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Cited by 1,562Attention Deficit Hyperactivity DisorderChild and Adolescent Psychosocial and Emotional DevelopmentClinical practice guidelines implementation

The DOI matches its Crossref record; 150 of the 152 references it cites were found in a registry or an index; 41 of the 151 sources its claims cite were checked for support.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Wolraich, Mark L., Hagan, Joseph F., Allan, Carla, Chan, Eugenia, Davison, Dale, Earls, Marian, Evans, Steven W., Flinn, Susan K., Froehlich, Tanya, Frost, Jennifer, Holbrook, Joseph R., Lehmann, Christoph Ulrich, Lessin, Herschel Robert, Okechukwu, Kymika, Pierce, Karen L., Winner, Jonathan D., Zurhellen, William, SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISORDER·2019·Pediatrics
DOI 10.1542/peds.2019-2528PMC PMC7067282
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Abstract

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline’s recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians’ ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.

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Crossref · 10.1542/peds.2019-2528

Cites

150 of 150 references verified0 citation errors · 0 not checkable

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Claims the paper makes

42 No full text of the sources · 19 Partly supported · 17 Own interpretation · 7 Own method · 5 Supported · 5 Sources not found · 4 Supported so far · 4 Not checked yet · 4 No basis given · 2 Couldn’t confirm · 1 Mixed support · accuracy not yet measured

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Show all 65 claims

  • It may state two separate claims as one. 24
  • Probably not a substantial claim. 27
45 of 45

  • The paper relies on this without support.

    Since the release of the 2011 guideline, the DSM has been revised to the fifth edition, and new ADHD-related research has been published.

    “Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published.”

  • The paper relies on this without support.

    ADHD is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions.

    “Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions.”

  • The paper relies on this without support.

    Symptoms of ADHD occur in childhood, and most children with ADHD will continue to have symptoms and impairment through adolescence and into adulthood.

    “Symptoms of ADHD occur in childhood, and most children with ADHD will continue to have symptoms and impairment through adolescence and into adulthood.”

  • The paper relies on this without support.

    The DSM-5 system is used by professionals in psychiatry, psychology, health care systems, and primary care; it is also well established with third-party payers.

    “The DSM-5 system is used by professionals in psychiatry, psychology, health care systems, and primary care; it is also well established with third-party payers.”

  • The paper relies on this without support.

    The DSM-5 classification criteria are based on the best available evidence for ADHD diagnosis and are the standard most frequently used by clinicians and researchers to render the diagnosis and document its appropriateness for a given child.

    “As with the previous guideline recommendations, the DSM-5 classification criteria are based on the best available evidence for ADHD diagnosis and are the standard most frequently used by clinicians and researchers to render the diagnosis and document its appropriateness for a given child.”

  • The paper relies on this without support.

    There are minimal changes in the specific behaviors from the DSM-IV, on which all the other DSM-based ADHD rating scales obtained normative data.

    “There are, however, minimal changes in the specific behaviors from the DSM-IV, on which all the other DSM-based ADHD rating scales obtained normative data.”

  • The paper relies on this without support.

    Both the ADHD Rating Scale-IV and the Conners Rating Scale have preschool-age normative data based on the DSM-IV.

    “Both the ADHD Rating Scale-IV and the Conners Rating Scale have preschool-age normative data based on the DSM-IV.”

  • The paper relies on this without support.

    The specific behaviors in the DSM-5 criteria for ADHD are the same for all children younger than 18 years and are only minimally different from the DSM-IV.

    “The specific behaviors in the DSM-5 criteria for ADHD are the same for all children younger than 18 years (ie, preschool-aged children, elementary and middle school-aged children, and adolescents) and are only minimally different from the DSM-IV.”

  • The paper relies on this without support.

    PTBM helps parents learn age-appropriate developmental expectations, behaviors that strengthen the parent-child relationship, and specific management skills for problem behaviors.

    “This type of training helps parents learn age-appropriate developmental expectations, behaviors that strengthen the parent-child relationship, and specific management skills for problem behaviors.”

  • The paper relies on this without support.

    PTBM has documented effectiveness with a wide variety of problem behaviors, regardless of etiology.

    “Clinicians do not need to have made an ADHD diagnosis before recommending PTBM because PTBM has documented effectiveness with a wide variety of problem behaviors, regardless of etiology.”

  • The paper relies on this without support.

    Obtaining teacher reports for adolescents is often more challenging than for younger children because many adolescents have multiple teachers.

    “Obtaining teacher reports for adolescents is often more challenging than for younger children because many adolescents have multiple teachers.”

  • The paper relies on this without support.

    An adolescent’s parents may have less opportunity to observe their child’s behaviors than they did when the child was younger.

    “Likewise, an adolescent’s parents may have less opportunity to observe their child’s behaviors than they did when the child was younger.”

  • The paper relies on this without support.

    Some problems experienced by children with ADHD are less obvious in adolescents than in younger children because adolescents are less likely to exhibit overt hyperactive behavior.

