Attention-Deficit/Hyperactivity Disorder (ADHD)

Overview

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that begins in childhood and is characterized by some combination of hyperactivity, impulsivity, and/or inattention. These symptoms are present to such a degree that they significantly interfere in at least 2 areas of the child's life, such as in the home and classroom. Four major ADHD types are currently recognized (predominantly inattentive, predominantly hyperactive-impulsive, combined, and unspecified). There is evidence that low levels of norepinephrine are found in the brains of people with ADHD. Norepinephrine and dopamine pathways are closely inter-related and deficiencies can affect 4 functional parts of the brain: frontal cortex, limbic system, basal ganglia, and the reticular activating system (see The Neuroscience of the ADHD Brain).
ADHD is a disorder that can be treated safely and with good efficacy. If undertreated or left untreated, it carries significant morbidity including an increased risk of substance abuse and mood disorders in adolescents. [Wilens: 2008] [Biederman: 2009] Some children who do not meet full criteria for diagnosis, and therefore would not be good candidates for medication, could respond to behavioral interventions, occupational therapy, and additional school supports. [Wolraich: 2019] Children with ADHD often are affected by other conditions including emotional or behavioral disorders, developmental disabilities, and other medical conditions. [Wolraich: 2019] According to the CDC, about 64% of those with ADHD have a comorbid mental, emotional, or behavioral disorder. There is also a higher prevalence of ADHD in those with autism spectrum disorder, tic disorders, and other learning disabilities.

Other Names & Coding

Attention deficit disorder (ADD) Attention deficit disorder with hyperactivity Attention deficit syndrome with hyperactivity

ICD-10 coding

F90.0, ADHD, predominantly inattentive type

F90.1, ADHD, predominantly hyperactive-impulsive type

F90.2, ADHD, combined type

F90.8, ADHD, other type

F90.9, ADHD, unspecified type

ICD-10 Coding for ADHD (icd10data.com) provides further coding details.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2013] generally designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits our including their codes or descriptions.

Prevalence

ADHD is one of the most common chronic disorders of childhood. According to the National Survey of Child’s Health in 2016, 9.4% of children in the U.S. have ever been diagnosed with ADHD. Worldwide, the pooled prevalence estimate is 7.2. [Thomas: 2015] [Wolraich: 2019] Boys are more than twice as likely as girls to have received a diagnosis of ADHD. [Visser: 2014]

Genetics

Heritability of ADHD is estimated at 74%, underscoring a high genetic influence. [Faraone: 2019] According to the American Academy of Pediatrics (AAP), a child with ADHD has a 1:4 chance of having a parent with ADHD, and is likely to have a sibling with ADHD. See Causes of ADHD: What We Know Today (HealthyChildren.org).
Currently, there appear to be several statistically significant genetic loci, with multiple copy number variants and fewer insertions and deletions, each contributing in small measure to the overall phenotype of an individual. [Faraone: 2019] Epigenetics likely play a large role as well. We know that premature birth, smoking during pregnancy, traumatic brain injury, heavy metal exposure (e.g., lead) can all predispose a child to developing ADHD symptoms.

Prognosis

Many children show improvement in adolescence, yet individuals may need support and treatment for this condition through adulthood. [Shaw: 2012] A subset of children will have worsening of symptoms as they reach adolescence and may go on to develop conduct disorder.

Practice Guidelines

Roles of the Medical Home

The medical home primary care clinician can treat most children with ADHD without subspecialty consultation or referral. Occasionally, additional expertise that includes psychologists, behavioral/developmental pediatricians, child/adolescent psychiatrists, and educational specialists, may be needed, particularly if the child has a comorbid condition. Even if children are referred elsewhere for diagnosis, ongoing evaluation and management should still be performed within the context of the medical home, and children with ADHD should be considered to have special health care needs. [Wolraich: 2019]
Ongoing communication with the child or adolescent, the parents, and teachers is essential for appropriate management. Periodic visits, in addition to well-child exams and acute-care visits, are generally needed to discuss status, manage medications, and evaluate and treat comorbid conditions. The AAP suggests that the medical home should:

Monitor and update family knowledge and understanding of ADHD.
Offer counseling to help support the family manage the child’s condition.
Provide developmentally appropriate education for the child about ADHD and updates as the child grows.
Be available to answer the family's questions.
Ensure coordination of health and other services, including therapies, school-based services, and supporting transition to adult services when appropriate.
Help families set specific goals in areas related to the child's condition and its effects on daily activities.
When appropriate, connect families with other families who have children with similar chronic conditions.

Clinical Assessment

Pearls & Alerts for Assessment

Inattentive presentation may go undiagnosed

Children with inattentive presentation may go undiagnosed for longer than the hyperactive/impulsive presentation, presumably because the symptoms are less bothersome to others. Among girls, the inattentive type is more common and may present simply as poor school performance that worsens when higher-level problem solving is required, typically in upper elementary grades.

Parent/teacher symptom assessment discrepancies

When family and teacher ratings of ADHD symptoms differ, additional sources, such as former teachers and coaches, may be helpful. Also, consider the setting: A teacher in a very structured classroom may not note symptoms easily observed in a less structured classroom or busy home. A child who expends a lot of effort to pay attention and behave appropriately at school may “fall apart” at home, resulting in more severe parent ratings.

Re-evaluation needed

Frequently re-evaluate to prevent under-treatment, monitor for side effects, and screen for comorbidities. [Wolraich: 2019]

Cardiac screening before stimulant use

The risk of serious cardiovascular events from stimulant and non-stimulant medications for ADHD is very low. The AAP does not recommend routine electrocardiogram or echocardiogram screening for heart disease prior to starting. Obtain additional evaluation if there are cardiac symptoms present or a concerning cardiac family history.

ADHD and autistic spectrum disorder

Children with autism may present with symptoms of ADHD during early elementary school, or earlier. If earlier, it may be difficult to differentiate from the autism symptoms. Children with autism spectrum disorder who present with significant hyperactivity, inattention, or impulsivity, despite adequate supports, should be evaluated for comorbid ADHD; 30-50% of children with ASD also suffer from ADHD symptoms. See Autism Spectrum Disorder for more about the diagnosis and treatment of ASD and comorbid conditions.

