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Pediatric

Am o
Po ica edi
er f P
lic n A atr
y c ics
of ad
th em
e
Mental Health

y
A Compendium of AAP
Clinical Practice Guidelines and Policies
Pediatric Mental Health
A Compendium of
AAP Clinical Practice
Guidelines and Policies
 AMERICAN ACADEMY OF PEDIATRICS
PUBLISHING STAFF

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 INTRODUCTION

Clinical practice guidelines have long provided physicians with evidence-based decision-making
tools for managing common pediatric conditions. Policy statements issued by the American
Academy of Pediatrics (AAP) are developed to provide physicians with a quick reference guide to
the AAP position on child health care issues. We have combined these 2 authoritative resources into
1 comprehensive manual to provide easy access to important clinical and policy information.

This manual contains an AAP clinical practice guideline, as well as AAP policy statements, clinical
reports, and technical reports.

Additional information about AAP policy can be found in a variety of professional publications
such as Pediatric Clinical Practice Guidelines & Policies, 19th Edition; Red Book®, 31st Edition; and
Red Book® Online (http://redbook.solutions.aap.org).
 AMERICAN ACADEMY OF PEDIATRICS

The American Academy of Pediatrics (AAP) and its member pediatricians dedicate their efforts and resources to
the health, safety, and well-being of infants, children, adolescents, and young adults. The AAP has approximately
67,000 members in the United States, Canada, and Latin America. Members include pediatricians, pediatric medical
subspecialists, and pediatric surgical specialists.

Core Values. We believe

• In the inherent worth of all children; they are our most enduring and vulnerable legacy.
• Children deserve optimal health and the highest quality health care.
• Pediatricians, pediatric medical subspecialists, and pediatric surgical specialists are the best qualified to provide
child health care.
• Multidisciplinary teams including patients and families are integral to delivering the highest quality health care.
• The AAP is the organization to advance child health and well-being and the profession of pediatrics.
Vision. Children have optimal health and well-being and are valued by society. American Academy of Pediatrics
members practice the highest quality health care and experience professional satisfaction and personal well-being.

Mission. The mission of the AAP is to attain optimal, physical, mental, and social health and well-being for all
infants, children, adolescents, and young adults. To accomplish this mission, the AAP shall support the professional
needs of its members.
 v

TABLE OF CONTENTS
Foreword .................................................................................. vi Executive Summary: Evaluation and Management of
Children With Acute Mental Health or Behavioral
Section 1 Problems. Part II: Recognition of Clinically
Attention-Deficit/Hyperactivity Disorder Challenging Mental Health Related Conditions
Clinical Practice Guideline for the Diagnosis, Presenting With Medical or Uncertain Symptoms ........... 273
Evaluation, and Treatment of Attention-Deficit/ Promoting Optimal Development: Screening for
Hyperactivity Disorder in Children and Behavioral and Emotional Problems ................................ 281
Adolescents ......................................................................... 3
Section 5
Section 2
Maltreatment
Adversity and Toxic Stress Clinical Considerations Related to the Behavioral
Early Childhood Adversity, Toxic Stress, and the Manifestations of Child Maltreatment ............................. 295
Role of the Pediatrician: Translating Developmental
Psychological Maltreatment ................................................... 309
Science Into Lifelong Health .............................................. 73
The Lifelong Effects of Early Childhood Adversity Section 6
and Toxic Stress.................................................................. 81 Mental Health Emergencies
Pediatric Mental Health Emergencies in the
Section 3
Emergency Medical Services System ................................ 319
Depression and Bipolar Disorder
Pediatric and Adolescent Mental Health Emergencies
Collaborative Role of the Pediatrician in the
in the Emergency Medical Services System
Diagnosis and Management of Bipolar
(Technical Report) ........................................................... 323
Disorder in Adolescents ..................................................... 99
Suicide and Suicide Attempts in Adolescents ........................ 335
Guidelines for Adolescent Depression in Primary Care
(GLAD-PC): Part I. Practice Preparation, Section 7
Identification, Assessment, and Initial Management ....... 117 Special Pediatric Populations and Support
Guidelines for Adolescent Depression in Primary Care Ensuring Comprehensive Care and Support for
(GLAD-PC): Part II. Treatment and Ongoing Transgender and Gender-Diverse Children and
Management ..................................................................... 139 Adolescents ...................................................................... 349
Incorporating Recognition and Management of Health and Mental Health Needs of Children in
Perinatal Depression Into Pediatric Practice .................... 155 US Military Families......................................................... 363
Incorporating Recognition and Management of Helping Children and Families Deal With Divorce
Perinatal Depression Into Pediatric Practice and Separation ................................................................. 377
(Technical Report) ........................................................... 165 The Pediatrician’s Role in Family Support and Family
Section 4 Support Programs ............................................................ 387
Mental Health/Behavioral Problems Providing Care for Children and Adolescents Facing
Addressing Early Childhood Emotional and Homelessness and Housing Insecurity............................. 393
Behavioral Problems......................................................... 197 Providing Care for Immigrant, Migrant, and Border
Addressing Early Childhood Emotional and Children ........................................................................... 399
Behavioral Problems (Technical Report).......................... 205 Providing Psychosocial Support to Children and
Evaluation and Management of Children and Families in the Aftermath of Disasters and Crises ........... 407
Adolescents With Acute Mental Health or Psychosocial Factors in Children and Youth With
Behavioral Problems. Part I: Common Clinical Special Health Care Needs and Their Families ................ 419
Challenges of Patients With Mental Health and/or Psychosocial Support for Youth Living With HIV.................. 433
Behavioral Emergencies ................................................... 219 Supporting the Family After the Death of a Child ................. 439
Evaluation and Management of Children With Acute Supporting the Grieving Child and Family ............................ 445
Mental Health or Behavioral Problems. Part II:
Recognition of Clinically Challenging Mental Section 8
Health Related Conditions Presenting With Mental Health Competencies
Medical or Uncertain Symptoms...................................... 241 Mental Health Competencies for Pediatric Practice .............. 459
Executive Summary: Evaluation and Management of Achieving the Pediatric Mental Health Competencies .......... 475
Children and Adolescents With Acute Mental
Health or Behavioral Problems. Part I: Common Index ...................................................................................... 489
Clinical Challenges of Patients With Mental
Health and/or Behavioral Emergencies ............................ 265
vi

FOREWORD
This is the first compendium of polices and clinical practice guidelines related to pediatric mental health from
the American Academy of Pediatrics (AAP). It is timely. As highlighted in the final policy statement, “[t]he
prevalence of mental health conditions in children and adolescents is increasing and, alarmingly, suicide rates
are now the second leading cause of death in young people from 10 to 24 years of age.” Pediatric clinicians
practicing in both primary care and subspecialty settings have a unique advantage: longitudinal, trusting
relationships with children, adolescents, and their families on which to build a therapeutic alliance. With
frequent contact and this bond of trust, we can elicit our patients’ and families’ concerns, recognize risks and
strengths in their social environment, partner with parents to build their children’s resilience, and address
emerging mental health symptoms. Our pediatric advantage positions us to provide help…and H E L2 P3
(described below).

Policies in the compendium provide clinical guidance aimed at all clinicians who provide care to children
and adolescents with mental health needs—pediatricians, family physicians, emergency medicine physicians,
nurse practitioners, and physician assistants. Topics run the gamut of acuity from preventive care to
emergency care, with management of common conditions and care of special populations in between.
Several policies include content on clinician self-care. Many go beyond the interface between clinician and
patient to offer guidance on preparing the practice and organizing the health care team; collaborating with
developmental and mental health specialists; engaging with other community providers of health and social
services; and advocating for improvements in payment, access to care, and mental health systems of care. As
such, the compendium is also a resource for child advocates and policy makers. The compendium concludes
with a policy statement on the competencies—knowledge, skills, and attitudes—pediatricians need to provide
mental health care to children and adolescents (including “common factors” communication techniques,
abbreviated by the mnemonic H E L2 P3 —an approach that is intuitive to experienced clinicians and proven
effective across a wide range of mental health concerns). The statement also offers resources to assist in
achieving the competencies.

The compendium is a publication of the AAP, whose mission is “to attain optimal physical, mental, and social
health and well-being for all infants, children, adolescents, and young adults.” Among the AAP strengths
are a commitment to evidence-based medicine and hundreds of pediatric experts willing to share their
expertise with others. Serving on leadership groups—committees, councils, and sections—these experts
are charged with providing policies, educational programming, and resources for AAP members and the
public. Given the crosscutting nature of mental health, policies in this compendium draw on the expertise
of leaders across many of these leadership entities. Authors of policies do not prescribe an exclusive course
of action or a standard of care. Rather, based on their review of all available data, they offer evidence-based
recommendations when supported by data and consensus when data are lacking. American Academy of
Pediatrics policies allow flexibility in individual situations and encourage sound clinical judgment.

I believe the guidance and resources in this compendium will motivate and help clinicians to improve the
mental health of children and adolescents in their care and, as a result, enhance their patients’ lifelong well-
being. I also believe this compendium will assist child advocates and policy makers in creating a framework of
payment, mental health consultation and specialty services, and public policy to support pediatric clinicians’
critical role in providing mental health care.

Jane Meschan Foy, MD, FAAP

AAP Board of Directors, 2013–2019
 1

SECTION 1
Attention-Deficit/
Hyperactivity Disorder
 3

CLINICAL PRACTICE GUIDELINE

Clinical Practice Guideline for the

Diagnosis, Evaluation, and Treatment of
Attention-Deficit/Hyperactivity
Disorder in Children and Adolescents
Mark L. Wolraich, MD, FAAP,a Joseph F. Hagan, Jr, MD, FAAP,b,c Carla Allan, PhD,d,e Eugenia Chan, MD, MPH, FAAP,f,g
Dale Davison, MSpEd, PCC,h,i Marian Earls, MD, MTS, FAAP,j,k Steven W. Evans, PhD,l,m Susan K. Flinn, MA,n
Tanya Froehlich, MD, MS, FAAP,o,p Jennifer Frost, MD, FAAFP,q,r Joseph R. Holbrook, PhD, MPH,s
Christoph Ulrich Lehmann, MD, FAAP,t Herschel Robert Lessin, MD, FAAP,u Kymika Okechukwu, MPA,v
Karen L. Pierce, MD, DFAACAP,w,x Jonathan D. Winner, MD, FAAP,y William Zurhellen, MD, FAAP,z SUBCOMMITTEE ON CHILDREN AND
ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISORDER

Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common abstract

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.
a
Section of Developmental and Behavioral Pediatrics, University of
Oklahoma, Oklahoma City, Oklahoma; bDepartment of Pediatrics, The
Robert Larner, MD, College of Medicine, The University of Vermont,
Burlington, Vermont; cHagan, Rinehart, and Connolly Pediatricians,
PLLC, Burlington, Vermont; dDivision of Developmental and Behavioral
Health, Department of Pediatrics, Children’s Mercy Kansas City, Kansas
City, Missouri; eSchool of Medicine, University of Missouri-Kansas City,
Kansas City, Missouri; fDivision of Developmental Medicine, Boston
Children’s Hospital, Boston, Massachusetts; gHarvard Medical School,
Harvard University, Boston, Massachusetts; hChildren and Adults with
Attention-Deficit/Hyperactivity Disorder, Lanham, Maryland; iDale
Davison, LLC, Skokie, Illinois; jCommunity Care of North Carolina,
Raleigh, North Carolina; kSchool of Medicine, University of North
Carolina, Chapel Hill, North Carolina; lDepartment of Psychology, Ohio
University, Athens, Ohio; mCenter for Intervention Research in Schools,
Ohio University, Athens, Ohio; nAmerican Academy of Pediatrics,
Alexandria, Virginia; oDepartment of Pediatrics, University of
Cincinnati, Cincinnati, Ohio; pCincinnati Children’s Hospital Medical
Center, Cincinnati, Ohio; qSwope Health Services, Kansas City, Kansas;
r
American Academy of Family Physicians, Leawood, Kansas; sNational
Center on Birth Defects and Developmental Disabilities, Centers for
Disease Control and Prevention, Atlanta, Georgia; tDepartments of
Biomedical Informatics and Pediatrics, Vanderbilt University, Nashville,
Tennessee; uThe Children’s Medical Group, Poughkeepsie, New York;
To cite: Wolraich ML, Hagan JF, Allan C, et al. AAP
SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH
ATTENTION-DEFICIT/HYPERACTIVE DISORDER. Clinical Practice
Guideline for the Diagnosis, Evaluation, and Treatment of
Attention-Deficit/Hyperactivity Disorder in Children and
Adolescents. Pediatrics. 2019;144(4):e20192528

PEDIATRICS Volume 144, number 4, October 2019:e20192528 FROM THE AMERICAN ACADEMY OF PEDIATRICS
4 Section 1: Attention-Deficit/Hyperactivity Disorder
INTRODUCTION
This article updates and replaces the
2011 clinical practice guideline
revision published by the American
Academy of Pediatrics (AAP), “Clinical
Practice Guideline: Diagnosis and
Evaluation of the Child with
Attention-Deficit/Hyperactivity
Disorder.”1 This guideline, like the
previous document, addresses the
evaluation, diagnosis, and treatment
of attention-deficit/hyperactivity
disorder (ADHD) in children from age
4 years to their 18th birthday, with
special guidance provided for ADHD
care for preschool-aged children and
adolescents. (Note that for the
purposes of this document,
“preschool-aged” refers to children
from age 4 years to the sixth
birthday.) Pediatricians and other
primary care clinicians (PCCs) may
continue to provide care after
18 years of age, but care beyond this
age was not studied for this guideline.
Since 2011, much research has
occurred, and the Diagnostic and
Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), has been
released. The new research and DSM-
5 do not, however, support dramatic
changes to the previous
recommendations. Hence, this new
guideline includes only incremental
updates to the previous guideline.
One such update is the addition of
a key action statement (KAS) about
the diagnosis and treatment of
coexisting or comorbid conditions in
children and adolescents with ADHD.
The subcommittee uses the term
“comorbid,” to be consistent with the
DSM-5.
Since 2011, the release of new
research reflects an increased
understanding and recognition of
ADHD’s prevalence and
epidemiology; the challenges it raises
for children and families; the need for
a comprehensive clinical resource for
the evaluation, diagnosis, and
treatment of pediatric ADHD; and the
barriers that impede the
2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
implementation of such a resource. In
response, this guideline is supported
by 2 accompanying documents,
available in the Supplemental
Information: (1) a process of care
algorithm (PoCA) for the diagnosis
and treatment of children and
adolescents with ADHD and (2) an
article on systemic barriers to the
care of children and adolescents with
ADHD. These supplemental
documents are designed to aid PCCs
in implementing the formal
recommendations for the evaluation,
diagnosis, and treatment of children
and adolescents with ADHD. Although
this document is specific to children
and adolescents in the United States
in some of its recommendations,
international stakeholders can modify
specific content (ie, educational laws
about accommodations, etc) as
needed. (Prevention is addressed in
the Mental Health Task Force
recommendations.2)
PoCA for the Diagnosis and
Treatment of Children and
Adolescents With ADHD
In this revised guideline and
accompanying PoCA, we recognize
that evaluation, diagnosis, and
treatment are a continuous process.
The PoCA provides recommendations
for implementing the guideline steps,
although there is less evidence for the
PoCA than for the guidelines. The
section on evaluating and treating
comorbidities has also been expanded
in the PoCA document.
Systems Barriers to the Care of
Children and Adolescents With ADHD
There are many system-level barriers
that hamper the adoption of the best-
practice recommendations contained
in the clinical practice guideline and
the PoCA. The procedures
recommended in this guideline
necessitate spending more time with
patients and their families,
developing a care management
system of contacts with school and
other community stakeholders, and
providing continuous, coordinated
care to the patient and his or her
family. There is some evidence that
African American and Latino children
are less likely to have ADHD
diagnosed and are less likely to be
treated for ADHD. Special attention
should be given to these populations
when assessing comorbidities as they
relate to ADHD and when treating for
ADHD symptoms.3 Given the
nationwide problem of limited access
to mental health clinicians,4
pediatricians and other PCCs are
increasingly called on to provide
services to patients with ADHD and to
their families. In addition, the AAP
holds that primary care pediatricians
should be prepared to diagnose and
manage mild-to-moderate ADHD,
anxiety, depression, and problematic
substance use, as well as co-manage
patients who have more severe
conditions with mental health
professionals. Unfortunately, third-
party payers seldom pay
appropriately for these time-
consuming services.5,6
To assist pediatricians and other
PCCs in overcoming such obstacles,
the companion article on systemic
barriers to the care of children and
adolescents with ADHD reviews the
barriers and makes recommendations
to address them to enhance care for
children and adolescents with ADHD.
ADHD EPIDEMIOLOGY AND SCOPE
Prevalence estimates of ADHD vary
on the basis of differences in research
methodologies, the various age
groups being described, and changes
in diagnostic criteria over time.7
Authors of a recent meta-analysis
calculated a pooled worldwide ADHD
prevalence of 7.2% among children8;
estimates from some community-
based samples are somewhat higher,
at 8.7% to 15.5%.9,10 National survey
data from 2016 indicate that 9.4% of
children in the United States 2 to
17 years of age have ever had an
ADHD diagnosis, including 2.4% of
children 2 to 5 years of age.11 In that
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
national survey, 8.4% of children 2 to
17 years of age currently had ADHD,
representing 5.4 million children.11
Among children and adolescents with
current ADHD, almost two-thirds
were taking medication, and
approximately half had received
behavioral treatment of ADHD in the
past year. Nearly one quarter had
received neither type of treatment of
ADHD.11
Symptoms of ADHD occur in
childhood, and most children with
ADHD will continue to have
symptoms and impairment through
adolescence and into adulthood.
According to a 2014 national survey,
the median age of diagnosis was
7 years; approximately one-third of
children were diagnosed before
6 years of age.12 More than half of
these children were first diagnosed
by a PCC, often a pediatrician.12 As
individuals with ADHD enter
adolescence, their overt hyperactive
and impulsive symptoms tend to
decline, whereas their inattentive
symptoms tend to persist.13,14
Learning and language problems are
common comorbid conditions with
ADHD.15
Boys are more than twice as likely as
girls to receive a diagnosis of
ADHD,9,11,16 possibly because
hyperactive behaviors, which are
easily observable and potentially
disruptive, are seen more frequently
in boys. The majority of both boys
and girls with ADHD also meet
diagnostic criteria for another mental
disorder.17,18 Boys are more likely to
exhibit externalizing conditions like
oppositional defiant disorder or
conduct disorder.17,19,20 Recent
research has established that girls
with ADHD are more likely than boys
to have a comorbid internalizing
condition like anxiety or
depression.21
Although there is a greater risk of
receiving a diagnosis of ADHD for
children who are the youngest in
their class (who are therefore less
PEDIATRICS Volume 144, number 4, October 2019
developmentally capable of
compensating for their weaknesses),
for most children, retention is not
beneficial.22
METHODOLOGY
As with the original 2000 clinical
practice guideline and the 2011
revision, the AAP collaborated with
several organizations to form
a subcommittee on ADHD (the
subcommittee) under the oversight of
the AAP Council on Quality
Improvement and Patient Safety.
The subcommittee’s membership
included representation of a wide
range of primary care and
subspecialty groups, including
primary care pediatricians,
developmental-behavioral
pediatricians, an epidemiologist from
the Centers for Disease Control and
Prevention; and representatives from
the American Academy of Child and
Adolescent Psychiatry, the Society for
Pediatric Psychology, the National
Association of School Psychologists,
the Society for Developmental and
Behavioral Pediatrics (SDBP), the
American Academy of Family
Physicians, and Children and Adults
with Attention-Deficit/Hyperactivity
Disorder (CHADD) to provide
feedback on the patient/parent
perspective.
This subcommittee met over a 3.5-
year period from 2015 to 2018 to
review practice changes and newly
identified issues that have arisen
since the publication of the 2011
guidelines. The subcommittee
members’ potential conflicts were
identified and taken into
consideration in the group’s
deliberations. No conflicts prevented
subcommittee member participation
on the guidelines.
Research Questions
The subcommittee developed a series
of research questions to direct an
evidence-based review sponsored by
1 of the Evidence-based Practice
5
Centers of the US Agency for
Healthcare Research and Quality
(AHRQ).23 These questions assessed
4 diagnostic areas and 3 treatment
areas on the basis of research
published in 2011 through 2016.
The AHRQ’s framework was guided
by key clinical questions addressing
diagnosis as well as treatment
interventions for children and
adolescents 4 to 18 years of age.
The first clinical questions pertaining
to ADHD diagnosis were as follows:
1. What is the comparative
diagnostic accuracy of approaches
that can be used in the primary
care practice setting or by
specialists to diagnose ADHD
among children younger than
7 years of age?
2. What is the comparative
diagnostic accuracy of EEG,
imaging, or executive function
approaches that can be used in the
primary care practice setting or by
specialists to diagnose ADHD
among individuals aged 7 to their
18th birthday?
3. What are the adverse effects
associated with being labeled
correctly or incorrectly as having
ADHD?
4. Are there more formal
neuropsychological, imaging, or
genetic tests that improve the
diagnostic process?
The treatment questions were as
follows:
1. What are the comparative safety
and effectiveness of pharmacologic
and/or nonpharmacologic
treatments of ADHD in improving
outcomes associated with ADHD?
2. What is the risk of diversion of
pharmacologic treatment?
3. What are the comparative safety
and effectiveness of different
monitoring strategies to evaluate
the effectiveness of treatment or
changes in ADHD status (eg,
worsening or resolving
symptoms)?
3
6 Section 1: Attention-Deficit/Hyperactivity Disorder

In addition to this review of the

research questions, the subcommittee
considered information from a review
of evidence-based psychosocial
treatments for children and
adolescents with ADHD24 (which, in
some cases, affected the evidence
grade) as well as updated information
on prevalence from the Centers for
Disease Control and Prevention.

