Society for Developmental and Behavioral Pediatrics (SDBP) Complex ADHD Practice Guideline was developed to improve the subspecialty level care of children and adolescents with “complex ADHD” by professionals with specialized training and/or experience. Therefore, the algorithms do not include basic information such as lists of diagnostic criteria. It is important to emphasize that the Process of Care Algorithms are to be used as companion documents to the Guideline. Key information and definitions in the Guideline are not repeated in the algorithms or in the following annotations to the algorithms. It is also beyond the scope of the algorithms to provide detailed recommendations about specific rating scales, questionnaires, pharmacological treatment selection, or medication dosing. The SDBP has convened a guideline implementation task force that will, over time, develop an online toolkit to further support implementation of the Guideline and Process of Care Algorithms.

Algorithm titles are underlined and followed in parentheses by the Key Action Statement to which they correspond.

Each algorithm includes numbered steps, using the following shapes:

Numbering of Steps and Corresponding Annotations

Comments on algorithm steps are numbered to match the corresponding step. The steps are presented in numerical order in the algorithms, with numbering from left to right as one moves from the top to the bottom of the algorithm. The steps are NOT always presented in numerical order in these annotations because at times it is more important to describe the likely path through as ection of the algorithm. Some steps do not have a corresponding annotation because the step is self-explanatory (e.g., a step that indicates that one should “exit” the algorithm).

ANNOTATIONS FOR SPECIFIC ALGORITHMS

Evaluation of a Child or Adolescent with Complex Attention-Deficit/Hyperactivity Disorder (Key Action Statements 1 and 2)

Step 1: It is anticipated that children and adolescents with complex attention-deficit/hyperactivity disorder (ADHD), as defined in this guideline, will have been referred for subspecialty level assessment to be performed by a clinician with specialized training and/or expertise.

Step 2: The clinician should obtain a comprehensive history, including the following:

• Attention-deficit/hyperactivity disorder symptoms and associated impairments
• Developmental, educational, and mental health history
• Review of systems with special attention to sleep, cardiac, and neurological history, as well as growth (height and weight) trajectory
• Medical history
• Family history, including family developmental, neurological, and mental health history
• Social history, including the history of adverse childhood experiences and peer victimization
• History of previous and current treatment and intervention for ADHD and/or previously identified coexisting conditions, including both psychosocial and pharmacological treatments, and assessment of response to previous and current treatments

The assessment also includes review of supplemental information:

• Attention-deficit/hyperactivity disorder-specific questionnaires
• Other standardized questionnaires (focused on functional impairments in key domains and potential coexisting conditions)
• Previsit questionnaires, intake materials
• Report of previous psychological/educational testing
• School reports, report cards, Individualized Education Program (IEP) plans, 504 Plans
• Primary care and specialty care records

Finally, the child or adolescent should be carefully observed and interviewed, followed by a comprehensive physical examination, considering the following:

• Age-appropriate interview/observation of child/adolescent
• Growth parameters (baseline height, weight, and head circumference)
• Vital signs (blood pressure, and pulse)
• General physical and neurological examination appropriate to age
• Signs of other disorders (e.g., dysmorphic features, skin lesions, thyroid dysfunction, and neurologic signs/deficits)
• Assessment of motor coordination (e.g., handwriting and balance)

Steps 3 and 4: If ADHD is confirmed, the clinician should assess for coexisting conditions that are common among children and adolescents with ADHD. As described in the Guideline, the assessment of a child with complex ADHD requires an accurate assessment of the child or adolescent's development and cognitive status, as well as the degree of functional impairments. Physicians may perform developmental assessments and assessments of functional impairment. However, formal assessment of cognitive status can best be administered by a child clinical psychologist or school psychologist. Assessment for coexisting conditions should be informed by the following recommendations:

• Obtain psychological and educational testing (or review the results of testing completed within past 2–3 years for children >6 years old)
• Consider testing even for children with previous testing under the following circumstances:
• Deterioration in mental health or functional status
• Poor academic progress not explained by previous test results
• Suboptimal response to treatment for core ADHD symptoms
• History suggests an emerging language or learning disorder not identified in previous testing
• Younger age (<6 years) at the time of previous testing
• Patients preparing for a transition to college

Step 5: If ADHD is not confirmed, consideration should be given to other conditions that may present with symptoms similar to ADHD. Identification of these other conditions may require psychological testing or mental health assessment. Less commonly, further neuropsychological testing may be required.

