New ADHD Guidelines Include Broader Age Range

Fran Lowry

October 17, 2011 (Boston, Massachusetts) — For the first time in a decade, the American Academy of Pediatrics has issued an updated set of guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) that now include younger, preschool children and adolescents.

The guidelines, "ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder," were released here at the American Academy of Pediatrics National Conference & Exhibition and simultaneously published online October 16 in Pediatrics.


Dr. Mark Wolraich
"We wrote the original guidelines in 2000 to 2001, and they were written for children between the ages of 6 and 12 because that's where most of the available evidence was at the time," Mark Wolraich, MD, CMRI/Shaun Walters professor of pediatrics and chief of the Section of Developmental and Behavioral Pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, told Medscape Medical News.

"Over the years, we have heard about the concern for preschool children and adolescents and what should be done with them. We've expanded the age group to include children aged 4 to 18 because there's certainly new evidence to support recommendations for the broader age group," said Dr. Wolraich, lead author of the guidelines.

Increase in Approved Medications

The last 10 years have also seen an increase in the number of medications that have been approved by the US Food and Drug Administration for the treatment of ADHD, and the new guidelines reflect this. They also emphasize the chronic nature of the disorder

"We had pushed for the idea that ADHD was a chronic illness in the initial guidelines, and that clinicians needed to use chronic illness principles in treating it, and this has been further emphasized," Dr. Wolraich said.

Other key recommendations include:

assessing children for other conditions that might coexist with ADHD, such as oppositional defiant and conduct disorders, anxiety, and depression;
making sure that Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria have been met;
obtaining information primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child's care;
first line of treatment for preschool-aged children 4 to 5 years old should be evidence-based parent- or teacher-administered behavior therapy;
titrating medication doses to achieve the maximum benefit with the least adverse effects; and
for adolescents, the primary care clinician should prescribe FDA-approved ADHD medications with their consent.
"The challenge in adolescents is you no longer have individual teachers as good reporters of their behavior, because they are going from class to class, and no one has them for a long period of time. It tends to be hard to get good information," Dr. Wolraich said.

He added that it is important to start treating children at a young age.

"When we can identify them earlier and provide appropriate treatment, we can increase their chance of succeeding in school. With our greater awareness now about ADHD and better ways of diagnosing and treating this disorder, more children are being helped."

Clinical Judgment Not Enough

Peter Jensen, MD, codirector of the Division of Child Psychiatry and Psychology at the Mayo Clinic, Rochester, Minnesota, told Medscape Medical News that the updated guidelines give more detailed instructions to help primary care physicians manage these patients.


Dr. Peter Jensen
"What's wonderful about the updated guidelines is they provide additional guidance and specificity over the guidelines that were published back in 2000 to 2001," Dr. Jensen said.

"Some of these kids have very complex problems; many also have anxiety and depression. The guidelines take note of this, and they also emphasize the use of rating scales from teachers and parents. They take us a step further," he added.

Providing more detailed guidance on the diagnosis and treatment of children with ADHD is important, he said.

"Many doctors treat ADHD by the seat of their pants," he said. "They are well intentioned, but when we are in the midst of a busy office day and frantic parents, and understaffed, our clinical judgment isn't enough, and we are prone to miss things. If the mom smiles we think all is well. But that is not as accurate as looking at the rating scale from the parents, from the teacher, and talking with Johnnie.

"Clinical judgment is not enough to replace these kinds of tools, and the guidelines add more of that kind of detail and will be more likely to help us keep from making errors of omission and commission."

Dr. Jensen said he suspected that ADHD may be increasing because so many demands for sustained attention are being placed on today's children.

"We expect our kids to learn more, do more, we expect them not just to go to college but to have 3 or 4 hobbies and activities they do in the afternoon and quickly get that homework done, and then we expose them to many different stimuli.

"They have the TV going, and the Game Boy going. All those things are competitors for attention. If you had a society where homework was not important, almost by definition you'd have fewer parents complaining about their child's inattention," said Dr. Jensen.

Dr. Wolraich disclosed that he is a past consultant to Shire, Lilly, Shinogi and Nextwave all of which produce medications for ADHD. Dr. Jensen has disclosed no relevant financial relationships.

American Academy of Pediatrics National Conference & Exhibition 2011. Presented October 16, 2011.

Pediatrics. Published online October 16, 2011

|| Link to PDF File || From Medscape

Omega-3 Effective for Treating Child ADHD

Deborah Brauser

September 8, 2011 — Supplementation with omega-3 fatty acid may decrease symptoms of attention-deficit/hyperactivity disorder (ADHD) in children, a new meta-analysis suggests.

In an evaluation of 10 trials with 699 total children with ADHD, investigators found that those who received omega-3 supplements had a "small but significant" improvement in symptom severity compared with those who were given placebo. This effect was also significant in the children who received supplements that specifically contained higher doses of eicosapentaenoic acid.