Evidence Review
This article followed the latest
version of the evidence base update
format used to develop the previous 3
clinical practice guidelines.24–26
Under this format, studies were only
included in the review when they met
a variety of criteria designed to
ensure the research was based on
a strong methodology that yielded
confidence in its conclusions.
The level of efficacy for each
treatment was defined on the basis of
child-focused outcomes related to FIGURE 1
AAP rating of evidence and recommendations.
both symptoms and impairment.
Hence, improvements in behaviors on
the part of parents or teachers, such
sites/default/files/pdf/cer-203-adhd- demonstrated a preponderance of
as the use of communication or
final_0.pdf. benefits over harms, the KAS provides
praise, were not considered in the
a “strong recommendation” or
review. Although these outcomes are The evidence is discussed in more
“recommendation.”27 Clinicians
important, they address how detail in published reports and
should follow a “strong
treatment reaches the child or articles.25
recommendation” unless a clear and
adolescent with ADHD and are,
Guideline Recommendations and Key compelling rationale for an
therefore, secondary to changes in the
Action Statements alternative approach is present;
child’s behavior. Focusing on
clinicians are prudent to follow
improvements in the child or The AAP policy statement, a “recommendation” but are advised
adolescent’s symptoms and “Classifying Recommendations for to remain alert to new information
impairment emphasizes the Clinical Practice Guidelines,” was and be sensitive to patient
disorder’s characteristics and followed in designating aggregate preferences27 (see Fig 1).
manifestations that affect children evidence quality levels for the
and their families. available evidence (see Fig 1).27 The When the scientific evidence
AAP policy statement is consistent comprised lower-quality or limited
The treatment-related evidence relied
with the grading recommendations data and expert consensus or high-
on a recent review of literature from
advanced by the University of quality evidence with a balance
2011 through 2016 by the AHRQ of
Oxford Centre for Evidence Based between benefits and harms, the KAS
citations from Medline, Embase,
Medicine. provides an “option” level of
PsycINFO, and the Cochrane Database
recommendation. Options are clinical
of Systematic Reviews. The subcommittee reached consensus
interventions that a reasonable
on the evidence, which was then used
The original methodology and report, health care provider might or might
to develop the clinical practice
including the evidence search and not wish to implement in the
guideline’s KASs.
review, are available in their entirety practice.27 Where the evidence
and as an executive summary at When the scientific evidence was at was lacking, a combination of
https://effectivehealthcare.ahrq.gov/ least “good” in quality and evidence and expert consensus

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
would be used, although this
did not occur in these
guidelines, and all KASs
achieved a “strong
recommendation” level except
for KAS 7, on comorbidities,
which received a recommendation
level (see Fig 1).
As shown in Fig 1, integrating
evidence quality appraisal with an
assessment of the anticipated balance
between benefits and harms leads to
a designation of a strong
recommendation, recommendation,
option, or no recommendation.
Once the evidence level was
determined, an evidence grade was
assigned. AAP policy stipulates that
the evidence supporting each KAS be
prospectively identified, appraised,
and summarized, and an explicit link
between quality levels and the grade
of recommendation must be defined.
Possible grades of recommendations
range from “A” to “D,” with “A” being
the highest:
• grade A: consistent level A studies;
• grade B: consistent level B or
extrapolations from level A studies;
• grade C: level C studies or
extrapolations from level B or level
C studies;
• grade D: level D evidence or
troublingly inconsistent or
inconclusive studies of any level;
and
• level X: not an explicit level of
evidence as outlined by the Centre
for Evidence-Based Medicine. This
level is reserved for interventions
that are unethical or impossible to
test in a controlled or scientific
fashion and for which the
preponderance of benefit or harm
is overwhelming, precluding
rigorous investigation.
Guided by the evidence quality and
grade, the subcommittee developed 7
KASs for the evaluation, diagnosis,
and treatment of ADHD in children
and adolescents (see Table 1).
PEDIATRICS Volume 144, number 4, October 2019
These KASs provide for consistent
and high-quality care for children and
adolescents who may have symptoms
suggesting attention disorders or
problems as well as for their families.
In developing the 7 KASs, the
subcommittee considered the
requirements for establishing the
diagnosis; the prevalence of ADHD;
the effect of untreated ADHD; the
efficacy and adverse effects of
treatment; various long-term
outcomes; the importance of
coordination between pediatric and
mental health service providers; the
value of the medical home; and the
common occurrence of comorbid
conditions, the importance of
addressing them, and the effects of
not treating them.
The subcommittee members with the
most epidemiological experience
assessed the strength of each
recommendation and the quality of
evidence supporting each draft KAS.
Peer Review
The guidelines and PoCA underwent
extensive peer review by more than
30 internal stakeholders (eg, AAP
committees, sections, councils, and
task forces) and external stakeholder
groups identified by the
subcommittee. The resulting
comments were compiled and
reviewed by the chair and vice chair;
relevant changes were incorporated
into the draft, which was then
reviewed by the full subcommittee.
KASS FOR THE EVALUATION,
DIAGNOSIS, TREATMENT, AND
MONITORING OF CHILDREN AND
ADOLESCENTS WITH ADHD
KAS 1
The pediatrician or other PCC should
initiate an evaluation for ADHD for
any child or adolescent age 4 years to
the 18th birthday who presents with
academic or behavioral problems and
symptoms of inattention,
hyperactivity, or impulsivity
7
(Table 2). (Grade B: strong
recommendation.)
The basis for this recommendation is
essentially unchanged from the
previous guideline. As noted, ADHD is
the most common neurobehavioral
disorder of childhood, occurring in
approximately 7% to 8% of children
and youth.8,18,28,29 Hence, the number
of children with this condition is far
greater than can be managed by the
mental health system.4 There is
evidence that appropriate diagnosis
can be accomplished in the primary
care setting for children and
adolescents.30,31 Note that there is
insufficient evidence to recommend
diagnosis or treatment for children
younger than 4 years (other than
parent training in behavior
management [PTBM], which does not
require a diagnosis to be applied); in
instances in which ADHD-like
symptoms in children younger than
4 years bring substantial impairment,
PCCs can consider making a referral
for PTBM.
KAS 2
To make a diagnosis of ADHD, the
PCC should determine that DSM-5
criteria have been met, including
documentation of symptoms and
impairment in more than 1 major
setting (ie, social, academic, or
occupational), with information
obtained primarily from reports from
parents or guardians, teachers, other
school personnel, and mental health
clinicians who are involved in the
child or adolescent’s care. The PCC
should also rule out any alternative
cause (Table 3). (Grade B: strong
recommendation.)
The American Psychiatric Association
developed the DSM-5 using expert
consensus and an expanding research
foundation.32 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.
5
8 Section 1: Attention-Deficit/Hyperactivity Disorder

TABLE 1 Summary of KASs for Diagnosing, Evaluating, and Treating ADHD in Children and Adolescents
KASs Evidence Quality, Strength of Recommendation
KAS 1: The pediatrician or other PCC should initiate an evaluation for ADHD for any child or Grade B, strong recommendation
adolescent age 4 years to the 18th birthday who presents with academic or behavioral
problems and symptoms of inattention, hyperactivity, or impulsivity.
KAS 2: To make a diagnosis of ADHD, the PCC should determine that DSM-5 criteria have been Grade B, strong recommendation
met, including documentation of symptoms and impairment in more than 1 major setting
(ie, social, academic, or occupational), with information obtained primarily from reports
from parents or guardians, teachers, other school personnel, and mental health
clinicians who are involved in the child or adolescent’s care. The PCC should also rule out
any alternative cause.
KAS 3: In the evaluation of a child or adolescent for ADHD, the PCC should include a process Grade B, strong recommendation
to at least screen for comorbid conditions, including emotional or behavioral conditions
(eg, anxiety, depression, oppositional defiant disorder, conduct disorders, substance use),
developmental conditions (eg, learning and language disorders, autism spectrum
disorders), and physical conditions (eg, tics, sleep apnea).
KAS 4: ADHD is a chronic condition; therefore, the PCC should manage children and Grade B, strong recommendation
adolescents with ADHD in the same manner that they would children and youth with
special health care needs, following the principles of the chronic care model and the
medical home.
KAS 5a: For preschool-aged children (age 4 years to the sixth birthday) with ADHD, the PCC Grade A, strong recommendation for PTBM
should prescribe evidence-based PTBM and/or behavioral classroom interventions as the
first line of treatment, if available.
Methylphenidate may be considered if these behavioral interventions do not provide Grade B, strong recommendation for methylphenidate
significant improvement and there is moderate-to-severe continued disturbance in the
4- through 5-year-old child’s functioning. In areas in which evidence-based behavioral
treatments are not available, the clinician needs to weigh the risks of starting
medication before the age of 6 years against the harm of delaying treatment.
KAS 5b. For elementary and middle school-aged children (age 6 years to the 12th birthday) Grade A, strong recommendation for medications
with ADHD, the PCC should prescribe FDA-approved medications for ADHD, along with Grade A, strong recommendation for training and behavioral
PTBM and/or behavioral classroom intervention (preferably both PTBM and behavioral treatments for ADHD with family and school
classroom interventions). Educational interventions and individualized instructional
supports, including school environment, class placement, instructional placement, and
behavioral supports, are a necessary part of any treatment plan and often include an IEP
or a rehabilitation plan (504 plan).
KAS 5c. For adolescents (age 12 years to the 18th birthday) with ADHD, the PCC should Grade A, strong recommendation for medications
prescribe FDA-approved medications for ADHD with the adolescent’s assent. The PCC is Grade A, strong recommendation for training and behavioral
encouraged to prescribe evidence-based training interventions and/or behavioral treatments for ADHD with the family and school
interventions as treatment of ADHD, if available. Educational interventions and
individualized instructional supports, including school environment, class placement,
instructional placement, and behavioral supports, are a necessary part of any treatment
plan and often include an IEP or a rehabilitation plan (504 plan).
KAS 6. The PCC should titrate doses of medication for ADHD to achieve maximum benefit with Grade B, strong recommendation
tolerable side effects.
KAS 7. The PCC, if trained or experienced in diagnosing comorbid conditions, may initiate Grade C, recommendation
treatment of such conditions or make a referral to an appropriate subspecialist for
treatment. After detecting possible comorbid conditions, if the PCC is not trained or
experienced in making the diagnosis or initiating treatment, the patient should be
referred to an appropriate subspecialist to make the diagnosis and initiate treatment.

The DSM-5 criteria define 4 3. attention-deficit/hyperactivity standard most frequently used by

dimensions of ADHD: disorder combined presentation clinicians and researchers to render
1. attention-deficit/hyperactivity (ADHD/C) (314.01 [F90.2]); and the diagnosis and document its
disorder primarily of the 4. ADHD other specified and appropriateness for a given child.
inattentive presentation (ADHD/I) unspecified ADHD (314.01 The use of neuropsychological
(314.00 [F90.0]); [F90.8]). testing has not been found to
2. attention-deficit/hyperactivity As with the previous guideline improve diagnostic accuracy in
disorder primarily of the recommendations, the DSM-5 most cases, although it may have
hyperactive-impulsive classification criteria are based on benefit in clarifying the child
presentation (ADHD/HI) (314.01 the best available evidence for or adolescent’s learning
[F90.1]); ADHD diagnosis and are the strengths and weaknesses. (See the

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents 9

TABLE 2 KAS 1: The pediatrician or other PCC should initiate an evaluation for ADHD for any child or adolescent age 4 years to the 18th birthday who
presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. (Grade B: strong recommendation.)
Aggregate evidence Grade B
quality
Benefits ADHD goes undiagnosed in a considerable number of children and adolescents. Primary care clinicians’ more-rigorous identification
of children with these problems is likely to decrease the rate of undiagnosed and untreated ADHD in children and adolescents.
Risks, harm, cost Children and adolescents in whom ADHD is inappropriately diagnosed may be labeled inappropriately, or another condition may be
missed, and they may receive treatments that will not benefit them.
Benefit-harm The high prevalence of ADHD and limited mental health resources require primary care pediatricians and other PCCs to play
assessment a significant role in the care of patients with ADHD and assist them to receive appropriate diagnosis and treatment. Treatments
available have good evidence of efficacy, and a lack of treatment has the risk of impaired outcomes.
Intentional vagueness There are limits between what a PCC can address and what should be referred to a subspecialist because of varying degrees of skills
and comfort levels present among the former.
Role of patient Success with treatment is dependent on patient and family preference, which need to be taken into account.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Wolraich et al31; Visser et al28; Thomas et al8; Egger et al30

PoCA for more information on
implementing this KAS.)
Special Circumstances: Preschool-Aged
Children (Age 4 Years to the Sixth
Birthday)
There is evidence that the diagnostic
criteria for ADHD can be applied to
preschool-aged children.33–39 A
review of the literature, including the
multisite study of the efficacy of
methylphenidate in preschool-aged
children, found that the DSM-5
criteria could appropriately identify
children with ADHD.25
To make a diagnosis of ADHD in
preschool-aged children, clinicians
should conduct a clinical interview
with parents, examine and observe
the child, and obtain information
from parents and teachers through
DSM-based ADHD rating scales.40
Normative data are available for the
DSM-5–based rating scales for ages
5 years to the 18th birthday.41 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. Both the ADHD
Rating Scale-IV and the Conners
Rating Scale have preschool-age
normative data based on 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. Hence, if
clinicians do not have the ADHD
Rating Scale-5 or the ADHD Rating
Scale-IV Preschool Version,42 any
other DSM-based scale can be used to
provide a systematic method for
collecting information from parents
and teachers, even in the absence of
normative data.
Pediatricians and other PCCs should
be aware that determining the
presence of key symptoms in this age
group has its challenges, such as

TABLE 3 KAS 2: To make a diagnosis of ADHD, the PCC should determine that DSM-5 criteria have been met, including documentation of symptoms and
impairment in more than 1 major setting (ie, social, academic, or occupational), with information obtained primarily from reports from parents
or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescent’s care. The PCC should
also rule out any alternative cause. (Grade B: strong recommendation.)
Aggregate evidence Grade B
quality
Benefits Use of the DSM-5 criteria has led to more uniform categorization of the condition across professional disciplines. The criteria are
essentially unchanged from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), for children up to
their 18th birthday, except that DSM-IV required onset prior to age 7 for a diagnosis, while DSM-5 requires onset prior to age 12.
Risks, harm, cost The DSM-5 does not specifically state that symptoms must be beyond expected levels for developmental (rather than chronologic) age
to qualify for an ADHD diagnosis, which may lead to some misdiagnoses in children with developmental disorders.
Benefit-harm The benefits far outweigh the harm.
assessment
Intentional vagueness None.
Role of patient Although there is some stigma associated with mental disorder diagnoses, resulting in some families preferring other diagnoses, the
preferences need for better clarity in diagnoses outweighs this preference.
Exclusions None.
Strength Strong recommendation.
Key references Evans et al25; McGoey et al42; Young43; Sibley et al46

PEDIATRICS Volume 144, number 4, October 2019 7

10
observing symptoms across multiple
settings as required by the DSM-5,
particularly among children who do
not attend a preschool or child care
program. Here, too, focused checklists
can be used to aid in the diagnostic
evaluation.
PTBM is the recommended primary
intervention for preschool-aged
children with ADHD as well as
children with ADHD-like behaviors
whose diagnosis is not yet verified.
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. 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. In addition, the
intervention’s results may inform the
subsequent diagnostic evaluation.
Clinicians are encouraged to
recommend that parents complete
PTBM, if available, before assigning
an ADHD diagnosis.
After behavioral parent training is
implemented, the clinician can
obtain information from parents and
teachers through DSM-5–based
ADHD rating scales. The clinician
may obtain reports about the
parents’ ability to manage their
children and about the child’s core
symptoms and impairments.
Referral to an early intervention
program or enrolling in a PTBM
program can help provide
information about the child’s
behavior in other settings or with
other observers. The evaluators for
these programs and/or early
childhood special education teachers
may be useful observers, as well.
Special Circumstances: Adolescents
(Age 12 Years to the 18th Birthday)
Obtaining teacher reports for
adolescents is often more challenging
than for younger children because
8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Section 1: Attention-Deficit/Hyperactivity Disorder
many adolescents have multiple
teachers. Likewise, an adolescent’s
parents may have less opportunity to
observe their child’s behaviors than
they did when the child was younger.
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. Of note,
adolescents’ reports of their own
behaviors often differ from other
observers because they tend to
minimize their own problematic
behaviors.43–45
Despite these difficulties, clinicians
need to try to obtain information
from at least 2 teachers or other
sources, such as coaches, school
guidance counselors, or leaders of
community activities in which the
adolescent participates.46 For the
evaluation to be successful, it is
essential that adolescents agree with
and participate in the evaluation.
Variability in ratings is to be
expected because adolescents’
behavior often varies between
different classrooms and with
different teachers. Identifying
reasons for any variability can
provide valuable clinical insight into
the adolescent’s problems.
Note that, unless they previously
received a diagnosis, to meet DSM-5
criteria for ADHD, adolescents must
have some reported or documented
manifestations of inattention or
hyperactivity/impulsivity before age
12. Therefore, clinicians must
establish that an adolescent had
manifestations of ADHD before age
12 and strongly consider whether
a mimicking or comorbid condition,
such as substance use, depression,
and/or anxiety, is present.46
In addition, the risks of mood and
anxiety disorders and risky sexual
behaviors increase during
adolescence, as do the risks of
intentional self-harm and suicidal
behaviors.31 Clinicians should also
be aware that adolescents are at
greater risk for substance use than
are younger children.44,45,47 Certain
substances, such as marijuana, can
have effects that mimic ADHD;
adolescent patients may also attempt
to obtain stimulant medication to
enhance performance (ie, academic,
athletic, etc) by feigning symptoms.48
Trauma experiences, posttraumatic
stress disorder, and toxic stress are
additional comorbidities and risk
factors of concern.
Special Circumstances: Inattention or
Hyperactivity/Impulsivity (Problem
Level)
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. When assessing
these children, diagnostic criteria
should be closely reviewed, which
may require obtaining more
information from other settings and
sources. Also consider that these
symptoms may suggest other
problems that mimic ADHD.
Behavioral interventions, such
as PTBM, are often beneficial for
children with hyperactive/impulsive
behaviors who do not meet full
diagnostic criteria for ADHD.
As noted previously, these programs
do not require a specific diagnosis
to be beneficial to the family. The
previous guideline discussed
the diagnosis of problem-level
concerns on the basis of the
Diagnostic and Statistical Manual for
Primary Care (DSM-PC), Child and
Adolescent Version,49 and made
suggestions for treatment and care.
The DSM-PC was published in 1995,
however, and it has not been revised
to be compatible with the DSM-5.
Therefore, the DSM-PC cannot be
used as a definitive source for
diagnostic codes related to ADHD and
comorbid conditions, although it can
be used conceptually as a resource for
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents 11

