Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.
- AAP —
- American Academy of Pediatrics
- ABP —
- American Board of Pediatrics
- ADHD —
- attention-deficit/hyperactivity disorder
- CHICA —
- Child Health Improvement Through Computer Animation
- CPG —
- clinical practice guideline
- DSM-5 —
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
- EHR —
- electronic health record
- HEDIS —
- Healthcare Effectiveness Data and Information Set
- HIT —
- health information technology
- MOC —
- Maintenance of Certification
- MTA —
- Multimodal Treatment of ADHD
- QI —
- quality improvement
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. National survey data from 2016 revealed that 9.4% of US children received an ADHD diagnosis at some point and that 8.4% currently had ADHD.1,2 It is now recognized as a lifelong disorder and remains 1 of the most extensively studied and yet highly controversial conditions. In reading and implementing the revised guidelines, it is important to understand the history and current standards of care about ADHD.
Despite changes in its name over time, ADHD has actually had a long history. In the mid-19th century, the characteristics of ADHD were described by Heinrich Hoffman, a German physician, and were represented by 2 of his characters (Fidgety Phil and Harry Who Looks in the Air) who appeared in his children’s book.3 In 1902, at a meeting of the Royal College of Physicians, George Still described a disease he characterized as resulting from a defect in moral character.4 He noted that the disorder manifested itself in patterns of restless, inattentive, and overaroused behaviors. He suggested that the children had likely experienced brain damage but that the behavior could also arise from hereditary and environmental factors.
The association with brain damage was further noted in 1917 to -1918 after the worldwide epidemic of influenza, when some of the children recovering from its encephalitis had symptoms of restlessness, inattention, impulsivity, easy arousability, and hyperactivity.5 However, subsequently, when there were many cases with similar behavioral manifestations, but no clear evidence of brain damage, the name of the disorder was changed to minimal cerebral/brain dysfunction/damage.5
As the association with brain damage became less prominent as the cause of ADHD, the name was revised to be more behaviorally descriptive. The change was reflected in the psychiatric classification system, the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II), in which it was called hyperkinetic reaction of childhood disorder.6 In 1980, because of the studies of Virginia Douglas and others,7,8 the primary impairment shifted from hyperactivity to inattention, as reflected in the name change to attention-deficit disorder in the DSM-III,9 and then to attention deficit/hyperactivity disorder in the DSM-III-Revised.10 In the DSM-IV,11 it was further categorized into 3 subtypes, inattentive, hyperactive/impulsive, and combined (involving both inattentive and hyperactive/impulsive domains), which remain the subcategories in the recently published DSM-5.12 However, in the DSM-5, the subtypes are now referred to as “presentations” to denote that an individual’s subcategorization is not necessarily fixed across the life span but can shift with age and development. The basis for the guidelines is best understood in the context of both its diagnostic and treatment history.
Although the diagnostic criteria for ADHD have evolved over time, the assessment and tools for evaluation have remained essentially the same. ADHD remains a largely clinical diagnosis. Current recommendations for diagnostic evaluation of possible ADHD include a comprehensive history taking of prenatal, perinatal, and family history; school performance; environmental factors; and a detailed physical examination. During the physical examination, particular attention should be paid to vital signs (cardiovascular, skin, thyroid, and neurologic systems, including assessment of motor coordination), and a mental health assessment used to probe for comorbid conditions should be performed. The use of teacher- or parent-reported behavior-rating scales started in the late 1960s13; now focus is on the behavioral criteria for ADHD as described in the DSM-5.12 Determining significant impairment is also an important criterion.