"I was actually expecting this treatment to not be effective at all, that we shouldn't expect much from a nutritional supplement that often takes a while to work. So the results were a surprise to me," lead author Michael H. Bloch, MD, assistant professor at the Yale Child Study Center at Yale University School of Medicine in New Haven, Connecticut, told Medscape Medical News.

"However, I would hope that nobody thinks the take-home message is that omega-3s are the answer for everyone in lieu of traditional medications," said Dr. Bloch.

In fact, the investigators note that the relative efficacy of this treatment "was modest compared with currently available pharmacotherapies for ADHD, such as psychostimulants, atomoxetine, or a2 agonists."

Still, because of its "relatively benign side-effect profile," they write, omega-3 supplements may be a reasonable add-on to traditional interventions or an option for families who do not want other psychopharmacologic treatments.
"I think the medication treatments we currently have for ADHD work best. But omega-3 represents a potentially safer alternative, especially in mild cases," said Dr. Bloch.

The study was published online August 16 in the Journal of the Academy of Child and Adolescent Psychiatry.

Past Research Results "Mixed"

According to the investigators, past research has shown that individuals with ADHD have omega-3 differences in both plasma and erythrocyte membranes compared with their healthy peers.

"Omega-3 fatty acids have anti-inflammatory properties and can alter central nervous system cell membrane fluidity and phospholipid composition," they explain.

Although several studies have looked at how effective omega-3 is in treating ADHD, the results have been mixed, prompting the need for the current meta-analysis.

The researchers examined 10 randomized control trials that compared omega-3 supplements with placebo in children with ADHD. All studies were conducted between 2001 and 2009 and lasted between 7 weeks and 4 months.

ADHD severity improvement, as measured by mean differences in rating scales, was the primary outcome. In secondary analysis, the investigators assessed dosing effects of the following omega-3 fatty acids found within the supplements used: eicosapentaenoic acid, docosahexaenoic acid, and α-linolenic acid.

Efficacy When Studies Combined

Results showed significant efficacy of omega-3 supplementation compared with placebo in only 2 of the trials. Of the remaining studies, 6 showed no benefit at all, and 2 showed benefit only on some of the ADHD rating scales.

Still, the overall analysis did show a significant improvement in ADHD symptoms for the participants receiving omega-3 compared with those receiving placebo (standard mean difference [SMD], 0.31; P < .0001).

"Looking at these studies individually, most did not find that omega-3 was effective. It was only when you combined them that the effect became significant to a small degree," said Dr. Bloch.

Results were similar when parental ratings of ADHD severity were assessed (SMD, 0.29; P = .0002), and when separate evaluations of inattentive (SMD, 0.29; P = .009) and hyperactivity (SMD, 0.23; P = .005) symptoms were conducted.

Omega-3 supplements that included higher doses of eicosapentaenoic acid were also significantly associated with lowering ADHD symptoms (P = .04).

There were no significant differences found for any dose of docosahexaenoic acid or α-linolenic acid, or between omega-3 monotherapy vs augmenting traditional ADHD medications with omega-3.

"No evidence of publication bias or heterogeneity between trials was found," write the researchers.

However, "because of poor quality and potential issues of blinding in many of the included trials," further studies are needed to replicate the results, they write.

"I think this is something that's potentially useful for families who either don't respond to treatment with traditional medications or are hesitant to take them because of side effects," said Dr. Bloch.
He added that he hopes a future multisite trial with at least 400 children will be conducted to finally give "a definitive answer on how much omega-3 might really work."

Missing Side Effects Profile

"This is a well-done meta-analysis with attention to several aspects," Jaswinder Kaur Ghuman, MD, associate professor of psychiatry and pediatrics at the University of Arizona, Tucson, told Medscape Medical News.

However, she added that one of her concerns is the investigators' statement that omega-3 treatments have a benign side effects profile.

"They did not include analysis of side effects from the included studies, neither do they discuss what are the side effects of omega-3 supplements. Anecdotally, I have seen some people be unable to tolerate [these] supplements due to gastrointestinal upset."

Dr. Ghuman said that if parents are interested in letting their children try omega-3 supplements for their ADHD symptoms, "they should be advised to use adequate doses for effectiveness and tolerability should be carefully monitored."

The study was supported by grants from the National Institutes of Health and from the National Center for Research Resources, and by the National Institute of Mental Health, the American Psychiatric Institute for Research and Education/Eli Lilly and Co Psychiatric Research Fellowship, the American Academy of Child and Adolescent Psychiatry/Eli Lilly and Co Pilot Research Award, the Trichotillomania Learning Center, and the National Alliance for Research on Schizophrenia and Depression. The study authors have disclosed no relevant financial relationships.
J Am Acad Child Adolesc Psychiatry. Published online August 16, 2011

From : Medscape