enriching the understanding of
problem-level manifestations.
KAS 3
In the evaluation of a child or
adolescent for ADHD, the PCC should
include a process to at least screen
for comorbid conditions, including
emotional or behavioral conditions
(eg, anxiety, depression, oppositional
defiant disorder, conduct disorders,
substance use), developmental
conditions (eg, learning and language
disorders, autism spectrum
disorders), and physical conditions
(eg, tics, sleep apnea) (Table 4).
(Grade B: strong recommendation.)
The majority of both boys and girls
with ADHD also meet diagnostic
criteria for another mental
disorder.17,18 A variety of other
behavioral, developmental, and
physical conditions can be comorbid
in children and adolescents who are
evaluated for ADHD, including
emotional or behavioral conditions or
a history of these problems. These
include but are not limited to learning
disabilities, language disorder,
disruptive behavior, anxiety, mood
disorders, tic disorders, seizures,
autism spectrum disorder,
developmental coordination disorder,
and sleep disorders.50–66 In some
cases, the presence of a comorbid
condition will alter the treatment
of ADHD.
The SDBP is developing a clinical
practice guideline to support
clinicians in the diagnosis of
treatment of “complex ADHD,” which
includes ADHD with comorbid
developmental and/or mental health
conditions.67
Special Circumstances: Adolescents
(Age 12 Years to the 18th Birthday)
At a minimum, clinicians should
assess adolescent patients with newly
diagnosed ADHD for symptoms and
signs of substance use, anxiety,
depression, and learning disabilities.
As noted, all 4 are common comorbid
conditions that affect the treatment
approach. These comorbidities make
it important for the clinician to
consider sequencing psychosocial and
medication treatments to maximize
the impact on areas of greatest risk
and impairment while monitoring for
possible risks such as stimulant abuse
or suicidal ideation.
KAS 4
ADHD is a chronic condition;
therefore, the PCC should manage
children and adolescents with ADHD
in the same manner that they would
children and youth with special
health care needs, following the
principles of the chronic care model
and the medical home (Table 5).
(Grade B: strong recommendation.)
As in the 2 previous guidelines, this
recommendation is based on the
evidence that for many individuals,
ADHD causes symptoms and
dysfunction over long periods of time,
even into adulthood. Available
treatments address symptoms and
function but are usually not curative.
Although the chronic illness model
has not been specifically studied in
children and adolescents with ADHD,
it has been effective for other chronic
conditions, such as asthma.68 In
addition, the medical home model has
been accepted as the preferred
standard of care for children with
chronic conditions.69
The medical home and chronic illness
approach may be particularly
beneficial for parents who also have
ADHD themselves. These parents can
benefit from extra support to help
them follow a consistent schedule for
medication and behavioral programs.
Authors of longitudinal studies have
found that ADHD treatments are
frequently not maintained over
time13 and impairments persist into
adulthood.70 It is indicated in
prospective studies that patients with
ADHD, whether treated or not, are at
increased risk for early death, suicide,
and increased psychiatric

TABLE 4 KAS 3: In the evaluation of a child or adolescent for ADHD, the PCC should include a process to at least screen for comorbid conditions, including
emotional or behavioral conditions (eg, anxiety, depression, oppositional defiant disorder, conduct disorders, substance use), developmental
conditions (eg, learning and language disorders, autism spectrum disorders), and physical conditions (eg, tics, sleep apnea). (Grade B: strong
recommendation.)
Aggregate evidence Grade B
quality
Benefits Identifying comorbid conditions is important in developing the most appropriate treatment plan for the child or adolescent with
ADHD.
Risks, harm, cost The major risk is misdiagnosing the comorbid condition(s) and providing inappropriate care.
Benefit-harm There is a preponderance of benefits over harm.
assessment
Intentional vagueness None.
Role of patient None.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Cuffe et al51; Pastor and Reuben52; Bieiderman et al53; Bieiderman et al54; Bieiderman et al72; Crabtree et al57; LeBourgeois et al58;
Chan115; Newcorn et al60; Sung et al61; Larson et al66; Mahajan et al65; Antshel et al64; Rothenberger and Roessner63; Froehlich et al62

PEDIATRICS Volume 144, number 4, October 2019 9

12 Section 1: Attention-Deficit/Hyperactivity Disorder

TABLE 5 KAS 4: ADHD is a chronic condition; therefore, the PCC should manage children and adolescents with ADHD in the same manner that they would
children and youth with special health care needs, following the principles of the chronic care model and the medical home. (Grade B: strong
recommendation.)
Aggregate evidence quality Grade B
Benefits The recommendation describes the coordinated services that are most appropriate to manage the condition.
Risks, harm, cost Providing these services may be more costly.
Benefit-harm assessment There is a preponderance of benefits over harm.
Intentional vagueness None.
Role of patient Family preference in how these services are provided is an important consideration, because it can increase adherence.
preferences
Exclusions None
Strength Strong recommendation.
Key references Brito et al69; Biederman et al72; Scheffler et al74; Barbaresi et al75; Chang et al71; Chang et al78; Lichtenstein et al77; Harstad and
Levy80

comorbidity, particularly substance
use disorders.71,72 They also have
lower educational achievement than
those without ADHD73,74 and
increased rates of incarceration.75–77
Treatment discontinuation also
places individuals with ADHD at
higher risk for catastrophic
outcomes, such as motor vehicle
crashes78,79; criminality, including
drug-related crimes77 and violent
reoffending76; depression71;
interpersonal issues80; and other
injuries.81,82
To continue providing the best care, it
is important for a treating
pediatrician or other PCC to engage in
bidirectional communication with
teachers and other school personnel
as well as mental health clinicians
involved in the child or adolescent’s
care. 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
Special Circumstances: Inattention
or Hyperactivity/Impulsivity
(Problem Level)
Children with inattention or
hyperactivity/impulsivity at the
problem level, as well as their
families, may also benefit from the
chronic illness and medical home
principles.
Recommendations for the Treatment
of Children and Adolescents With
ADHD: KAS 5a, 5b, and 5c
Recommendations vary depending on
the patient’s age and are presented
for the following age ranges:
a. preschool-aged children: age
4 years to the sixth birthday;
b. elementary and middle
school–aged children: age 6 years
to the 12th birthday; and
c. adolescents: age 12 years to the
18th birthday.
The KASs are presented, followed by
information on medication,
psychosocial treatments, and special
circumstances.
KAS 5a
For preschool-aged children (age
4 years to the sixth birthday) with
ADHD, the PCC should prescribe
evidence-based behavioral PTBM
and/or behavioral classroom
interventions as the first line of
treatment, if available (grade A:
strong recommendation).
Methylphenidate may be considered
if these behavioral interventions do
not provide significant improvement
and there is moderate-to-severe
continued disturbance in the 4-
through 5-year-old child’s
functioning. In areas in which
evidence-based behavioral
treatments are not available, the
clinician needs to weigh the risks of
starting medication before the age of
6 years against the harm of delaying
treatment (Table 6). (Grade B: strong
recommendation.)
A number of special circumstances
support the recommendation to
initiate PTBM as the first treatment
of preschool-aged children (age
4 years to the sixth birthday) with
ADHD.25,83 Although it was limited to
children who had moderate-to-
severe dysfunction, the largest
multisite study of methylphenidate
use in preschool-aged children
revealed symptom improvements
after PTBM alone.83 The overall
evidence for PTBM among
preschoolers is strong.
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. One
evidence-based PTBM, parent-child
interaction therapy, is a dyadic
therapy for parent and child. The
PoCA contains criteria for the
clinician’s use to assess the quality of
PTBM programs. If the child attends
preschool, behavioral classroom
interventions are also recommended.
In addition, preschool programs (such
as Head Start) and ADHD-focused
organizations (such as CHADD84) can
also provide behavioral supports. The
issues related to referral, payment,
and communication are discussed in
the section on systemic barriers in
the Supplemental Information.

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents 13

TABLE 6 KAS 5a: For preschool-aged children (age 4 years to the sixth birthday) with ADHD, the PCC should prescribe evidence-based behavioral PTBM
and/or behavioral classroom interventions as the first line of treatment, if available (grade A: strong recommendation). Methylphenidate may be
considered if these behavioral interventions do not provide significant improvement and there is moderate-to-severe continued disturbance in
the 4- through 5-year-old child’s functioning. In areas in which evidence-based behavioral treatments are not available, the clinician needs to
weigh the risks of starting medication before the age of 6 years against the harm of delaying treatment (grade B: strong recommendation).
Aggregate evidence Grade A for PTBM; Grade B for methylphenidate
quality
Benefits Given the risks of untreated ADHD, the benefits outweigh the risks.
Risks, harm, cost Both therapies increase the cost of care; PTBM requires a high level of family involvement, whereas methylphenidate has some
potential adverse effects.
Benefit-harm Both PTBM and methylphenidate have relatively low risks; initiating treatment at an early age, before children experience repeated
assessment failure, has additional benefits. Thus, the benefits outweigh the risks.
Intentional vagueness None.
Role of patient Family preference is essential in determining the treatment plan.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Greenhill et al83; Evans et al25

In areas in which evidence-based
behavioral treatments are not
available, the clinician needs to
weigh the risks of starting
methylphenidate before the age
of 6 years against the harm of
delaying diagnosis and treatment.
Other stimulant or nonstimulant
medications have not been
adequately studied in children in
this age group with ADHD.
KAS 5b
For elementary and middle
school–aged children (age 6 years to
the 12th birthday) with ADHD, the
PCC should prescribe US Food and
Drug Administration (FDA)–approved
medications for ADHD, along with
PTBM and/or behavioral classroom
intervention (preferably both PTBM
and behavioral classroom interven-
tions). Educational interventions
and individualized instructional
supports, including school environment,
class placement, instructional
placement, and behavioral supports,
are a necessary part of any
treatment plan and often include an
Individualized Education Program
(IEP) or a rehabilitation plan (504
plan) (Table 7). (Grade A: strong
recommendation for medications;
grade A: strong recommendation for
PTBM training and behavioral
treatments for ADHD implemented
with the family and school.)
The evidence is particularly strong for
stimulant medications; it is sufficient,
but not as strong, for atomoxetine,
extended-release guanfacine, and
extended-release clonidine, in that
order (see the Treatment section, and
see the PoCA for more information on
implementation).
KAS 5c
For adolescents (age 12 years to the
18th birthday) with ADHD, the PCC
should prescribe FDA-approved
medications for ADHD with the
adolescent’s assent (grade A: strong
recommendation). The PCC is
encouraged to prescribe evidence-
based training interventions and/or
behavioral interventions as treatment
of ADHD, if available. Educational
interventions and individualized
instructional supports, including
school environment, class
placement, instructional placement,
and behavioral supports, are
a necessary part of any treatment
plan and often include an IEP or
a rehabilitation plan (504 plan)
(Table 8). (Grade A: strong
recommendation.)
Transition to adult care is an
important component of the chronic
care model for ADHD. Planning for
the transition to adult care is an
ongoing process that may culminate
after high school or, perhaps, after
college. To foster a smooth transition,
it is best to introduce components at
the start of high school, at about
14 years of age, and specifically focus
during the 2 years preceding high
school completion.
Psychosocial Treatments
Some psychosocial treatments for
children and adolescents with ADHD
have been demonstrated to be
effective for the treatment of ADHD,
including behavioral therapy and
training interventions.24–26,85 The
diversity of interventions and
outcome measures makes it
challenging to assess a meta-analysis
of psychosocial treatment’s effects
alone or in association with
medication treatment. As with
medication treatment, the long-term
positive effects of psychosocial
treatments have yet to be determined.
Nonetheless, ongoing adherence
to psychosocial treatment is
a key contributor to its beneficial
effects, making implementation of
a chronic care model for child health
important to ensure sustained
adherence.86
Behavioral therapy involves training
adults to influence the contingencies
in an environment to improve the
behavior of a child or adolescent in
that setting. It can help parents and
school personnel learn how to
effectively prevent and respond to
adolescent behaviors such as

PEDIATRICS Volume 144, number 4, October 2019 11

14 Section 1: Attention-Deficit/Hyperactivity Disorder

TABLE 7 KAS 5b: For elementary and middle school–aged children (age 6 years to the 12th birthday) with ADHD, the PCC should prescribe US Food and
Drug Administration (FDA)–approved medications for ADHD, along with PTBM and/or behavioral classroom intervention (preferably both PTBM
and behavioral classroom interventions). Educational interventions and individualized instructional supports, including school environment,
class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include an
Individualized Education Program (IEP) or a rehabilitation plan (504 plan). (Grade A: strong recommendation for medications; grade A: strong
recommendation for PTBM training and behavioral treatments for ADHD implemented with the family and school.)
Aggregate evidence Grade A for Treatment with FDA-Approved Medications; Grade A for Training and Behavioral Treatments for ADHD With the Family and
quality School.
Benefits Both behavioral therapy and FDA-approved medications have been shown to reduce behaviors associated with ADHD and to improve
function.
Risks, harm, cost Both therapies increase the cost of care. Psychosocial therapy requires a high level of family and/or school involvement and may lead
to increased family conflict, especially if treatment is not successfully completed. FDA-approved medications may have some
adverse effects and discontinuation of medication is common among adolescents.
Benefit-harm Given the risks of untreated ADHD, the benefits outweigh the risks.
assessment
Intentional vagueness None.
Role of patient Family preference, including patient preference, is essential in determining the treatment plan and enhancing adherence.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Evans et al25; Barbaresi et al73; Jain et al103; Brown and Bishop104; Kambeitz et al105; Bruxel et al106; Kieling et al107; Froehlich et al108;
Joensen et al109

interrupting, aggression, not
completing tasks, and not complying
with requests. Behavioral parent and
classroom training are well-
established treatments with
preadolescent children.25,87,88 Most
studies comparing behavior therapy
to stimulants indicate that stimulants
have a stronger immediate effect on
the 18 core symptoms of ADHD.
Parents, however, were more satisfied
with the effect of behavioral therapy,
which addresses symptoms and
functions in addition to ADHD’s core
symptoms. The positive effects of
behavioral therapies tend to persist,
but the positive effects of medication
cease when medication stops.
Optimal care is likely to occur when
both therapies are used, but the
decision about therapies is heavily
dependent on acceptability by, and
feasibility for, the family.
Training interventions target skill
development and involve repeated
practice with performance feedback
over time, rather than modifying
behavioral contingencies in a specific
setting. Less research has been
conducted on training interventions
compared to behavioral treatments;
nonetheless, training interventions
are well-established treatments to
target disorganization of materials
and time that are exhibited by
most youth with ADHD; it is likely
that they will benefit younger
children, as well.25,89 Some training
interventions, including social
skills training, have not been shown
to be effective for children with
ADHD.25

TABLE 8 KAS 5c: For adolescents (age 12 years to the 18th birthday) with ADHD, the PCC should prescribe FDA-approved medications for ADHD with the
adolescent’s assent (grade A: strong recommendation). The PCC is encouraged to prescribe evidence-based training interventions and/or
behavioral interventions as treatment of ADHD, if available. Educational interventions and individualized instructional supports, including school
environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include
an IEP or a rehabilitation plan (504 plan). (Grade A: strong recommendation.)
Aggregate evidence Grade A for Medications; Grade A for Training and Behavioral Therapy
quality
Benefits Training interventions, behavioral therapy, and FDA-approved medications have been demonstrated to reduce behaviors associated
with ADHD and to improve function.
Risks, harm, cost Both therapies increase the cost of care. Psychosocial therapy requires a high level of family and/or school involvement and may lead
to unintended increased family conflict, especially if treatment is not successfully completed. FDA-approved medications may have
some adverse effects, and discontinuation of medication is common among adolescents.
Benefit-harm Given the risks of untreated ADHD, the benefits outweigh the risks.
assessment
Intentional vagueness None.
Role of patient Family preference, including patient preference, is likely to predict engagement and persistence with a treatment.
preferences
Exclusions None.
Strength Strong recommendation.
Key references Evans et al25; Webster-Stratton et al87; Evans et al95; Fabiano et al93; Sibley and Graziano et al94; Langberg et al96; Schultz et al97; Brown
and Bishop104; Kambeitz et al105; Bruxel et al106; Froehlich et al108; Joensen et al109