Steps 6 to 9: If the child or adolescent is determined to have ADHD without any significant coexisting condition, treatment should be initiated using the approach described below (Behavioral/Educational Treatment for Complex ADHD). If a coexisting condition is identified, treatment should be guided by the relevant algorithms that address each major coexisting condition.

Behavioral/Educational Treatment for Complex Attention-Deficit/Hyperactivity Disorder (Age ≥ 6 Years) (Key Action Statement 3)

Psychosocial treatments, targeting areas of functional impairment, are the foundation of treatment for children and adolescents with complex ADHD. Therefore, the Behavioral/Educational Treatment algorithm should be considered as the starting place when planning treatment, although treatment decisions should be informed by family preferences and clinical judgment, taking into consideration available resources.

Step 1: All parents and patients should be provided with psychoeducation about ADHD, including information about the benefits and risks of different treatment modalities. This step is especially important, given the availability of information about ADHD on the Internet that is often misleading or inaccurate. Evidence-based psychosocial treatment should be initiated for all children and adolescents with complex ADHD.

Step 2: Ongoing assessment and monitoring should be conducted using tools such as patient and family interviews, standardized questionnaires and rating scales, and reports from school to determine the extent to which the child or adolescent is experiencing continued significant impairment in key domains of functioning. ADHD-specific rating scales are essential to monitoring core ADHD symptoms.

Steps 3 and 4: If a child is experiencing continued significant functional impairment, ongoing treatment decisions should take into consideration the degree of impairment, parental preference, risk/benefit of treatment options and, at times, the availability of resources to support treatment decisions. The Panel would like to emphasize that it is essential for insurers to provide coverage for evidence-based treatment options and that further efforts are required to support the development of a workforce capable of delivering evidence-based treatments to children and adolescents with ADHD wherever they live.

Treatment options to be considered at Step 4 include intensified behavioral treatment (Step 7) and/or medical (pharmacological) treatment (Step 8).

Steps 5, 6 and 9: Once functional impairments are adequately addressed, the child or adolescent should have ongoing maintenance monitoring, consisting of in-person clinic visits approximately every 4 to 6 months. For patients who are treated with medication, visit frequency should be every 3 to 4 months, depending on the patient's response, occurrence of side effects, and coexisting conditions. Monitoring should include at least annual screening for coexisting conditions that may develop over time and, for adolescents, screening for substance use and abuse at every visit (see Substance Use Disorder Screening algorithm below for details).

Steps 7, 8, and 11: Functional impairments are likely to change over time and are often related to the child's or adolescent's developmental stage. Therefore, monitoring visits should include an assessment of function, with consideration of earlier steps (Steps 6 and/or 9) to improve function. If coexisting conditions develop, further treatment should be guided by the relevant algorithm for ADHD with a coexisting condition (Step 11). This iterative approach—identification of treatment targets based on functional impairment, initiation of treatment, and assessment of response—is central to the treatment of complex ADHD.

Complex Attention-Deficit/Hyperactivity Disorder General Medication Treatment of Core Attention-Deficit/Hyperactivity Disorder Symptoms (Age ≥ 6 Years) (Key Action Statement 4)

This algorithm provides a suggested approach for initiation and maintenance of pharmacological treatment of core ADHD symptoms. The algorithm is intended for treatment of children whose core ADHD symptoms represent a significant source of functional impairment.

Step 1: As described elsewhere, psychosocial treatment is the foundation of treatment for children and adolescents with complex ADHD, and it is anticipated that psychosocial treatment will generally already be in place for patients who are started on pharmacological treatment. However, the decision to implement pharmacological treatment and the timing of this decision are clinical judgments based on each patient's profile of symptoms, functional impairments, and response to previous treatment, respecting family background and preferences.

Step 2: The clinician should provide the patient and family with psychoeducation about pharmacological treatment of ADHD, including the benefits, risks, and side effects. Baseline ADHD-specific rating scales should be obtained before initiation of treatment, along with a baseline assessment of functional impairment. In addition, a premedication baseline assessment of ADHD medication “side effects” should be performed because many potential “side effects” actually represent symptomatology that is present before initiation of pharmacological treatment (e.g., headache, poor appetite, poor sleep quality, and abdominal pain). It is important to identify specific target symptoms and treatment goals to inform ongoing assessment of treatment progress.