    “Furthermore, some problems experienced by children with ADHD are less obvious in adolescents than in younger children because adolescents are less likely to exhibit overt hyperactive behavior”

  • The paper relies on this without support.

    Variability in ratings is to be expected because adolescents’ behavior often varies between different classrooms and with different teachers.

    “Variability in ratings is to be expected because adolescents’ behavior often varies between different classrooms and with different teachers.”

  • The paper relies on this without support.

    Certain substances, such as marijuana, can have effects that mimic ADHD.

    “Certain substances, such as marijuana, can have effects that mimic ADHD”

  • The paper relies on this without support.

    Trauma experiences, posttraumatic stress disorder, and toxic stress are additional comorbidities and risk factors of concern.

    “Trauma experiences, posttraumatic stress disorder, and toxic stress are additional comorbidities and risk factors of concern.”

  • The paper relies on this without support.

    Teachers, parents, and child health professionals typically encounter children who demonstrate behaviors relating to activity level, impulsivity, and inattention but who do not fully meet DSM-5 criteria.

    “Teachers, parents, and child health professionals typically encounter children who demonstrate behaviors relating to activity level, impulsivity, and inattention but who do not fully meet DSM-5 criteria.”

  • The paper relies on this without support.

    These symptoms may suggest other problems that mimic ADHD.

    “Also consider that these symptoms may suggest other problems that mimic ADHD.”

  • The paper relies on this without support.

    Behavioral interventions, such as PTBM, are often beneficial for children with hyperactive/impulsive behaviors who do not meet full diagnostic criteria for ADHD.

    “Behavioral interventions, such as PTBM, are often beneficial for children with hyperactive/impulsive behaviors who do not meet full diagnostic criteria for ADHD.”

  • The paper relies on this without support.

    The DSM-PC was published in 1995, and it has not been revised to be compatible with the DSM-5.

    “The DSM-PC was published in 1995, however, and it has not been revised to be compatible with the DSM-5.”

  • The paper relies on this without support.

    In some cases, the presence of a comorbid condition will alter the treatment of ADHD.

    “In some cases, the presence of a comorbid condition will alter the treatment of ADHD.”

  • The paper relies on this without support.

    Available treatments address symptoms and function but are usually not curative.

    “Available treatments address symptoms and function but are usually not curative.”

  • The paper relies on this without support.

    This communication can be difficult to achieve.

    “This communication can be difficult to achieve and is discussed in both the PoCA and the section on systemic barriers to the care of children and adolescents with ADHD in the Supplemental Information, as is the medical home model.69”

  • The paper relies on this without support.

    PTBM programs for preschool-aged children are typically group programs and, although they are not always paid for by health insurance, they may be relatively low cost.

    “PTBM programs for preschool-aged children are typically group programs and, although they are not always paid for by health insurance, they may be relatively low cost.”

  • The paper relies on this without support.

    One evidence-based PTBM, parent-child interaction therapy, is a dyadic therapy for parent and child.

    “One evidence-based PTBM, parent-child interaction therapy, is a dyadic therapy for parent and child.”

  • The paper relies on this without support.

    Other stimulant or nonstimulant medications have not been adequately studied in children in this age group with ADHD.

    “Other stimulant or nonstimulant medications have not been adequately studied in children in this age group with ADHD.”

  • The paper relies on this without support.

    The medical home and chronic illness approach may be particularly beneficial for parents who also have ADHD themselves.

    “The medical home and chronic illness approach may be particularly beneficial for parents who also have ADHD themselves.”

  • The paper relies on this without support.

    Stimulants have a stronger immediate effect on the 18 core symptoms of ADHD than behavior therapy in most studies comparing them.

    “Most studies comparing behavior therapy to stimulants indicate that stimulants have a stronger immediate effect on the 18 core symptoms of ADHD.”

  • The paper relies on this without support.

    Parents were more satisfied with the effect of behavioral therapy than with stimulants.

    “Parents, however, were more satisfied with the effect of behavioral therapy, which addresses symptoms and functions in addition to ADHD’s core symptoms.”

  • The paper relies on this without support.

    The positive effects of behavioral therapies tend to persist, whereas the positive effects of medication cease when medication stops.

    “The positive effects of behavioral therapies tend to persist, but the positive effects of medication cease when medication stops.”

  • The paper relies on this without support.

    Some nonmedication treatments for ADHD-related problems have too little evidence to recommend them or have been found to have little or no benefit, including mindfulness, cognitive training, diet modification, EEG biofeedback, and supportive counseling.

    “Some nonmedication treatments for ADHD-related problems have either too little evidence to recommend them or have been found to have little or no benefit. These include mindfulness, cognitive training, diet modification, EEG biofeedback, and supportive counseling.”

  • The paper relies on this without support.

    The suggestion that cannabidiol oil has any effect on ADHD is anecdotal and has not been subjected to rigorous study.

