ADHD Diagnosis and Treatment

Guidelines: A Historical Perspective

Mark L. Wolraich, MD,a Eugenia Chan, MD, MPH,b Tanya Froehlich, MD, MS,c Rachel L. Lynch, MD,d Ami Bax, MD, MS,a
Susan T. Redwine, MD,a Demvihin Ihyembe, MD,a Joseph F. Hagan, Jr, MDe

Attention-deficit/hyperactivity disorder (ADHD) is the most common abstract

behavioral condition and the second most common chronic illness in children.
The observance of specific behaviors in multiple settings have remained the
most successful method for diagnosing the condition, and although there are
differences in specific areas of the brain, and a high heritability estimate
(∼76%), they are not diagnostically specific. Medications, and particularly
stimulant medication, have undergone rigorous studies to document their a
University of Oklahoma Health Sciences Center, The
University of Oklahoma, Oklahoma City, Oklahoma; bBoston
efficacy dating back to the 1970s. Likewise, behavioral interventions in the
Children’s Hospital, Boston, Massachusetts; cDepartment of
form of parent training and classroom programs have demonstrated robust Pediatrics, University of Cincinnati and Cincinnati Children’s
efficacy during the same time period. Both medication and behavioral Hospital Medical Center, Cincinnati, Ohio; dMayo Clinic,
Rochester, Minnesota; and eUniversity of Vermont Children’s
interventions are symptomatic treatments. The availability of only Hospital, Burlington, Vermont
symptomatic treatments places ADHD in the same category as other chronic
Dr Wolraich developed the outline for the article,
conditions such as diabetes and asthma. Successful treatment of most wrote the introduction and discussion, and reviewed
individuals requires ongoing adherence to the therapy. Improved and revised the manuscript as a whole; Drs Chan
communication between patients and their families, primary and mental and Froehlich wrote the sections on training,
continuing education, and electronic communication
health providers, and school personnel is necessary for effective ADHD and reviewed and revised the manuscript as
treatment. Further enhancement of electronic systems to facilitate family, a whole; Drs Lynch and Hagan Jr, wrote the section
school, and provider communication can improve monitoring of ADHD on long-term follow-up and reviewed and revised the
manuscript as a whole; Drs Bax and Redwine, wrote
symptoms and functional performance. The American Academy of Pediatrics the section on diagnosis and reviewed and revised
ADHD guidelines were initially developed to help primary care clinicians the manuscript as a whole; Dr Ihyembe wrote the
address the needs of their patients with ADHD and were further refined with section on treatment and reviewed and revised the
manuscript as a whole; and all authors approved the
the second revision in 2019.
final manuscript as submitted and agree to be
accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2019-1682

Attention-deficit/hyperactivity Despite changes in its name over time, Accepted for publication Aug 5, 2019
disorder (ADHD) is the most ADHD has actually had a long history. In Address correspondence to Mark L. Wolraich, MD,
common behavioral condition and the mid-19th century, the Child Study Center, The University of Oklahoma,
1100 13th St, Oklahoma City, OK 73116. E-mail: mark-
the second most common chronic characteristics of ADHD were described [email protected]
illness in children. National survey by Heinrich Hoffman, a German
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
data from 2016 revealed that 9.4% physician, and were represented by 2 of 1098-4275).
of US children received an ADHD his characters (Fidgety Phil and Harry Copyright © 2019 by the American Academy of
diagnosis at some point and that Who Looks in the Air) who appeared in Pediatrics
8.4% currently had ADHD.1,2 It his children’s book.3 In 1902, at FINANCIAL DISCLOSURE: The authors have indicated
is now recognized as a lifelong a meeting of the Royal College of they have no financial relationships relevant to this
disorder and remains 1 of the most Physicians, George Still described article to disclose.
extensively studied and yet highly a disease he characterized as resulting FUNDING: No external funding.
controversial conditions. In reading from a defect in moral character.4 He
and implementing the revised noted that the disorder manifested To cite: Wolraich ML, Chan E, Froehlich T, et al.
guidelines, it is important to itself in patterns of restless, inattentive, ADHD Diagnosis and Treatment Guidelines: A
Historical Perspective. Pediatrics. 2019;144(4):
understand the history and current and overaroused behaviors. He
e20191682
standards of care about ADHD. suggested that the children had likely

