KEY ACTION STATEMENTS

Document Overview

Design and created by Guideline Central in participation with the Society for Developmental and Behavioral Pediatrics.

Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Society for Developmental and Behavioral Pediatrics

Publication Date: Feb 1, 2020

Page Last Updated: May 5, 2026

Recommendation Grading System

Strength of Action Terms in Guideline Statements and Implied Levels of Obligation
Strength	Definition	Implied Obligation
Strong Recommendation (S)	A strong recommendation means that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits, in the case of a strong negative recommendation) and that the quality of the supporting evidence is excellent (grade A or B). In some clearly identified circumstances, strong recommendations may be made on the basis of lesser evidence, when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms.	Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Recommendation (R)	A recommendation means that the benefits exceed the harms (or that the harms exceed the benefits, in the case of a negative recommendation) but that the quality of evidence is not as strong (grade B or C). In some clearly identified circumstances, recommendations may be based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms.	Clinicians should also generally follow a recommendation but should remain alert to new information and sensitive to patient preferences.
Option (O)	An option means that either the quality of evidence is suspect (grade D) or that well-done studies (grade A, B, or C) show little clear advantage to one approach versus another.	Clinicians should be flexible in their decision making regarding appropriate practice, although they may set bounds on alternatives. Patient preference should have a substantial influencing role.

Aggregate Grades of Evidence by Question Type
Grade	Treatment	Diagnosis	Prognosis
A	Systematic review^a of randomized trials	Systematic review^a of cross-sectional studies with consistently applied reference standard and blinding	Systematic review^a of inception cohort studies^b
B	Randomized trials, or observational studies with dramatic effects or highly consistent evidence	Cross-sectional studies with consistently applied reference standard and blinding	Inception cohort studies^b
C	Non-randomized or historically controlled studies, including case-control and observational studies	Non-consecutive studies, case-control studies, or studies with poor, non-independent, or inconsistently applied reference standards	Cohort study, control arm of a randomized trial, case series, or case-control studies; poor quality prognostic cohort study
D	Case reports, mechanism-based reasoning, or reasoning from first principles
X	Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over harm

^a A systematic review may be downgraded to level B because of study limitations, heterogeneity, or imprecision
^b A group of individuals identified for subsequent study at an early, uniform point in the course of the specified health condition, or before the condition develops.

Document Overview

Document Title: Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Authoring Society: Society for Developmental and Behavioral Pediatrics

Document Publication Date: Feb 1, 2020

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: journals.lww.com/jrnldbp/Fulltext/2020/03001/Society_for_Developmental_and_Behavioral.3.aspx

Source Citation: Barbaresi WJ, Campbell L, Diekroger EA, Froehlich TE, Liu YH, O'Malley E, Pelham WE Jr, Power TJ, Zinner SH, Chan E. Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder. J Dev Behav Pediatr. 2020 Feb/Mar;41 Suppl 2S:S35-S57. doi: 10.1097/DBP.0000000000000770. PMID: 31996577.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: This practice guideline is developed to facilitate integrated, interprofessional assessment and treatment of children and adolescents with “complex ADHD” defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Scope: Assessment and Screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D010372 - Pediatrics

D003933 - Diagnosis

D019958 - Attention Deficit and Disruptive Behavior Disorders

D001289 - Attention Deficit Disorder with Hyperactivity

D010372 - Pediatrics

D003933 - Diagnosis

D019958 - Attention Deficit and Disruptive Behavior Disorders

D001289 - Attention Deficit Disorder with Hyperactivity

Keywords: ADHD, coexisting conditions, complex adhd, pediatrics

Target Patient Population: Patients with ADHD

Inclusion Criteria: Male, Female, Adolescent, Child

Health Care Settings: Ambulatory, Childcare Center, Outpatient, School

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant, Psychologist, Social Worker

Recommendation Development Processes & Methodology

Number of Source Documents: 216

Literature Search Start Date: Thursday, September 1, 2016

Literature Search End Date: Thursday, March 1, 2018

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: No