Step 3: Initial pharmacological treatment should generally be with either of the 2 classes of stimulant medication (methylphenidate or amphetamine) at the lowest formulated dose. The following factors should be considered when selecting a medication:

• History of response to previous treatment with medication
• Duration of desired effect (length of school day, homework, and afterschool activities; intermediate-release preparations [6–8 hours] vs extended-release preparations [10–12 hours])
• Ability to swallow pills
• Potential for abuse/misuse/diversion (tablet and beaded formulations have higher potential than osmotic-controlled release oral delivery system, prodrug, or dermal formulations)

Step 4: Treatment effects should be assessed using ADHD-specific rating scales such as the Vanderbilt² Assessment Scale to assess changes in core ADHD symptoms. Assessment of functional impairment should be based on information from parent/child interview, reports from school, and, where possible, ratings of functional impairment such as the Clinical Global Improvement³ or the Impairment Rating Scale.⁴ Significant improvement, by convention, may be represented by the following:

• >25% decrease in parent or teacher Vanderbilt total or relevant subscale score
• Patient no longer meets 6/9 positive items criteria on relevant Vanderbilt subscale, reported by the parent or teacher
• ≥1 category increase in parent-rated OR teacher-rated Clinical Global Improvement score
• Patient has met or maintained a satisfactory level of symptoms and functioning

In addition, however, a general principle should be to titrate treatment to maximal effect with minimal side effects.

There is no single optimal approach to initiation and titration of medication. In some situations, the initial choice of medication and dose may be effective. However, it is more typical for adjustments in medication dose or trials of a second or third medication option to be required before an optimal response is achieved. In general, treatment should be initiated with the lowest reasonable dose, with upward titration at approximately weekly intervals until target symptoms and function are maximally improved or intolerable side effects occur. Clinicians may wish to consider the following scheme as 1 possible option for initiation of medication:

• Attention-deficit/hyperactivity disorder rating scales and side effect rating scales administered at pretreatment baseline and weekly on Fridays for 4 weeks
• Parent to inform the teacher “We will be making frequent changes to student's treatment this month, so it will be important to get your feedback every week about student's performance” but otherwise keep the teacher blinded as to the child's medication condition
• Week 1: Start at the lowest dose on Saturday; follow up by phone or email at the end of week or if significant side effects are noted
• Week 2: Increase to next dose if equivocal effectiveness and minimal/tolerable side effects
• Week 3: Discontinue medication; keep the teacher blinded
• Week 4: Resume most recent dose and complete in-person follow-up visit

Side effects should be characterized by type and severity:

Minimal/Tolerable Side Effects

• Side effects rated as “mild” (e.g., appetite suppression and delayed sleep onset without significant reduction in duration of sleep; see exclusions)
• Side effects rated as “moderate” but are able to be mitigated by appropriate education and/or other strategies (e.g., increasing caloric density to manage decreased appetite; change in medication timing or formulation to manage sleep onset delay)
• Exclusions: any significant side effect

Significant Side Effects

• Any suicidal ideation
• Any hallucinations or psychotic thoughts
• Moderate to severe aggression or irritability that is not associated with the medication wearing off
• Moderate to severe irritability, mood lability or mania
• Weight loss >2 graphed percentile categories since the start of medication treatment
• Atomoxetine: jaundice
• Alpha agonist: significant daytime sedation (unable to wake up, constantly falling asleep); >10 point decrease in blood pressure or evidence of postural hypotension

Steps 5 to 8: Steps 5 through 8 describe potential results of the assessment of response (progress toward treatment goals) and occurrence of side effects. Step 5 (inadequate progress toward treatment goals and targets, with minimal side effects) leads to an iterative process of adjustments in treatment, with the overall goal of achieving treatment goals with minimal side effects. During this process, an in-person assessment is recommended within the first 4 to 6 weeks of treatment to assess for side effects, to obtain vital signs and weight, and to perform a cardiac examination. When treatment is deemed to have achieved treatment goals/targets with minimal side effects (Step 6), treatment is continued with ongoing monitoring. Steps 7 and 8 represent distinct patterns of response to treatment and/or side effects, with subsequent treatment decisions as indicated in the algorithm.

Step 9: While adjusting medication doses during the medication titration process, it is important to continue appropriate psychosocial treatment and to consider adjustments in psychosocial treatment.

Steps 10 to 13: When treatment goals are achieved, medication and psychosocial interventions are continued, and the child or adolescent is seen for in-person clinic visits every 3 to 4 months to monitor response to treatment, occurrence of side effects, and, on at least an annual basis, to screen for development of coexisting conditions. For adolescents, monitoring visits should include screening for substance use.

Steps 11 and 12: These steps highlight the importance of assessing for the occurrence of side effects to medication. Often, milder side effects can be managed or tolerated as described earlier. More severe or intolerable side effects require consideration of other medications and/or intensified psychosocial treatment.