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
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 suggestion that
cannabidiol oil has any effect on ADHD
is anecdotal and has not been
subjected to rigorous study. Although
it is FDA approved, the efficacy for
external trigeminal nerve stimulation
(eTNS) is documented by one 5-week
randomized controlled trial with just
30 participants receiving eTNS.90 To
date, there is no long-term safety and
efficacy evidence for eTNS. Overall, the
current evidence supporting
treatment of ADHD with eTNS is
sparse and in no way approaches the
robust strength of evidence
documented for established
medication and behavioral treatments
for ADHD; therefore, it cannot be
recommended as a treatment of ADHD
without considerably more extensive
study on its efficacy and safety.
Special Circumstances: Adolescents
Much less research has been
published on psychosocial treatments
with adolescents than with younger
children. PTBM has been modified to
include the parents and adolescents
in sessions together to develop
a behavioral contract and improve
parent-adolescent communication
and problem-solving (see above).91
Some training programs also include
motivational interviewing
approaches. The evidence for this
behavioral family approach is mixed
and less strong than PTBM with pre-
adolescent children.92–94 Adolescents’
responses to behavioral contingencies
are more varied than those of
younger children because they can
often effectively obstruct behavioral
contracts, increasing parent-
adolescent conflict.
Training approaches that are focused
on school functioning skills have
consistently revealed benefits for
PEDIATRICS Volume 144, number 4, October 2019
adolescents.95–97 The greatest
benefits from training interventions
occur when treatment is continued
over an extended period of time,
performance feedback is constructive
and frequent, and the target
behaviors are directly applicable to
the adolescent’s daily functioning.
Overall, behavioral family approaches
may be helpful to some adolescents
and their families, and school-based
training interventions are well
established.25,94 Meaningful
improvements in functioning have
not been reported from cognitive
behavioral approaches.
Medication for ADHD
Preschool-aged children may
experience increased mood lability
and dysphoria with stimulant
medications.83 None of the
nonstimulants have FDA approval for
use in preschool-aged children. For
elementary school–aged students, the
evidence is particularly strong for
stimulant medications and is
sufficient, but less strong, for
atomoxetine, extended-release
guanfacine, and extended-release
clonidine (in that order). The effect
size for stimulants is 1.0 and for
nonstimulants is 0.7. An individual’s
response to methylphenidate verses
amphetamine is idiosyncratic, with
approximately 40% responding to
both and about 40% responding to
only 1. The subtype of ADHD does not
appear to be a predictor of response
to a specific agent. For most
adolescents, stimulant medications
are highly effective in reducing
ADHD’s core symptoms.73
Stimulant medications have an effect
size of around 1.0 (effect size =
[treatment M 2 control M)/control
SD]) for the treatment of ADHD.98
Among nonstimulant medications, 1
selective norepinephrine reuptake
inhibitor, atomoxetine,99,100 and 2
selective a-2 adrenergic agonists,
extended-release guanfacine101,102
and extended-release clonidine,103
have also demonstrated efficacy in
15
reducing core symptoms among
school-aged children and adolescents,
although their effect sizes, —around
0.7 for all 3, are less robust than that
of stimulant medications.
Norepinephrine reuptake inhibitors
and a-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.
A free list of the currently available,
FDA-approved medications for ADHD
is available online at www.
ADHDMedicationGuide.com. Each
medication’s characteristics are
provided to help guide the clinician’s
prescription choice. With the
expanded list of medications, it is less
likely that PCCs need to consider the
off-label use of other medications.
The section on systemic barriers in
the Supplemental Information
provides suggestions for fostering
more realistic and effective payment
and communication systems.
Because of the large variability in
patients’ response to ADHD
medication, there is great interest in
pharmacogenetic tools that can help
clinicians predict the best medication
and dose for each child or adolescent.
At this time, however, the available
scientific literature does not provide
sufficient evidence to support their
clinical utility given that the genetic
variants assayed by these tools have
generally not been fully studied with
respect to medication effects on
ADHD-related symptoms and/or
impairment, study findings are
inconsistent, or effect sizes are not of
sufficient size to ensure clinical
utility.104–109 For that reason, these
pharmacogenetics tools are not
recommended. In addition, these tests
may cost thousands of dollars and are
typically not covered by insurance.
For a pharmacogenetics tool to be
recommended for clinical use, studies
would need to reveal (1) the genetic
variants assayed have consistent,
replicated associations with
13
16
medication response; (2) knowledge
about a patient’s genetic profile
would change clinical decision-
making, improve outcomes and/or
reduce costs or burden; and (3) the
acceptability of the test’s operating
characteristics has been
demonstrated (eg, sensitivity,
specificity, and reliability).
Side Effects
Stimulants’ most common short-term
adverse effects are appetite loss,
abdominal pain, headaches, and
sleep disturbance. The Multimodal
Treatment of Attention Deficit
Hyperactivity Disorder (MTA) study
results identified stimulants as having
a more persistent effect on decreasing
growth velocity compared to most
previous studies.110 Diminished
growth was in the range of 1 to 2 cm
from predicted adult height. The
results of the MTA study were
particularly noted among children
who were on higher and more
consistently administered doses of
stimulants.110 The effects diminished
by the third year of treatment, but no
compensatory rebound growth was
observed.110 An uncommon significant
adverse effect of stimulants is the
occurrence of hallucinations and other
psychotic symptoms.111
Stimulant medications, on average,
increase patient heart rate (HR) and
blood pressure (BP) to a mild and
clinically insignificant degree (average
increases: 1–2 beats per minute for HR
and 1–4 mm Hg for systolic and
diastolic BP).112 However, because
stimulants have been linked to more
substantial increases in HR and BP in
a subset of individuals (5%–15%),
clinicians are encouraged to monitor
these vital signs in patients receiving
stimulant treatment.112 Although
concerns have been raised about
sudden cardiac death among children
and adolescents using stimulant and
medications,113 it is an extremely rare
occurrence. In fact, stimulant
medications have not been shown to
increase the risk of sudden death
14
Section 1: Attention-Deficit/Hyperactivity Disorder
beyond that observed in children who
are not receiving stimulants.114–118
Nevertheless, before initiating therapy
with stimulant medications, it is
important to obtain the child or
adolescent’s history of specific cardiac
symptoms in addition to the family
history of sudden death,
cardiovascular symptoms, Wolff-
Parkinson-White syndrome,
hypertrophic cardiomyopathy, and
long QT syndrome. If any of these risk
factors are present, clinicians should
obtain additional evaluation to
ascertain and address potential safety
concerns of stimulant medication use
by the child or adolescent.112,114
Among nonstimulants, the risk of
serious cardiovascular events is
extremely low, as it is for stimulants.
The 3 nonstimulant medications that
are FDA approved to treat ADHD (ie,
atomoxetine, guanfacine, and
clonidine) may be associated with
changes in cardiovascular parameters
or other serious cardiovascular events.
These events could include increased
HR and BP for atomoxetine and
decreased HR and BP for guanfacine
and clonidine. Clinicians are
recommended to not only obtain the
personal and family cardiac history, as
detailed above, but also to perform
additional evaluation if risk factors are
present before starting nonstimulant
medications (ie, perform an
electrocardiogram [ECG] and possibly
refer to a pediatric cardiologist if the
ECG is not normal).112
Additional adverse effects of
atomoxetine include initial
somnolence and gastrointestinal tract
symptoms, particularly if the dosage is
increased too rapidly, and decreased
appetite.119–122 Less commonly, an
increase in suicidal thoughts has been
found; this is noted by an FDA black
box warning. Extremely rarely,
hepatitis has been associated with
atomoxetine. Atomoxetine has also
been linked to growth delays
compared to expected trajectories in
the first 1 to 2 years of treatment, with
a return to expected measurements
after 2 to 3 years of treatment, on
average. Decreases were observed
among those who were taller or
heavier than average before
treatment.123
For extended-release guanfacine and
extended-release clonidine, adverse
effects include somnolence, dry
mouth, dizziness, irritability,
headache, bradycardia, hypotension,
and abdominal pain.30,124,125 Because
rebound hypertension after abrupt
guanfacine and clonidine
discontinuation has been
observed,126 these medications
should be tapered off rather than
suddenly discontinued.
Adjunctive Therapy
Adjunctive therapies may be
considered if stimulant therapy is not
fully effective or limited by side
effects. Only extended-release
guanfacine and extended-release
clonidine have evidence supporting
their use as adjunctive therapy with
stimulant medications sufficient to
have achieved FDA approval.127 Other
medications have been used in
combination on an off-label basis,
with some limited evidence available
to support the efficacy and safety of
using atomoxetine in combination
with stimulant medications to
augment treatment of ADHD.128
Special Circumstances: Preschool-Aged
Children (Age 4 Years to the Sixth
Birthday)
If children do not experience
adequate symptom improvement
with PTBM, medication can be
prescribed for those with moderate-
to-severe ADHD. Many young children
with ADHD may require medication
to achieve maximum improvement;
methylphenidate is the recommended
first-line pharmacologic treatment of
preschool children because of the lack
of sufficient rigorous study in the
preschool-aged population for
nonstimulant ADHD medications and
dextroamphetamine. Although
amphetamine is the only medication
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
with FDA approval for use in children
younger than 6 years, this authorization
was issued at a time when approval
criteria were less stringent than current
requirements. Hence, the available
evidence regarding dextroampheta-
mine’s use in preschool-aged children
with ADHD is not adequate to
recommend it as an initial ADHD
medication treatment at this time.80
No nonstimulant medication has
received sufficient rigorous study in
the preschool-aged population to be
recommended for treatment of ADHD
of children 4 through 5 years of age.
Although methylphenidate is the
ADHD medication with the strongest
evidence for safety and efficacy in
preschool-aged children, it should be
noted that the evidence has not yet
met the level needed for FDA
approval. Evidence for the use of
methylphenidate consists of 1
multisite study of 165 children83 and
10 other smaller, single-site studies
ranging from 11 to 59 children, for
a total of 269 children.129 Seven of the
10 single-site studies revealed efficacy
for methylphenidate in preschoolers.
Therefore, although there is moderate
evidence that methylphenidate is safe
and effective in preschool-aged
children, its use in this age group
remains on an “off-label” basis.
With these caveats in mind, before
initiating treatment with medication,
the clinician should assess the severity
of the child’s ADHD. Given current
data, only preschool-aged children
with ADHD and moderate-to-severe
dysfunction should be considered for
medication. Severity criteria are
symptoms that have persisted for at
least 9 months; dysfunction that is
manifested in both home and other
settings, such as preschool or child
care; and dysfunction that has not
responded adequately to PTBM.83
The decision to consider initiating
medication at this age depends, in
part, on the clinician’s assessment
of the estimated developmental
impairment, safety risks, and potential
PEDIATRICS Volume 144, number 4, October 2019
consequences if medications are not
initiated. Other considerations affecting
the treatment of preschool-aged
children with stimulant medications
include the lack of information and
experience about their longer-term
effects on growth and brain
development, as well as the potential
for other adverse effects in this
population. It may be helpful to obtain
consultation from a mental health
specialist with specific experience with
preschool-aged children, if possible.
Evidence suggests that the rate of
metabolizing methylphenidate is
slower in children 4 through 5 years of
age, so they should be given a low dose
to start; the dose can be increased in
smaller increments. Maximum doses
have not been adequately studied in
preschool-aged children.83
Special Circumstances: Adolescents
(Age 12 Years to the 18th Birthday)
As noted, before beginning
medication treatment of adolescents
with newly diagnosed ADHD,
clinicians should assess the patient
for symptoms of substance use. If
active substance use is identified, the
clinician should refer the patient to
a subspecialist for consultative
support and guidance.2,1302134
In addition, diversion of ADHD
medication (ie, its use for something
other than its intended medical
purposes) is a special concern among
adolescents.135 Clinicians should
monitor the adolescent’s symptoms and
prescription refill requests for signs of
misuse or diversion of ADHD
medication, including by parents,
classmates, or other acquaintances of
the adolescent. The majority of states
now require prescriber participation in
prescription drug monitoring programs,
which can be helpful in identifying and
preventing diversion activities. They
may consider prescribing nonstimulant
medications that minimize abuse
potential, such as atomoxetine and
extended-release guanfacine or
extended-release clonidine.
17
Given the risks of driving for
adolescents with ADHD, including
crashes and motor vehicle violations,
special concern should be taken to
provide medication coverage for
symptom control while
driving.79,136,137 Longer-acting or late-
afternoon, short-acting medications
may be helpful in this regard.138
Special Circumstances: Inattention
or Hyperactivity/Impulsivity (Problem
Level)
Medication is not appropriate for
children whose symptoms do not
meet DSM-5 criteria for ADHD.
Psychosocial treatments may be
appropriate for these children and
adolescents. As noted, psychosocial
treatments do not require a specific
diagnosis of ADHD, and many of the
studies on the efficacy of PTBM
included children who did not have
a specific psychiatric or ADHD
diagnosis.
Combination Treatments
Studies indicate that behavioral
therapy has positive effects when it is
combined with medication for pre-
adolescent children.139 (The
combined effects of training
interventions and medication have
not been studied.)
In the MTA study, researchers found
that although the combination of
behavioral therapy and stimulant
medication was not significantly more
effective than treatment with
medication alone for ADHD’s core
symptoms, after correcting for
multiple tests in the primary
analysis,139 a secondary analysis of
a combined measure of parent and
teacher ratings of ADHD symptoms
did find a significant advantage for
the combination, with a small effect of
d = 0.28.140 The combined treatment
also offered greater improvements on
academic and conduct measures,
compared to medication alone, when
the ADHD was comorbid with anxiety
and the child or adolescent lived in
a lower socioeconomic environment.
15
18 Section 1: Attention-Deficit/Hyperactivity Disorder

In addition, parents and teachers of
children who received combined
therapy reported that they were
significantly more satisfied with the
treatment plan. Finally, the combination
of medication management and
behavioral therapy allowed for the use
of lower stimulant dosages, possibly
reducing the risk of adverse effects.141
School Programming and Supports
Encouraging strong family-school
partnerships helps the ADHD
management process.142 Psychosocial
treatments that include coordinating
efforts at school and home may
enhance the effects.
Children and adolescents with ADHD
may be eligible for services as part of
a 504 Rehabilitation Act Plan (504
plan) or special education IEP under
the “other health impairment”
designation in the Individuals with
Disability Education Act (IDEA).143
(ADHD qualifies as a disability under
a 504 plan. It does not qualify under
an IEP unless its severity impairs the
child’s ability to learn. See the PoCA
for more details.) It is helpful for
clinicians to be aware of the eligibility
criteria in their states and school
districts to advise families of their
options. Eligibility decisions can vary
considerably between school
districts, and school professionals’
independent determinations might
not agree with the recommendations
of outside clinicians.
There are essentially 2 categories of
school-based services for students
with ADHD. The first category
includes interventions that are
intended to help the student
independently meet age-appropriate
academic and behavioral
expectations. Examples of these
interventions include daily report
cards, training interventions, point
systems, and academic remediation of
skills. If successful, the student’s
impairment will resolve, and the
student will no longer need services.
The second category is intended to
provide changes in the student’s
program so his or her ADHD-related
problems no longer result in failure and
cause distress to parents, teachers, and
the student.144 These services are
referred to as “accommodations” and
include extended time to complete tests
and assignments, reduced homework
demands, the ability to keep study
materials in class, and provision of the
teacher’s notes to the student. These
services are intended to allow the
student to accomplish his work
successfully and communicate that the
student’s impairment is acceptable.
Accommodations make the student’s
impairment acceptable and are separate
from interventions aimed at improving
the students’ skills or behaviors. In the
absence of such interventions, long-
term accommodations may lead to
reduced expectations and can lead to
the need for accommodations to be
maintained throughout the student’s
education.
Encouraging strong family-school
partnerships helps the ADHD
management process, and addressing
social determinants of health is
essential to these partnerships.145,146
Psychosocial treatments that include
coordinating efforts at school and
home may enhance the effects.
KAS 6
The PCC should titrate doses of
medication for ADHD to achieve
maximum benefit with tolerable side
effects (Table 9). (Grade B: strong
recommendation.)
The MTA study is the landmark study
comparing effects of methylphenidate
and behavioral treatments in children
with ADHD. Investigators compared
treatment effects in 4 groups of
children who received optimal
medication management, optimal
behavioral management, combined
medication and behavioral
management, or community treatment.
Children in the optimal medication
management and combined medication
and behavioral management groups
underwent a systematic trial with 4
different doses of methylphenidate, with
results suggesting that when this full
range of doses is administered, more
than 70% of children and adolescents
with ADHD are methylphenidate
responders.140
Authors of other reports suggest that
more than 90% of patients will have
a beneficial response to 1 of the
psychostimulants if a range of
medications from both the
methylphenidate and amphetamine
and/or dextroamphetamine classes

TABLE 9 KAS 6: The PCC should titrate doses of medication for ADHD to achieve maximum benefit with tolerable side effects. (Grade B: strong
recommendation.)
Aggregate evidence Grade B
quality
Benefits The optimal dose of medication is required to reduce core symptoms to, or close to, the levels of children without ADHD.
Risks, harm, cost Higher levels of medication increase the chances of side effects.
Benefit-harm The importance of adequately treating ADHD outweighs the risk of adverse effects.
assessment
Intentional vagueness None.
Role of patient The families’ preferences and comfort need to be taken into consideration in developing a titration plan, as they are likely to predict
preferences engagement and persistence with a treatment.
Exclusions None
Strength Strong recommendation
Key references Jensen et al140; Solanto147; Brinkman et al149

16 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
are tried.147 Of note, children in the
MTA study who received care in the
community as usual, either from
a clinician they chose or to whom
their family had access, showed less
beneficial results compared with
children who received optimal
medication management. The
explanation offered by the study
investigators was that the community
treatment group received lower
medication doses and less frequent
monitoring than the optimal
medication management group.
A child’s response to stimulants is
variable and unpredictable. For this
reason, it is recommended to titrate
from a low dose to one that achieves
a maximum, optimal effect in controlling
symptoms without adverse effects.
Calculating the dose on the basis of
milligrams per kilogram has not usually
been helpful because variations in dose
have not been found to be related to
height or weight. In addition, because
stimulant medication effects are seen
rapidly, titration can be accomplished in
a relatively short time period. Stimulant
medications can be effectively titrated
on a 7-day basis, but in urgent
situations, they may be effectively
titrated in as few as 3 days.140
Parent and child and adolescent
education is an important component
in the chronic illness model to ensure
cooperation in efforts to achieve
appropriate titration, remembering
that the parents themselves may be
significantly challenged by
ADHD.148,149 The PCC should alert
parents and children that changing
medication dose and occasionally
changing a medication may be
necessary for optimal medication
management, may require a few
months to achieve optimal success,
and that medication efficacy should
be monitored at regular intervals.
By the 3-year (ie, 36-month) follow-up
to the MTA interventions, there were
no differences among the 4 groups (ie,
optimal medications management,
optimal behavioral management,
PEDIATRICS Volume 144, number 4, October 2019
a combination of medication and
behavioral management, and
community treatment). This
equivalence in poststudy outcomes
may, however, have been attributable
to convergence in ongoing treatments
received for the 4 groups. After the
initial 14-month intervention, the
children no longer received the careful
monthly monitoring provided by the
study and went back to receiving care
from their community providers;
therefore, they all effectively received
a level of ongoing care consistent with
the “community treatment” study arm
of the study. After leaving the MTA
trial, medications and doses varied for
the children who had been in the
optimal medication management or
combined medication and behavioral
management groups, and a number
stopped taking ADHD medication. On
the other hand, some children who
had been in the optimal behavioral
management group started taking
medication after leaving the trial. The
results further emphasize the need to
treat ADHD as a chronic illness and
provide continuity of care and, where
possible, provide a medical home.140
See the PoCA for more on
implementation of this KAS.
KAS 7
The PCC, if trained or experienced in
diagnosing comorbid conditions, may
initiate treatment of such conditions
or make a referral to an appropriate
subspecialist for treatment. After
detecting possible comorbid
conditions, if the PCC is not trained or
experienced in making the diagnosis
or initiating treatment, the patient
should be referred to an appropriate
subspecialist to make the diagnosis
and initiate treatment (Table 10).
(Grade C: recommendation.)
The effect of comorbid conditions on
ADHD treatment is variable. In some
cases, treatment of the ADHD may
resolve the comorbid condition. For
example, treatment of ADHD may
lead to improvement in coexisting
aggression and/or oppositional
19
defiant, depressive, or anxiety
symptoms.150,151
Sometimes, however, the comorbid
condition may require treatment in
addition to the ADHD treatment. If the
PCC is confident of his or her ability to
diagnose and treat certain comorbid
conditions, the PCC may do so. The
PCC may benefit from additional
consultative support and guidance
from a mental health subspecialist or
may need to refer a child with ADHD
and comorbid conditions, such as
severe mood or anxiety disorders, to
subspecialists for assessment and
management. The subspecialists could
include child and adolescent
psychiatrists, clinical child
psychologists, developmental-
behavioral pediatricians,
neurodevelopmental disability
physicians, child neurologists, or
child- or school-based evaluation
teams.
IMPLEMENTATION: PREPARING THE
PRACTICE
It is generally the role of the primary
care pediatrician to manage mild-to-
moderate ADHD, anxiety, depression,
and substance use. The AAP
statement “The Future of Pediatrics:
Mental Health Competencies for
Pediatric Primary Care” describes the
competencies needed in both
pediatric primary and specialty care
to address the social-emotional and
mental health needs of children and
families.152 Broadly, these include
incorporating mental health content
and tools into health promotion,
prevention, and primary care
intervention, becoming
knowledgeable about use of
evidence-based treatments, and
participating as a team member and
comanaging with pediatric and
mental health specialists.
The recommendations made in this
guideline are intended to be integrated
with the broader mental health
algorithm developed as part of the AAP
Mental Health Initiatives.2,133,153
Pediatricians have unique opportunities
17
20 Section 1: Attention-Deficit/Hyperactivity Disorder

TABLE 10 KAS 7: The PCC, if trained or experienced in diagnosing comorbid conditions, may initiate treatment of such conditions or make a referral to an
appropriate subspecialist for treatment. After detecting possible comorbid conditions, if the PCC is not trained or experienced in making the
diagnosis or initiating treatment, the patient should be referred to an appropriate subspecialist to make the diagnosis and initiate treatment.
(Grade C: recommendation.)
Aggregate evidence Grade C
quality
Benefits Clinicians are most effective when they know the limits of their practice to diagnose comorbid conditions and are aware of resources
in their community.
Risks, harm, cost Under-identification or inappropriate identification of comorbidities can lead to inadequate or inappropriate treatments.
Benefit-harm The importance of adequately identifying and addressing comorbidities outweighs the risk of inappropriate referrals or treatments.
assessment
Intentional vagueness None.
Role of patient The families’ preferences and comfort need to be taken into consideration in identifying and treating or referring their patients with
preferences comorbidities, as they are likely to predict engagement and persistence with a treatment.
Exclusions None.
Strength Recommendation.
Key references Pliszka et al150; Pringsheim et al151

to identify conditions, including ADHD,
intervene early, and partner with both
families and specialists for the benefit
of children’s health. A wealth of useful
information is available at the AAP
Mental Health Initiatives Web site
(https://www.aap.org/en-us/advocacy-
and-policy/aap-health-initiatives/
Mental-Health/Pages/Tips-For-
Pediatricians.aspx).
It is also important for PCCs to be
aware of health disparities and social
determinants that may impact patient
outcomes and strive to provide
culturally appropriate care to all
children and adolescents in their
practice.145,146,154,155
The accompanying PoCA provides
supplemental information to support
PCCs as they implement this
guideline’s recommendations. In
particular, the PoCA describes steps
for preparing the practice that provide
useful recommendations to clinicians.
For example, the PoCA includes
information about using standardized
rating scales to diagnose ADHD,
assessing for comorbid conditions,
documenting all aspects of the
diagnostic and treatment procedures
in the patient’s records, monitoring
the patient’s treatment and outcomes,
and providing families with written
management plans.
The AAP acknowledges that some
PCCs may not have the training,
experience, or resources to diagnose
and treat children and adolescents
with ADHD, especially if severity or
comorbid conditions make these
patients complex to manage. In these
situations, comanagement with
specialty clinicians is recommended.
The SDBP is developing a guideline to
address such complex cases and aid
pediatricians and other PCCs to
manage these cases; the SDBP
currently expects to publish this
document in 2019.67
AREAS FOR FUTURE RESEARCH
There is a need to conduct research
on topics pertinent to the diagnosis
and treatment of ADHD,
developmental variations, and
problems in children and adolescents
in primary care. These research
opportunities include the following:
• assessment of ADHD and its
common comorbidities: anxiety,
depression, learning disabilities,
and autism spectrum disorder;
• identification and/or development
of reliable instruments suitable for
use in primary care to assess the
nature or degree of functional
impairment in children and
adolescents with ADHD and to
monitor improvement over time;
• refinement of developmentally
informed assessment procedures
for evaluating ADHD in
preschoolers;
• study of medications and other
therapies used clinically but not
FDA approved for ADHD;
• determination of the optimal
schedule for monitoring children
and adolescents with ADHD,
including factors for adjusting
that schedule according to age,
symptom severity, and progress
reports;
• evaluation of the effectiveness and
adverse effects of medications used
in combination, such as a stimulant
with an a-adrenergic agent,
selective serotonin reuptake
inhibitor, or atomoxetine;
• evaluation of processes of care to
assist PCCs to identify and treat
comorbid conditions;
• evaluation of the effectiveness of
various school-based interventions;
• comparisons of medication use
and effectiveness in different
ages, including both harms and
benefits;
• development of methods to involve
parents, children, and adolescents
in their own care and improve
adherence to both psychosocial and
medication treatments;
• conducting research into
psychosocial treatments, such as
cognitive behavioral therapy and
cognitive training, among others;