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PEDIATRICS Volume 144, number 4, October 2019:e20191682 SPECIAL ARTICLE
experienced brain damage but that DIAGNOSIS sufficient for the disorder.17
the behavior could also arise from Although the diagnostic criteria for Therefore, identifying genes linked to
hereditary and environmental factors. ADHD have evolved over time, the ADHD has been difficult, and genetic
assessment and tools for evaluation testing is currently not useful for
The association with brain damage
have remained essentially the same. diagnostic purposes.18
was further noted in 1917 to -1918
ADHD remains a largely clinical
after the worldwide epidemic of
diagnosis. Current recommendations TREATMENT
influenza, when some of the children
for diagnostic evaluation of possible
recovering from its encephalitis had Stimulant medications and behavioral
ADHD include a comprehensive
symptoms of restlessness, interventions have been the mainstay
history taking of prenatal, perinatal,
inattention, impulsivity, easy for the treatment of children with
and family history; school
arousability, and hyperactivity.5 ADHD for .45 years. In 1937,
performance; environmental factors;
However, subsequently, when there
and a detailed physical examination. Bradley19 was the first to report that
were many cases with similar Benzedrine improved the behaviors
During the physical examination,
behavioral manifestations, but no of children hospitalized for behavior
particular attention should be paid to
clear evidence of brain damage, the problems. Dextroamphetamine was
vital signs (cardiovascular, skin,
name of the disorder was changed to also approved in 1937, but it did not
thyroid, and neurologic systems,
minimal cerebral/brain dysfunction/ become of interest for treating
including assessment of motor
damage.5 children with minimal brain
coordination), and a mental health
assessment used to probe for dysfunction until the mid-1950s.20
As the association with brain damage Methylphenidate became available in
comorbid conditions should be
became less prominent as the cause
performed. The use of teacher- or 195421 and became popular when
of ADHD, the name was revised to be amphetamines lost favor. As early as
parent-reported behavior-rating
more behaviorally descriptive. The 1977,22 there were 62 blinded,
scales started in the late 1960s13;
change was reflected in the placebo-controlled studies of
now focus is on the behavioral
psychiatric classification system, the stimulant medications demonstrating
criteria for ADHD as described in the
Diagnostic and Statistical Manual of their efficacy and safety. By 1999,
DSM-5.12 Determining significant
Mental Disorders, Second Edition their benefits and safety had been
impairment is also an important
(DSM-II), in which it was called
criterion. shown in .300 positive rigorous
hyperkinetic reaction of childhood studies.23 Since that time, hundreds
disorder.6 In 1980, because of the Unfortunately, the objective of additional rigorous studies have
studies of Virginia Douglas and assessments currently available for consistently confirmed their efficacy
others,7,8 the primary impairment ADHD are of limited use in clarifying and safety when taken in the
shifted from hyperactivity to the diagnosis, including therapeutic dose range for children
inattention, as reflected in the name neuropsychological tests (which have from 4 years of age to adulthood.14
change to attention-deficit disorder in a low strength of evidence14) as well
Behavioral interventions that are
the DSM-III,9 and then to attention as EEG and neuroimaging (for which
focused on behavior modification,
deficit/hyperactivity disorder in the the evidence remains insufficient14).
such as parent behavior-management
DSM-III-Revised.10 In the DSM-IV,11 it The scientific community has also
training and school behavior-
was further categorized into 3 been interested in understanding
management programs, have also
subtypes, inattentive, hyperactive/ how neurotransmitter systems are
long been demonstrated to be
impulsive, and combined (involving involved in ADHD because animal
efficacious.24 Other interventions,
both inattentive and hyperactive/ models, neuroimaging studies, and
including diets, herbal and other
impulsive domains), which remain pharmacologic studies provide
supplements, EEG training, and
the subcategories in the recently support for the involvement of
neuropsychological or cognitive
published DSM-5.12 However, in the dopaminergic and adrenergic
training interventions, lack the level
DSM-5, the subtypes are now referred derangements in ADHD.15,16 However,
of empirical support for their efficacy
to as “presentations” to denote that no evidence-based methods for
achieved by the US Food and Drug
an individual’s subcategorization is assessing these neurotransmitter
Administration–approved ADHD
not necessarily fixed across the life systems have been developed and
medications and the aforementioned
span but can shift with age and shown to have utility in the ADHD
behavioral interventions.14
development. The basis for the diagnostic assessment. Although
guidelines is best understood in the ADHD has a high heritability estimate In the Multimodal Treatment of
context of both its diagnostic and (∼76%), no specific genetic pattern ADHD (MTA) study, funded by the
treatment history. has been shown to be necessary or National Institute of Mental Health,25