Unfortunately, the objective assessments currently available for ADHD are of limited use in clarifying the diagnosis, including neuropsychological tests (which have a low strength of evidence14) as well as EEG and neuroimaging (for which the evidence remains insufficient14). The scientific community has also been interested in understanding how neurotransmitter systems are involved in ADHD because animal models, neuroimaging studies, and pharmacologic studies provide support for the involvement of dopaminergic and adrenergic derangements in ADHD.15,16 However, no evidence-based methods for assessing these neurotransmitter systems have been developed and shown to have utility in the ADHD diagnostic assessment. Although ADHD has a high heritability estimate (∼76%), no specific genetic pattern has been shown to be necessary or sufficient for the disorder.17 Therefore, identifying genes linked to ADHD has been difficult, and genetic testing is currently not useful for diagnostic purposes.18
Stimulant medications and behavioral interventions have been the mainstay for the treatment of children with ADHD for >45 years. In 1937, Bradley19 was the first to report that Benzedrine improved the behaviors of children hospitalized for behavior problems. Dextroamphetamine was also approved in 1937, but it did not become of interest for treating children with minimal brain dysfunction until the mid-1950s.20 Methylphenidate became available in 195421 and became popular when amphetamines lost favor. As early as 1977,22 there were 62 blinded, placebo-controlled studies of stimulant medications demonstrating their efficacy and safety. By 1999, their benefits and safety had been shown in >300 positive rigorous studies.23 Since that time, hundreds of additional rigorous studies have consistently confirmed their efficacy and safety when taken in the therapeutic dose range for children from 4 years of age to adulthood.14
Behavioral interventions that are focused on behavior modification, such as parent behavior-management training and school behavior-management programs, have also long been demonstrated to be efficacious.24 Other interventions, including diets, herbal and other supplements, EEG training, and neuropsychological or cognitive training interventions, lack the level of empirical support for their efficacy achieved by the US Food and Drug Administration–approved ADHD medications and the aforementioned behavioral interventions.14
In the Multimodal Treatment of ADHD (MTA) study, funded by the National Institute of Mental Health,25 researchers examined the benefits of both stimulant medication and behavioral interventions in a multisite study over a 14-month period, with 10-year follow-up surveillance. Although stimulant medication had the strongest effect on core ADHD symptoms and behavioral interventions were most acceptable to families, combined medication and behavioral therapy was most effective, particularly when comorbidity or additional family issues were present. However, after leaving the active trial, participating families no longer received the same level of medication or behavioral interventions. Therefore, because neither medication nor behavioral treatment of ADHD is curative and both only work when being actively administered, it has been difficult to demonstrate their long-term benefits.
Because ADHD continues into adulthood for many individuals,26 both patients with persistent symptoms and those whose ADHD symptoms have resolved are at risk for emergence of other psychiatric disorders and adverse outcomes as they approach their adult years.27 Understanding the long-term outcomes for children with ADHD is crucial as systems are built and improved to provide optimal care.
Consistent norm-referenced criteria used to diagnose ongoing ADHD in adults are lacking. This has led to wide variation in reported rates of persistence of ADHD into adulthood,28 with persistence rates ranging from 4% to 78%.28 Multiple factors contribute to this variation, including inconsistent diagnostic criteria, use of varying informants (self-report versus parent informant) to assess for the presence of current ADHD symptoms, and recall of childhood symptoms.29 Furthermore, studies in which a population-based sample is used may lose more patients to follow-up and may include patients with less severe symptoms, leading to lower persistence rates than in those conducted in clinical samples.28 In addition, symptoms of hyperactivity are more likely to diminish over time and with the onset of puberty, whereas inattentive symptoms are more likely to persist, making features of ADHD more subtle and often less obvious in adulthood versus childhood.30 All of these factors impact the rates of identified ongoing ADHD. Despite these challenges, childhood risk factors that may help predict persistence of ADHD into adulthood have been identified. These include increased severity of childhood ADHD symptoms, comorbid conduct disorder, comorbid major depressive disorder, and parent mental health problems.31 Child IQ, socioeconomic status, parental education, and parent-child relationship were not associated with more likely persistence of ADHD symptoms.32