Step 13: If, in the course of maintenance monitoring, the patient's level of function deteriorates, treatment becomes ineffective, or new coexisting conditions are identified, treatment should be guided by earlier steps of the algorithm as appropriate (i.e., returning to Step 4).

Steps 14 to 16: If the child or adolescent has stable symptoms and functional status with minimal side effects, maintenance monitoring continues. If the treatment targets and acceptable function are not maintained, special consideration should be given to a more detailed assessment for new coexisting conditions. If a coexisting condition is identified, treatment should proceed according to the relevant algorithm. If no coexisting condition is identified, medication treatment choices and psychosocial intervention and intensity should be reconsidered as described in earlier steps.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AND COEXISTING CONDITIONS

In the following sections, we provide annotations for the algorithms describing the process of care for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and an identified coexisting condition. There are several general principles that should be considered when caring for patients with ADHD plus a coexisting condition:

1. When a coexisting condition is identified, an assessment should be completed to determine whether the coexisting condition is equally, less, or more impairing than the impairment associated with ADHD itself. Treatment should target the major source of functional impairment (i.e., ADHD vs the coexisting condition) in specific domains (e.g., academic problems, difficulty getting along with peers, and noncompliance with teachers and parents). When both conditions are equally impairing, the decision of which condition to treat first should be made with the patient and family using principles of shared decision-making.
2. An assessment of the degree of impairment attributable to ADHD versus impairment associated with the coexisting condition will be aided by the use of questionnaires specific to the coexisting condition. An analysis of the child's or adolescent's function in key domains (educational, behavioral, and social) may be needed to determine the most important source of functional impairment. This assessment is essential to identify treatment targets and goals.
3. The overarching goal of the algorithms for the treatment of ADHD and coexisting conditions is to facilitate a systematic approach that focuses on improvement in function across domains. This is an iterative process that takes place over time, given that the source of functional impairment will inevitably change based on the unique profile and environment of the child or adolescent, including changes related to different developmental stages (preschool, school-age, and adolescence).
4. When treatments are successful in addressing the primary source of a patient's impairment (e.g., core ADHD symptoms), there are often “residual” or novel impairments in other domains of functioning that may be attributable to a coexisting condition (e.g., aggression). These residual impairments will then become the targets of additional or modified treatment approaches.
5. The algorithms for ADHD with coexisting conditions are not intended to be detailed comprehensive guidelines for the treatment of the specific coexisting condition (e.g., anxiety, depression). Rather, they are intended to help the clinician to identify treatment goals at a given point in the treatment process, based on the patient's most concerning problems and impairments. Clinicians should consult primary sources and guidelines for these conditions.

Attention-Deficit/Hyperactivity Disorder and Coexisting Autism Spectrum Disorder

Step 1: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosing ADHD and coexisting autism spectrum disorder (ASD) is allowed.⁵ It is important to recognize the different ways that symptoms of ASD and ADHD emerge in the developing child. In general, diagnoses of ASD are being made in toddlers and young preschool-age children, whereas diagnoses of ADHD are more typically made in school-age children. Thus, it is more likely that symptoms of ASD will be recognized before those of ADHD.⁶ Among children for whom ADHD is diagnosed first, symptoms of ASD may be more subtle or milder.

In children/adolescents with ASD, other health conditions (e.g., sleep disorders, seizures, and pain) may contribute to observed behaviors that may be confused with primary symptoms of ADHD. These conditions should be considered as potential causes for hyperactive, impulsive, and inattentive behaviors in children and adolescents with ASD.

Step 2: It is beyond the scope of this guideline to provide detailed information on the assessment and treatment of ASD. However, it is important for the clinician to ensure that children and adolescents are receiving appropriate treatment for ASD in all cases before making a determination about the extent to which ADHD symptoms may represent a separate source of functional impairment.

Steps 3 and 4 & Steps 7, 10, and 11: If impairing symptoms of ADHD do not persist after implementation of treatment for ASD, further care is focused on maintenance monitoring of overall progress, including assessment for emergence of impairing symptoms of ADHD and/or other coexisting conditions. Detailed information about the ongoing monitoring of ASD is beyond the scope of this guideline.

Steps 5: The approach used in a functional behavioral analysis (FBA) (i.e., identification of problem behaviors, along with antecedents and responses to specific behaviors) helps to ensure an accurate understanding of the underlying factors that are contributing to behaviors that, in turn, adversely affect function. To determine whether functional impairments are attributable to ADHD or to coexisting ASD, a formal FBA may be required.