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320 WOLRAICH et al
researchers examined the benefits of patients to follow-up and may include symptoms.35 There is also great
both stimulant medication and patients with less severe symptoms, interest in determining whether
behavioral interventions in leading to lower persistence rates ADHD treatment can improve
a multisite study over a 14-month than in those conducted in clinical academic outcomes. Barbaresi et al33
period, with 10-year follow-up samples.28 In addition, symptoms of documented an association between
surveillance. Although stimulant hyperactivity are more likely to treatment with stimulant medication
medication had the strongest effect diminish over time and with the onset during childhood and improved
on core ADHD symptoms and of puberty, whereas inattentive reading scores, reduced school
behavioral interventions were most symptoms are more likely to persist, absenteeism, and reduced grade
acceptable to families, combined making features of ADHD more subtle retention, but in their study of young
medication and behavioral therapy and often less obvious in adulthood adults, Voigt et al34 found that those
was most effective, particularly when versus childhood.30 All of these treated with at least 3 months of
comorbidity or additional family factors impact the rates of identified stimulants during childhood and
issues were present. However, after ongoing ADHD. Despite these those who were not treated had
leaving the active trial, participating challenges, childhood risk factors that similar academic achievement test
families no longer received the same may help predict persistence of ADHD scores. The authors did, however,
level of medication or behavioral into adulthood have been identified. document a link (albeit weak)
interventions. Therefore, because These include increased severity of between increased duration of
neither medication nor behavioral childhood ADHD symptoms, stimulant treatment and improved
treatment of ADHD is curative and comorbid conduct disorder, comorbid math test achievement among
both only work when being actively major depressive disorder, and parent those treated with at least 3 months
administered, it has been difficult to mental health problems.31 Child IQ, of stimulants during childhood.
demonstrate their long-term benefits. socioeconomic status, parental Mental health outcomes have also
education, and parent-child been examined in individuals
relationship were not associated with diagnosed with ADHD during
LONG-TERM OUTCOMES more likely persistence of ADHD childhood. Most of the children and
Because ADHD continues into symptoms.32 adolescents with ADHD who died by
adulthood for many individuals,26 suicide also had comorbid substance
both patients with persistent In previous studies, researchers have use disorder and other psychiatric
symptoms and those whose ADHD also examined long-term academic diagnoses.27
symptoms have resolved are at risk outcomes in children diagnosed with
for emergence of other psychiatric ADHD in childhood. In a prospective The studies indicating adverse adult
disorders and adverse outcomes as birth-cohort population-based study, outcomes in individuals diagnosed
they approach their adult years.27 Barbaresi et al33 found that with ADHD during childhood,
Understanding the long-term those with childhood ADHD had whether their symptoms improved
outcomes for children with ADHD is evidence of long-term academic with age, emphasize the importance
crucial as systems are built and underachievement compared with of chronic care services for adults
improved to provide optimal care. non-ADHD controls. In their study of with ADHD. Unfortunately, there is
young adults, Voigt et al34 showed evidence that smooth transitions into
Consistent norm-referenced criteria that lower academic scores were seen adult services often do not occur for
used to diagnose ongoing ADHD in even in those whose ADHD symptoms individuals with a history of
adults are lacking. This has led to had resolved by adulthood compared childhood ADHD. Eklund et al36
wide variation in reported rates of with children who did not have studied adolescents and young adults
persistence of ADHD into childhood ADHD. The presence of in the United Kingdom at the time of
adulthood,28 with persistence rates a learning disorder along with ADHD health care transition and found
ranging from 4% to 78%.28 Multiple has a further negative impact on higher caregiver-burden ratings as
factors contribute to this variation, academic achievement.29 Similarly, well as decreased use of the service
including inconsistent diagnostic the long-term follow-up of the MTA model. The results emphasize the
criteria, use of varying informants study25 revealed that those whose importance of continuity of care and
(self-report versus parent informant) ADHD symptoms did not persist into the need for successful transition of
to assess for the presence of current adulthood still had worse academic care to clinicians who provide adult
ADHD symptoms, and recall of outcomes than those in the non- services.36 Of note, the expectation
childhood symptoms.29 Furthermore, ADHD control group, with the worst that adolescents and young adults
studies in which a population-based academic outcomes experienced by will assume increasing responsibility
sample is used may lose more the group with persistent ADHD for their medical and mental health