In previous studies, researchers have also examined long-term academic outcomes in children diagnosed with ADHD in childhood. In a prospective birth-cohort population-based study, Barbaresi et al33 found that those with childhood ADHD had evidence of long-term academic underachievement compared with non-ADHD controls. In their study of young adults, Voigt et al34 showed that lower academic scores were seen even in those whose ADHD symptoms had resolved by adulthood compared with children who did not have childhood ADHD. The presence of a learning disorder along with ADHD has a further negative impact on academic achievement.29 Similarly, the long-term follow-up of the MTA study25 revealed that those whose ADHD symptoms did not persist into adulthood still had worse academic outcomes than those in the non-ADHD control group, with the worst academic outcomes experienced by the group with persistent ADHD symptoms.35 There is also great interest in determining whether ADHD treatment can improve academic outcomes. Barbaresi et al33 documented an association between treatment with stimulant medication during childhood and improved reading scores, reduced school absenteeism, and reduced grade retention, but in their study of young adults, Voigt et al34 found that those treated with at least 3 months of stimulants during childhood and those who were not treated had similar academic achievement test scores. The authors did, however, document a link (albeit weak) between increased duration of stimulant treatment and improved math test achievement among those treated with at least 3 months of stimulants during childhood. Mental health outcomes have also been examined in individuals diagnosed with ADHD during childhood. Most of the children and adolescents with ADHD who died by suicide also had comorbid substance use disorder and other psychiatric diagnoses.27
The studies indicating adverse adult outcomes in individuals diagnosed with ADHD during childhood, whether their symptoms improved with age, emphasize the importance of chronic care services for adults with ADHD. Unfortunately, there is evidence that smooth transitions into adult services often do not occur for individuals with a history of childhood ADHD. Eklund et al36 studied adolescents and young adults in the United Kingdom at the time of health care transition and found higher caregiver-burden ratings as well as decreased use of the service model. The results emphasize the importance of continuity of care and the need for successful transition of care to clinicians who provide adult services.36 Of note, the expectation that adolescents and young adults will assume increasing responsibility for their medical and mental health care can be particularly challenging for individuals with ADHD.37
Therefore, as children with ADHD reach adolescence, a structured transition of health care services from pediatric to adult services is necessary, with particular attention paid to ongoing monitoring and treatment (if indicated) of ADHD-related mental health concerns. ADHD’s status as a chronic illness with effective symptomatic treatments, such as can be found for asthma and diabetes, underscores the need to provide chronic care, preferably in a medical home or a medical home–like setting. Optimal care for individuals with ADHD requires continuity and coordination of interventions as well as monitoring by medical, mental health, and educational providers. Guidelines for ADHD care, such as those drafted by the American Academy of Pediatrics (AAP), have been developed to meet these needs and provide the basis for training programs.
Guidelines and Quality Improvement Projects
Growing awareness of poor quality of care for children with ADHD38 and the societal implications for inadequate or inappropriate diagnosis and treatment of individuals with ADHD as they enter adulthood38,39 led to the development of the first AAP clinical practice guidelines (CPGs) for the diagnosis and evaluation of ADHD in 2000.40 This was followed by a practice guideline for the treatment of ADHD in 2001.41 These recommendations were updated in 201142 and again in 2019.43 Following the AAP’s lead, many professional organizations and health care systems worldwide have since developed their own CPGs and associated tool kits or care process models that are tailored to the needs of their specialty, clinical population, and/or health care organization.38
Adherence to CPGs has since emerged as a primary focus of quality improvement (QI) initiatives. One of the earliest projects on this subject was the ADHD Learning Collaborative, which worked to implement a model of care for children with ADHD that is consistent with the AAP guidelines. It involved 40 pediatric practices, mostly in North Carolina, from 2000 to 2003. In May 2003, the AAP introduced an online continuing education module called Managing Your Patients with ADHD as part of the then-nascent Education in Quality Improvement for Pediatric Practice series, which offers a structured process to encourage individual participants to make lasting changes in their practice.44
AAP activities also include the Education in Quality Improvement for Pediatric Practice series and a variety of Chapter Quality Network collaboratives.45 A recent Chapter Quality Network collaborative from December 2015 to January 2017 included pediatricians, practices, and chapters from 5 states; participants used QI methods to test evidence-based care processes and embed them into clinical workflows. The collaborative included learning sessions and monthly calls to share best practices and review data.46 The Illinois and Vermont chapters are currently recruiting for a planned QI learning collaborative to increase adherence to the AAP’s ADHD guidelines.47
The American Board of Pediatrics (ABP) has also emphasized the importance of improving care by incorporating the module Improving Professional Practice and Quality Improvement as part 4 of Maintenance of Certification (MOC). Pediatricians must earn 40 to 60 points every 5-year MOC cycle by participating actively in activities designed to help physicians assess and improve the quality of patient care and in processes that will lead to improved health. This incentive has accelerated the growth of QI activities focused on improving ADHD care. For example, the ABP sponsors 2 performance improvement modules: Initial Diagnosis of Attention Deficit Hyperactivity Disorder in Pediatric Patients and Follow-up Care of Pediatric Patients with Attention Deficit Hyperactivity Disorder.48 These online modules can be completed by individual physicians or a team. Health care organizations certified by the ABP as portfolio sponsors also offer MOC part 4 projects, available nationwide, focused on improving ADHD care (eg, the Center for ADHD at Cincinnati Children’s Hospital Medical Center).