In some patients, it may be impossible to determine which set of symptoms are the primary source of functional impairment. In these situations, the clinician will need to consider simultaneous intensive treatment of both the ADHD and ASD symptoms.

Step 8: When impairing symptoms of ADHD persist despite appropriate behavioral and other treatment for ASD (as per Step 2), consideration should be given to pharmacological treatment for ADHD as per the General Medication Treatment Algorithm.

Steps 6 and 10: Children with ADHD and coexisting ASD may manifest impairing symptoms of aggression, irritability, or other disruptive behaviors that require more intensive behavioral treatment. When these symptoms are severe, despite intensive behavioral interventions, pharmacological treatment with atypical neuroleptics may be considered. Discussion of treatment with atypical neuroleptics is beyond the scope of this guideline.

Steps 9 and 11: When impairing symptoms of other coexisting conditions are present, treatment should be guided by other algorithms as indicated. It is important to re-emphasize that other health conditions (e.g., sleep disorders, seizures, pain) may contribute to observed behaviors that may be confused with primary symptoms of ADHD. This guideline does not include algorithms for treatment of these other conditions.

Attention-Deficit/Hyperactivity Disorder and Coexisting Tics

Steps 1 and 2: This algorithm is intended for children and adolescents with chronic or severe tic disorders, which are more likely to be associated with ADHD and with other coexisting disorders.

It is important for the clinician to consider other non-tic movements or noises (e.g., stereotypies, habits, compulsions, and fidgetiness) in the differential diagnosis of tics. It is also important to recognize that tics are very common in the general population and are more common among those with ADHD. Tics may emerge at the same ages at which stimulant medications are prescribed, and it should not be assumed that onset of tics is caused by stimulant treatment; this is important information to share with parents when ADHD pharmacological treatment is being considered.

Children with ADHD and coexisting tics require particularly careful consideration of treatment options. For children with ADHD and chronic or severe tics, it may be appropriate to consider reduced doses of stimulant medication with addition of an alpha-adrenergic agonist.⁷

Steps 4 to 6: Children and adolescents with ADHD and coexisting chronic tics are at a much greater risk for anxiety disorders and the closely related obsessive-compulsive disorder. For children with ADHD, tics, and anxiety, treatment should be guided by the ADHD and Coexisting Anxiety algorithm. It is also important to recognize that insufficient sleep may exacerbate anxiety, ADHD symptoms, and tics.

Step 7: The clinician should determine whether tics or ADHD symptoms are causing greater functional impairment. This determination requires the participation of the child or adolescent and his or her parents because there may be discrepancies in their perspectives. Impairments associated with tics may include depression, poor self-esteem, self-injury, functional disruption because of tics and/or efforts to suppress them, or pain.

Step 8: Consensus is lacking among tic experts regarding treatment strategies for ADHD with coexisting chronic tic disorders because of the limited availability of high-quality research. Therefore, treatment recommendations in this algorithm reflect the consensus opinion of the Panel. Treatment of chronic tics should include Comprehensive Behavioral Intervention for Tics, at times combined with alpha agonist medications (particularly clonidine) based on clinical judgment about the severity and functional impact of the tics. Treatment for tics is complicated by the fact that tic severity typically waxes and wanes on its own, making it difficult to judge the effectiveness of treatment. Furthermore, currently available treatments are imperfect, so treatment goals aim for reduction, rather than elimination, of tic behaviors. It is therefore important to foster the development of coping and resiliency strategies in patients with ADHD and coexisting chronic tics.

Step 9: When assessing response to pharmacological treatment of tics, it is important to understand that response to alpha-adrenergic agonists may have a latency of weeks before a therapeutic effect on tic suppression is observed.

Steps 10 to 13: When assessing the impact of treatment, the clinician must consider both the response (i.e., progress toward treatment goals and targets) and any side effects of treatment that emerge. Steps 10 to 13 are arranged to facilitate clinical decision-making about treatment response and emergence of side effects in a systematic manner, beginning with Step 10 and proceeding to subsequent steps as indicated in the algorithm.

Step 14: This step describes titration of alpha-adrenergic agonist medication.

Steps 15 and 18: Treatment is continued when deemed effective, based on assessment of tics and related functional impairments. At this point, the clinician should also determine whether residual ADHD symptoms are causing impairment and therefore whether pharmacological treatment for ADHD should be added.