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PEDIATRICS Volume 144, number 4, October 2019 321
care can be particularly challenging Adherence to CPGs has since emerged accelerated the growth of QI activities
for individuals with ADHD.37 as a primary focus of quality focused on improving ADHD care. For
improvement (QI) initiatives. One of example, the ABP sponsors 2
Therefore, as children with ADHD the earliest projects on this subject performance improvement modules:
reach adolescence, a structured was the ADHD Learning Initial Diagnosis of Attention Deficit
transition of health care services from Collaborative, which worked to Hyperactivity Disorder in Pediatric
pediatric to adult services is implement a model of care for Patients and Follow-up Care of
necessary, with particular attention children with ADHD that is consistent Pediatric Patients with Attention
paid to ongoing monitoring and with the AAP guidelines. It involved Deficit Hyperactivity Disorder.48
treatment (if indicated) of ADHD- 40 pediatric practices, mostly in These online modules can be
related mental health concerns. North Carolina, from 2000 to 2003. In completed by individual physicians or
ADHD’s status as a chronic illness May 2003, the AAP introduced an a team. Health care organizations
with effective symptomatic online continuing education module certified by the ABP as portfolio
treatments, such as can be found for called Managing Your Patients with sponsors also offer MOC part 4
asthma and diabetes, underscores the ADHD as part of the then-nascent projects, available nationwide,
need to provide chronic care, Education in Quality Improvement for focused on improving ADHD care (eg,
preferably in a medical home or Pediatric Practice series, which offers the Center for ADHD at Cincinnati
a medical home–like setting. Optimal a structured process to encourage Children’s Hospital Medical Center).
care for individuals with ADHD individual participants to make
Measures of ADHD care quality are
requires continuity and coordination lasting changes in their practice.44
of interventions as well as monitoring necessary to know whether a change
by medical, mental health, and AAP activities also include the represents an improvement, and the
Education in Quality Improvement for ADHD guidelines soon became the
educational providers. Guidelines for
Pediatric Practice series and a variety basis for developing performance
ADHD care, such as those drafted by
of Chapter Quality Network indicators. Although many local QI
the American Academy of Pediatrics
(AAP), have been developed to meet collaboratives.45 A recent Chapter initiatives or multisite collaboratives
these needs and provide the basis for Quality Network collaborative from have developed their own ADHD
training programs. December 2015 to January 2017 quality measures tailored to their
included pediatricians, practices, and respective specific aims, efforts to
chapters from 5 states; participants develop and validate measures of
used QI methods to test evidence- ADHD care have also occurred at the
GUIDELINES AND QUALITY based care processes and embed national level. These measures are
IMPROVEMENT PROJECTS them into clinical workflows. The commonly used or adapted for use in
collaborative included learning QI initiatives.
Growing awareness of poor quality of
sessions and monthly calls to share
care for children with ADHD38 and Developed and maintained by the
best practices and review data.46 The
the societal implications for National Committee for Quality
Illinois and Vermont chapters are
inadequate or inappropriate Assurance, the Healthcare
currently recruiting for a planned QI
diagnosis and treatment of Effectiveness Data and Information
learning collaborative to increase
individuals with ADHD as they enter Set (HEDIS) is 1 of the most widely
adherence to the AAP’s ADHD
adulthood38,39 led to the development used tools for performance
guidelines.47
of the first AAP clinical practice measurement and improvement
guidelines (CPGs) for the diagnosis The American Board of Pediatrics among health plans. HEDIS specifies
and evaluation of ADHD in 2000.40 (ABP) has also emphasized the a set of standardized measures, with
This was followed by a practice importance of improving care by data collected through surveys,
guideline for the treatment of ADHD incorporating the module Improving medical records, and administrative
in 2001.41 These recommendations Professional Practice and Quality data such as insurance claims. The
were updated in 201142 and again in Improvement as part 4 of HEDIS measures for ADHD, beginning
2019.43 Following the AAP’s lead, Maintenance of Certification (MOC). in 2006, were based to a great extent
many professional organizations and Pediatricians must earn 40 to 60 on the initial AAP CPG. HEDIS
health care systems worldwide have points every 5-year MOC cycle by implemented the measure Follow-Up
since developed their own CPGs and participating actively in activities Care for Children Prescribed ADHD
associated tool kits or care process designed to help physicians assess Medication49 with the following
models that are tailored to the needs and improve the quality of patient phases:
of their specialty, clinical population, care and in processes that will lead to • Initiation Phase: Assesses children
and/or health care organization.38 improved health. This incentive has between 6 and 12 years of age who were