Measures of ADHD care quality are necessary to know whether a change represents an improvement, and the ADHD guidelines soon became the basis for developing performance indicators. Although many local QI initiatives or multisite collaboratives have developed their own ADHD quality measures tailored to their respective specific aims, efforts to develop and validate measures of ADHD care have also occurred at the national level. These measures are commonly used or adapted for use in QI initiatives.
Developed and maintained by the National Committee for Quality Assurance, the Healthcare Effectiveness Data and Information Set (HEDIS) is 1 of the most widely used tools for performance measurement and improvement among health plans. HEDIS specifies a set of standardized measures, with data collected through surveys, medical records, and administrative data such as insurance claims. The HEDIS measures for ADHD, beginning in 2006, were based to a great extent on the initial AAP CPG. HEDIS implemented the measure Follow-Up Care for Children Prescribed ADHD Medication49 with the following phases:
• Initiation Phase: Assesses children between 6 and 12 years of age who were diagnosed with ADHD and had one follow-up visit with a practitioner with prescribing authority within 30 days of their first prescription of ADHD medication.
• Continuation and Maintenance Phase: Assesses children between 6 and 12 years of age who had a prescription for ADHD medication and remained on the medication for at least 210 days, and had at least two follow-up visits with a practitioner in the 9 months after the Initiation Phase.49
The Pediatric Quality Measures Program was established by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services as part of the Child Health Insurance Program Reauthorization Act in 2009.50 Grantees were charged with identifying and developing pediatric quality measures. For ADHD, the following measures were developed:
Accurate ADHD Diagnosis: patients 4 to 18 years whose diagnosis of ADHD was based on a clinical examination with a physician that included (1) confirmation of functional impairment in ≥2 settings and (2) assessment of core ADHD symptoms through a validated diagnostic tool based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria or through direct assessment of the patient;
ADHD Chronic Care Follow-up: patients 4 to 18 years with a diagnosis of ADHD who attended at least 1 ADHD follow-up care visit within a calendar year; and
Behavior Therapy as First-Line Treatment of Preschool-Aged Children with ADHD: patients aged 4 to 5 years with a diagnosis of ADHD for whom ADHD-focused, evidence-based behavior therapy was prescribed as a first-line treatment.
As interest in the development of patient-reported outcomes that could be derived from electronic health records (EHRs) grew, the Office of the National Coordinator for Health Information Technology contracted with Mathematica Policy Research to test a pediatric-screening electronic clinical quality measure for ADHD:
ADHD: Symptom Reduction in Follow-Up Period: the percentage of children ages 4 to 18 who had been diagnosed with ADHD and demonstrated a 25% reduction in symptoms 6 to 12 months from baseline, as measured by using the Vanderbilt ADHD Diagnostic Rating Scale (regardless of the treatment prescribed).
As it became clearer that systems barriers, such as communication and documentation burden, accounted for much of the difficulty in implementing key portions of the ADHD guidelines,51 more recent QI initiatives have been focused on leveraging health information technology (HIT) to overcome these challenges.