Screening

For the Condition

An evaluation for ADHD should be initiated if the child presents with inattention, hyperactivity, impulsivity, low school achievement for the child's IQ, and/or behavior problems. [Wolraich: 2019] The evaluation will require gathering information from people from at least 2 settings (e.g., parent, teacher, coach, and/or therapist). Use of specific ADHD screens is helpful, even rating scales based on DSM-IV criteria, which closely resemble the DSM-5 criteria. Many of these tools also screen for additional problems that can masquerade as or be comorbid with ADHD, such as autism spectrum disorder, anxiety, depression, defiant behavior, and learning and language concerns. It should be recognized that these measures are subject to the biases of the people completing them. Specific ADHD checklists include:

Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB): These 2002 versions are forms for initial and follow-up assessments for teacher and parent informants. Includes scoring instructions, no fee required.
NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) ( 3.9 MB) and NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) ( 3.6 MB): These 2002 forms, in Spanish (with English translation), are for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required. Newer Vanderbilt scales are available for purchase at Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Ed. (AAP); however, the 2002 forms still meet the new diagnostic criteria and are standard of practice among pediatrician and child psychiatrists.
Conners 3rd Edition: Administered to parents and teachers of children and adolescents 6–18 years old; self-report, 8–18 years old, and updated to align with DSM-5 diagnostic criteria for ADHD. According to [Wolraich: 2019], this tool also may be useful for preschoolers. Available for a fee.
ADHD Rating Scale-5 for Children and Adolescents: Contains 14, 5-minute scales with child (ages 5-10) and adolescent versions for teachers and parents (English and Spanish). Updated to DSM-5 diagnostic criteria for ADHD, and includes normative data for preschoolers based on DSM-IV. Available for a fee.

Brown Executive Function/Attention Scales (Brown EF/A Scales): ADHD and executive function assessment scales for reporters including self, parent, and teacher; ages 3-adult, each taking 10-15 minutes, digital or paper-versions available for a fee. Based on DSM-5.
Screening & Surveillance Tools and Family Educational Handouts (DB Peds) has information and checklists for ADHD screening and other developmental and behavioral disorders. See also Mental Health Screening for Children & Teens.
Be aware of the limitations of using screening tools, questionnaires, and scales to accurately assess and diagnose ADHD. When in doubt, rely on multiple sources of information from at least 2 settings and align the input with DSM-5 diagnostic criteria.
Periodic repetition of behavior scales completed by parents and teachers can be help track response to medication and behavioral interventions. These are often completed every 6-12 months or more often during medication titration. It is important to pick a time during the school year when the teacher has had some exposure to the student. Subjective reports can also be very helpful. Obtaining useful input from teachers of students in upper grades can be challenging due to more limited exposure to the student; consider multiple sources.

For Complications

If treatment does not seem to be effective, consider using a validated screening tool to identify and help diagnose comorbid conditions, such as anxiety, depression, oppositional-defiant disorder, conduct disorder, substance use or abuse, learning disorders, mood disorders, language disorders, sleep problems including sleep apnea, tics, other neurological disorders including autism, and trauma. It is very important to treat comorbid conditions first, before assuming medication is not effective for ADHD symptoms. Symptoms commonly mistaken for ADHD symptoms are also present in the aforementioned conditions.
The following screening tools may be helpful:

Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh): Child self-assessment with 41 (brief) questions that have fill-in circles for possible answers. Contains scoring information, no fee required.
Generalized Anxiety Disorder Scale (GAD-7): A 7-question screening tool about anxiety, completed by patient. General population screen, can be used in teens. Free at Patient Health Questionnaire (PHQ) Screeners (select screen from drop-down menu on right).
Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) ( 47 KB): Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.
Patient Health Questionnaire-9 (PHQ-9): Nine-question depression screen with scoring information that can be used with adolescents. Questions are based on DSM-IV diagnostic criteria for major depressive disorder. Free at Patient Health Questionnaire (PHQ) Screeners (select screen from drop-down menu on right).
Severity Measure for Depression - Ages 11–17 ( 228 KB): Adolescent-focused, 9-question, depression screen with scoring information. No fee required.
Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB): Depression screening tool, with 20 questions, takes about 10 minutes to complete. No fee required.
DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) ( 367 KB) and DSM-5 Self-Rated Level 1 Symptom Measure—Age 11–17 (APA) ( 250 KB): Free, 25-question assessments for initial patient interview and monitoring treatment progress. Includes scoring instructions.
Achenbach System of Empirically Based Assessment (ASEBA): A variety of screening tools are available for a fee. (Child Behavior Checklist (CBCL))
SEEK Parent Screening Questionnaire (PSQ-R): Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions; free to download in English, Chinese, Spanish, and Vietnamese.
Behavior Assessment System for Children, Third Edition (BASC-3): Assessment for children 2-21 years of age that takes about 15 minutes to complete; available for purchase.
Car, Relax, Alone, Friends, Forget, Trouble (CRAFFT 2.1/2.1+N): A 6-question behavioral health screening tool recommended by the American Academy of Pediatrics' Committee on Substance Abuse to screen adolescents for high-risk alcohol and other drug use disorders. Available for free download in 13 languages.

Presentations

Presentation may vary considerably based on subtype of ADHD (predominantly inattentive, predominantly hyperactive-impulsive, combined), developmental age, severity, environment, comorbid conditions, and other factors. Young children with the inattentive type may have significant difficulty attending to the reading of a picture book, whereas adolescents may have difficulty finishing homework and performing required tasks. Inattentive students may not be noticed until they start falling behind in school, often in the upper elementary grades when problem-solving becomes more complex.
Preschoolers with the hyperactive/impulsive type may constantly be physically active, running in circles, and climbing on furniture, whereas adolescents with this type may engage in risky behaviors. Hyperactive children are typically noticed earlier due to disrupting their classrooms or getting into trouble at home.
It is important to consider developmental age when deciding whether the level of inattentiveness and/or hyperactivity is abnormal. A child with the cognitive level of a 5-year-old, although he may be twice that age, usually has the activity level and attention span of a 5-year-old. It is also important to take a history of the symptoms over time, as children who start with symptoms of hyperactivity in preschool may present with more inattentive/impulsive symptoms in adolescence.

Diagnostic Criteria

When DSM-5 was updated in 2013, minor changes were made to diagnosis criteria for ADHD, including onset of symptoms before age 12 instead of age 7, and fewer symptom criteria needed to diagnose adolescents than children. (See ADHD and DSM-5 (APA) ( PDF Document

259 KB) for 2 pages of DSM-5 updates.)
DSM-5 Criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Based on types of symptoms, 3 presentations of ADHD can occur:

Predominantly inattentive presentation: Six or more symptoms of inattention (listed below) for children up to age 16, or 5 or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
- Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
- Has trouble holding attention on tasks or play activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked)
- Has trouble organizing tasks and activities
- Avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period (such as schoolwork or homework)
- Loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
- Is easily distracted
- Is forgetful in daily activities
Predominantly hyperactive-impulsive presentation: Six or more symptoms of hyperactivity-impulsivity (listed below) for children up to age 16, or 5 or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
- Fidgets with or taps hands or feet, or squirms in seat
- Leaves seat in situations when remaining seated is expected
- Runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
- Is unable to play or take part in leisure activities quietly
- Is "on the go" acting as if "driven by a motor"
- Talks excessively
- Blurts out an answer before a question has been completed
- Has trouble waiting for his/her turn
- Interrupts or intrudes on others (e.g., butts into conversations or games)
ADHD combined type: If enough symptoms of both inattention and hyperactivity-impulsivity criteria were present for the past 6 months.
In addition, the following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several symptoms are present in 2 or more settings (e.g., at home, school or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with or reduce the quality of social, school, or work functioning.
The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Presentation may change over time. Obtaining information from 2 sources (such as home and daycare or preschool) for preschool-aged children to make a diagnosis of ADHD may be difficult, but is necessary. [Wolraich: 2019]

Clinical Classification

Presentations: [American: 2013]

ADHD predominantly inattentive presentation
ADHD predominantly hyperactive-impulsive presentation
ADHD combined type

Severity: [American: 2013]

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms of functional impairment between "mild" and "severe" are present.
Severe: Many symptoms in excess of those required to make diagnosis, or severe symptoms that are particularly severe and result in marked impairment in social or school functioning.