18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
• development of standardized and
documented tools to help primary
care providers identify comorbid
conditions;
• development of effective electronic
and Web-based systems to help
gather information to diagnose and
monitor children and adolescents
with ADHD;
• improvements to systems for
communicating with schools,
mental health professionals, and
other community agencies to
provide effective collaborative care;
• development of more objective
measures of performance to more
objectively monitor aspects of
severity, disability, or impairment;
• assessment of long-term outcomes
for children in whom ADHD was
first diagnosed at preschool ages;
and
• identification and implementation
of ideas to address the barriers
that hamper the implementation
of these guidelines and the
PoCA.
CONCLUSIONS
Evidence is clear with regard to the
legitimacy of the diagnosis of ADHD
and the appropriate diagnostic
criteria and procedures required to
ABBREVIATIONS
AAP: American Academy of Pediatrics
ADHD: attention-deficit/
hyperactivity disorder
ADHD/C: attention-deficit/
hyperactivity disorder
combined presentation
ADHD/HI: attention-deficit/
hyperactivity disorder
primarily of the
hyperactive-impulsive
presentation
ADHD/I: attention-deficit/
hyperactivity disorder
primarily of the
inattentive presentation
PEDIATRICS Volume 144, number 4, October 2019
establish a diagnosis, identify
comorbid conditions, and effectively
treat with both psychosocial and
pharmacologic interventions. The
steps required to sustain appropriate
treatments and achieve successful
long-term outcomes remain
challenging, however.
As noted, this clinical practice
guideline is supported by 2
accompanying documents available in
the Supplemental Information: the
PoCA and the article on systemic
barriers to the car of children and
adolescents with ADHD. Full
implementation of the guideline’s
KASs, the PoCA, and the
recommendations to address barriers
to care may require changes in office
procedures and the identification of
community resources. Fully
addressing systemic barriers requires
identifying local, state, and national
entities with which to partner to
advance solutions and manifest
change.156
SUBCOMMITTEE ON CHILDREN AND
ADOLESCENTS WITH ADHD (OVERSIGHT BY
THE COUNCIL ON QUALITY IMPROVEMENT
AND PATIENT SAFETY)
Mark L. Wolraich, MD, FAAP, Chairperson,
Section on Developmental Behavioral
Pediatrics
AHRQ: Agency for Healthcare
Research and Quality
BP: blood pressure
CHADD: Children and Adults with
Attention-Deficit/
Hyperactivity Disorder
DSM-5: Diagnostic and Statistical
Manual of Mental Disorders,
Fifth Edition DSM-IV:
Diagnostic and Statistical Manual of
Mental Disorders Fourth Edition
DSM-PC: Diagnostic and Statistical
Manual for Primary Care
ECG: electrocardiogram
eTNS: external trigeminal nerve
stimulation
21
Joseph F. Hagan Jr, MD, FAAP, Vice
Chairperson, Section on Developmental
Behavioral Pediatrics
Carla Allan, PhD, Society of Pediatric
Psychology
Eugenia Chan, MD, MPH, FAAP,
Implementation Scientist
Dale Davison, MSpEd, PCC, Parent Advocate,
Children and Adolescents with Attention-
Deficit/Hyperactivity Disorder
Marian Earls, MD, MTS, FAAP, Mental Health
Leadership Work Group
Steven W. Evans, PhD, Clinical Psychologist
Tanya Froehlich, MD, FAAP, Section on
Developmental Behavioral Pediatrics/Society
for Developmental and Behavioral Pediatrics
Jennifer Frost, MD, FAAFP, American
Academy of Family Physicians
Joseph R. Holbrook, PhD, MPH,
Epidemiologist, Centers for Disease Control
and Prevention
Herschel Robert Lessin, MD, FAAP, Section
on Administration and Practice Management
Karen L. Pierce, MD, DFAACAP, American
Academy of Child and Adolescent Psychiatry
Christoph Ulrich Lehmann, MD, FAAP,
Partnership for Policy Implementation
Jonathan D. Winner, MD, FAAP, Committee
on Practice and Ambulatory Medicine
William Zurhellen, MD, FAAP, Section on
Administration and Practice Management
STAFF
Kymika Okechukwu, MPA, Senior Manager,
Evidence-Based Medicine Initiatives
Jeremiah Salmon, MPH, Program Manager,
Policy Dissemination and Implementation
CONSULTANT
Susan K. Flinn, MA, Medical Editor
FDA: US Food and Drug
Administration
HR: heart rate
IDEA: Individuals with Disability
Education Act
IEP: Individualized Education
Program
KAS: key action statement
MTA: The Multimodal Treatment
of Attention Deficit
Hyperactivity Disorder
PCC: primary care clinician
PoCA: process of care algorithm
PTBM: parent training in behavior
management
SDBP: Society for Developmental
and Behavioral Pediatrics
19
22 Section 1: Attention-Deficit/Hyperactivity Disorder

v
American Academy of Pediatrics, Itasca, Illinois; wAmerican Academy of Child and Adolescent Psychiatry, Washington, District of Columbia; xFeinberg School of
Medicine, Northwestern University, Chicago, Illinois; yAtlanta, Georgia; and zHolderness, New Hampshire
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual
circumstances, may be appropriate.
All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or
before that time.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and
Prevention. Dr Holbrook was not an author of the accompanying supplemental section on barriers to care.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements
with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
DOI: https://doi.org/10.1542/peds.2019-2528
Address correspondence to Mark L. Wolraich, MD, FAAP. Email: mark-wolraich@ouhsc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved
through a process approved by the American Academy of Pediatrics board of directors. Dr Allan reports a relationship with ADDitude Magazine; Dr Chan reports
relationships with TriVox Health and Wolters Kluwer; Dr Lehmann reports relationships with International Medical Informatics Association, Springer Publishing, and
Thieme Publishing Group; Dr Wolraich reports a Continuing Medical Education trainings relationship with the Resource for Advancing Children’s Health Institute; the
other authors have indicated they have no potential conflicts of interest to disclose.

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Supplemental Information
IMPLEMENTING THE KEY ACTION
STATEMENTS OF THE AAP ADHD
CLINICAL PRACTICE GUIDELINES:
AN ALGORITHM AND EXPLANATION
FOR PROCESS OF CARE FOR THE
EVALUATION, DIAGNOSIS, TREATMENT,
AND MONITORING OF ADHD IN
CHILDREN AND ADOLESCENTS
I. INTRODUCTION
Practice guidelines provide a broad
outline of the requirements for high-
quality, evidence-based care. The
AAP “Clinical Practice Guideline:
Diagnosis and Evaluation of the Child
With Attention-Deficit/Hyperactivity
Disorder” provides the evidence-
based processes for caring for
children and adolescents with ADHD
symptoms or diagnosis. This
document supplements that
guideline. It provides a PoCA that
details processes to implement the
guidelines; describes procedures for
the evaluation, treatment, and
monitoring of children and
adolescents with ADHD; and
addresses practical issues related to
the provision of ADHD-related care
within a typical, busy pediatric
practice. The algorithm is entirely
congruent with the guidelines and is
based on the practical experience
and expert advice of clinicians who
are experienced in the diagnosis and
management of children and
adolescents with ADHD. Unlike the
guidelines, this algorithm is based
primarily on expert opinion and has
a less robust evidence base because
of the lack of clinical studies
specifically addressing this approach.
Understanding that providing
appropriate care to children with
PEDIATRICS Volume 144, Number 4, October 2019
Section 1: Attention-Deficit/Hyperactivity Disorder
ADHD in a primary care setting faces
a number of challenges and barriers,
the subcommittee has also provided
an additional article describing
needed changes to address barriers
to care (found in the Supplemental
Information).
In this algorithm, we describe
a continuous process; as such, its
constituent steps are not intended to
be completed in a single office visit
or in a specific number of visits.
Evaluation, treatment, and
monitoring are ongoing processes to
be addressed throughout the child’s
and adolescent’s care within the
practice and in transition planning
as the adolescent moves into the
adult care system. Many factors will
influence the pace of the process,
including the experience of the PCC,
the practice’s volume, the longevity
of the relationship between the PCC
and family, the severity of concerns,
the availability of academic records
and school input, the family’s
schedule, and the payment
structure.
An awareness of the AAP “Primary
Care Approach to Mental Health
Care Algorithm,” which is available
on the AAP Mental Health Initiatives
Web site, will enhance the
integration of the procedures
described in this document (http://
www.aap.org/mentalhealth). That
algorithm describes the process to
integrate an initial psychosocial
assessment at well visits and a brief
mental health update at acute and
chronic care visits. Mental health
concerns, including symptoms of
inattention and impulsivity, may
present when (1) elicited during the
initial psychosocial assessment at
a routine well visit, (2) elicited
during a brief mental health update
at an acute or chronic visit, or (3)
presented during a visit triggered by
a family or school concern.
When concerns are identified, the
algorithm describes the process of
conducting a brief primary care
intervention, secondary screening,
diagnostic assessment, treatment,
and follow-up. Like this document,
the mental health algorithm is
intended to present a process that
may involve more than 1 visit and
may be completed over time.
This algorithm assumes that the
primary care practice has adopted the
initial psychosocial assessment and
mental health update, as described by
the AAP Mental Health Initiatives.153
It begins with steps paralleling the
secondary assessment of the general
mental health algorithm. Both
algorithms focus on the care team
and include the family as a part of
that team.
In light of the prevalence of ADHD,
the severe consequences of untreated
ADHD, and the availability of effective
ADHD treatments, the AAP
recommends that every child and
adolescent identified with signs or
symptoms suggestive of ADHD be
evaluated for ADHD or other
conditions that may share its
symptomatology. Documenting all
aspects of the diagnostic and
treatment procedures in the patient’s
records will improve the ability of the
1
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents 29

SUPPLEMENTAL FIGURE 2
ADHD care algorithm. CYSHCN, children and youth with special health care needs; TFOMH, Task Force on Mental Health.

pediatrician to best treat children assessment for ADHD. This may occur In those instances, the PCC would
with ADHD. in a variety of ways. monitor for emerging issues.

Pediatricians and other PCCs Many parents bring their child or

II. EVALUATION FOR ADHD
II a. A Child or Adolescent Presents
With Signs and Symptoms
Suggesting ADHD
The algorithm’s steps can be
implemented when a child or
adolescent presents to a PCC for an
traditionally have long-standing
relationships with the child and family,
which foster the opportunity to
identify concerns early on. The young
child may have a history of known
ADHD risks, such as having parents
who have been diagnosed with ADHD
or having extremely low birth weight.
adolescent to the PCC with specific
concerns about the child’s or
adolescent’s ability to sustain
attention, curb activity levels, and/or
inhibit impulsivity at home, school, or
in the community. In many instances,
the parents may express concerns
about behaviors and characteristics

2

30
SUPPLEMENTAL FIGURE 3
Evaluate for ADHD. TFOMH, Task Force on Mental Health.
that are associated with ADHD but
may not mention the core ADHD
symptoms. For example, parents may
report that their child is getting poor
grades, does not perform well in team
sports (despite being athletic), has
few friends, or is moody and quick to
anger. These children and adolescents
may have difficulty remaining
organized; planning activities; or
inhibiting their initial thoughts,
actions, or emotions, which are
behaviors that fall under the umbrella
of executive functioning (ie, planning,
prioritizing, and producing) or
cognitive control. Problems with
executive functions may be correlated
with ADHD and are common among
children and adolescents with ADHD.
As recommended by Bright Futures (a
national health promotion and
prevention initiative led by the
AAP157), routine psychosocial
screening at preventive visits may
identify concerns on the part of
parent or another clinician (see below
for more information on co-occurring
conditions.)
Finally, parents may bring a child to
a PCC for ADHD evaluation on the
SUPPLEMENTAL FIGURE 4
Perform a diagnostic evaluation for ADHD and evaluate or screen for comorbid disorders
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Section 1: Attention-Deficit/Hyperactivity Disorder
basis of the recommendation of
a teacher, tutor, coach, etc.
(See the ADHD guideline’s KAS 1.)
II b. Perform a Diagnostic Evaluation
for ADHD and Evaluate or Screen for
Comorbid Disorders
When a child or adolescent presents
with concerns about ADHD, as
described above, the clinician should
initiate an evaluation for ADHD. (See
the ADHD guideline’s KASs 2 and 3.)
II c. Gather Information From the
Family
As noted previously, the
recommendations in the
accompanying guideline are intended
to be integrated with the broader
mental health algorithm developed as
part of the AAP Mental Health
Initiatives.2,133,153 It is also important
for pediatricians and other PCCs to be
aware of health disparities and social
determinants that may affect patient
outcomes and to provide culturally
appropriate care to all children and
adolescents in their practice,
including during the initial evaluation
and assessment of the patient’s
condition.145,146,154,155,158
Ideally, the PCC’s office staff obtains
information from the family about the
visit’s purpose at scheduling so that
an extended visit or multiple visits
can be made available for the initial
ADHD evaluation. This also increases
the efficiency of an initial evaluation.
Data on the child’s or adolescent’s
symptoms and functioning can be
gathered from parents, school
personnel, and other sources before
the visit. Parents can be given rating
scales that are to be completed before
the visit by teachers, coaches, and
others who interact with the child.
This strategy allows the PCC to focus
on the most pertinent issues for that
child or adolescent and family at the
time of the visit. (See later discussion
for more information on rating
scales.) Note that schools will not
release data to pediatric providers
without written parental consent.
During the office evaluation session,
the PCC reviews the patient’s medical,
family, and psychosocial history.
Developmental history is presumed
to be part of the patient’s medical
3
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
history. Family members (including
parents, guardians, and other frequent
caregivers) are asked to identify their
chief concerns and provide a history of
the onset, frequency, and duration of
problem behaviors, situations that
increase or decrease the problems,
previous treatments and their results,
and the caregivers’ understanding of
the issues. It is important to assess
behaviors and conditions that are
frequent side effects of stimulant
medication (ie, sleep difficulties, tics,
nail-biting, skin-picking, headaches,
stomachaches, or afternoon
irritability) and preexisting conditions,
so they are not confused with the
frequent side effects of stimulants.
This enables the PCC to compare
changes if medication is initiated later.
A sound assessment of symptoms and
functioning in major areas can be
used to construct an educational and
behavioral profile that includes the
child’s strengths and talents. Many
children with ADHD exhibit
enthusiasm, exuberance, creativity,
flexibility, the ability to detect and
quickly respond to subtle changes in
the environment, a sense of humor,
a desire to please, etc. The most
common areas of functioning affected
by ADHD include academic
achievement; relationships with
peers, parents, siblings, and adult
authority figures; participation in
recreational activities, such as sports;
and behavior and emotional
regulation, including risky behavior.
The child’s and family’s histories can
provide information about the status
of symptoms and functioning and
help determine age of onset and other
factors that may be associated with
the presenting problems. It also
identifies any potential traumatic
events that the child may have
experienced, such as a family death,
separation from the family, or
physical or mental abuse.
The child or adolescent’s medical
history can help identify factors
associated with ADHD, such as
4
prenatal and perinatal complications
and exposures (eg, preterm delivery,
maternal hypertension, prenatal
alcohol exposure), childhood
exposures, and head trauma.
The family history includes any
medical syndromes, developmental
delays, cognitive limitations, learning
disabilities, trauma or toxic stress, or
mental illness in the patient and
family members, including ADHD,
mood, anxiety, and bipolar disorders.
Ask what the family has already tried,
what works, and what does not work
to avoid wasting time on
interventions that have already been
attempted unsuccessfully. Parental
tobacco and substance use, including
their use prenatally, are relevant risk
factors for, and correlate with,
ADHD.159 ADHD is highly heritable
and is often seen in other family
members who may or may not have
been formally diagnosed with ADHD.
For this reason, asking about family
members’ school experience,
including time and task management,
grades, and highest grade level
achieved, can aid in treatment
decisions.
The psychosocial history is important
in any ADHD evaluation and usually
includes queries about environmental
factors, such as family stress and
problematic relationships, which
sometime contribute to the child or
adolescent’s overall functioning. The
caregivers’ current and past
approaches to parenting and the
child’s misbehavior can provide
important information that may
explain discrepancies between
reporters. For example, parents may
reduce their expectations for their
child with ADHD as a means to relieve
parenting stress. When these
expectations are reduced (eg,
eliminating chores, not monitoring
homework completion, etc), parents
may experience far fewer problems
with the child than do teachers who
may have maintained expectations for
the child to complete tasks and follow
rules. Knowing the parents’ approach
31
to parenting may help the PCC
understand differences in ratings
completed by parents versus
teachers.
Further evidence for an ADHD
diagnosis includes an inability to
independently complete daily
routines in an age-appropriate
manner as well as multiple and short-
lasting friendships, trouble keeping
and/or making friends, staying up
late to complete assignments, and
late, incomplete, and/or lost
assignments. Somatic symptoms and
school avoidance are more common
among girls and may mask an ADHD
diagnosis. With information obtained
from the parents and school
personnel, the PCC can make a clinical
judgment about the effect of the core
and associated ADHD symptoms on
academic achievement, classroom
performance, family and social
relationships, independent
functioning, and safety and/or
unintentional injuries.
If other issues exist, such as self-
injuries, comorbid mental health
issues also need to be evaluated.
Possible areas of functional
impairment that require evaluation
include domains such as self-
perception, leisure activities, and
self-care (ie, bathing, toileting,
dressing, and eating). Additional
guidance regarding functional
assessment is available through the
AAP ADHD Toolkit2 and the AAP
Mental Health Initiatives.133,160 The
ADHD Toolkit2 is being revised
concurrently with the development of
these updated guidelines. After
publication, the toolkit may be
accessed at https://www.aap.org/en-
us/professional-resources/quality-
improvement/Pages/Quality-
Improvement-Implementation-Guide.
aspx. Additionally, a new Education in
Quality Improvement for Pediatric
Practice Module was developed on
the basis of the new clinical
recommendations and can also be
accessed by using the same
link above.

