Clinical practice guidelines for the assessment and management of attention-deficit/hyperactivity disorder

INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders. ADHD affects around 5%–7% of school-aged children. It is a neurodevelopmental disorder that runs a chronic course and causes significant impairments across various domains of everyday functioning, such as peer and social functioning, academic functioning, and occupational functioning across the lifespan. Besides the patient, ADHD also has significant negative impact on the caregivers. This guideline seeks to lay out guidelines for effective and comprehensive assessment, diagnosis, and management of ADHD. It attempts to update the previous guidelines taking into account the current state of evidence that can inform clinical practice. These guidelines ought to be read in conjunction with the earlier version of the treatment guidelines on ADHD as developed and published by the Indian Psychiatric Society in 2007. SCOPE OF THIS DOCUMENT This guideline provides a framework for diagnosis and management of ADHD in children and adolescents aged up to 18 years. In this document, the terms “child” and “children” represent all individuals below 18 years of age, unless specified otherwise. The term “adolescent” represents individuals between 13 and 18 years of age. The term “preschoolers” is used to indicate individuals who are below 6 years of age. These guidelines may not be applicable to adult patients who have ADHD as their treatment needs may be different. Finally, it is expected that recommendations made will have to be tailored to suit the needs of individual patients. ASSESSMENT AND EVALUATION A comprehensive assessment including detailed history, mental state, and physical examination is needed to reach the diagnosis and estimate the severity and impact of the disorder on the patient and caregivers. Comorbid developmental, psychiatric, and medical disorders and psychosocial or environmental factors such as family discord, parenting, and parental substance abuse that are directly relevant to the management should be assessed as far as possible. Table 1 presents the components of a comprehensive assessment, and Table 2 shows the clinical questions that need to be answered while undertaking the process of assessment.Table 1: Components of a comprehensive assessment and evaluation (text in parenthesis may be used as a guide for assessment)Table 2: Clinical questions to be answered in the process of assessmentThe assessment of preschoolers, children, and adolescents for ADHD comprises clinical interviews with parents and the patient, as well as obtaining information directly or indirectly (through parent accounts) from other relevant sources and settings including preschool, daycare, and school. Information from teachers may be obtained by requesting for teacher observation reports (unstructured) or teacher ratings on a structured rating scale (See Rating scales Section). Such requests should be sent through parents after explaining to them the need for such information and seeking their and the child's explicit consent and assent. Parents or the child may be reluctant to initiate such a communication for several reasons, the most important being fear of the child being stigmatized. Clinicians must, as far as possible, explain to the parents the need of teacher report and how this can aid in assessment, diagnosis, and management. If the child and parents are still reluctant, then the clinicians may satisfy themselves through parent and child accounts of symptoms and functioning in the school setting and review of school work and report cards. Further, in the Indian context, the clinician may involve other family members such as grandparents, especially if the child resides in a joint or an extended family. This will provide additional important information, opportunities to understand methods the family uses to handle the problematic behaviors, and expectations and perceptions regarding and treatment of these behaviors. It is important to remember that the histories may vary considerably on the perceptions regarding and such behaviors, their and opportunities for The histories from sources may other to provide a and interviews seeking information across various domains of functioning and in various settings are the The process of assessment may one It is an as far as be to be on accounts across settings as for the assessment, and it should on needs of the patient and the family. The diagnosis should be on the as for the symptoms of and the of and of the symptoms be into symptoms are of other psychiatric disorders such as or disorders that may ADHD be The symptoms be it is that the clinician the and a clinical of the mental of the child or is or the of is that the symptoms should be for the mental to ADHD. is that as a child may with ADHD are as not to have of and have and a child is to have still or in is expected to for in and is by of being and is in the of out of other children, on and into the presents as and of the and childhood years. on the other may as in and of may as and substance adolescents may with to and and a that the symptoms from their childhood may the symptoms are in or settings such as school or preschool, and It may be in that the can vary considerably on the in a Table shows the factors that can symptoms of that may of it is important to the by the symptoms in domains of functioning including social and academic or and In for the diagnosis, it is that the symptoms should in one The clinician to an of the severity of ADHD on the severity and of symptoms and severity of impairments by the In may be that should by be used as evidence for if need to be into account while management. These or behaviors, in and and substance abuse or behaviors. The clinician must, as far as for the that ADHD symptoms can have on Such are in and academic chronic to years of and affects social with ADHD may be to social are their with and have opportunities needed for peer to peer these all to social as social of and by and may all the of and of these children may diagnosis and It is important to that the disorder may be a diagnosis or may be a Table the with ADHD. Table presents clinical to ADHD from other and psychiatric disorders. The clinician