Differential Diagnosis

Other diagnoses that should be considered are listed below:

Seizures/Epilepsy, particularly Childhood Absence Epilepsy
Hearing Loss and Deafness, including middle ear infections causing hearing loss or auditory processing disorder, may contribute to inattention. Any suspicious symptoms or findings should trigger evaluation for hearing deficits.
Sleep Issues may cause daytime difficulties, such as hyperactivity and inattention. Consider further evaluation if history and physical exam (e.g., large tonsils) suggest obstructive sleep apnea.
Tourette Syndrome could lead to speaking out inappropriately or repetitive noises, which could be confused with the impulsiveness or repetitive noises seen with ADHD.
Learning disabilities may be the etiology of poor school performance and may accompany ADHD. If these are a concern, refer for psychological testing. Children with learning disabilities will often score significantly higher on IQ testing compared to achievement testing.
Depression or anxiety are similar psychiatric problems that may occur with ADHD or cause symptoms of ADHD that may resolve when the primary disorder is treated. If concerned, consider a referral to child psychiatry or psychology. Ask about life changes causing anxiety or difficulty concentrating, such as a parent's death, divorce, etc.
Autism Spectrum Disorder may present like ADHD, including difficulties with focus on non-preferred activities. Children with ADHD may also present with social skill deficits. [Kotte: 2013] ADHD and autism spectrum disorder may be genetically linked. [Rommelse: 2010]
Substance Use Disorders can present like ADHD with both inattention and hyperactivity, although the pattern is more likely to occur sporadically, timed with the substance use.
Side effects of medication can cause changes in behaviors; however, symptoms may align with the start of a new medication or a dose change.
Trauma/childhood adverse events can lead to hypervigilance and arousal that can be mistaken for ADHD or can overlap with actual ADHD. [Kaya: 2008] Screening for adverse events in childhood can help in the differential diagnosis as well as provide insight into ways to tailor support for struggling families. See Toxic Stress Screening and the Foster Care module for more information.
Hyperthyroidism can cause nervousness, weight loss, decreased concentration, mood swings and outbursts, and other symptoms; however, most symptoms are reversible with appropriate treatment.

Medical Conditions Causing Attention-Deficit/Hyperactivity Disorder (ADHD)

Medical increasing risk of ADHD include: (see Causes of ADHD: What We Know Today (HealthyChildren.org))

Fetal alcohol or nicotine exposures can contribute to ADHD symptoms. See Fetal Alcohol Spectrum Disorders for more information. Prenatal methamphetamine exposure has been associated with reduced executive function and processing speed in children. [Smith: 2015] [Brinker: 2019]
Traumatic Brain Injury or post-concussive attention problems
Prematurity
Environmental toxins such as lead, organophosphates, or pyrethroid pesticides can be linked to behaviors, although toxins are rarely thought to be the sole cause of ADHD. [Weydert: 2018]
ADHD has not been found to be caused by: immunizations, allergies, excessive sugar intake, or food additives, or maternal iodine status during pregnancy. [Levie: 2020]

Comorbid & Secondary Conditions

Comorbid conditions include:

The clinician should suspect a comorbid condition under the following conditions:

Lack of improvement in behavioral symptoms despite appropriate treatment and services for ADHD
Persistent school underachievement or school avoidance
Parental concern for a comorbid condition
Low self-esteem, anxiety, irritability, sleep disturbance, or sadness
Negative/oppositional behaviors
Suspected or reported substance use

Comorbid conditions can vary by the developmental stage of the child. For a detailed discussion, see [Pliszka: 2006].

History & Examination

Evaluation of the child with possible ADHD requires time, the use of checklists, and more than 1 information source, for instance, parents and teachers. Many children will require more than 1 visit - the first to discuss the diagnosis and the second to go over the information gathered and begin treatment, if necessary. If the child has a complicated clinical picture and referral for a diagnostic evaluation is made to a specialist, follow-up back in the medical home. [Wolraich: 2019] Critical components of ongoing assessment include current functioning at home and school and success, and/or side effects of treatment methods (behavioral and medication-based). See NICHQ Vanderbilt ADHD Primary Care Initial Evaluation Form ( PDF Document

1.7 MB) for a printable form.

Current & Past Medical History

Take a full medical history that includes heart problems and motor and vocal tics. Ask about:

Previous illnesses or accidents that may contribute to attention problems
Recent medical problems, growth, appetite, and possible side effects of medication for ADHD
History of mood or anxiety disorders
Adherence to prescribed medication or therapies
Staring, brief eye-blinking, or other automatisms - consider absence seizures if “spacing out” events are occurring multiple times per day with a clear interruption of activity, such as speaking, walking, or drinking
Sleep onset and duration, as well as the presence of snoring or restless sleep
Toileting and elimination

Family History

Ask about a family history of ADHD, associated conditions, cardiovascular disease, sudden death, and mental health disorders, including bipolar disorder and psychosis. Growing evidence suggests that risk of cardiovascular disease and sudden cardiac death is extremely low with the use of both stimulant and non-stimulant ADHD medications. [Martinez-Raga: 2013] It is helpful to ask about experiences with medications used to treat ADHD in other family members; this can guide selection of initial therapy.

Pregnancy/Perinatal History

Ask about any pregnancy or perinatal problems that may contribute to poor intellectual and behavioral functioning.