    “The suggestion that cannabidiol oil has any effect on ADHD is anecdotal and has not been subjected to rigorous study.”

  • The paper relies on this without support.

    There is no long-term safety and efficacy evidence for eTNS.

    “To date, there is no long-term safety and efficacy evidence for eTNS.”

  • The paper relies on this without support.

    Much less research has been published on psychosocial treatments with adolescents than with younger children.

    “Much less research has been published on psychosocial treatments with adolescents than with younger children.”

  • The paper relies on this without support.

    Meaningful improvements in functioning have not been reported from cognitive behavioral approaches for adolescents.

    “Meaningful improvements in functioning have not been reported from cognitive behavioral approaches.”

  • The paper relies on this without support.

    None of the nonstimulants have FDA approval for use in preschool-aged children.

    “None of the nonstimulants have FDA approval for use in preschool-aged children.”

  • The paper relies on this without support.

    The effect size for nonstimulants is 0.7.

    “The effect size for stimulants is 1.0 and for nonstimulants is 0.7.”

  • The paper relies on this without support.

    An individual’s response to methylphenidate versus amphetamine is idiosyncratic, with approximately 40% responding to both and about 40% responding to only one.

    “An individual’s response to methylphenidate verses amphetamine is idiosyncratic, with approximately 40% responding to both and about 40% responding to only 1.”

  • The paper relies on this without support.

    The subtype of ADHD does not appear to be a predictor of response to a specific agent.

    “The subtype of ADHD does not appear to be a predictor of response to a specific agent.”

  • The paper relies on this without support.

    The evidence base supporting norepinephrine reuptake inhibitors and α-2 adrenergic agonists is considerably less than that for stimulants, although it was adequate for FDA approval.

    “Norepinephrine reuptake inhibitors and α-2 adrenergic agonists are newer medications, so, in general, the evidence base supporting them is considerably less than that for stimulants, although it was adequate for FDA approval.”

  • The paper relies on this without support.

    Pharmacogenetic tests may cost thousands of dollars and are typically not covered by insurance.

    “In addition, these tests may cost thousands of dollars and are typically not covered by insurance.”

  • The paper relies on this without support.

    Stimulants’ most common short-term adverse effects are appetite loss, abdominal pain, headaches, and sleep disturbance.

    “Stimulants’ most common short-term adverse effects are appetite loss, abdominal pain, headaches, and sleep disturbance.”
42 of 42

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Citations

Cites

Show all 152 references

Research works printed but not linked: 5

  1. American Academy of Pediatrics Task Force on Mental Health, 2010, Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit [CD-ROM]
  2. Wolraich, 1996, The Classification of Child and Adolescent Mental Conditions in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version
  3. Robin, 1989, The Guilford Family Therapy Series. Negotiating Parent–Adolescent Conflict: A Behavioral–Family Systems Approach
  4. Avigan, 2004, Review of AERS Data From Marketed Safety Experience During Stimulant Therapy: Death, Sudden Death, Cardiovascular SAEs (Including Stroke). Report No. D030403
  5. Davila, 1991, Memorandum on clarification of policy to address the needs of children with attention deficit disorders within general and/or special education, 261

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Metadata

Authors
Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & DISORDER, S. O. C. A. A. W. A.-D.
Affiliations
  • University of Oklahoma (US)
  • University of Vermont (US)
  • Children's Mercy Hospital (US)
  • Boston Children's Hospital (US)
  • Children and Adults with Attention Deficit/Hyperactivity Disorder (US)
  • University of North Carolina at Chapel Hill (US)
  • Ohio University (US)
  • American Academy of Pediatrics (US)
  • Cincinnati Children's Hospital Medical Center (US)
  • American Academy of Family Physicians (US)
  • Centers for Disease Control and Prevention (US)
  • Vanderbilt University (US)
  • uThe Children’s Medical Group, Poughkeepsie, New York;
  • Northwestern University (US)
  • yAtlanta, Georgia; and
  • zHolderness, New Hampshire
Corresponding author
Wolraich, Mark L.
ORCID
Venue
Pediatrics
Publisher
American Academy of Pediatrics (AAP)
Published
2019-10-01
Volume
144
Issue
4
ISSN
  • 0031-4005 (ISSN-L)
  • 1098-4275
DOI
10.1542/peds.2019-2528
PMC
PMC7067282
OpenAlex
W4213383170
Semantic Scholar
b0fa6ec69e8a7d09cc706e5e07fce062628ce632
Cited by
1,562
References
152
Citations by year
2026: 309 · 2025: 288 · 2024: 257 · 2023: 218 · 2022: 202 · 2021: 173 · 2020: 102 · 2019: 8
FWCI
88.24
Type
journal article
Language
en
Open access
closed
Locations
PEDIATRICS (publishedVersion)
Funders
National Institutes of Health (CC999999)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Keywords
attention deficit hyperactivity disorder, ADHD treatment, comorbidities, children and adolescents, DSM-5

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