Electronic Communication and Care Monitoring Systems
Given the potential of HIT to facilitate coordinated and efficient care, promote cross-system communication, and expedite the collection of ADHD-specific rating scales for evidence-based diagnosis and treatment monitoring, recognition of its capacity to improve ADHD care is growing. Broadly speaking, these HIT systems are divided into 2 domains: EHR-based systems and stand-alone (EHR-independent) software platforms. As ADHD-related HIT systems are developed, there is a burgeoning of literature in which their performance is evaluated, as reviewed below.
In a cluster randomized trial, Co et al52 investigated the performance of an EHR-based ADHD decision support system. This system features an ADHD note template with fields for key AAP ADHD guideline elements40,41 and sends automated reminders to clinicians to schedule a visit for children with ADHD every 3 to 6 months.52 Use of the system increased visits and improved documentation of ADHD symptoms, notation of treatment effectiveness, and documentation of adverse effects at follow-up. Unfortunately, the template was used at only 32% of ADHD assessment visits because of a variety of factors (eg, forgetting about the template, finding the template difficult to use).52
Carroll et al53 evaluated a decision support system (Child Health Improvement Through Computer Animation [CHICA]54). The CHICA system prompts physicians to provide caregivers and teachers with ADHD rating scales. Returned scales are scanned into the CHICA system, which generates a summary document with scores, interpretations, and treatment recommendations. The cluster randomized trial revealed that the use of structured diagnostic assessments (defined as collecting both parent- and teacher-reported ADHD rating scales during the ADHD evaluation) improved in the intervention group (from 60% at baseline to 81% at follow-up), whereas the control group’s performance dropped (from 50% at baseline to 38% at follow-up).53
Investigators at Children’s Hospital of Philadelphia developed the ADHD Care Assistant, a system that sends electronic ADHD rating scales to parents and teachers, presents results seamlessly in the EHR and allows parents to elect automated sharing of ADHD information between themselves and teachers, thereby facilitating communication.55 Michel et al56 found that most parents are amenable to sharing ADHD rating scale information collected in the system with teachers, but parents viewed only 16% of teacher-submitted ADHD surveys, and teachers viewed 30% of parent surveys. The investigators concluded that in future efforts, researchers should target the development of strategies to encourage viewing of shared information.
Stand-alone Software Systems
Although a number of ADHD-related stand-alone software systems have been developed, there have been limited publications in which their effectiveness is evaluated. Lavigne et al57 examined a combined ADHD practice-management intervention that involved 2 hours of didactic training on ADHD medication management by using the Focus on ADHD Medication Management Program software. In the intervention group, parent- and teacher-reported paper rating-scale results were then entered into the focus program, and its output provided recommendations. Although use of the focus program was suboptimal in the intervention group (it was used by only approximately one-quarter of patients with ADHD seen by the intervention group), when it was used, adherence to the recommended ADHD medication titration procedures increased, and improved ADHD symptom control resulted.57
Chan et al39 developed the TriVox Health Web-based platform (www.trivoxhealth.com), which enables clinicians to administer online ADHD clinical questionnaires and rating scales to parents and teachers to monitor patients remotely, between visits, and at customizable intervals.58 This includes a notification for clinicians when new data are available to view and an alert notification if there is potentially actionable data. They found that the TriVox Health trigger algorithm facilitated timely changes in the care plan between face-to-face visits because nurses were able to successfully contact parents in response to the alerts. Two-thirds of the alerts led to a care plan change before the next scheduled appointment.58
Epstein et al59 developed an ADHD Web portal (now available at www.mehealth.com) in an effort to integrate ADHD QI efforts and provide multiple clinically salient functionalities. The meHealth software is a comprehensive system that includes training for clinicians regarding the AAP ADHD guidelines and recommendations; automated online collection of parent- and teacher-reported ADHD rating scales for ADHD assessment and treatment monitoring (including side effect reporting) at customizable intervals; algorithms that automate scoring of parent- and teacher-reported ADHD rating scales and produce assessment and treatment reports; customizable automated alerts to clinicians when behavior ratings worsen or side effects flare; a communication feature that allows communication between clinicians, parents, and teachers; and easy-to-use behavioral treatment tools for use by parents and teachers. A cluster randomized trial revealed that clinicians using the system had significantly higher rates of many AAP-recommended practices and had a high degree of satisfaction (94%).60 A second study revealed that among children prescribed ADHD medication, significantly greater improvements in parent-reported ADHD symptom ratings were achieved when the Web portal system was used for treatment monitoring (compared with usual care by the control group).61
Limitations of Electronic Communication and Care Monitoring Systems
EHR-based systems tend to lack the usability present in the stand-alone systems and are more restrictive in their abilities to include communication between families, teachers, primary care physicians, and other patient providers. The stand-alone systems often do not communicate directly with patient’s electronic medical records, which are not currently searchable and usually entail an additional cost, so their reports usually need to be attached as scanned documents. However, efforts are currently underway to integrate some of the stand-alone systems into the most commonly used EHRs.