Developmental & Educational Progress

Assess developmental milestones and intellectual and social functioning in family and daycare or school settings. Be aware that age and interest level will affect children's ability to attend to tasks; video games and other highly stimulating activities are not good indicators of a child's ability to attend. Assessment should include documentation of:

ADHD DSM-5 criteria by parent interview or by use of a specific checklist, such as the Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB)
Specific symptoms by use of a checklist by teacher, found in Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB)
Age at which the problem behaviors began, the settings in which the behaviors occur, and to what degree the child is impaired by the symptoms

Ask families to bring current school records to evaluate success of treatment. Also, obtain past schoolwork and report cards, a teacher narrative that discusses behavior, a learning assessment, degree of impairment, and the teacher's interventions to deal with the problems. If there is an Individualized Education Plan or 504 Plan in place at the school, ask for copies of testing as well as the plan.
Be sure to inquire about fine and gross motor skills, as many children with ADHD have poor coordination and could meet criteria for a developmental coordination disorder. [Wolraich: 2019]
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Social & Family Functioning

Inquire about:

Recent changes in the family that may be causing anxiety or depression
Behavior and functioning within the family and elsewhere (e.g., church or during extracurricular activities)
Consistency or changes of medication
Use of complementary/alternative treatments
Parenting challenges

Physical Exam

General

Assess general appearance and interaction with the environment.

Vital Signs

HR | RR | BP - Resting tachycardia or hypertension may indicate hyperthyroidism or another hypermetabolic state that may present with hyperactivity. Increased heart rate and hypertension can occur with stimulant use. [Hailpern: 2014] Use of alpha agonists, such as guanfacine or clonidine, can lower blood pressure and can cause rebound hypertension if discontinued abruptly. [Committee: 2001]

Growth Parameters

Ht | Wt | BMI - Because stimulant medications may cause appetite suppression, follow weight closely. Although stimulants may slow height to some extent when first started, this effect appears to decrease over time. Some studies have shown a slight decrease in projected height with long-term stimulant use, although more data needs to be collected to confirm this finding [Harstad: 2014] [Troksa: 2019]; it is still prudent to regularly measure children’s height and weight while on medications.

HEENT/Oral

Check for middle ear fluid, which, if persistent, may cause conductive hearing loss. Assess tonsillar size and potential for obstruction and sleep disturbance. Also, check thyroid size, consistency.

Neurologic Exam

Children with ADHD should have normal neurologic exams, although so-called "soft neurologic signs," such as clumsiness or motor overflow, may be present.

Testing

Sensory Testing

Perform routine vision screening and, if indicated, hearing screening.

Laboratory Testing

Lab testing is not indicated unless there are specific concerns from the medical history, such as lead exposure or symptoms of hyperthyroidism. Consider checking ferritin as a marker of iron deficiency, as this can be associated with disordered sleep, which in turn can negatively impact daytime attention and behavior. [Abou-Khadra: 2013] [Cortese: 2009] If malnutrition is suspected of playing a role in the child’s performance, specific nutritional markers could be tested as well. For example, some experts advise considering labs to evaluate for low ferritin, zinc, and red blood cell magnesium because these factors have each been associated with a worsening of ADHD symptoms in certain subsets of children. [Weydert: 2018]

Imaging

Rarely, children with absence epilepsy may present with ADHD signs. EEG is necessary only if there is a clear pattern of seizures.

Other Testing

Testing for intelligence: Usually performed by the school, an IQ test, such as the Wechsler Intelligence Scale for Children [WISC], and a learning disability test, such as the Woodcock-Johnson, may be helpful when there seems to be a discrepancy between ability and performance.
Echocardiogram and EKG: In 2008, the American Heart Association recommended that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. [Vetter: 2008] However, the 2019 clinical practice guidelines published by the AAP recommends using clinical judgment regarding screening when there are cardiac symptoms or a significant cardiac or sudden death history in the family. [McPherson: 2004] See Stimulants and Cardiovascular Monitoring (AAP) for further discussion.

Specialty Collaborations & Other Services

Developmental - Behavioral Pediatrics (see NM providers [2])

Consult for expert assessment in diagnosing complicated cases, such as for discriminating symptoms related to developmental delay, or for diagnosis of younger children.

Psychiatry/Medication Management (see NM providers [3])

Consult to help with diagnosis and management of situations complicated by underlying medical issues, such as a history of traumatic brain injury, comorbid psychiatric conditions such as mood or anxiety disorders, or for children who fail to respond to standard therapies.

General Counseling Services (see NM providers [10])

This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.

Neuropsychiatry/Neuropsychology (see NM providers [1])

Consult when full psychological testing is not available through the school district or if learning disabilities are suspected. May also be helpful in designing and implementing behavioral plans and therapies.

Pediatric Cardiology (see NM providers [3])

Consult if there are concerns about a child's cardiac status that would affect treatment and management decisions.

Treatment & Management

Overview

Management principles vary with the age of the individual: [Wolraich: 2019]

Preschool children (4-5 years old) should first receive parent training in behavior management (PTBM) and/or behavioral classroom interventions. If this is not successful and function continues to be moderately to severely impaired, methylphenidate may be considered.
For school-aged children 6-11 years old, FDA-approved medication therapy, PTBM, and educational supports are recommended. First-line pharmacotherapy includes stimulant medications. For those that cannot tolerate stimulants or if parents are hesitant to start a stimulant, second-line therapy includes alpha-agonists such as clonidine and guanfacine as well as atomoxetine. Tricyclic antidepressants (TCAs) and bupropion have been shown to have some efficacy as well on inattention. Educational interventions include structuring the school environment, class placement, instructional placement, and behavioral supports, and may necessitate a 504 rehabilitation plan or individualized educational plan (IEP) to be implemented (see School Accommodations: IEPs & 504s for more information).
For adolescents, similar treatments are recommended, but the consent should be obtained before medicating. Long-acting guanfacine, atomoxetine, or clonidine, or stimulants that have lower abuse potential, such as lisdexamfetamine (Vyvanse) and OROS extended-release methylphenidate (Concerta), can be considered. [Wolraich: 2019] Involve the adolescent in the treatment plan.

Medical home providers should be watchful for unsuccessful or inadequate therapy, or improvement that is not sustained. If there is inadequate response, the dosage and treatment compliance should be examined.
Consider using a validated screening tool to identify and help diagnose comorbid conditions. See Screening for Comorbid Conditions, above, for screening tools. The following Portal pages provide diagnosis and management information for comorbid conditions and ADHD:

Pearls & Alerts for Treatment & Management

Stimulant use & cardiac events

AAP guidelines indicate that evidence does not clearly demonstrate an increased risk of serious cardiovascular events, such as MI, QT prolongation, sudden death, or ventricular arrhythmias, in children using stimulant medication.

Tics, Tourette syndrome, and stimulant use

Recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics. Alpha agonists, including guanfacine and clonidine, have beneficial effects on both tics and ADHD. For those whose tics are exacerbated by stimulants, treatment with atomoxetine or an alpha agonist may be considered. Treatment with desipramine can lower tics but has other safety concerns, so it is generally avoided. [Osland: 2018] Do not expect medications to resolve tics fully. [Pringsheim: 2019]

Stimulant drug misuse

Frequent or early requests for stimulant refills may suggest misuse. Prescribers should carefully monitor their prescription refill requests.