as far as into and current and psychiatric with Clinical for disorder from other of preschoolers, clinicians also in that the symptoms may be or may represent the of the In the the clinician should from ADHD parent for (See a for should be especially while children and This may be from the by (See Section). It is that the clinician be of the of symptoms of disorder are as of the in a child with and with the symptoms are to be to the are The clinicians also the of in the of other disorders. a child with disorder is with the symptoms of and are to social communication and of and clinical and information across various and domains will the clinician in such Table 6 presents the clinical to guide the process of the clinical to guide the process of the medical disorders may with ADHD. Such may be to is and symptoms may be in such as or may be to such as and may be especially in children with neurodevelopmental disorders such as The clinician also medical This should a of or or state examination state examination of a or a child may be out with parent It is important that the clinicians themselves with and work that in as well as the child in an such and it is clinicians to the of the and and The clinician may or may not evidence of and the of as children may or the is structured with adult as in the This should not be as evidence of of ADHD. Further, children not be of their should not on their and with children for ADHD. clinicians may this to for disorders including as well as to It may and and of to It is that children and adolescents also be from their this their need for and may their and impact on their the clinician need not on ADHD symptoms may the regarding symptoms and peer and state examination should a assessment of and of of and symptoms as far as possible. may be evidence of should be and to other may be if is of the such should not be a has with the or Rating scales Rating scales and may in the these are can these a clinical These parent and teacher rating parent and teacher rating and ADHD rating These can be in structured information from other sources such as the rating scales may in treatment The scales may or ADHD or is of the rating scales are and not have Indian it be to these in clinical practice. such as and and may be The clinical scales and assessment of functioning scale may be used for and is not If is may be in of the may be and be after if disorder is the assessment for the should be out after of ADHD observation may be out by an it is a clinical such as are not in clinical practice. physical are needed or to ADHD. and and should not be out clinical In is to or in the should be should be clinical are of a A a comprehensive treatment factors that need to be into account are and of the severity of domains of functioning how symptoms or may everyday developmental, psychiatric, and medical psychosocial factors and and and or the child and family. The as far as the child's current and It is that needs assessment be an process as needs may with the children and their family be out to the regarding the Table presents the for a comprehensive treatment to guide of a comprehensive treatment treatment for it is important to a with the child and their accounts of perceptions and regarding and them information regarding diagnosis and The management is a with the child or and the family. for the perceptions and is perceptions regarding diagnosis and treatment may be by other family and other and may from the These perceptions may treatment as well as to parents who the as ADHD to be or to the child may for to the child and may not or parent as regarding and of may not with that of the on the treatment may to of these reasons, to and a in and treatment expectations from treatment also parents of children with ADHD and disorder may of all the symptoms with and may the treatment such expectations are not to treatment The clinician may into account that the needs by the parents and the patient may be different. the parents may be academic while the child may not this as an of the clinician as far as an to with the child and parents and into account their and Parents have by or teachers for their child's or are and by the the child is to the The clinician not the their and negative with the extended family and including and A with will the child and parents treatment can are in Table to remember while of diagnosis the diagnosis, the clinician may as a the parents and other significant family members their perceptions regarding the of the behaviors. The clinician may the diagnosis as a or a with and environmental The clinician may also the psychosocial factors that can the course and of the disorder parenting, family Further, the clinician as far as and the parents and the regarding ADHD. It may be by detailed the clinician diagnosis, if This is as treatment and course and may vary such It is not in clinical for parents to that their child has a and these parents and patients are of and reluctant to with the that the child will be by the Such are in the child's The clinician the while the diagnosis and the child and The clinician not the diagnosis to the school the consent of the patient and if the child to the by the school. may be out and should as far as be tailored for a child and the family. The clinician may involve other significant family members these or may with them as and such need is Table presents the for extended family members in for extended family members in the Indian may by the patient and family regarding their of their and their regarding may detailed of symptoms of and and including of and and environmental factors such as or regarding including that the symptoms are to child's or of and treatment and with and of The components that may be in are in Table Components of OF with other psychiatric the treatment are as and other of for the evidence for of treatment with has or in a of not and and negative perceptions of family and on the other if and may in symptoms as well as functioning in made in the in one or settings to the or the impact of the Such should the and functioning of the Such and in the child's The such as to up and for on from and be made and The child be in of in the as well as The physical also be structured with for a for in the and for of the of and may be