Step 17: When tics continue to be significant and impairing despite behavioral and pharmacological treatment with an alpha-adrenergic agonist, consideration should be given to using an alternative alpha-adrenergic agonist (e.g., if treatment has been with a clonidine preparation, changing to a guanfacine preparation). When tics and related impairments are severe and have not responded to behavioral treatment and pharmacological treatment with an alpha-adrenergic agonist, consideration should be given to treatment with an atypical neuroleptic and/or referral to a clinician with additional expertise in the management of tics.

Attention-Deficit/Hyperactivity Disorder and Coexisting Substance Use Disorder

This algorithm emphasizes age-based screening for substance use disorder (SUD), given the elevated risk for SUD among children and adolescents with ADHD.

Steps 1 and 4: SUD screening is not recommended for children ≤ age 8 years. However, psychoeducation for parents of children with ADHD should include information about heightened risk for development of SUD.

Steps 2 and 5: Although children between ages 9 through 11 years are not typically viewed as being at risk for substance use, this algorithm recommends initiation of screening at this age because of the high risk for SUD among children and adolescents with ADHD. In this age group, it is recommended that clinicians use the 2-question National Institute on Alcohol Abuse and Alcoholism (NIAAA) Youth Alcohol Screening Tool, which was developed for use in children as young as 9 years.⁸

Steps 7, 8, and 13: When there has been no alcohol use by the 9-year-old to 11-year old-patient, no further screening is recommended at that visit. When there has been any alcohol use by the patient, the clinician should provide brief intervention and consider referral for further evaluation or treatment. Additional details about brief intervention, assessment of the severity of substance use, and the decision to refer for treatment are included in the NIAA alcohol screening guide for practitioners.

Step 3: All children ≥age 12 years should be formally screened for substance use at each clinic visit.

Step 6: Screening for SUD in this algorithm is based on the principles of screening, brief intervention, and referral to treatment approach (S2BI).^9,10 A toolkit to facilitate screening is available online.¹¹ It is recommended that the initial question relate to alcohol use by friends, followed by a question about alcohol use by the patient.

Steps 9 and 17: When there has been no substance use in the past year, exit the algorithm.

Steps 10 and 14: Children and adolescents who have used substances 1 to 2 times in the past year are deemed to not have an SUD.

Steps 11 and 15: Children and adolescents who have used substances monthly during the past year are deemed to have mild-moderate SUD.

Step 18: Children and adolescents with no SUD (but who have used substances 1–2 times in the past year) or mild-moderate SUD should be assessed for the use of other substances, including prescription and nonprescription (illegal) drugs. Brief intervention should be provided as described in the American Academy of Pediatrics 2016 policy.⁹

Step 20: Children and adolescents with no SUD or mild-moderate SUD should be very carefully monitored for SUD at all future visits.

Steps 12 and 16: Children and adolescents who use substances weekly or more often are deemed to have severe SUD.

Steps 19 and 21: Children and adolescents with severe SUD should be assessed for the use of other substances as in Step 17 above. Brief intervention should be provided, along with referral for SUD treatment, depending on the availability of trained clinicians and services in the local community.

Attention-Deficit/Hyperactivity Disorder and Coexisting Anxiety

Step 2: The clinician should determine whether ADHD or anxiety symptoms are causing greater functional impairment. This process requires careful consideration of function across domains (home, school, community, and social/peers) using information from clinical interviews and standardized questionnaires provided by both the patient and parents or guardians.

Step 3: If anxiety symptoms are more impairing, treatment should be initiated with cognitive behavioral therapy (CBT) appropriate to the child or adolescent's age and developmental stage. It is important to assist the family in identifying qualified local therapists who provide CBT for anxiety.

Step 4: If it is determined that ADHD symptoms are more impairing than anxiety symptoms, treatment should be guided by the ADHD treatment algorithms.

Steps 5 to 7: If anxiety symptoms are improved to the extent that residual ADHD symptoms are more impairing, treatment should be guided by the relevant ADHD treatment algorithm (Step 7). If anxiety symptoms are still impairing, consideration should be given to modification or intensification of CBT.

Steps 8 to 10: If anxiety symptoms continue to be the major source of impairment, consideration should be given to a trial of pharmacological treatment with a selective serotonin reuptake inhibitor while continuing CBT and careful monitoring of response to treatment (Step 9). Detailed information about pharmacological treatment of anxiety is beyond the scope of this guideline. If anxiety symptoms are improved and residual ADHD symptoms are impairing, treatment should be guided by the relevant ADHD treatment algorithm (Step 10).