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322 WOLRAICH et al
diagnosed with ADHD and had one Information Technology contracted reminders to clinicians to schedule
follow-up visit with a practitioner with with Mathematica Policy Research to a visit for children with ADHD every 3
prescribing authority within 30 days of
test a pediatric-screening electronic to 6 months.52 Use of the system
their first prescription of ADHD
medication. clinical quality measure for ADHD: increased visits and improved
• ADHD: Symptom Reduction in documentation of ADHD symptoms,
• Continuation and Maintenance Phase:
Assesses children between 6 and 12 years Follow-Up Period: the percentage notation of treatment effectiveness,
of age who had a prescription for ADHD of children ages 4 to 18 who had and documentation of adverse effects
medication and remained on the been diagnosed with ADHD and at follow-up. Unfortunately, the
medication for at least 210 days, and template was used at only 32% of
had at least two follow-up visits with demonstrated a 25% reduction in
symptoms 6 to 12 months from ADHD assessment visits because of
a practitioner in the 9 months after the
Initiation Phase.49 baseline, as measured by using the a variety of factors (eg, forgetting
Vanderbilt ADHD Diagnostic Rating about the template, finding the
The Pediatric Quality Measures template difficult to use).52
Scale (regardless of the treatment
Program was established by the
prescribed). Carroll et al53 evaluated a decision
Agency for Healthcare Research and
Quality and the Centers for Medicare As it became clearer that systems support system (Child Health
and Medicaid Services as part of the barriers, such as communication and Improvement Through Computer
Child Health Insurance Program documentation burden, accounted for Animation [CHICA]54). The CHICA
Reauthorization Act in 2009.50 much of the difficulty in system prompts physicians to provide
Grantees were charged with implementing key portions of the caregivers and teachers with ADHD
identifying and developing pediatric ADHD guidelines,51 more recent QI rating scales. Returned scales are
quality measures. For ADHD, the initiatives have been focused on scanned into the CHICA system,
following measures were developed: leveraging health information which generates a summary
technology (HIT) to overcome these document with scores,
• Accurate ADHD Diagnosis: patients interpretations, and treatment
4 to 18 years whose diagnosis of challenges.
recommendations. The cluster
ADHD was based on a clinical
randomized trial revealed that the
examination with a physician that ELECTRONIC COMMUNICATION AND use of structured diagnostic
included (1) confirmation of CARE MONITORING SYSTEMS assessments (defined as collecting
functional impairment in $2
Given the potential of HIT to facilitate both parent- and teacher-reported
settings and (2) assessment of core
coordinated and efficient care, ADHD rating scales during the ADHD
ADHD symptoms through
promote cross-system evaluation) improved in the
a validated diagnostic tool based on
communication, and expedite the intervention group (from 60% at
Diagnostic and Statistical Manual of
collection of ADHD-specific rating baseline to 81% at follow-up),
Mental Disorders, Fourth Edition
scales for evidence-based diagnosis whereas the control group’s
Text Revision criteria or through
and treatment monitoring, performance dropped (from 50% at
direct assessment of the patient;
recognition of its capacity to improve baseline to 38% at follow-up).53
• ADHD Chronic Care Follow-up: ADHD care is growing. Broadly
patients 4 to 18 years with Investigators at Children’s Hospital of
speaking, these HIT systems are Philadelphia developed the ADHD
a diagnosis of ADHD who attended divided into 2 domains: EHR-based
at least 1 ADHD follow-up care visit Care Assistant, a system that sends
systems and stand-alone (EHR- electronic ADHD rating scales to
within a calendar year; and independent) software platforms. As parents and teachers, presents results
• Behavior Therapy as First-Line ADHD-related HIT systems are seamlessly in the EHR and allows
Treatment of Preschool-Aged developed, there is a burgeoning of parents to elect automated sharing of
Children with ADHD: patients aged literature in which their performance ADHD information between
4 to 5 years with a diagnosis of is evaluated, as reviewed below. themselves and teachers, thereby
ADHD for whom ADHD-focused,
facilitating communication.55 Michel
evidence-based behavior therapy EHR-Based Systems et al56 found that most parents are
was prescribed as a first-line
In a cluster randomized trial, Co amenable to sharing ADHD rating
treatment.
et al52 investigated the performance scale information collected in the
As interest in the development of of an EHR-based ADHD decision system with teachers, but parents
patient-reported outcomes that could support system. This system features viewed only 16% of teacher-
be derived from electronic health an ADHD note template with fields submitted ADHD surveys, and
records (EHRs) grew, the Office of the for key AAP ADHD guideline teachers viewed 30% of parent
National Coordinator for Health elements40,41 and sends automated surveys. The investigators concluded