for effective Parents can the child in and their through of and in such as in the or the on and by or a in the parent may are for or will with are structured as to and the are The teachers can and and to the may the especially on or such as The parent or teacher may a to the child Such may be or physical or a on the and the or the child from from the The may be in the of the from the and child's the with the the child is to read that with other on the with on the are being by the child and other child in the to the The should be as as possible. The should with the The of and other around should be Parents may of the to to through of to important If to of the child it may be may be with in the of or The may be of around after of being or in children or the adult in The parent may the child to out a such as or or that the child physical In the teacher may the child to or from the other may also be to and work if that them to The child be opportunities to their for by in physical such as or children, to children in their work as to not not of their of on and of may their and their may be to of these the Indian of for of these these be in conjunction with other and not be used as a In should be made after obtaining consent to with the school. a it should be to the school teachers that ADHD is a diagnosis and of environmental and will the should be made to their with the for detailed Table the environmental that can be and to and or parent are and such to parents that are to Parents be that for parent not that their is the them in for and that are significant members of the family may be in such if The clinician remember while with the parents and family that a parent or have ADHD with and and or may have other that may the effective of the may be for individual The for individual parental or family in or in to parent are out if individual and if It environmental effective communication management and for and taking of and may with to ADHD have in in the earlier communication effective of into on while and between is and is or regarding The used are setting of of by of behaviors, of or and being to the should be across a parent being across and across individuals be between the and also if parents be to on their child's and their and Parents also be to their and the child's through should also be from the and by them in the be Table 13 presents the components of a parent Components of for of children with In of children and who have from environmental and parent of still have significant impairments in may be may be in peer functioning or social functioning or in to management. may on social in with with and and and management. may it is not well if this into academic The treatment should as far as be tailored to the individual needs on current of severity and and if by the that may need to be into account in and of as to or neurodevelopmental or psychiatric or physical treatment and of or in the who has to the medical uses it for or to assessment a and should be and on the or Indian of and with assessment of and should be and medical and family that into account for should be This that of or of that is as to or or on or in to or or previous that and or of of years of should be A should be the if of these are and be in the patient The be and on and may be with the for age. If the is or or is the or for age, it should be If is or or is or are of or a is on an should be and a should be is for a is are and should be to their of of and of be and should be if is to be Table the assessment a assessment be the of on the symptoms will with and will not with Parents also be the with and a to a The with evidence for ADHD and is the in are several of in the Indian These and has a with a of of after and this is the of to need or have a of of while the has of of to their the and need in the and may as to is individual in and with or of be for individual in for management of The that have evidence for ADHD in children and adolescents and and of and are not in is a as in the individuals may by the and taking it in the and or is by may have and are of has evidence of other is an 2 in as is not in and are are not to their If a has to be the child and parents be of the and as the may In of and and may a in the of the treatment regarding and may be In of parents be regarding the of with of the of should not be should be a in Table and and be after are a and on and in with the of a medical and are to a of the for 2 years. The clinician the of for the is the of the child should be in 2 The clinician may be on a structured scale or on a such as If possible, ratings may be obtained from the teachers should be made regarding the of after of after the and of such Parents and teachers may report that the child is in the This may be to or of the Such will aid the clinician to the or the should be made regarding This should be from parents and the children and adolescents report that not the and are not Such may to the and should be The child's and should be and may be a for the should be on and on the to be across settings and domains of should be made regarding The child's and should be should be on and should be and should be on the and and should be on may the and while can should be if has A of an if with may be as to for is that for it may be an for around with for an Besides to the and other important factors that may are especially if the child needs to a the school and perceptions of patients and regarding and of the and that of to the and for may be a In of to or may be are A with additional as may be to and patient and family are and should be out as far as possible. are in taking the child is expected to have for These can be or may and opportunities for in and up the symptoms may or may not also provide with opportunities to for need for are for such not such as with the of or of of The need for should be a The impact on functioning including of and of treatment and treatment in and as well as patient and family are the factors to be into A clinical that indicate that ADHD has of need to and of a of is or to of or the if that it may be are a to of parents should be to the child in as and a to that being Table presents the of ADHD with on for and management of these with and their with disorder such as of psychiatric and