32
The patient needs to be screened for
hearing and/or visual problems
because these can mimic inattention.
A full review of systems may reveal
other symptoms or disorders, such as
sleep disturbances, absence seizures,
or tic disorders, which may assist in
formulating a differential diagnosis
and/or developing management
plans. Internal feelings such as
anxiety and depression can occur but
may not be noticeable to parents and
teachers, so it is important to elicit
feedback about them from the patient
as well.
The information gathered from this
diagnostic interview, combined with
the data from the rating scales (see
below), provides an excellent
foundation for determining the
presence of symptoms and
impairment criteria needed to
diagnose ADHD.
II d. Use Parent Rating Scales and
Other Tools
Rating scales that use the DSM-5
criteria for ADHD can help obtain the
information that will contribute to
making a diagnosis. Rating scales for
parents that use DSM-5 criteria for
ADHD are helpful in obtaining the
core symptoms required to make
a diagnosis on the basis of the DSM-
5.161 Because changes in the 18 core
symptoms are essentially unchanged
from DSM-IV criteria, DSM-IV–based
rating scales can be used if DSM-5
rating scales are not readily available.
Some of these symptom rating scales
include symptoms of commonly
comorbid conditions and measures of
impairment in a variety of domains
that are also required for
a diagnosis.41,162 Some available
measures are limited because they
provide only a global rating.163,164
Caregiver and teacher endorsement
of the requisite number of ADHD
symptoms on the rating scales is not
sufficient for diagnosis. A rating scale
documents the presence of
inattention, hyperactivity, and
impulsivity symptoms but not
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Section 1: Attention-Deficit/Hyperactivity Disorder
whether these symptoms are actually
attributable to ADHD versus
a mimicking condition. Caregivers
may misread or misunderstand some
of the behaviors. Furthermore, rating
scales do not inform the PCC about
contextual influences that may
account for the symptoms and
impairment. Likewise, broadband
rating scales that assess general
mental health functioning do not
provide reliable and valid indications
of ADHD diagnoses, although they can
help to screen for concurrent
behavioral conditions.165
Nevertheless, parent ratings provide
valuable information on their
perspective of the child’s symptoms
and impairment and add information
about normative levels of the parents’
perspectives, which help the PCC
determine the degree with which the
problems are or are not in the typical
range for the child’s age and sex.
Finally, broad rating scales that assess
general mental health functioning do
not provide sufficient information
about all the ADHD core symptoms
but may help screen for the
concurrent behavioral conditions.165
To address the rating scales’
limitations, pediatricians and other
PCCs need to interview parents and
may need to review documents such
as report cards and standardized test
results and historical records of
detentions, suspensions, and/or
expulsions from school, which can
serve as evidence of functional
impairment. Further evidence may
include difficulty developing and
maintaining lasting friendships. This
information is discussed below.
II e. Gather Information From School
and Community Informants
Information from parents is not the
only source that informs diagnostic
decisions for children and
adolescents because a key criterion
for an ADHD diagnosis is the display
of symptoms and impairments in
multiple settings. Gathering data from
other adults who regularly interact
with the child or adolescent being
evaluated provides rich additional
information for the evaluation.
The information from various sources
may be inconsistent because parents
and teachers observe the children at
different times and under different
circumstances, as described
previously.166 Disagreement may
result from differences in students’
behavior and performance in
different classrooms, their
relationship with the teachers, or
variations in teachers’ expectations,
as well as training in or experience
with behavior management. Classes
with high homework demands or
classes with less structure are often
the most problematic for students
with ADHD. Investigating these
inconsistencies can lead to
hypotheses about the child that help
inform the eventual clinical diagnoses
and treatment decisions.167
Teachers and Other School Personnel
Teachers and other school personnel
can provide critically important
information because they develop
a rich sense of the typical range of
behaviors within a specific age group
over time. School and classrooms
settings provide the greatest social
and performance expectations that
potentially tax children and
adolescents with ADHD. Parents and
older children may be the best
sources for identifying the school
personnel who can best complete
rating scales for an ADHD evaluation.
The value of school ratings increases
as children age because parents often
have less detailed information about
their child’s behavior and
performance at school as the student
moves into the higher grades. With
elementary and middle school
children, the classroom teacher is
usually the best source; he or she may
be the only source necessary. Other
school staff, such as a special
education teacher or school
counselor, may be valuable sources of
information. Direct communication
5
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
with a school psychologist and/or
school counselor may provide
additional information on the child’s
functioning within the context of the
classroom and school.
In secondary schools, students
interact with many teachers who
often instruct .100 students daily. As
a result, high school teachers may not
know the students as well as
elementary and middle school
teachers do. Parents and students
may be encouraged to choose the 2 or
3 teachers who they believe know the
student best and solicit their input
(eg, math and English teachers or, for
children or adolescents with learning
disabilities, a teacher in an area of
strong function and a teacher in an
area of weak function). Regardless of
the presence of a learning disability, it
is helpful to obtain feedback from the
teacher of the class in which the child
or adolescent is having the most
difficulty. The ADHD Toolkit provides
materials relevant to school data
collection.
Teachers may communicate their
major concerns using questionnaires
or verbally in person, via secure e-mail
(if available), or over the telephone. It
is important to ask an appropriate
school representative to complete
a validated ADHD instrument or
behavior scale based on the DSM-5
criteria for ADHD. A school
representative’s report might include
information about any comorbid or
alternative conditions, including
disruptive behavior disorders,
depression and anxiety disorders, tics,
or learning disabilities. As noted, some
parent rating scales have a version for
teachers and assess symptoms and
impairment in multiple domains.41
Teacher rating scales exist that
specifically target behavior and
performance at school,168 which
provide a comprehensive and detailed
description of a student’s school
functioning relative to normative data.
In addition to the academic
information, it is important to request
6
information characterizing the child
or adolescent’s level of functioning
with regard to peer, teacher, and other
authority figure relationships, ability
to follow directions, organizational
skills, history of classroom disruption,
and assignment completion.
Academic Records
In addition to ratings from teachers
and other school staff, academic
records are sometimes available to
inform a PCC’s evaluation. These
records include report cards; results
from reading, math, and written
expression standardized tests; and
other assessments of academic
competencies. If a child were
referred for an evaluation for special
education services, his or her file is
likely to contain a report on the
evaluation, which can be useful
during an ADHD evaluation. School
records pertaining to office
discipline referrals, suspensions,
absences, and detentions can
provide valuable information about
social function and behavioral
regulation. Parents often keep report
cards from early grades, which can
provide valuable information about
age of onset for children older than
12 years. Teachers in primary
grades often provide information
pertaining to important information
about the history of the presenting
problems.
Other Community Sources
It can be helpful to obtain
information not only from school
professionals but also from
additional sources, such as
grandparents, faith-based
organization group leaders, scouting
leaders, sports coaches, and others.
Depending on the areas in which the
child or adolescent exhibits
impairment, these adults may be
able to provide a valuable
perspective on the nature of the
presenting problems, although the
accuracy of their reporting has not
been studied.
33
II f. Gather Information From the
Child or Adolescent
Another source of information is from
the child or adolescent. This
information is often collected but
carries less weight than information
from other sources because of
children’s and adolescents’ limited
ability to accurately report their
strengths and weaknesses, including
those associated with ADHD.169 As
a result, information gathered from the
child about specific ADHD behaviors
may do little to inform the presence or
absence of symptoms and impairments
because evidence suggests that children
tend to minimize their problems and
blame others for concerns.170
Nevertheless, self-report may provide
other values. First, self-report is the
primary means by which one can
screen for internalizing conditions
such as depression and anxiety. The
AAP Mental Health Initiatives133 and
the Guidelines for Adolescent
Depression in Primary Care171–173
recommend the use of validated
diagnostic rating scales for adolescent
mood and anxiety disorders for
clinicians who wish to use this
format.174–178 As measures of internal
mental disorders, these data are likely
to be more valid than the reports of
adults about their children’s behaviors.
Second, youth with ADHD are prone
to talk impulsively and excessively
when adults show an interest in
them. They may share useful
information about the home or
classroom that parents and teachers
do not know or impart. In addition,
many share their experience with
risky and dangerous behaviors that
may be unknown to the adults in
their lives. This information can be
critical in both determining
a diagnosis and designing treatment.
Third, even if little information of
value is obtained, the fact that the
PCC takes the time to meet alone and
ask questions of the child or
adolescents demonstrates respect
and lays the foundation for

34
collaboration in the decision-making
and treatment process to follow. This
relationship building is particularly
important for adolescents.
Fourth, by gaining an understanding
of the child’s perspective, the PCC can
anticipate the likely acceptance or
resistance to treatment.
Interviewing the child or adolescent
provides many important benefits
beyond the possibility of informing
the diagnosis and warrants its
inclusion in the evaluation. For
example, part of this interview
includes asking the child or
adolescent to identify personal goals
(eg, What do you want to be when
you grow up? What do you think that
requires? How can we help you get
there?). It is helpful when children
perceive the pediatrician and other
PCCs as seeking to help them achieve
their goals rather than arbitrarily
labeling them as deficient, defective,
or needing to be fixed in some way.
II g. Clinical Observations and
Physical Examination of the Child or
Adolescent
The physical and neurologic
examination needs to be
comprehensive to determine if
further medical or developmental
assessments are indicated. Baseline
height, weight, BP, and pulse
measurements are required to be
recorded in the medical record. It is
important to look for behaviors that
are consistent with ADHD’s
symptoms, including the child’s level
of attention, activity, and impulsivity
during the encounter. Yet, ADHD is
context dependent, and for this
reason, behaviors and core symptoms
that are seen in other settings are
often not observed during an office
visit.179 Although the presence of
hyperactivity and inattention during
an office visit may provide supporting
evidence of ADHD symptoms, their
absence is not considered evidence
that the child does not have ADHD.
Observations of a broad range of
behaviors can be important for
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Section 1: Attention-Deficit/Hyperactivity Disorder
considering their contribution to the
presenting problems and the
potential diagnosis of other
conditions. Careful attention to these
various behaviors can provide useful
information when beginning the next
step involving making diagnostic
decisions. For example, hearing and
visual acuity problems can often lead
to inattention and overactivity at
school. Attending to concerns about
anxiety is also important given that
young children may become
overactive when they are in anxiety-
provoking situations like a clinic visit.
In addition, observing the child’s
language skills is important because
difficulties with language can be
a symptom of a language disorder
and predictor of subsequent reading
problems. This observation is
particularly important with young
children given that language
disorders may present as problems
with sustaining attention and
impulsivity. A language disorder may
also involve pragmatic usage or the
social use of language, which can
contribute to social impairment. If the
PCC, family, and/or school have
concerns about receptive, expressive,
or pragmatic language, it is important
to make a referral for a formal speech
and language evaluation. Dysmorphic
features also need to be noted
because symptoms of ADHD are
similar to characteristics of children
with some prenatal exposures and
genetic syndromes (eg, fetal alcohol
exposure,180,181 fragile X syndrome).
Many children with ADHD have poor
coordination, which may be severe
enough to warrant a diagnosis of
developmental coordination disorder
and referral to occupational and/or
physical therapy. Findings of poor
coordination can affect how well the
child performs in competitive sports,
a frequent source of social
interactions for children, and can
adversely affect the child’s writing
skills. Detecting any motor or verbal
tics is important as well, particularly
because the use of stimulant
medications may cause or
exacerbate tics.
Finally, it is important to evaluate the
child’s cardiovascular status because
cardiovascular health must be
considered if ADHD medication
becomes an option. Cardiac illness is
rare, and more evidence is required
to determine if children or
adolescents with ADHD are at
increased risk when taking ADHD
medications. Nevertheless, before
initiating therapy with stimulant
medications, it is important to obtain
the child or adolescent’s history of
specific cardiac symptoms, as well as
the family history of sudden death,
cardiovascular symptoms, Wolff-
Parkinson-White syndrome,
hypertrophic cardiomyopathy, and
long QT syndrome. If any of these risk
factors are present, clinicians should
obtain additional evaluation with an
ECG and possibly consult with
a pediatric cardiologist.
II h. Gather Information About
Conditions That Mimic or Are
Comorbid With ADHD
It is important for the PCC to obtain
information about the status and
history of conditions that may mimic
or are comorbid with ADHD, such as
depression, anxiety disorders, and
posttraumatic stress disorder. Several
validated rating scales are within the
public domain and can help identify
comorbid conditions. Examples
include the Pediatric Symptom
Checklist-17 as a screen for
depression and anxiety182; the Screen
for Child Anxiety Related Emotional
Disorders, more specifically for
anxiety disorders176; the Patient
Health Questionnaire modified for
adolescents; the Screening to Brief
Intervention tool183,184; and the Child
and Adolescent Trauma Screen for
exposure to trauma.185 All include
questionnaire forms for both parents
and patients.2 The results help the
PCC assess the extent to which
reported impairment and/or distress
are associated with ADHD versus
7
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
comorbid conditions. These
conditions are described in greater
detail later.
Safety and Serious Mental Illness
Concerns
PCCs may be asked to complete
mental health or safety assessments,
particularly for adolescents.
Assessment requests may come from
schools or other settings after
a behavioral crisis, aggressive
behavior, or destructive behaviors
have occurred. With patient or
guardian consent, information may be
shared regarding diagnosis and
current treatment strategies.
Pediatricians and other PCCs are
encouraged to exercise caution when
asked to predict the likelihood of
future behaviors in the absence of
detailed understanding of the
environment in which the behaviors
occurred. Self-injurious behaviors or
threats of self-harm are serious
concerns that, when possible, should
immediately be referred to
community mental health crisis
services or experienced child mental
health professionals. PCCs are
encouraged to provide further
monitoring of the child or adolescent
with these comorbidities.
III. MAKING DIAGNOSTIC DECISIONS
After gathering all of the relevant
available information, the PCC will
consider an ADHD diagnosis as well
as a diagnosis of other related and/or
comorbid disorders. The primary
SUPPLEMENTAL FIGURE 5
Making diagnostic decisions.
8
decision-making process involves
comparing the information obtained
to the DSM-5 criteria for ADHD.
Although this assessment is
straightforward, there are some
issues the PCC needs to consider,
including development, sex, and other
disorders that may fit the presenting
problems better than ADHD (see
below for more on these issues).
III a. DSM-5 Criteria for ADHD
The DSM-5 criteria define 4
dimensions of ADHD:
1. ADHD/I (314.00 [F90.0]);
2. ADHD/HI (314.01 [F90.1]);
3. ADHD/C (314.01 [F90.2]); and
4. ADHD other specified and
unspecified ADHD (314.01
[F90.8]).
To make a diagnosis of ADHD, the
PCC needs to establish that 6 or more
(5 or more if the adolescent is
17 years or older) core symptoms are
present in either or both of the
inattention dimension and/or the
hyperactivity-impulsivity dimension
and occur inappropriately often. The
core symptoms and dimensions are
presented in Supplemental Table 2.
• ADHD/I: having at least 6 of 9
inattention behaviors and less than
6 hyperactive-impulsive behaviors;
• ADHD/HI: having at least 6 of 9
hyperactive-impulsive behaviors
and less than 6 inattention
behaviors;
• ADHD/C: having at least 6 of 9
behaviors in both the inattention
and hyperactive-impulsive
dimensions; and
• ADHD other specified and
unspecified ADHD: These
categories are meant for children
who meet many of the criteria for
ADHD, but not the full criteria, and
who have significant impairment.
“ADHD other specified” is used if
the PCC specifies those criteria that
have not been met; “unspecified
ADHD” is used if the PCC does not
specify these criteria.
35
In school-aged children and
adolescents, diagnostic criteria for
ADHD include documentation of the
following criteria:
• At least 6 of the 9 behaviors
described in the inattentive domain
occur often, and to a degree, that is
inconsistent with the child’s
developmental age. (For
adolescents 17 years and older,
documentation of at least 5 of the 9
behaviors is required.)
• At least 6 of the 9 behaviors
described in the hyperactive-
impulsive domain occur often, and
to a degree, that is inconsistent
with the child’s developmental age.
(For adolescents 17 years and
older, documentation of at least 5 of
the 9 behaviors is required.)
• Several inattentive or hyperactive-
impulsive symptoms were present
before age 12 years.
• There is clear evidence that the
child’s symptoms interfere with or
reduce the quality of his or her
social, academic, and/or
occupational functioning.
• The symptoms have persisted for at
least 6 months.
• The symptoms are not attributable
to another physical, situational, or
mental health condition.
Clear evidence exists that these
criteria are appropriate for
preschool-aged children (ie, age
4 years to the sixth birthday),
elementary and middle school-aged
children (ie, age 6 years to the 12th
birthday), and adolescents (ie, age
12 years to the 18th birthday).30,31
DSM-5 criteria have also been
updated to better describe how
inattentive and hyperactive-impulsive
symptoms present in older
adolescents and adults.
DSM-5 criteria require evidence of
symptoms before age 12 years. In
some cases, however, parents and
teachers may not recognize ADHD
symptoms until the child is older than
12 years, when school tasks and