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PEDIATRICS Volume 144, number 4, October 2019 323
that in future efforts, researchers Epstein et al59 developed an ADHD entail an additional cost, so their
should target the development of Web portal (now available at www. reports usually need to be attached as
strategies to encourage viewing of mehealth.com) in an effort to scanned documents. However, efforts
shared information. integrate ADHD QI efforts and are currently underway to integrate
provide multiple clinically salient some of the stand-alone systems into
Stand-alone Software Systems functionalities. The meHealth the most commonly used EHRs.
software is a comprehensive system
Although a number of ADHD-related
that includes training for clinicians
stand-alone software systems have
regarding the AAP ADHD guidelines DISCUSSION
been developed, there have been
and recommendations; automated In the extensive research that has
limited publications in which their
online collection of parent- and been undertaken to help define the
effectiveness is evaluated. Lavigne
teacher-reported ADHD rating scales
et al57 examined a combined ADHD anatomic, functional, and genetic
for ADHD assessment and treatment characteristics of ADHD, as well as
practice-management intervention
monitoring (including side effect environmental contributing factors, it
that involved 2 hours of didactic
reporting) at customizable intervals; has become clear that there are
training on ADHD medication
algorithms that automate scoring of differences in brain size as well as
management by using the Focus on
parent- and teacher-reported ADHD activity level in the catecholamine
ADHD Medication Management
rating scales and produce assessment system. For example, differences in
Program software. In the intervention
and treatment reports; customizable the mean volumes of the prefrontal
group, parent- and teacher-reported
automated alerts to clinicians when cortex, the basal ganglia, and the
paper rating-scale results were then
behavior ratings worsen or side cerebellar vermis for groups of
entered into the focus program, and
effects flare; a communication feature patients with ADHD compared with
its output provided
that allows communication between unaffected controls have been shown,
recommendations. Although use of
clinicians, parents, and teachers; and but the degree of overlap between
the focus program was suboptimal in
easy-to-use behavioral treatment these groups is too high for
the intervention group (it was used
tools for use by parents and teachers. neuroimaging parameters to be used
by only approximately one-quarter of
A cluster randomized trial revealed for diagnosing individual cases.
patients with ADHD seen by the
that clinicians using the system had Similarly, although there is a strong
intervention group), when it was
significantly higher rates of many familial pattern for ADHD, there is no
used, adherence to the recommended
AAP-recommended practices and had specific inherited gene pattern. In
ADHD medication titration
a high degree of satisfaction (94%).60 addition, risk of ADHD is increased by
procedures increased, and improved
A second study revealed that among
ADHD symptom control resulted.57 environmental factors, including
children prescribed ADHD prematurity, maternal alcohol intake
Chan et al39 developed the TriVox medication, significantly greater or smoking during pregnancy,
Health Web-based platform (www. improvements in parent-reported childhood lead exposure, and head
trivoxhealth.com), which enables ADHD symptom ratings were trauma, but these factors are
clinicians to administer online ADHD achieved when the Web portal system contributory, not diagnostic.
clinical questionnaires and rating was used for treatment monitoring Furthermore, neuropsychological and
scales to parents and teachers to (compared with usual care by the EEG assessments have not been
monitor patients remotely, between control group).61 shown to improve on the diagnostic
visits, and at customizable intervals.58 procedures first defined in the 2000
This includes a notification for Limitations of Electronic
AAP guidelines40 (and maintained in
clinicians when new data are Communication and Care Monitoring
Systems the 201138 and 2019 updated
available to view and an alert guidelines43).
notification if there is potentially EHR-based systems tend to lack the
actionable data. They found that the usability present in the stand-alone Once an ADHD diagnosis has been
TriVox Health trigger algorithm systems and are more restrictive in established, evidence-based
facilitated timely changes in the care their abilities to include treatments are available. Medications,
plan between face-to-face visits communication between families, particularly stimulant medication,
because nurses were able to teachers, primary care physicians, have undergone rigorous studies to
successfully contact parents in and other patient providers. The document their efficacy dating back
response to the alerts. Two-thirds of stand-alone systems often do not to the 1970s. Likewise, behavioral
the alerts led to a care plan change communicate directly with patient’s interventions in the form of parent
before the next scheduled electronic medical records, which are training and classroom programs
appointment.58 not currently searchable and usually have demonstrated robust efficacy