disorders may to in children with ADHD. It is that or including around be including such as the child to for to in or a parent to be is the of parental in setting and behaviors. It is that and for be These may a and that and or in the and also not in the In individual or in children and in may be used for including are for disorders and not In preschoolers, is evidence of of are regarding especially to and In children years and and have to be have to be to and have evidence for is is not evidence of in or between the of The of the is in that may in with taking a in school and has evidence of with the other is evidence of for are that for has the evidence of the has In preschoolers, is evidence for and individual parent In children years and is evidence of for parent and in children and adolescents for other psychosocial and psychosocial is evidence directly with psychosocial In preschoolers, is evidence of for and psychosocial with with the In children years of and is evidence of for and psychosocial is evidence of of the with the being for the symptoms being in and the for especially are for psychosocial it is that this is of the ADHD regarding and is evidence that of a In are and should be of with psychosocial has to be psychosocial to the treatment may and be Besides evidence of of the is also evidence that of psychosocial may and of on and It is that all children and adolescents be regarding need for and and physical of and and or is not evidence for such as of and or of several as in the as in the management of ADHD. are evidence of and not evidence of or of If it is that the it is that parents be to detailed and of be in with an It may to for an through of of and between the and the family and are not in for The clinical of may be in individual in in such as of in a with several child's of child and as well as of or and is evidence for the of or or for the treatment of and it is that such may not be for this evidence indicate that may have on symptoms and and have have to the is not evidence to for treatment of ADHD. It is that with the school be a and all with the school should be after parental and consent and as far as should be made through the It is clinical to the while with the taking report and reports and parent reports may into of and in A with the teachers will the to the diagnosis and that it is a disorder and to environmental that a teacher can in the and teachers these children to their other and while These children are or are and school can be in Besides clinicians with the parents may be to with the child's teachers and the report cards. These report aid in the and across the the in management of disorder The evidence for is in preschoolers, are regarding the of the is evidence for and individual parent these in be psychosocial In children years of and is evidence of for and psychosocial to be in the symptoms of ADHD and psychosocial in and functioning in In environmental while in may be In the with the psychosocial may be for or impairments in In of parent be Besides the evidence for and and severity of the other important factors that the in ADHD current patient and and Table the factors the in the management of the in management of in management of disorder 1 presents the for ADHD. It is expected that the and may have to be tailored to suit the needs of an individual and to the child and family as far as be to all is not the of management in and aged 6 years as are regarding and it is to a from ADHD in that environmental as well as management may be The may be as or individual The clinician factors that may the effective of the parent 1: The for school-aged children and it is that environmental be the of environmental or in the severity is that such is the of management on the In children with of parent and school If the is not or parent is not and severity is of If ADHD is be The of and is by by all individuals who on a with the with review and In children and adolescents who have on still have impairments in a additional psychosocial an impairments in peer functioning social In of to a psychosocial with and In of on for after the child and regarding the these may and If child is on the the while for If an is the may psychosocial a in that it be if after the and of of If is after review the diagnosis, may parent In of parent for and to the If is and or in with the Table 18 out the factors to to or to to or the or parent and other psychosocial with the school be out with consent of child and be of environmental and management be made with teacher reports regarding child's and and of treatment The clinician regarding and needs of the child and family. The management may be in with needs as in earlier Further, the clinician review the need for treatment a to functioning in various and of of or of treatment be assessment, assessment of symptoms and functioning this involve involve and be across The child and family be in regarding of and and including of not and in be such as of has with in in an earlier In of psychosocial it is expected that may the may be or such as or management may be In a child is on and the may be The children and adolescents and their be of The clinician for of symptoms or impairments in functioning that need to be In of and the may be as for children and adolescents be and should be to or may be a in of while may be a in of disorder is evidence for In of children with or is an important children with or and of In such children, the diagnosis of ADHD should be and the should be A may be In of or disorder with the or disorder should be and after of the a review of diagnosis of ADHD should be The clinician should the need for and then may a or a the and in the individual and In of the clinician the severity of of attempts or and of symptoms to the clinical If the of these are should be In of or or management may be on the individual the other if is not with and ADHD symptoms are to symptoms to clinical and ADHD be the symptoms and may be to the ADHD and with effective treatment of ADHD. In of substance treatment of ADHD and substance should be The clinician the of and If this is a may be If disorder or disorder is parent the in to ADHD parent should be Further, of and should be assessed and a may be in may be for to Clinical on for management. and of are of