In the extensive research that has been undertaken to help define the anatomic, functional, and genetic characteristics of ADHD, as well as environmental contributing factors, it has become clear that there are differences in brain size as well as activity level in the catecholamine system. For example, differences in the mean volumes of the prefrontal cortex, the basal ganglia, and the cerebellar vermis for groups of patients with ADHD compared with unaffected controls have been shown, but the degree of overlap between these groups is too high for neuroimaging parameters to be used for diagnosing individual cases. Similarly, although there is a strong familial pattern for ADHD, there is no specific inherited gene pattern. In addition, risk of ADHD is increased by environmental factors, including prematurity, maternal alcohol intake or smoking during pregnancy, childhood lead exposure, and head trauma, but these factors are contributory, not diagnostic. Furthermore, neuropsychological and EEG assessments have not been shown to improve on the diagnostic procedures first defined in the 2000 AAP guidelines40 (and maintained in the 201138 and 2019 updated guidelines43).
Once an ADHD diagnosis has been established, evidence-based treatments are available. Medications, particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. The landmark MTA ADHD treatment trial documented the additional benefits obtained by combining medication and behavioral interventions. However, despite this evidence of treatment efficacy, the long-term outcomes for individuals with ADHD have been less optimal than those for individuals who are unaffected.
One of the major reasons for suboptimal outcomes in individuals with ADHD is that both medication and behavioral interventions are symptomatic treatments. Neither treatment is curative, although maturity enables some individuals with ADHD to compensate adequately for their ADHD-related challenges. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions, such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. The MTA study demonstrated that rigorously administered medication and behavioral therapies were highly efficacious during the clinical trial, but when ADHD management was transferred back to community providers, who provided less-intense services after the trial, symptom control waned.
Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication, improve monitoring of ADHD symptoms and functional performance, and better integrate with electronic medical records is on the horizon, but barriers such as cost and privacy regulations have limited their use as of yet.
The AAP ADHD guidelines and their revisions strongly emphasize the need to treat ADHD as a chronic illness for which the important elements are as follows: (1) strong and continuous relationships between the clinicians, the patients, and their families; (2) a focus on educating the families about the condition and its treatments; (3) understanding the family’s needs and priorities; (4) developing adequate communication between all those providing care to the patient; (5) continuity of care, taking into account the changing needs and abilities of patients and their families over time; (6) providing appropriate anticipatory guidance regarding monitoring for and prevention of mental health and academic challenges; and (7) providing transition plans. With continued development of electronic tools and innovative systems to enhance communication, hopefully it will be possible to address these key ADHD care elements and to implement the newly revised guidelines at a much higher level of quality of care.
- Accepted August 5, 2019.
- Address correspondence to Mark L. Wolraich, MD, Child Study Center, The University of Oklahoma, 1100 13th St, Oklahoma City, OK 73116. E-mail:
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: Dr Chan has a potential conflict of interest, in that she is a coinventor of the TriVox Health health information technology referenced in this article. In the future, it is possible that this technology will be sold commercially. If this were to occur, Dr Chan and Boston Children’s Hospital might receive financial benefits in the form of compensation. As in all research studies, the hospital has taken steps designed to ensure that this potential for financial gain does not endanger research subjects or undercut the validity and integrity of the information learned by this research; the other authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2528.
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- Copyright © 2019 by the American Academy of Pediatrics