Managing ADHD with a Chronic Illness and Family Model Childhood and Adolescent Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurobehavioral disorder that severely affects the academic performance, well-being, and social interactions of children and adolescents. The American Academy of Pediatrics (AAP) first published the Clinical Practice Guidelines for the Diagnosis and Evaluation of Children with ADHD in 2000, followed by the Guidelines for the Treatment of School-Aged Children with ADHD in 2001, as a basis for clinicians to diagnose and treat the disorder. Currently, as psychiatrists’ understanding of ADHD increases, the old guidelines cannot fully meet the requirements for diagnosis and treatment. The AAP has therefore revised the guidelines, namely the Clinical Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. The age range is expanded to 4 to 18 years In for the perimeter: Tongnan ADHD is the most common type of neurobehavioral disorder in children, with a prevalence of approximately 8%. There is growing evidence to support the diagnosis of ADHD in preschool children. while previous guidelines limited the age to 6 to 12 years, the new guidelines are limited to 4 to 18 years. The guidelines suggest that primary care physicians should be the first to evaluate children aged 4 to 18 years with symptoms of learning, behavior problems, attention, hyperactivity, or impulsivity (strong recommendation/level B evidence), with the goal of early action to intervene in children who do not yet meet diagnostic criteria for ADHD, and the new guidelines provide appropriate treatment recommendations for this. Identifying core symptoms first Evidence supports that the same diagnostic criteria for ADHD apply to preschoolers (4 to 5 years of age), but the DSM-IV staging of ADHD may not be appropriate for this group and needs to be adjusted appropriately, but identifying core symptoms is a huge challenge. For adolescents, physicians need information from more than two teachers and other resources such as coaches, school counselors, etc. Adolescents with ADHD, especially untreated adolescents, are at high risk for developing substance abuse, mood and anxiety disorders, and risky sexual behaviors and should be alerted. For children whose symptom level does not adequately meet DSM-IV diagnostic criteria, the DSM-PC is available for diagnosis. Timely assessment of co-morbidities in ADHD Assessment of ADHD should include timely assessment of co-morbidities such as emotional or behavioral disorders (e.g., anxiety, depression, oppositional defiant and conduct disorders), developmental conditions (e.g., learning and language disorders or other neurodevelopmental disorders), and somatic conditions (e.g., tics, sleep apnea) (strongly recommended/level B evidence). It is important for clinicians to identify co-morbidities to shape the overall treatment plan, and perhaps certain co-morbidities may alter the treatment strategy for ADHD. The guidelines also state that primary care physicians who cannot effectively treat co-morbidities may be referred to specialists for evaluation and treatment. Adherence to a chronic disease management and family medicine model ADHD is a chronic disease that can continue to cause symptoms and dysfunction in children and into adulthood, and a chronic disease management and family medicine model should be followed (strong recommendation/level B evidence). Because many parents of children with ADHD also have the disorder, it is important to treat children with ADHD with medication and behavioral management for their parents as well. The guidelines emphasize that the chronic disease management model is also applicable to children who do not yet have sufficient criteria for an ADHD diagnosis. Medication + behavioral treatment works best The treatment of ADHD is primarily based on age group. For preschoolers (4 to 5 years old), behavioral interventions should be preferred (strongly recommended/level A evidence); if behavioral interventions are not effective and the child has moderate to severe functional impairment, methylphenidate treatment may be given (evidence-based evidence B/strongly recommended). For elementary school children (6 to 11 years of age), a combination of FDA-approved medications for ADHD (strong recommendation/Level A evidence) and/or behavioral interventions by parents and/or teachers is more effective (strong recommendation/Level B evidence). Medications supported by strong evidence were preferred to central stimulants, followed by tomoxetine, guanfacine extended-release, and colistin extended-release in that order (strong recommendation/Level A evidence). In addition, the school setting and curriculum should be part of the treatment plan. For adolescents (12 to 18 years of age), a combination of FDA-approved medications (strongly recommended/level A evidence) and behavioral therapy (generally recommended/level C evidence) may be more effective. Medication In general, stimulants are effective in reducing core symptoms in most children with ADHD. Studies have shown that a selective norepinephrine reuptake inhibitor, tomoxetine, and two selective alpha2-adrenergic agonists, guanfacine extended-release and colistin extended-release, have both been shown to be effective in reducing the core symptoms of ADHD, and the FDA has approved them for the treatment of ADHD, but studies have confirmed that these drugs are less effective than stimulants. It is important to emphasize that none of these three drugs are