Steps 11 to 13: For children and adolescents whose anxiety has required pharmacological treatment, the clinician should provide ongoing monitoring of response and, when response is inadequate, the clinician should consider alternative medications and/or adaptations in intensity or approach to CBT.

Attention-Deficit/Hyperactivity Disorder and Coexisting Depression

Step 2: Children or adolescents with ADHD and coexisting depression should be evaluated at every visit to determine if there are any “red flags” that indicate severe symptoms. These include

• Suicidal ideation or behavior
• Homicidal ideation or behavior
• Previous suicide attempts
• Signs or symptoms of psychosis
• Mania
• Severe functional impairment due to depression

Step 3: If 1 of the above “red flags” is present, consideration should be given to referral to a child psychiatrist/qualified mental health professional or, in urgent situations (e.g., suicidal ideation with plan and intent), to emergency or crisis services.

Step 4: The clinician should determine whether ADHD or symptoms of depression are causing greater functional impairment. This process requires careful consideration of function across domains (home, school, community, and social/peers) using information from clinical interviews and standardized questionnaires provided by both the patient and parents or guardians. If ADHD symptoms are more impairing than depression, treatment should be guided by the relevant ADHD treatment algorithms (Step 6).

Step 5: For children or adolescents whose symptoms of depression represent the major source of functional impairment, treatment should include evidence-based therapy (i.e., CBT or interpersonal therapy), with the addition of a selective serotonin reuptake inhibitor if needed. A detailed discussion about psychotherapeutic and medical treatment for depression is beyond the scope of this guideline.

Steps 7 to 9: These steps illustrate an iterative process of monitoring and treatment targeting ADHD or coexisting depression, depending on the source of impairment.

Attention-Deficit/Hyperactivity Disorder and Coexisting Disruptive Behavior Disorders

Step 1: This algorithm describes an approach to the treatment of children and adolescents with ADHD and coexisting disruptive behavior disorders (i.e., oppositional defiant disorder and conduct disorder, including aggressive and bullying behavior).

Step 2: It may be difficult to determine the extent to which functional impairments are primarily due to core symptoms of ADHD versus disruptive behaviors such as oppositionality and aggression. As with ADHD and other coexisting conditions, this determination requires careful consideration of function across domains (home, school, community, and social/peers) using information from clinical interviews and standardized questionnaires provided by both the patient and parents or guardians. If ADHD symptoms are more impairing than disruptive behaviors, treatment should be guided by the relevant ADHD treatment algorithms (Step 4).

Step 3: This step includes services and supports that should be implemented for children and adolescents with functional impairments due to disruptive behaviors. For those whose impairments are judged to be severe (e.g., frequent school suspensions, aggressive behaviors, delinquency), more intensive psychosocial interventions including multisystemic therapy may be required. As described in the guideline, children and adolescents in this situation may benefit from combined psychosocial and pharmacological treatment for their ADHD and coexisting disruptive behaviors.

Step 5: Children and adolescents with ADHD and coexisting disruptive behaviors require especially careful, ongoing monitoring of their symptoms and impairments given the implications of severe disruptive behaviors for the patient, family, and community. For adolescents with ADHD and externalizing behaviors, if medical treatment is initiated, careful management and monitoring is needed given the potential for medication diversion/abuse.

Step 6: When disruptive behaviors are deemed to have improved to the extent that they no longer represent the major source of impairment, intensive behavioral treatment should be continued, along with treatment of ADHD according to the relevant algorithms.

Step 7: When disruptive behaviors continue to be impairing despite implementation of intensive behavioral treatments, consideration should be given to pharmacological treatment for patients who are not already being treated with medication.

Preschool-Age Complex Attention-Deficit/Hyperactivity Disorder General Medication Treatment (Ages ≥ 3 Years to ≤ 6 Years)

Step 1: In this age group, medication effectiveness is lower and side effects are more common than in older children. This algorithm is intended to guide treatment of preschool-age children with ADHD who have functional impairments that persist despite implementation of psychosocial treatments in keeping with the steps outlined in the Behavioral/Educational Treatment Algorithm.

Step 2: Pharmacological treatment of ADHD in preschool-age children should be undertaken only after parents are provided with psychoeducation specific to pharmacological treatment in this age group, including the risks, benefits, and side effects of medications. Baseline assessment before initiation of medication should include ADHD-specific rating scales, an assessment of functional status, and an inventory of symptoms that could also later be characterized as medication side effects (e.g., headache, sleep, appetite, and irritability). Treatment goals should be determined through the shared decision-making process.