36
responsibilities become more
challenging and exceed the child’s
ability to perform effectively in
school. For these children, history can
often identify an earlier age of onset
of some ADHD symptoms. Delayed
recognition may also be seen more
often in ADHD/I, which is more
commonly diagnosed in girls.
If symptoms arise suddenly without
previous history, the PCC needs to
consider other conditions, including
mood or anxiety disorders, substance
use, head trauma, physical or sexual
abuse, neurodegenerative disorders,
sleep disorders (including sleep
apnea), or a major psychological stress
in the family or school (such as
bullying). In adolescents and young
adults, PCCs are encouraged to
consider the potential for false
reporting and misrepresentation of
symptoms to obtain medications for
other than appropriate medicinal use
(ie, diversion, secondary gain). The
majority of states now require
prescriber participation in prescription
drug monitoring programs, which can
be helpful in identifying and
preventing diversion activities.
Pediatricians and other PCCs may
consider prescribing nonstimulant
medications that minimize abuse
potential, such as atomoxetine and
extended-release guanfacine or
extended-release clonidine.
In the absence of other concerns and
findings on prenatal or medical
history, further diagnostic testing will
not help to reach an ADHD diagnosis.
Compared to clinical interviews,
standardized psychological tests, such
as computerized attention tests, have
not been found to reliably
differentiate between youth with and
without ADHD.187,188 Appropriate
further assessment is indicated if an
underlying etiology is suspected.
Imaging studies or screening for high
lead levels and abnormal thyroid
hormone levels can be pursued if they
are suggested by other historic or
physical information, such as history
or symptoms of a tumor or significant
PEDIATRICS Volume 144, Number 4, October 2019
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Section 1: Attention-Deficit/Hyperactivity Disorder
brain injury. When children
experience trauma, their evaluation
needs to include the consideration of
both the trauma and ADHD because
they can co-occur and can exacerbate
ADHD symptoms. Toxic stress has
shown to be associated with the
incidence of pediatric ADHD, but the
conclusion that ADHD is
a manifestation of this stress has not
been demonstrated.188
Patients with ADHD commonly have
comorbid conditions, such as
oppositional defiant disorder, anxiety,
depression, and language and
learning disabilities. These conditions
may present with ADHD symptoms
and need evaluation because their
treatment may relieve symptoms.
Additionally, some conditions may
present with ADHD symptoms and
respond to treatment of the primary
condition, such as sleep disorders,
absence seizures, and
hyperthyroidism. (Comorbid
conditions are discussed later in this
document.)
In addition, the behavioral
characteristics specified in the DSM-5
remain subjective and may be
interpreted differently by various
observers. Rates of ADHD and its
treatment have been found to be
different for different racial and/or
ethnic groups.50,189 Cultural norms
and the expectations of parents or
teachers may influence reporting of
symptoms. Hence, the clinician
benefits from being sensitive to
cultural differences about the
appropriateness of behaviors and
perceptions of mental health
conditions.145,155
After the diagnostic evaluation, a PCC
will be able to answer the following
questions:
• How many inattentive and
hyperactive/impulsive behavior
criteria for ADHD does the child or
adolescent manifest across major
settings of his or her life?
• Have these criteria been present for
6 months or longer?
• Was the onset of these or similar
behaviors present before the child’s
12th birthday?
• What functional impairments are
caused by these behaviors?
• Could any other condition be
a better explanation for the
behaviors?
• Is there evidence of comorbid
problems or disorders?
On the basis of this information, the
clinician is usually able to arrive at
a preliminary diagnosis of whether
the child or adolescents has ADHD or
not. (For children and adolescents
who do not receive an ADHD
diagnosis, see below.)
III b. Developmental Considerations
Considerations About the Child or
Adolescent’s Age
Although the diagnostic criteria for
ADHD are the same for children up to
age 17 years, developmental
considerations affect the
interpretation of whether a symptom
is present. Before school age, the
primary set of distinguishing
symptoms involve hyperactivity,
although this can be difficult to
identify as outside of the normal
range given the large variability in
this young age group. Similarly,
difficulties sustaining attention are
difficult to determine with young
children because of considerable
variability in presentation and the
limited demands for children in this
age group to sustain attention over
time. (See below for more
information on developmental
delays.)
Some children demonstrate
hyperactivity and inattention that are
clearly beyond the normal range.
They may experience substantial
impairment to an extent that baby-
sitters or child care agencies refuse to
care for them, parents are unable to
take them shopping or to restaurants,
or they routinely engage in dangerous
or risky behaviors. In these extreme
cases, the PCC may be able to make
9
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents
the decision for an ADHD diagnosis
more quickly than other scenarios
that require a thorough assessment.
For other young children, the
diagnosis will be less obvious, and
developmental and environmental
issues may lead the PCC to be
cautious in making an ADHD
diagnosis. In these situations,
monitoring for the emergence or
clarification of ADHD symptoms and/
or providing a diagnosis of other
specified ADHD or unspecified ADHD
are appropriate options.
Adolescence is another
developmental period when
developmental considerations are
warranted. Beginning at age 17 years,
there are only 5 symptoms of
inattention and/or 5 symptoms of
hyperactivity/impulsivity required
for an ADHD diagnosis. Hyperactivity
typically diminishes for most children
during adolescence, but problems
associated with impulsivity can be
dangerous and can include impaired
driving, substance use, risky sexual
behavior, and suicide. Disorganization
of time and resources can be
associated with substantial academic
problems at school. Parent-child
conflict and disengagement from
school can provide a context that
contributes toward poor long-term
outcomes. Comorbid depression and
conduct disorder are common but do
not negate the importance of
diagnosing ADHD when the
developmental path warrants it and
the ADHD symptoms exacerbate
problems associated with the
comorbid conditions.
Adolescence is the first
developmental period for which age
of onset of symptoms must be
documented before 12 years. School
records and parent reports are often
the richest source for making this
determination. It is important to try
to identify adolescents (or their
parents) who are pursuing
a diagnosis of ADHD for secondary
gains such as school accommodations,
standardized testing
10
accommodations, and/or stimulant
prescriptions. In addition,
impairment sometimes emerges
when expectations for the adolescent
markedly increase or when
accommodations are removed. The
teenager’s level of functioning may
stay the same, but when faced with
the expectations of advanced
placement courses or a part-time job,
failure to keep pace with increasing
expectations may lead to concerns
that warrant an evaluation for ADHD.
These examples emphasize the
importance of determining an early
age of onset.
Considerations About the Child or
Adolescent’s Sex
ADHD is diagnosed in boys about
twice as often as it is diagnosed in
girls. There are many hypotheses
about reasons for this difference; the
primary reason appears to simply be
that the disorder is more common in
boys than girls. Some have raised
concerns that the difference may be
attributable to variances in society’s
expectations for boys versus girls or
underdiagnosis in girls, but these
reasons are unlikely to account for
the large difference in diagnoses.
Hence, no adjustment is needed in
terms of the standards for girls to
meet the criteria for an ADHD
diagnosis compared with boys.
Girls are less likely to exhibit
hyperactivity symptoms, which are
the most easily observable of all
ADHD symptoms, particularly in
younger patients. This fact may
account for a portion of the difference
in diagnosis between girls and boys.
As a result, it is important to fully
consider a diagnosis of ADHD,
predominantly inattentive
presentation, when evaluating girls.
Symptoms of inattention alone can
complicate the diagnosis because
inattention is 1 of the most common
symptoms across all disorders in the
DSM-5. After puberty, it is more
common for depression and anxiety
to be diagnosed in girls than in boys,
37
and symptoms of inattention may be
a result of these disorders as well as
ADHD. Examining the age of onset
and considering other distinguishing
features, such as avoidance and
anhedonia, can help the PCC clarify
this challenging differential when
evaluating girls for ADHD. For
example, does the inattention occur
primarily in anxiety-provoking
situations or when the child or
adolescent is experiencing periods of
low mood and then remit when the
anxiety or mood improves?
III c. Consideration of Comorbid
Conditions
If other disorders are suspected or
detected during the diagnostic
evaluation, an assessment of the
urgency of these conditions and their
impact on the ADHD treatment plan
should be made. Comorbid conditions
provide unique challenges for
treatment planning. Urgent
conditions need to be addressed
immediately with services capable of
handling crisis situations. These
conditions include suicidal thoughts
or acts and other behaviors with the
potential to severely injure the child,
adolescent, and/or other people,
including severe temper outbursts or
child abuse. Note that adolescents are
potentially more likely to provide
honest answers if the PCC asks
sensitive questions in the absence of
the parents and may respond more
readily to rating scales that assess
mood or anxiety. In addition,
substance use disorders require
immediate attention and may precede
or coincide with beginning treatment
of ADHD. Additional information is
available in the complex ADHD
guideline published by the SDBP.67
Evidence shows that comorbid
conditions may improve with
treatment of ADHD, including
oppositional behaviors and
anxiety.140 For example, children with
ADHD and comorbid anxiety
disorders may find that addressing
the ADHD symptoms with
38
SUPPLEMENTAL FIGURE 6
Consideration of comorbid conditions. TFOMH, Task Force on Mental Health.
medications also decreases anxiety or
mood symptoms. Other children may
require additional therapeutic
treatments to treat the ADHD
adequately and treat comorbid
conditions, including cognitive
behavioral therapy (CBT), academic
interventions, or different and/or
additional medications.
The PCC may evaluate and treat the
comorbid disorder if it is within his or
her training and expertise. In
addition, the PCC can provide
education to the family and child or
adolescent about triggers for
inattention and/or hyperactivity. If
the PCC requires the advice of
a subspecialist, the clinician is
encouraged to consider carefully
when to initiate treatment of ADHD.
In some cases, it may be advisable to
delay the start of medication until the
role of each member of the treatment
team is established (see below).
Integrated care models can be helpful
(see www.integratedcareforkids.org).
The following are brief discussions of
sleep disorders, psychiatric disorders,
PEDIATRICS Volume 144, Number 4, October 2019
FROM THE AMERICAN
Section
emotion dysregulation, exposure to
trauma, and learning disabilities, all
of which can manifest in manners
similar to ADHD and can complicate
making a diagnosis.
(See the ADHD guideline’s KAS 3.)
Sleep Disorders
Sleepiness impairs most people’s
ability to sustain attention and often
leads to caffeine consumption to
counter these effects. In the same
way, sleep disturbance can lead to
symptoms and impairment that
mimic or exacerbate ADHD
symptoms. A child with ADHD may
have difficulty falling asleep because
of the busy thoughts caused by ADHD.
Some sleep disorders are frequently
associated with ADHD or present as
symptoms of inattention,
hyperactivity, and impulsivity, such as
obstructive sleep apnea syndrome
and restless legs syndrome and/or
periodic limb movement disorder
(RLS/PLMD).190–193
The differential diagnosis of insomnia
in children and adolescents with
ADHD includes the following:
ACADEMY
1: Attention-Defi OF PEDIATRICS
cit/Hyperactivity Disorder
• inadequate sleep hygiene (eg,
inconsistent bedtimes and wake
times, absence of a bedtime
routine, electronics in the bedroom,
caffeine use)194;
• ADHD medication (stimulant and
nonstimulant) effects:
o direct effects on sleep
architecture: prolonged sleep
onset, latency, and decreased
sleep duration, increased night
wakings195–197; and
o indirect effects: inadequate
control of ADHD symptoms in
the evening and medication
withdrawal or rebound
symptoms198,199;
• sleep problems associated with
comorbid psychiatric conditions
(eg, anxiety and mood disorders,
disruptive behavior disorders)200;
• circadian-based phase delay in
sleep-wake patterns, which have
been shown to occur in some
children with ADHD, resulting in
both prolonged sleep onset and
difficulty waking in the
morning201; and
11
Another random document with
no related content on Scribd:
 PRIMER SEMICORO
Ya no hay duda, amigos, ya no hay duda alguna; pero roguemos a
los dioses, cuyo poder es grande.
SEGUNDO SEMICORO
¡Oh rey Peán!,[335] que encuentres algún alivio a los males de
Admeto; concédelo, concédelo, ya que antes de ahora lo hallaste, y la
librarás de la muerte y ahuyentarás al mortífero Hades.
PRIMER SEMICORO
¡Hola, hola, oh, oh, hijo de Feres!; ¡qué desdicha es la tuya de
perder a tu esposa!
SEGUNDO SEMICORO
¿No merece esto el suicidio, y aun algo más que suspender e
cuello de elevado lazo?
PRIMER SEMICORO
No a una mujer querida, sino a la más querida verás muerta hoy.
SEGUNDO SEMICORO
Mira, mira cómo ella y su esposo salen del palacio. ¡Oh, clama!
¡Oh, gime, tierra ferea, que la mejor de las esposas, devorada por la
enfermedad, descenderá al infernal subterráneo de Hades!...
EL CORO
Nunca dejaré de negar que las nupcias traen más placer que dolor
y así lo infiero de lo que nos dice la tradición, y de esta desdicha de
rey, quien, después de perder a su esposa, la mejor de todas, no
podrá vivir una vida tolerable. (Llega Alcestis, sostenida por sus
esclavas, con Admeto y sus hijos).
ALCESTIS
¡Sol y luz del día, aéreos torbellinos de ligeras nubes!
ADMETO
A ti y a mí nos ven; a dos desdichados que para morir en nada
pecaron contra los dioses.
ALCESTIS
 ¡Oh tierra y techos de estos atrios, y nupciales tálamos de Yolco, m
patria!
ADMETO
Ten ánimo, ¡oh desventurada!; no me abandones, sino ruega a los
dioses poderosos que de ti se apiaden.
ALCESTIS (mirando fijamente, como fuera de sí).
Veo, veo una lancha de dos remos; Caronte,[336] el barquero de los
muertos, teniendo en sus manos el garfio, me llama ya. «¿Por qué
vacilas? Date prisa; tú sola me detienes». Con estas palabras me
insta.
ADMETO
¡Ay de mí!, ¡qué amarga navegación me has recordado! ¡Oh
desventurada!, ¡qué horribles desdichas sufrimos!
ALCESTIS
Alguien, alguien me lleva (¿no lo ves?) a la mansión de los muertos
¿Qué haces? ¡Suéltame! ¡Qué peregrinación emprendo, ay mísera!
ADMETO
Triste para los que te aman, y aún más triste para mí y para tus
hijos, que te llorarán conmigo.
ALCESTIS (volviendo en sí).
Soltadme, soltadme; recostadme, que ya no puedo sostenerme. La
muerte se acerca, y noche tenebrosa envuelve mis ojos. ¡Oh hijos
hijos, ya no, ya no tenéis madre! ¡Adiós, hijos, y que veáis esta luz
(Se desmaya).
ADMETO
¡Ay de mí! Oigo esta triste palabra, peor para mí que el último
suplicio. No, por los dioses; no me abandones, no, por tus hijos, que
dejarás huérfanos; levántate, reanímate; si tú mueres moriré también
Tú eres para mí todo, viva yo o no viva: solo a tu amor rindo culto
(Cae a sus pies y apoya la cabeza en su regazo).
ALCESTIS (abriendo los ojos y fijándolos en Admeto).
 ¡Oh Admeto!, (ves en qué estado me hallo), quiero hablarte antes
de morir. Dejo la vida probándote mi respetuoso amor, y consiento en
que veas esta luz al precio de ella, y cuando en vez de esto podría
casarme con el tesalio que quisiera, y habitar en palacio de reyes, no
deseo vivir sin ti con hijos huérfanos de padre, ni me apiadé de m
poseyendo gracias juveniles que me prometían largo deleite. Pero tu
padre y tu madre te hicieron traición, aun cuando por su edad bien
podían haber muerto con decoro, y salvado a su hijo y alcanzado
gloria. Tú eras el único fruto de su himeneo, y faltando no tenían
esperanza de engendrar otros. Y ambos hubiésemos vivido y no
gemirías huérfano de tu esposa, ni educarías a hijos huérfanos
también. Pero algún dios ha dispuesto que así suceda: sea, pues
Concédeme una gracia teniendo presente que yo nunca te pediré
demasiado, si la vida vale tanto, y será justo lo que te suplique; tú
mismo lo conocerás si eres prudente, como creo, y amas a estos hijos
no menos que yo: sean ellos los señores en mi palacio y no les des
madrastra, que, como ha de ser peor que yo, por celos maltratará a
tus hijos y a los míos. Ruégote, pues, que no te cases segunda vez
La madrastra, que sucede a la esposa, es enemiga de los frutos de
anterior matrimonio, y no más piadosa que una víbora. Y el varón tiene
en su padre gran defensa (porque le habla y con él se entiende); pero
tú, ¡oh hija mía!, ¿cómo te educarán mientras seas virgen para vivi
honestamente, cual la esposa de tu padre? Torpe fama puede
mancharte con su hálito, y en la flor de tu juventud desbaratar tus
bodas. No será tu madre la que te lleve al altar del himeneo, ni te
infundirá valor con su presencia en los dolores del parto, ¡oh hija!
porque nadie es tan cariñoso como una madre. Pero debo morir, y no
mañana o el día tercero de este mes,[337] sino que dentro de muy poco
me contarán entre los muertos. Reíd alegres, que tú, ¡oh esposo!
puedes vanagloriarte de haber poseído la mejor de las mujeres, y
vosotros, hijos, la mejor de las madres.[338]
EL CORO
Ten confianza; no temo hablar por él; hará cuanto deseas si no
pierde la razón.
ADMETO
 Se hará, se hará lo que ruegas; no temas, que si yo te poseí viva
después que mueras tú sola serás llamada esposa mía, y ninguna otra
tesalia ocupará tu lugar, que no hay quien te iguale ni en nobleza ni en
belleza. A los dioses pido que me dejen gozar de la compañía de mis
hijos, que de la tuya no he disfrutado como quería. No llevaré tu luto
un año, sino mientras durare mi vida, ¡oh esposa!, y odiaré a mi madre
y rechazaré a mi padre, que me amaban en apariencia, no en realidad
tú me has salvado dando tu existencia por la mía. ¿Y no he de gemi
perdiendo tal compañera? Se acabarán los banquetes, no vendrán ya
mis comensales, y desaparecerán para siempre las coronas y los
cánticos que llenaban mi palacio; jamás tocaré la lira, ni cantaré al son
de la flauta libia, que contigo se van todos mis placeres. Tu imagen
obra de hábil artista, será colocada en mi tálamo, y me prosternaré
ante ella, y la ceñirán mis brazos invocando tu nombre muchas voces
y se me figurará, aunque no sea cierto, que estrecho a mi esposa
amada; frío deleite según creo, pero suficiente, no obstante, para
aliviar el peso que me oprime. En mis sueños te aparecerás y me
llenarás de gozo, que es grato ver de noche a los que amamos en
cualquier ocasión que se presenten. Si yo tuviese el estro y la voz de
Orfeo para aplacar con mis versos a la hija de Deméter o a su esposo
descendería al infierno y te sacaría de él sin temer al perro de Hades
ni al barquero que, apoyado en sus remos, transporta a las almas
hasta que te restituyese a la luz. Espérame allí, pues, cuando muera, y
prepara la morada en donde vivirás conmigo. Una misma caja de
cedro nos encerrará a ambos, y uno junto a otro descansarán nuestros
cuerpos, que ni muerto me separaré de ti, ya que tú sola me has sido
fiel.
EL CORO
Y yo llevaré contigo triste luto, como un amigo por otro, por esta
reina que tanto lo merece.
ALCESTIS
¡Oh hijos, ya habéis oído a vuestro padre, que me ha prometido no
casarse jamás en daño vuestro, ni olvidarse de mí!
ADMETO
Y ahora lo ratifico, y así lo haré.
 ALCESTIS
Bajo esta condición recibe mis hijos de mi mano. (Pone en las de
Admeto las mano de sus hijos).
ADMETO
Los acepto, caro presente de una mano también cara.
ALCESTIS
Que seas tú en mi lugar la madre de estos niños.
ADMETO
Y mucho lo necesitan, huérfanos de ti.
ALCESTIS