Systems

Pharmacy & Medications

Stimulant medications are known to decrease symptoms of ADHD [Chavez: 2009] and are recommended as first-line treatment for children 6 years of age and older by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. [Wolraich: 2019] [Pliszka: 2007] Stimulants work on dopamine and norepinephrine receptors in the brain. Approximately 75% of children with ADHD will respond to stimulant treatment if dosing is correct. Start at a low dose in either stimulant class (methylphenidates or amphetamines), and then every week increase the dose until the optimum effect is achieved. The maximum dose is reached for the child's age and weight or until side effects intervene. Side effects tend to be dose dependent, so if side effects occur, lower the dose to the last dose where the patient did not experience those side effects. Consider using a longer-acting stimulant for school-aged children to avoid re-dosing at school. A short-acting stimulant can be given in the early afternoon if a longer-acting formulation wears off too early to complete homework or other activities after school. Shorter-acting stimulants may be useful if appetite is significantly impaired; for example, school personnel may dispense a second dose to a student after lunch if authorized in the health care plan. If one stimulant is not effective at the highest tolerable dose, try another stimulant in the other class. Most children will respond favorably to either the first or second stimulant class. Stimulants may be prescribed for some children for school days or during the school year only, depending on circumstances and child or family preference. Medication holidays can be useful for children who have an excessive decline in weight or height percentiles, e.g., crossing 2 or more percentile lines on the growth chart.
Prescribers should carefully monitor their prescription refill requests; frequent or early requests for stimulant refills may suggest misuse. Stimulants with relatively less abuse potential include lisdexamfetamine (Vyvanse), methylphenidate patch (Daytrana), or OROS extended-release methylphenidate (Concerta). Consult your state’s controlled substance database to verify how frequently patients fill prescriptions and who else has prescribed their medications.
Medication tables for stimulants and non-stimulants can be found at:

ADHD Medication Tables ( 152 KB)

The tables provides information about different classes of medications, dosing options, estimated duration of effect, and timing of immediate vs. longer-acting medication release (when available). They also includes formulations, such as chewable, liquid, patch, capsules with contents that can be sprinkled, and tablets that can be divided, flavors, generic and brand options for prescribing, and FDA-approval status.

Non-stimulant medications approved by the FDA for ADHD, such as atomoxetine (Strattera), extended-release clonidine (Kapvay), and extended-release guanfacine (Intuniv) may also be considered. The AAP recommends their use if stimulants (one from each class) have been tried and are not successful. Atomoxetine is a selective norepinephrine reuptake inhibitor and can cause nausea and sleepiness. Guanfacine and clonidine are norepinephrine receptor type alpha-2 agonists that can cause sedation and hypotension (more so in clonidine), and both are available in short and long-acting formulations. These medications need to be used daily without medication holidays. Extended-release guanfacine and clonidine have been shown to have efficacy as add-on therapies with stimulants. These non-stimulant medications for ADHD can take several weeks for full effect.
Side effects for both stimulant medications classes include mild stomachaches and headaches, depressed appetite and weight loss, difficulty sleeping, increased blood pressure and heart rate, and irritability/anxiety. FDA labels for stimulants include warnings and precautions for those with a cardiac abnormality or condition or significant side effects (e.g., poor growth, tic exacerbation, psychosis, and peripheral vasculopathy, seizures, serotonin syndrome, and visual disturbances. (See Pearls and Alerts section, above.) Rare side effects can also occur; the FDA warns that methylphenidates and atomoxetine can cause priapism, and atomoxetine can cause suicidality. Rarely, psychiatric symptoms, such as manic symptoms, paranoia, and hallucinations, may occur. Use of stimulant patches can result in changes to underlying skin pigmentation. For more information, see Safety Review of Medications Used to Treat ADHD in Children and Young Adults (FDA).
Effects of stimulants on comorbid conditions need further study. Some of what is known are as follows:

Cardiac problems: The FDA (Safety Review of Medications Used to Treat ADHD in Children and Young Adults (FDA)) advises that “stimulant products and atomoxetine should generally not be used in patients with serious heart problems, or for whom an increase in blood pressure or heart rate would be problematic.” Regular monitoring of heart rate and blood pressure is advised. While one large retrospective study showed no increase in serious cardiac events associated with stimulants used to treat ADHD, a previous study associated these medications with a small to moderate risk of sudden cardiac death, which the FDA has not excluded.
Fetal alcohol spectrum disorders (FASD): Children with FASD often have problems with attention and impulsivity; stimulant treatment may help, or it could make symptoms worse.
Tics/Tourette syndrome: FDA package labeling for stimulants indicates that tics may be exacerbated by stimulants; however, recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and can be helpful in some tic disorders. [Osland: 2018] Untreated ADHD may be more troubling to the child than the tics themselves. [Erenberg: 2005] However, monitoring of tics before and after starting stimulants is warranted due to individual variation. [Tourette's: 2002] Consider alternatives such as atomoxetine or alpha agonists if tics are exacerbated while on stimulants.
Autism: Children with autism spectrum disorder have a decreased response rate to ADHD medications and an increased rate of reported side effects. Despite these concerns, recent information suggests that medication may be helpful. Given their sensitivities to side effects, a general rule of thumb regarding psychotropic medication for those with autism spectrum disorder is to 'start low and go slow.' Cautious monitoring for unexpected effects on the child's functioning (e.g., an increase in anxiety symptoms) should be maintained. [Posey: 2007] There is growing evidence that ADHD and autism spectrum disorder may be linked genetically. [Rommelse: 2010] [Ronald: 2008] See Evaluation and Medication Choice for ADHD Disorder Symptoms in Autism Spectrum Disorders (AAP) for treatment of comorbid ADHD and autism spectrum disorder. [Mahajan: 2012]
Other neurologic conditions: ADHD symptoms are often observed in children with neurologic conditions, such as neural tube defects, muscular dystrophy, cerebral palsy, intellectual disability, and various genetic syndromes. Stimulants are often helpful for these symptoms in children with intellectual disability [Aman: 2003], but not necessarily in children with velocardiofacial syndrome (22q11.2 Deletion Syndrome). [Antshel: 2007] Treatment for ADHD symptoms in neurologic and other conditions should be accompanied by close monitoring to assure response and limit side effects.