Step 3: Initial medication choice for preschool-age children with ADHD is based on the available literature that supports the use of methylphenidate in this age group.¹² Although recent research has shown that developmental-behavioral pediatricians often choose alpha-adrenergic agonists to treat preschoolers with ADHD,¹³ it is important to emphasize that there is limited evidence for effectiveness of alpha-adrenergic agonists in this age group. When initiating pharmacological treatment in this age group, consideration should be given to baseline characteristics including severe impulsivity, aggressive behavior, irritability, or concerns about mood.

Step 4: Treatment should begin with a low dose of short-acting methylphenidate.

Step 5: When an alpha-adrenergic agonist is chosen, treatment should be initiated with a low dose of clonidine or guanfacine, followed by assessment of treatment response and occurrence of side effects as described above.

Step 6: Assessment of response to treatment and occurrence of side effects is similar to the approach recommended for school-age children. An in-person assessment is recommended within the first 3 to 4 weeks of treatment to assess for side effects, to obtain vital signs and weight, and to perform a cardiac examination. Treatment effects should be assessed using ADHD-specific rating scales such as the ADHD Rating Scale-IV Preschool Version¹⁴ to assess changes in core ADHD symptoms. Assessment of functional impairment should be based on information from parent/child interview, reports from school, and, where possible, ratings of functional impairment using indices such as the Clinical Global Improvement.³ Significant improvement, by convention, may be represented by the following:

• >25% decrease in parent or teacher Vanderbilt total or relevant subscale score
• Patient no longer meets 6/9 positive items criteria on relevant Vanderbilt subscale, reported by the parent or teacher
• ≥1 category increase in parent-rater OR teacher-rated Clinical Global Improvement score
• Patient has met or maintained a satisfactory level of symptoms and functioning

In addition, however, a general principle should be to titrate treatment to maximal effect with minimal side effects.

Side effects should be characterized by type and severity:

Minimal/Tolerable Side Effects

• Side effects rated as “mild” (e.g., appetite suppression and delayed sleep onset without significant reduction in duration of sleep; see exclusions)
• Side effects rated as “moderate” that respond to appropriate education and/or other strategies (e.g., increasing caloric density to manage decreased appetite; change in medication timing to manage sleep onset delay)
• Exclusions: any significant side effect

Significant Side Effects

• Any hallucinations or psychotic thoughts
• Moderate to severe aggression or irritability that is not associated with the medication wearing off
• Moderate to severe irritability, mood lability or mania
• Weight loss >2 graphed percentile categories since start of medication treatment

Steps 7 to 10: Steps 7 through 10 describe potential results of the assessment of response (progress toward treatment goals) and occurrence of side effects. Step 7 (inadequate progress toward treatment goals and targets, with minimal side effects) leads to an iterative process of adjustments in treatment, with the overall goal of achieving treatment goals with minimal side effects. During this process, an in-person assessment is recommended within the first 4 to 6 weeks of treatment to assess for side effects, to obtain vital signs and weight, and to perform a cardiac examination. When treatment is deemed to have achieved treatment goals/targets with minimal side effects (Step 8), treatment is continued with ongoing monitoring. Steps 9 and 10 represent distinct patterns of response to treatment and/or side effects, with subsequent treatment decisions as indicated in the algorithm.

Step 11: This step describes titration of medication dose and frequency of administration, with careful monitoring of response and side effects. Titration of medication doses should be made in small increments, with careful monitoring of response and side effects. For some children, depending on observed duration of action and medication being prescribed, consideration may be given to twice a day or three times a day dosing. It is important to also consider intensified behavioral and educational treatments, depending on the severity of ADHD symptoms and related impairments.

Step 12: For children being treated with short-acting methylphenidate, once treatment goals are reached, consideration should be given to changing to an equivalent dose of intermediate acting methylphenidate.

Step 13: For some children treated with either methylphenidate or an alpha-adrenergic agonist who have a significant improvement in function, mild side effects may be manageable, and a decision may be made to continue the medication despite the occurrence of side effects.

Step 14: For some children treated with either methylphenidate or an alpha-adrenergic agonist, side effects may not be tolerable, and consideration should then be given to treatment with another category of medication or reverting to a lower dose of medication combined with intensified psychosocial treatment.

Step 15: When treatment goals are achieved, medication and psychosocial interventions are continued, and the child is seen for in-person visits to monitor response to treatment, occurrence of side effects, and, on at least an annual basis, to screen for development of coexisting conditions. Careful monitoring for changes in core ADHD symptoms or the development of coexisting conditions is critically important given the rapid developmental changes that occur in this age group.