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324 WOLRAICH et al
during the same time period. The Improved communication between mental health and academic
landmark MTA ADHD treatment trial patients and their families, primary challenges; and (7) providing
documented the additional benefits and mental health providers, and transition plans. With continued
obtained by combining medication school personnel is necessary for development of electronic tools and
and behavioral interventions. effective ADHD treatment. Further innovative systems to enhance
However, despite this evidence of enhancement of electronic systems to communication, hopefully it will be
treatment efficacy, the long-term facilitate family, school, and provider possible to address these key ADHD
outcomes for individuals with ADHD communication, improve monitoring care elements and to implement the
have been less optimal than those for of ADHD symptoms and functional newly revised guidelines at a much
individuals who are unaffected. performance, and better integrate higher level of quality of care.
One of the major reasons for with electronic medical records is on
suboptimal outcomes in individuals the horizon, but barriers such as cost
with ADHD is that both medication and privacy regulations have limited ABBREVIATIONS
and behavioral interventions are their use as of yet. AAP: American Academy of
symptomatic treatments. Neither Pediatrics
treatment is curative, although The AAP ADHD guidelines and their ABP: American Board of Pediatrics
maturity enables some individuals revisions strongly emphasize the ADHD: attention-deficit/
with ADHD to compensate adequately need to treat ADHD as a chronic hyperactivity disorder
for their ADHD-related challenges. illness for which the important CHICA: Child Health Improvement
The availability of only symptomatic elements are as follows: (1) strong Through Computer
treatments places ADHD in the same and continuous relationships Animation
category as other chronic conditions, between the clinicians, the patients, CPG: clinical practice guideline
such as diabetes and asthma. and their families; (2) a focus on DSM-5: Diagnostic and Statistical
Successful treatment of most educating the families about the Manual of Mental
individuals requires ongoing condition and its treatments; (3) Disorders, Fifth Edition
adherence to the therapy. The MTA understanding the family’s needs and EHR: electronic health record
study demonstrated that rigorously priorities; (4) developing adequate HEDIS: Healthcare Effectiveness
administered medication and communication between all those Data and Information Set
behavioral therapies were highly providing care to the patient; (5) HIT: health information
efficacious during the clinical trial, continuity of care, taking into account technology
but when ADHD management was the changing needs and abilities of MOC: Maintenance of Certification
transferred back to community patients and their families over time; MTA: Multimodal Treatment
providers, who provided less-intense (6) providing appropriate of ADHD
services after the trial, symptom anticipatory guidance regarding QI: quality improvement
control waned. monitoring for and prevention of

POTENTIAL CONFLICT OF INTEREST: Dr Chan has a potential conflict of interest, in that she is a coinventor of the TriVox Health health information technology
referenced in this article. In the future, it is possible that this technology will be sold commercially. If this were to occur, Dr Chan and Boston Children’s Hospital
might receive financial benefits in the form of compensation. As in all research studies, the hospital has taken steps designed to ensure that this potential for
financial gain does not endanger research subjects or undercut the validity and integrity of the information learned by this research; the other authors have
indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2528.

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 ADHD Diagnosis and Treatment Guidelines: A Historical Perspective
Mark L. Wolraich, Eugenia Chan, Tanya Froehlich, Rachel L. Lynch, Ami Bax,
Susan T. Redwine, Demvihin Ihyembe and Joseph F. Hagan Jr
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-1682 originally published online September 30, 2019;

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 ADHD Diagnosis and Treatment Guidelines: A Historical Perspective
Mark L. Wolraich, Eugenia Chan, Tanya Froehlich, Rachel L. Lynch, Ami Bax,
Susan T. Redwine, Demvihin Ihyembe and Joseph F. Hagan Jr
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-1682 originally published online September 30, 2019;

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