supported for use in preschool children. Common adverse effects of stimulants are decreased appetite, abdominal pain, headache, and sleep disturbances. Unlike the results of previous studies, the more persistent adverse effect of stimulants is a reduction in growth rate, especially when used at high doses or for prolonged periods of time in children, with growth reductions typically in the range of 1 to 2 cm. This adverse effect tapers off by the third year of treatment, but there is no rebound compensation for height after discontinuation of the drug. Additional serious side effects of stimulant administration are hallucinations and other psychotic symptoms (rare), and sudden cardiac death (extremely rare), but there is insufficient evidence whether stimulants increase the risk of sudden death. Therefore, clinicians must know whether the child has a history of cardiac disease, Woolf-Butchinson-White syndrome, a family history of sudden death, hypertrophic cardiomyopathy, and long QT interval syndrome before administering the medication. In addition, stimulant application in preschool children can cause emotional instability and poor mood. Adverse effects of the non-stimulant tomoxetine include sleepiness at initiation and gastrointestinal symptoms, especially with rapid dosing, decreased appetite, increased incidence of suicidal ideation (rare), and hepatitis (rare). α2 adrenergic agonists have been associated mainly with sleepiness and dry mouth. The drug is not completely contraindicated in children 4 to 5 years of age. Medication may be considered for preschool children with ADHD who have moderate to severe dysfunction. Moderately severe dysfunction is defined as 1) symptoms that have persisted for at least 9 months, 2) dysfunction in both the home and other settings, and 3) poor behavioral treatment. Because of the low metabolic rate of the drug in children 4 to 5 years of age, small doses should be started and increases should be as small as possible, but the maximum dose has not been adequately studied. Dextroamphetamine is the only drug approved by the FDA for the treatment of children under 6 years of age, but it is based on empirical evidence. Most studies support stimulant treatment of preschool-aged children with ADHD with moderate evidence of safety and efficacy, but the FDA has not approved it for use in preschool-aged children. Therefore, dextroamphetamine is not recommended for preschool children at this time. For adolescents newly diagnosed with ADHD, physicians should prescribe medications that do not have a propensity for abuse, such as tomoxetine (Zelda), guanfacine extended-release or colistin extended-release (non-stimulants) or stimulants with a lesser propensity for substance abuse, such as ly dextroamphetamine dimesylate, Ritalin patches, or controlled-release (Focusa). It is important to note that medications are not indicated for the treatment of adolescents who do not meet the diagnostic criteria for ADHD in the DSM-IV. Behavior therapy Behavior therapy is usually conducted by parents who are trained to use specific techniques to improve the child’s resilience, shape the child’s behavior, and improve the child’s ability to manage his or her own behavior. Positive reinforcement, ignoring, experiencing consequences, or punitive approaches are generally used to shape behavior. Table 1 lists the major behavioral intervention approaches that are evidence-based. The long-term positive effects of behavioral treatment are positive. Many studies have found that stimulants are significantly more effective than behavioral treatments in improving core symptoms in patients with ADHD. Medication combined with behavioral treatment can improve children’s academic performance and behavioral problems more significantly than medication alone, with more satisfactory treatment outcomes, lower doses of stimulant use, and fewer adverse effects. It is important to emphasize that concurrent behavioral treatment at school and home can further improve efficacy. Titrating medication doses for maximum benefit The guidelines emphasize that the dose of ADHD medication should be titrated to achieve maximum efficacy and minimal side effects (strong recommendation/level B evidence). The optimal therapeutic dose is the one that reduces core symptoms and leaves the child with little or no ADHD symptoms. Studies have shown that more than 70% of children or adolescents with ADHD use an appropriate dose of stimulant that is effective in reducing core symptoms. Therefore, titration of the drug to the maximum dose that can control symptoms without causing drug side effects should be recommended, rather than a strict value of how many milligrams per kilogram of body weight. In particular, it should be noted that titration takes several months to achieve optimal results and should be monitored regularly. Stimulants have a rapid onset of action, with effective titration achieved in 3-7 days, and their long-term effects depend on compliance with the drug, regular monitoring, etc. Currently, maintaining appropriate therapy and achieving long-term efficacy remains a challenge. In conclusion, this guideline provides a platform for primary care physicians to build alliances with families for early detection of behavioral problems in children and adolescents and early prevention of psychiatric disorders. In addition, primary care physicians should also collaborate with psychiatrists to refer children and adolescents with ADHD for timely and effective treatment.