For preschool-age children, the only stimulant approved for use by the FDA is dextroamphetamine; however, methylphenidate is the medication class recommended in this age group by the AAP in the latest guidelines. [Wolraich: 2019] Depending on the functioning of the child and symptoms of ADHD, some providers will use stimulant medications "off-label" for younger children. Parent training in behavior management (PTBM) or educational behavior interventions are recommended as first-line management, and medications should be used only if not successful. None of the non-stimulant medications is currently licensed for use in preschoolers.
Off-label medications are occasionally used to manage ADHD, particularly in patients with comorbidities, such as depression, include bupropion (Wellbutrin), modafinil (Provigil or Nuvigil), and tricyclic antidepressants, such as desipramine (Norpramin) and imipramine (Tofranil). [American: 2013]
If treatment fails, consider:

Under-treatment: Medications should be titrated to maximum doses without adverse side effects instead of relying on milligram-per-kilogram recommendations to ensure adequate treatment of symptoms.
Noncompliance with medication: This may be more common in families where parents also have symptoms of ADHD. [Wolraich: 2019]
A comorbid condition

For more information and updates on FDA-approved medications for ADHD, see FDA-Approved Drugs in Attention Deficit/Hyperactivity Disorder (ADHD - Pediatric) (CenterWatch), and scroll to bottom of the page. ADHD: Parents Medication Guide (AACAP) ( PDF Document

1.1 MB) may be helpful for parents. Medications used for ADHD, along with dosing guidelines and pharmacokinetics, can be found at Algorithm for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD (AAP) ( PDF Document

406 KB) on page S12. Finally, The Child Medication Fact Book for Psychiatric Practice (2018) is an excellent resource for information about psychiatric medications.

Specialty Collaborations & Other Services

Developmental - Behavioral Pediatrics (see NM providers [2])

Consult for guidance on managing more complex cases, such as for children who have comorbid conditions, intellectual disability, or difficult-to-treat ADHD.

Psychiatry/Medication Management (see NM providers [3])

Consult to help with diagnosis and management of situations complicated by underlying medical issues.

Mental Health/Behavior

Although stimulant medications are the mainstay of ADHD treatment, behavior therapy, parent training, and classroom behavior interventions have an evidence-based role in managing ADHD. In some cases, behavior therapy is recommended as first-line in mild to moderate cases of ADHD in children, when the family prefers not to use medications, or in children younger than 6 years old. In general, for ADHD without comorbid conditions, training parents in behavior management is considered more effective than putting the child into therapies to better understand their feelings or thought processes. See also [Wolraich: 2019] and [Shrestha: 2020] for summaries and links to various parent training in behavior management (PTBM) approaches, including positive parenting programs, parent-child interactive therapy, Incredible Years, the Kazdin method, and others.
Most children with ADHD respond to more structure and fewer distractions in the environment. Behavior management takes advantage of this and includes the use of time-outs, a token economy, and daily school report cards while teaching the parents to respond consistently to a child's misbehavior. For instance, when a child comes home from school, a parent should inquire about homework, set a time and place for the child to do the homework, keep external noise (e.g., television) to a minimum, and then check that the homework is completed. Parents should be reminded that the long-acting preparations of stimulant medication are beginning to wear off in the afternoon, so homework attempted sooner rather than later would probably be more successful. Classes are often available locally through school systems and mental health or other agencies to train parents in achieving directed supervision and in managing behavioral problems.
Before starting medications, work with parents and school to identify 3 to 6 target behaviors or outcomes based on the needs and strengths of the child. The goals should be realistic and measurable. These may include: [Wolraich: 2019]

Improvements in relationships with parents, siblings, teachers, and peers
Decreased disruptive behaviors
Improved academic performance, particularly in volume of work, efficiency, completion, and accuracy
Increased independence in self-care or homework
Improved self-esteem
Enhanced safety in the community, such as in crossing streets or riding bicycles

For a child who is not finishing homework, a goal might be to finish 75% of homework. For another child, 3 days without fighting with siblings might be a goal.
The medical home should then collaborate with the family to develop a comprehensive treatment plan, which might include stimulant medication and behavioral management, as well as treatment of associated conditions.
Talking to Parents About Behavioral Treatment for ADHD offers more detailed advice on how to talk to parents about behavioral treatments for ADHD.

Specialty Collaborations & Other Services

General Counseling Services (see NM providers [10])

This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.

Pediatric Neurology (see NM providers [5])

Referral may be helpful in managing ADHD, particularly if there are concerns about head injury or other neurologic conditions, such as seizures.

Learning/Education/Schools

School performance and testing reports may be very helpful in assessing the impact of the attention deficit and will provide a baseline to measure response to treatment. Periodic use of checklists and/or rating scales can assist in guiding therapy adjustments.
The school will usually conduct an evaluation to determine if the child qualifies for special education services. If so, the school, with parental input, will develop an individualized education program (IEP). If the child does not qualify for special education services, he or she may qualify for a 504 plan for children with disabilities who need accommodations.
The medical home may be involved in planning and evaluating the child's school services. Direct communication is often very helpful for both the provider and the school. Signed consent from the parents should be in place before these conversations or meetings take place.
Teachers can help the child with ADHD by setting clear goals, decreasing distractions, offering subtle reminders to stay on task, and providing more structure. A daily or weekly "report card" or "contract" system with positive reinforcement for reaching goals can also help. For some children, a 504 plan may provide for desired classroom adaptations, such as preferential seating and decreased workload. See School Accommodations: IEPs & 504s in the Portal's For Physicians & Professionals section for more detail on IEPs and 504 plans. Letter Requesting Assessment from Teacher (AAP) is a sample of a request for a teacher to complete a behavior assessment for their student. Attention-Deficit/Hyperactivity Disorder (ADHD) for Educators may also be helpful.
Parents should be encouraged to meet with the child's teacher early in the year to discuss the child's diagnosis, needs, and what has worked or failed in the past. This is particularly true if the family is changing school districts or if the child is transitioning to middle or high school. Ongoing meetings, not necessarily at the time of parent-teacher conferences, may also be helpful. Families should know that many colleges and universities have programs to support students with various disabilities throughout their years in higher education. See also Specific Learning Disability.

Specialty Collaborations & Other Services

School Districts (see NM providers [90])

The medical home provider can work with the school to ensure appropriate services are provided to qualifying students, as well as to obtain periodic feedback on how treatment interventions are affecting the child’s school participation and performance. Contact the district officials if the school is unable or unwilling to offer needed services. The child’s family should authorize a release of information to allow two-way communication between the school and the physician’s office.

Funding & Access to Care

Barriers to treatment of ADHD may include lack of insurance and other systemic barriers, including language and access to medication. [Rushton: 2004] Copays can be high, even when insured. Financial support for the cost of some medications may be available through the drug manufacturers. Consequences of non-treatment include poor achievement, decreased self-esteem, poor relationships, increased morbidity from accidents, and increases in comorbid problems, such as conduct and mood disorder. [Biederman: 2009]

Specialty Collaborations & Other Services

Medical Care Expense Assistance (see NM providers [39])

There are a variety of organizations that either provide health care or help find or fund it.

Health Insurance Counseling and Advocacy (see NM providers [5])

Organizations that can help families find insurance and healthcare options based on their individual situations.

CHIP, State Children's Health Insur Prog (see NM providers [0])

The Children's Health Insurance Program, or CHIP, is a state health insurance plan for children. Depending on income and family size, working Utah families who do not have other health insurance may qualify for CHIP.