¡Oh hijos! ¡Cuando convenía que yo viviera, desciendo a los
infiernos!
ADMETO
¡Ay de mí! ¿Qué haré, pues, sin ti?
ALCESTIS
El tiempo mitigará tu pena: el muerto nada es.
ADMETO
Llévame contigo, por los dioses, llévame allá abajo.
ALCESTIS
Basta conmigo, que muero por ti.
ADMETO
¡Oh destino! ¡Qué esposa me arrebatas!
ALCESTIS
En tinieblas mis ojos ya me pesan.
ADMETO
Yo también muero si me dejas, ¡oh mujer!
ALCESTIS
Ya puedes decir que he muerto, y que nada soy.
 ADMETO
Alza el rostro; no abandones a tus hijos.
ALCESTIS
Contra mi voluntad lo hago: adiós, hijos.
ADMETO
Míralos, míralos.
ALCESTIS
Nada soy ya.
ADMETO
¿Qué haces? ¿Nos abandonas?
ALCESTIS
Adiós.
ADMETO
Yo muero, desventurado de mí. (Déjase caer Admeto en el seno de
Alcestis).
EL CORO
Ya expiró, ya no existe la esposa de Admeto.
EUMELO
¡Ay de mí! ¡Cuánta es mi desdicha! Ya mi madre bajó a los
infiernos; ya no respira, ¡oh padre!, debajo del sol, sino que
abandonándome infortunada, me deja huérfano. Mira, mira sus
párpados y sus manos inertes. Escucha, oye, madre, yo te lo ruego
Yo te llamo, yo, madre, tu tierno hijo; yo te llamo besando tus labios.
ADMETO
Ya ni oye ni ve: grave calamidad nos ha herido a todos.
EUMELO
Tan joven, ¡oh padre!, me veo abandonado, y me deja solo m
madre. ¡Oh qué tristes penas sufro! Y tú, mi tierna hermana...[339
también te afliges... ¡Oh padre!, en vano, en vano tomaste esposa, y
no has llegado a la vejez en su compañía, que ha muerto antes
contigo, ¡oh madre!, perece también tu familia.
EL CORO
Preciso es, ¡oh Admeto!, que soportes con valor esta desventura: tú
no eres ni el primero ni el último de los mortales que pierde una buena
esposa; recuerda, pues, que necesariamente todos hemos de morir.
ADMETO
Lo sé, y este mal no ha sobrevenido de repente; pero por lo mismo
que me era conocido, atormentábame hacía tiempo. Ea, pues
celebremos con pompa sus exequias: quedaos aquí, y relevándoos
unos a otros, cantad lúgubre canción al cruel dios de los infiernos. Que
todos mis súbditos de la Tesalia lleven luto por esta mujer, corten sus
cabellos y vistan negras ropas; y vosotros, los que uncís los caballos a
las cuadrigas, y cabalgáis en sendos corceles, cortad con el hierro sus
crines. Que en la ciudad no se oiga el sonido de las flautas, ni los
acordes de la lira, en doce lunas completas. Nunca daré sepultura a
otro cadáver más amado, ni a quien más obligaciones deba: digna es
de que yo la honre, ya que solo ha muerto por mí. (Mientras canta e
coro se llevan al palacio el cadáver de Alcestis, seguido de Admeto y
de sus hijos).
EL CORO
Estrofa 1.ª — ¡Oh hija de Pelias!, que habites contenta en el palacio
tenebroso de Hades, y que sepa el dios de negra cabellera,[340] y e
anciano que con el remo y el timón transporta sentado a los muertos
que la mujer más buena, sí, la más buena, atravesará la laguna
Aquerontia en la birreme barquilla.
Antístrofa 1.ª — Mucho te celebrarán los poetas, y la rústica lira de
siete cuerdas, y canciones no acompañadas de ella, cuando los años
en su curso, traigan en Esparta el aniversario del mes Carneo,[341] y se
vea la luna en toda su plenitud y en la brillante y feliz Atenas
Inagotable materia dejas al morir a los que rinden culto a las Musas.
Estrofa 2.ª — Ojalá que en mi mano estuviera, ojalá que me fuese
posible devolverte a la luz desde el palacio de Hades y las ondas de
Cocito,[342] con los remos del río infernal: que tú, la única, la mujer más
querida, tú sola has consentido en rescatar de los infiernos a tu
esposo al precio de tu vida. Leve sea la tierra que te cubra, ¡oh mujer
Si tu marido eligiere nuevo tálamo, muy odioso me será, sin duda, y
también a tus hijos.
Antístrofa 2.ª — Como ni su madre ni su anciano padre quisieran
morir por Admeto, habiéndolo engendrado, ni consintieran en salvarlo
a pesar de sus blancos cabellos, tú, en la flor de tu juventud, te
sacrificaste por tu esposo. Séame dado tener en mi lecho compañera
tan leal, que es suerte rara en la vida; viviría conmigo siempre sin
molestia.
HERACLES (que llega desde lejos).
Extranjeros que habitáis esta tierra de Feres, ¿podré encontrar a
Admeto en su palacio?
EL CORO
En él está el hijo de Feres, ¡oh Heracles! Pero di: ¿qué asunto te
trae a la región de los tesalios? ¿Cuál es la causa de tu venida a la
ciudad ferea?
HERACLES
Dar remate a uno de los trabajos que me impone el tirinteo[343
Euristeo.
EL CORO
¿Y adónde vas? ¿Qué errante peregrinación te ha ordenado?
HERACLES
Robar el carro de cuatro caballos del tracio Diomedes.
EL CORO
¿Y cómo podrás conseguirlo? ¿No sabes acaso quién es ese
extranjero?
HERACLES
No; nunca estuve en territorio bistonio.[344]
EL CORO
Sin pelear no te harás dueño de los caballos.
HERACLES
 Pero tampoco podía oponerme a este trabajo.
EL CORO
Tendrás que matarlo para volver, o allí morirás.
HERACLES
No será, sin duda, mi primera lucha.
EL CORO
¿Y qué ganarás si lo vences?
HERACLES
Traer los caballos al rey de Tirinto.
EL CORO
No es fácil hacerles tascar el freno.
HERACLES
Lo tascarán, a no respirar fuego.
EL CORO
Pero despedazan en un momento a los hombres.
HERACLES
La carne humana es pasto de las fieras de los montes, no de
caballos.[345]
EL CORO
Verás los pesebres teñidos de sangre.
HERACLES
¿Quién es padre del que se jacta de darlos tal alimento?
EL CORO
Ares[346] es el señor de los tracios armados de peltas, ricos en oro.
HERACLES
Tal es uno de los trabajos que el destino me ordena (siempre cruel y
extremado conmigo), puesto que he de pelear con los hijos de Ares
primero con Licaón,[347] después con Cicno, y en tercer lugar con los
caballos y con su dueño. Pero nadie podrá decir nunca que el hijo de
Alcmena ha temido a ningún enemigo.
EL CORO
Mira a Admeto, nuestro soberano, que sale de su palacio.
ADMETO
Salve, hijo de Zeus, de la sangre de Perseo.[348]
HERACLES
Salve tú, Admeto, rey de los tesalios; que seas feliz.
ADMETO
Tal sería mi deseo; ya antes me has dado pruebas de tu
benevolencia.
HERACLES
¿Qué significa esta lúgubre tonsura?
ADMETO
Hoy he de sepultar cierto cadáver.
HERACLES
Que los dioses libren de males a tus hijos.
ADMETO
Mis hijos viven en el palacio.
HERACLES
¿Quizá habrá muerto tu padre, ya de edad avanzada?
ADMETO
Vive, y mi madre también, ¡oh Heracles!
HERACLES
¿Ha muerto acaso tu mujer Alcestis?
ADMETO
De dos maneras distintas podría replicarte.
HERACLES
 ¿Y hablas de ella como si estuviese muerta, o como si viviese
todavía?
ADMETO
Existe y no existe, y su recuerdo me llena de dolor.
HERACLES
Nada entiendo; pronuncias palabras incomprensibles.
ADMETO
¿Ignoras su destino?
HERACLES
Sé que se había obligado a morir por ti.
ADMETO
¿Cómo ha de existir, pues, si consintió en esto?
HERACLES
¡Ah! No llores a tu esposa antes de tiempo; espera que llegue su
día.
ADMETO
El que había de morir ha muerto, y el muerto ya no existe.[349]
HERACLES
Diferencia hay; tal es la opinión común sobre el ser y el no ser.
ADMETO
Tú piensas así, Heracles, y yo de otra manera.
HERACLES
Y al fin, ¿por qué lloras? ¿Cuál de tus amigos es el difunto?
ADMETO
Una mujer; de ella hablé hace poco.
HERACLES
¿Extranjera, o pariente tuya?
ADMETO
 Extranjera; aunque, por otra parte, era de mi familia.
HERACLES
¿Y cómo perdió la vida en tu palacio?
ADMETO
Muerto su padre, se educó en él como huérfana.
HERACLES
¡Ay de mí! ¡Ojalá, Admeto, que no te encontrara agobiado por ese
dolor!
ADMETO
¿Y por qué hablas así?
HERACLES
Buscaré hospitalidad en otra parte.
ADMETO
No debes hacerlo, ¡oh rey!; mucho lo sentiría.
HERACLES
Molesta es a los que lloran la venida de un huésped.
ADMETO
Los muertos, muertos están; vente a mi palacio.
HERACLES
No parece bien sentarse a la mesa de amigos afligidos.
ADMETO
El aposento para los huéspedes, que te aguarda, está separado de
palacio.
HERACLES
Déjame ir, que me harás singular favor.
ADMETO
No debes ausentarte en busca de otro albergue. Ve delante (A uno
de sus servidores), abre los aposentos para los huéspedes que no
comunican con mi morada,[350] y manda a los esclavos que los sirven
que te den abundante alimento; cerrad por dentro la puerta que da a
palacio, pues no está bien que quienes cenan oigan nuestros
lamentos, ni que contristemos a los huéspedes. (Vanse Heracles y e
esclavo).
EL CORO
¿Qué haces? Tú, víctima de tan intolerable calamidad, ¿te atreves
a recibir huéspedes? ¿Deliras acaso?
ADMETO
¿Y me alabarías, por ventura, si rechazase de mi morada y de
Feres al que me pide hospitalidad? No seguramente, que en nada se
disminuiría mi mal, y me llamarían inhospitalario, y a mis desdichas
domésticas se añadiría la de recibir mi palacio ese dictado odioso
Heracles es el mejor de mis huéspedes cuando voy al árido país de
Argos.
EL CORO
¿Cómo, pues, ocultabas la calamidad presente a ese recién venido
tu amigo, según dices?
ADMETO
No hubiera entrado en mi palacio conociendo mis males. Y
paréceme que, si acaso se los participo, no aprobará mi conducta, n
me alabará; pero mis atrios no están acostumbrados a rechazar ni a
despreciar a los extranjeros. (Entra en el palacio.)
EL CORO
Estrofa 1.ª — ¡Oh palacio de varón liberal!, que a muchos has
hospedado, al pitio Apolo, poderoso por su lira, su más digno
habitante, que se rebajó hasta el punto de ser pastor de tus ovejas
cantando pastoriles epitalamios en las tendidas laderas con deleite de
sus ganados.
Antístrofa 1.ª — Y atraídos por sus cantos pastaban cerca de Apolo
pintados linces,[351] y le acompañaba escuadrón de rojos leones
abandonando los bosques otrios,[352] y junto a tu cítara, ¡oh Febo!
saltaba el manchado cervatillo cruzando con pies ligeros entre los
ásperos abetos, alegre y bullicioso con tus versos.
 Estrofa 2.ª — Por esto habita un palacio riquísimo en ovejas, cabe
la laguna Bebia, de cristalina corriente, y por límites de sus campos y
tierras aradas tiene el cielo de los Molosos, hacia donde el sol se
pone, y domina en el mar Egeo hasta la costa escarpada del Pelión.
Antístrofa 2.ª — Y ahora, húmedos sus párpados, abre las puertas
de su palacio para dar hospitalidad, y llora en su regia mansión la
reciente muerte de su muy amada esposa. Las almas nobles son
naturalmente bondadosas, y los hombres de bien disfrutan de los
dones de la sabiduría. Confianza abrigo en mi corazón que su piedad
ha de contribuir a que le sea propicia la fortuna. (Mientras canta e
coro, traen a Alcestis en su féretro, rodeada de todos los esclavos, que
forman el fúnebre cortejo).
ADMETO
Benévolos habitantes de Feres, que estáis aquí presentes: ya los
servidores llevan el cadáver, adornado con toda pompa, a la pira y a
sepulcro; vosotros, como es costumbre, saludad a la difunta, que sale
ahora a recorrer su último camino.
EL CORO
Veo a tu padre, que se acerca con trémulos pasos, seguido de sus
servidores, quienes traen en sus manos tristes galas para ofrecerlas
en los funerales de tu esposa.
FERES
Como tú siento tus males, ¡oh hijo!; has perdido (y nadie podrá
contradecirlo) una esposa buena y casta. Pero es menester que te
resignes, por insufrible que sea tu desdicha. Acepta estos dones, que
cubrirá la tierra; debemos honrar este cuerpo, ya sin vida por salvar la
tuya; no ha consentido que la muerte me robe mis hijos, ni que la
tristeza consumiese mi vejez, privado de ti. Todas las mujeres deben
alabarla eternamente por su valor en ejecutar tan gloriosa hazaña
Adiós tú, que salvaste a este, y nos diste la mano cuando caíamos
que plácida descanses en el palacio de Hades. Con tales esposas
debían casarse los mortales y nada perderían, pues de otra manera no
les conviene contraer himeneo.
ADMETO[353]
 Ni yo te he llamado para que vengas a estos funerales, ni me es
grata tu presencia. Y jamás le servirán tus dones, que nada tuyo
necesita para ser enterrada. Debieras haber llorado cuando yo estaba
amenazado de muerte; pero te alejaste, y consentiste que muriera otra
más joven, siendo tú viejo, y ahora te lamentas de la suerte de esta
No verdaderamente has sido para mí un padre, ni la que dice que me
dio a luz, y por eso la llaman mi madre, sino que, nacido de sangre de
esclavo, allegáronme a escondidas a los pechos de tu esposa.[354
Viniendo ahora has probado quién eres, y no creo que puedas
llamarme hijo tuyo. Cobarde apareces como ninguno, cuando en edad
tan avanzada, y habiendo llegado al término de la vida, no quisiste n
osaste morir por tu hijo, sino que aprobaste el sacrificio de esta muje
extraña, a la cual, después de esto, miraré como si hubiese sido a un
tiempo mi padre y mi madre. Y renunciaste voluntariamente a la lucha
gloriosa para ti, de dar por tu hijo una vida que de todas maneras
habías de perder en breve; si lo hubieses hecho, esta y yo
hubiésemos vivido tranquilos el resto de nuestros días, y no gemiría
por estos males, privado de mi esposa. Sin embargo, disfrutaste de
cuanto puede gozar un hombre feliz; reinaste joven, y me engendraste
para heredar tu cetro, y te libraste de morir sin descendencia, y de
dejar abandonado este palacio para servir a otros extraños. No dirás
por eso que yo, menospreciando tu vejez, he merecido que me
condenes a esa pena; siempre te honré como pocos, y en
agradecimiento de esto tú y mi madre me correspondisteis de esa
manera. Date, pues, trazas de tener pronto otros hijos que te
alimenten ya viejo, te sepulten con pompa y celebren en tu obsequio
suntuosos funerales. No seré yo quien lo haga, que he muerto ya para
ti, si atendemos a tu probada voluntad; y si he encontrado otro
salvador, y veo la luz, digo que seré su hijo, y cuidaré con ternura de
su vejez. Vanamente los ancianos desean morir, maldiciendo la
senectud y larga vida; si la muerte se acerca, ninguno la desea, y ya la
vejez no les parece tan intolerable.[355]
EL CORO
Dejaos de eso ahora: bastante tiene con la calamidad presente, ¡oh
Admeto!; no exasperes a tu padre.
FERES
 ¡Oh hijo! ¿A quién insultas con tales oprobios? ¿A algún esclavo
tuyo lidio o frigio?[356] ¿Ignoras acaso que yo soy tesalio, y que lo era
también mi padre, y hombre libre, según la ley? Con harta injuria me
tratas, y ya que has lanzado contra nosotros esos dicterios juveniles
no te irás de aquí sin oír lo que mereces. Yo, que te engendré para
mandar en este palacio, y te eduqué, no debo morir por ti, que ni mis
padres ni los griegos me han enseñado que los padres han de mori
por sus hijos. ¿Qué injusticia he cometido contigo? ¿De qué bien te he
privado? No mueras tú por mí, ni yo tampoco por ti. Gozas viendo la
luz; y ¿por qué has de creer que a tu padre no sucede lo mismo? He
pensado que debe ser insoportable vivir en el infierno, y que, por corta
que sea la vida, es, no obstante, dulce. Tú sí que temes la muerte sin
decoro, y vives evitando tu funesto destino, y arrancando a esta la
vida; y tú, el más pusilánime de todos, ¿me acusas de cobarde
vencido por una mujer que muere por ti, ¡oh bello jovencito!?
¡Sagazmente discurriste no perecer jamás, si persuades siempre a tu
esposa que imite a Alcestis, y después afrentas a tus amigos que no
han querido hacerlo, siendo tú tan tímido! Calla y piensa que, si tú
amas tanto la vida, los demás también la aman; y si me maldices, yo
te devolveré tu maldición, y no sin justicia.
EL CORO
Sobradas injurias se han oído ya y se oyeron antes. Deja, ¡oh
anciano!, de maldecir a tu hijo.
ADMETO
Habla, que yo hablé ya; pero si te amarga la verdad, no debieras
haber faltado en mi daño.
FERES
Pecara, sin duda, muriendo por ti.
ADMETO
¿Es lo mismo que perezca un hombre en la flor de sus años que un
anciano?
FERES
Está dispuesto que vivamos una sola vez, no dos.
 ADMETO
¡Así vivirás más que Zeus!
FERES
¿Conque insultas injustamente a tus padres?
ADMETO
Ya sé que no te desagrada una larga vida.
FERES
¿Pero no entierras en tu lugar este cadáver?
ADMETO
Prueba indubitable de tu timidez, ¡oh tú!, el más cobarde de los
hombres.
FERES
Nadie afirmará que ha muerto por mi causa; no lo dirás tú, en
verdad.
ADMETO
¡Ay de mí! ¡Ojalá que algún día me necesites!
FERES
Cásate muchas veces, y habrá más mujeres que mueran por ti.
ADMETO
Es para ti una afrenta: tú no quisiste dejar la vida.
FERES
Agrádame esta luz: es de Apolo, y pláceme sin duda.
ADMETO
Cobarde eres, no cual conviene a los hombres.
FERES
No te burlarás de mí enterrando el cadáver de un anciano.
ADMETO
Y morirás sin gloria cuando llegue tu última hora.
 FERES
Después de muerto pueden decir de mí lo que quieran.
ADMETO
¡Ay, ay de mí! ¡Qué impudente vejez![357]
FERES
Alcestis no fue impudente, pero fue necia.
ADMETO
Vete, y déjame sepultar este cadáver.
FERES
Me iré y lo sepultarás, habiendo sido tú causa de su muerte; pero
todavía pagarás lo que debes a sus parientes. No será hombre
Acasto[358] si no venga a su hermana. (Retírase).
ADMETO
Que mueras tú y tu compañera; sobrevivid a vuestro hijo, vegetad
como merecéis, que nunca habitaréis conmigo bajo el mismo techo. S
pudiera renegar de tu paternidad por medio de pregoneros, no
vacilaría en hacerlo. Pero vamos (ya que es preciso sufrir el ma
presente) a acompañar el cadáver a la pira.
EL CORO (mientras el fúnebre cortejo abandona el teatro).
¡Ay, ay de mí!, desventurada por tu osadía; adiós, noble y la mejo
de las mujeres; que Hades y el infernal Hermes te acojan benévolos, y
si allí hay premio para los buenos, que participes de él y te sientes
junto a la esposa del rey de los infiernos. (Acompaña al fúnebre
cortejo,[359] que sale de palacio).
UN ESCLAVO
Muchos huéspedes he visto en el palacio de Admeto de distinta
procedencia, a quienes he servido a la mesa; pero jamás traspasó sus
puertas ninguno como este. En primer lugar, aunque vio llorar a m
amo, entró en él sin miramiento; después no aceptó con modestia los
presentes que se le hicieron, sabedor de nuestra desdicha, y si algo le
faltaba, nos llamaba hasta que se lo llevábamos. Y tomando en su
mano la copa de yedra, bebió el vino puro de negra uva hasta que sus
ardientes vapores lo envolvieron, y coronó su cabeza de ramos de
mirto, aullando y cantando desatinos.[360] Oíase una doble melodía: é
entonaba sus canciones, sin cuidarse de los males que afligen a
palacio de Admeto, y nosotros los siervos llorábamos a nuestra
soberana, y, sin embargo, ocultábamos al huésped las lágrimas de
nuestros ojos, como nos lo había mandado nuestro amo. Y yo ahora lo
invito al banquete, cuando será quizá algún ratero redomado o algún
salteador, mientras mi dueña deja su morada, y no la acompaño, n
levanto al cielo mis manos, ni la lloro, cuando era mi madre y de todos
los esclavos, librándonos de innumerables males siempre que
aplacaba con su dulzura las iras de su esposo. ¿No he de aborrecer a
un huésped que en tan mala ocasión ha llegado?
HERACLES (que viene coronado de mirto).
¡Ay de ti! ¿Por qué me miras con esos ojos torvos e inquietos? No
agradan a los huéspedes tristes servidores, sino que los traten con
cortesía. Tú, al contrario, que ves delante de ti a un amigo de tu
dueño, con tu semblante compungido y fruncidas cejas descubres a
las claras la aflicción que te causan males ajenos. Acércate aquí, para
que aprendas a ser más comedido. ¿Conoces la naturaleza humana?
Yo creo que no; ¿y cómo había de ser? Óyeme, pues. Necesariamente
han de morir todos los hombres, y no hay uno que pueda contar con e
día de mañana. Todos ignoramos el camino que lleva la Fortuna, y n
puede adivinarse, ni hay arte que lo enseñe. Ya que has oído esta
lección de mí, alégrate y bebe, mira como tuyos estos instantes, y de
los demás no te acuerdes. Rinde culto a Afrodita, la diosa más grata a
los mortales, y la más afable. De nada más te cuides, y sigue m
consejo si, como yo creo, te parece razonable. ¿No abandonarás tu
excesiva tristeza, y beberás conmigo atravesando estas puertas
coronado de guirnaldas? No dudes que el ruido de las copas te llevará
a otra región más alegre, y disipará tu pena y tus cuidados. Como
somos mortales, debemos saber lo que nos interesa, puesto que, a m
juicio, para los tristes y austeros la vida no es vida, sino una
calamidad.[361]
EL ESCLAVO
Lo sabemos; pero no está ahora mi ánimo para tomar parte en
banquetes y bromas.
 HERACLES
La muerta es una mujer extranjera; no llores, pues, más de lo justo
que viven los dueños de este palacio.
EL ESCLAVO
¿Cómo que viven? ¿Ignoras la desgracia ocurrida en él?
HERACLES
Acaso me haya engañado tu dueño.
EL ESCLAVO
Excesiva es su bondad para con los huéspedes.
HERACLES
Y por celebrar los funerales de un extranjero, ¿no debía tratarme
bien?
EL ESCLAVO
Sin duda los funerales son peregrinos en demasía.
HERACLES
Nada me ha dicho por ventura de alguna otra calamidad que le
haya sobrevenido.
EL ESCLAVO
No te inquietes; las desdichas de nuestros dueños solo a nosotros
afectan.
HERACLES
Tus palabras no aluden seguramente a males extraños.
EL ESCLAVO
A no ser así, de ningún modo debiera contristarte cuando piensas
disfrutar de los placeres de la mesa.
HERACLES
¿Habré acaso sufrido grave injuria de los que me dan hospitalidad?
EL ESCLAVO
No has llegado al palacio en la mejor ocasión para que se te
hospede; estamos de luto, y ya ves nuestra cabeza rasurada y