Medicaid (see NM providers [8])

A combined federal and state program administered by the state that provides medical benefits for individuals and families with limited incomes who fit into an eligibility group that is recognized by federal and state law.

Prescription Drug Assistance (see NM providers [20])

Many organizations can provide information on and links to prescription assistance programs, or discounts and/or support toward prescription costs.

Financial Assistance, Other (see NM providers [19])

Local and national organizations and programs can help families receive financial support to help with their child’s chronic conditions.

Complementary & Alternative Medicine

Integrative medicine methods support a holistic approach to health care. They encompasses mind-body practices (e.g., yoga, meditation, mindfulness, music therapy), biologics (such as nutrition and herbs), manipulative and body-based practices (e.g., chiropractic, osteopathic), alternative (non-Western) medical systems (e.g., Ayurveda, Traditional Chinese Medicine), and energy-based systems (e.g., acupuncture). Clinicians should ask families about any complementary or alternative therapies they are using to manage symptoms of ADHD. Popular practices include special diets, herbal supplements, homeopathic treatments, vision therapy, chiropractic adjustments, yeast infection treatments, motion-sickness medication, metronome training, auditory stimulation, applied kinesiology (realigning bones in the skull), and brain wave neurobiofeedback. Many of these practices are not proven effective and/or are detrimental to the child's health.
A 2020 review of non-pharmacologic approaches to ADHD showed selected benefits for different integrative medicine approaches. Mindfulness-based approaches, such as meditation, yoga, and Tai Chi, had some benefits for attention and self-regulation. Sleep hygiene (e.g., regular sleep-wake schedule and bed-time routine, avoiding screens and technology and limiting lighting in the room, room darkening and cooling, considering white noise or a weighted blanket) is important. Daily exercise is beneficial. For a more in-depth review of integrative approaches to managing ADHD, see [Weydert: 2018] and [Shrestha: 2020]. The following list of books was compiled in 2020 from input by various members of the AAP’s Section on Integrative Medicine:

Neurofeedback and technology-based interventions: Although there is some support for neurofeedback (a specific kind of biofeedback) for ADHD to increase beta waves in the brain and help with plasticity, this therapy historically has not been covered by insurance, has significant out-of-pocket expenses for the family, and its effects are not consistently maintained once treatment has been discontinued. Examples include the electroencelphalogram (EEG)-based brain-computer interface, which demonstrated positive results on attention in randomized controlled studies. [Lim: 2019] This type of system may rely on game software, electrodes attached to the child, and in some studies, immersion in a virtual reality environment. [Ali: 2015] Although this type of technology sounds interesting, it is not widely accessible.
In 2020, the FDA cleared an evidence-based video gaming software, EndeavorRx, to treat ADHD. [Kollins: 2020] This system will be available by prescription for children 8-12 years old with inattentive or combination-type ADHD. Other game systems targeting attention have been under investigation as well and may provide additional treatment options in the future. [McDermott: 2020] These systems do not rely on electrodes and virtual reality, so they are more amenable to use outside of a research setting. Even lower-tech, downloadable apps, such as Decoder (available as part of the Peak Brain Training App), have demonstrated approved attention via application of cognitive training “games” in young adults; however, the long-term impact has not been demonstrated. [Savulich: 2019]
In 2019, the FDA approved the first non-drug medical device for treatment of ADHD in children ages 7-12 who are not taking prescription ADHD medications. This device, called the Monarch eTNS (external Trigeminal Nerve Stimulation) System , delivers low-level electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. Two initial studies demonstrated positive effects. [McGough: 2019] [McGough: 2015]
Numerous other “brain training” programs have been developed loosely based on principles of balancing the brain through stimulation of underdeveloped neural pathways; however, they are time-consuming, expensive, and not based on high-quality evidence. For a collection of articles about different interventions, see Brain Training (CHADD).
Diet and nutrition: Results from studies evaluating the effects of food elimination diets on ADHD have been mixed. At this time, food elimination diets, including avoidance of food dyes or sugar, are not considered evidence-based. Yet, if parents observe an improvement in behavior with the elimination of food dyes, artificial food additives, gluten, preservatives, or excessive sugar in the diet, limiting or removing these is unlikely to harm the child.
Supplementation of omega-3 fatty acids and replenishment of low vitamin D, ferritin, magnesium, or zinc may benefit certain populations; however, there is not much guidance on testing or supplementation. [Weydert: 2018]

No Related Issues were found for this diagnosis.

Ask the Specialist

Although clinical practice guidelines recommend starting with stimulant medications for first-line therapy, when would you be more likely to treat with something else first (and what would you use)?

The alpha-2 agonists can be very useful in children with developmental disabilities, such as autism spectrum disorder, because of a lower side effect profile and higher tolerability in children with comorbid conditions like tics, anxiety, or sleep problems.

Which stimulant medications are the least likely to be abused or sold illegally?

Long-acting stimulant medications, such as Vyvanse and Concerta, have lower abuse potential because of their mechanism of release; the Daytrana patch is also a good stimulant option to use when there are concerns about abuse. Non-stimulant options, such as Intuniv, Kapvay, and Strattera, can also be useful when concerned about the potential misuse of stimulant medications.

Is there any special guidance on management of ADHD in children with autism?

Children with autism have a poorer response to stimulant medications with more side effects than typically developing children with ADHD. Starting with lower doses and titrating up slowly is very important in this group of patients. Non-stimulant medications, such as the alpha 2 agonists, may also be a good option. See the 2012 guidelines for treatment of ASD and ADHD at [Mahajan: 2012] for more information.

Why is my patient having such difficulty with tantrums? Should I be worried about an additional diagnosis?

If there are significant behavioral concerns despite adequate supports and/or medication management, it is important to consider additional or alternative diagnoses including oppositional defiant disorder, conduct disorder, mood or anxiety disorder, and autism spectrum disorder. However, children with ADHD can also have significant difficulties with executive functioning, which not only can affect organization and planning, but also can affect an individual's ability to shift between tasks, self-regulate, and adapt to new information or situations. Executive functioning skills only show mild improvement with medication management; they require behavioral interventions and supports.

My patient has been diagnosed with sensory processing disorder/sensory integration disorder and has significant difficulties with attention and hyperactivity. Can the sensory processing disorder explain this all, or do they also have ADHD?

Although many children have sensory processing difficulties that affect their day-to-day lives, sensory processing disorder is not a recognized stand-alone diagnosis, and the AAP recommends screening for comorbid conditions, including autism spectrum disorder, ADHD, developmental coordination disorder, and childhood anxiety disorders. For a child that presents with sensory concerns and symptoms of ADHD, it is important to diagnose ADHD and address the sensory components as part of their behavior support. [Zimmer: 2012]

Resources for Clinicians

Books Attention-Deficit Hyperactivity Disorder, Fourth Edition: A Handbook for Diagnosis and Treatment
This book presents extensive knowledge on the nature, diagnosis, assessment, and treatment of ADHD; by Barkley R (22018), published by the Guilford Press (4th. ed.).
ADHD in Adolescents: Development, Assessment, and Treatment 1st Edition (2019)
Bringing together leading authorities, this book written by Stephen Becker, PhD, synthesizes current knowledge about the nature, impact, and treatment of attention-deficit/hyperactivity disorder (ADHD) in the crucial developmental period of adolescence. Contributors explore the distinct challenges facing teens with ADHD as they navigate intensifying academic demands; new risks in the areas of driving, substance use, and romantic relationships; and co-occurring mental health problems. Best practices in clinical assessment are presented.

On the Web

National Resource Center on ADHD (NRC)
A clearinghouse for the latest evidence-based information on ADHD; funded by the Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities.

Helpful Articles

PubMed search for ADHD in children, last 1 year.

Weydert JA, Brown ML, McClafferty H.
Integrative Medicine in Pediatrics.
Adv Pediatr. 2018;65(1):19-39. PubMed abstract
Keywords: ADHD; Abdominal pain; Acupuncture; Complementary & alternative medicine (CAM); Integrative medicine; Massage; Mind–body therapy; Nutrition.

Pringsheim T, Steeves T.
Pharmacological treatment for Attention Deficit Hyperactivity Disorder (ADHD) in children with comorbid tic disorders.
Cochrane Database Syst Rev. 2011(4):CD007990. PubMed abstract

Nikles J, Mitchell GK, de Miranda Araújo R, Harris T, Heussler HS, Punja S, Vohra S, Senior HEJ.
A systematic review of the effectiveness of sleep hygiene in children with ADHD.
Psychol Health Med. 2020;25(4):497-518. PubMed abstract
The objective of this systematic review of the literature is to evaluate the effectiveness of sleep hygiene interventions for sleep difficulties in children with ADHD.

Shrestha M, Lautenschleger J, Soares N.
Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review.
Transl Pediatr. 2020;9(Suppl 1):S114-S124. PubMed abstract / Full Text
Medication and non-pharmacological treatments are evidence-based interventions for ADHD in various age groups, and this article will elaborate on the psychosocial, physical and integrative medicine interventions that have been studied in ADHD.

Storebø OJ, Pedersen N, Ramstad E, Kielsholm ML, Nielsen SS, Krogh HB, Moreira-Maia CR, Magnusson FL, Holmskov M, Gerner T, Skoog M, Rosendal S, Groth C, Gillies D, Buch Rasmussen K, Gauci D, Zwi M, Kirubakaran R, Håkonsen SJ, Aagaard L, Simonsen E, Gluud C.
Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents - assessment of adverse events in non-randomised studies.
Cochrane Database Syst Rev. 2018;5:CD012069. PubMed abstract / Full Text
This systematic review of randomised clinical trials (RCTs) demonstrated no increase in serious adverse events, but a high proportion of participants suffered a range of non-serious adverse events.

Corkum P, Begum EA, Rusak B, Rajda M, Shea S, MacPherson M, Williams T, Spurr K, Davidson F.
The Effects of Extended-Release Stimulant Medication on Sleep in Children with ADHD.
J Can Acad Child Adolesc Psychiatry. 2020;29(1):33-43. PubMed abstract / Full Text
Although stimulant medications, such as methylphenidate hydrochloride (MPH), are effective at reducing the core symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD), they may also disrupt children's sleep. This study aimed to investigate the acute impact of extended-release MPH on sleep using both actigraphy and polysomnography (PSG).

Houghton R, de Vries F, Loss G.
Psychostimulants/Atomoxetine and Serious Cardiovascular Events in Children with ADHD or Autism Spectrum Disorder.
CNS Drugs. 2020;34(1):93-101. PubMed abstract / Full Text
Using large US claims data, this study found no evidence of increased serious cardiovascular risk in children and adolescents with ADHD or ASD exposed to ADHD medications (i.e., stimulants and atomoxetine).

Reed VA, Buitelaar JK, Anand E, Day KA, Treuer T, Upadhyaya HP, Coghill DR, Kryzhanovskaya LA, Savill NC.
The Safety of Atomoxetine for the Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Comprehensive Review of Over a Decade of Research.
CNS Drugs. 2016;30(7):603-28. PubMed abstract
The aim of this paper was to comprehensively review publications that addressed one or more of seven major safety topics relevant to atomoxetine treatment of children and adolescents (aged ≥6 years) diagnosed with ADHD.

Punja S, Shamseer L, Hartling L, Urichuk L, Vandermeer B, Nikles J, Vohra S.
Amphetamines for attention deficit hyperactivity disorder (ADHD) in children and adolescents.
Cochrane Database Syst Rev. 2016;2:CD009996. PubMed abstract
A systematic review to assess the efficacy and safety of amphetamines for ADHD in children and adolescents

AAP.
American Academy of Pediatrics/American Heart Association clarification of statement on cardiovascular evaluation and monitoring of children and adolescents with heart disease receiving medications for ADHD: May 16, 2008.
J Dev Behav Pediatr. 2008;29(4):335. PubMed abstract

Atkinson M, Hollis C.
NICE guideline: attention deficit hyperactivity disorder.
Arch Dis Child Educ Pract Ed. 2010;95(1):24-7. PubMed abstract
Guidelines that the cover diagnosis, treatment, and management of ADHD; National Institute for Health and Care Excellence (UK).

Brimble MJ.
Diagnosis and management of ADHD: a new way forward?.
Community Pract. 2009;82(10):34-7. PubMed abstract

Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry. 2013;70(7):740-9. PubMed abstract / Full Text

Kim JW, Kim BN, Cho SC.
The dopamine transporter gene and the impulsivity phenotype in attention deficit hyperactivity disorder: a case-control association study in a Korean sample.
J Psychiatr Res. 2006;40(8):730-7. PubMed abstract

Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs. 2009;23(12):1057-83. PubMed abstract

Murphy TK, Lewin AB, Storch EA, Stock S.
Practice parameter for the assessment and treatment of children and adolescents with tic disorders.
J Am Acad Child Adolesc Psychiatry. 2013;52(12):1341-59. PubMed abstract / Full Text

Pelsser LM, Frankena K, Toorman J, Savelkoul HF, Dubois AE, Pereira RR, Haagen TA, Rommelse NN, Buitelaar JK.
Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial.
Lancet. 2011;377(9764):494-503. PubMed abstract

Perrin JM, Friedman RA, Knilans TK.
Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder.
Pediatrics. 2008;122(2):451-3. PubMed abstract / Full Text

Rushton JL, Fant KE, Clark SJ.
Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.
Pediatrics. 2004;114(1):e23-8. PubMed abstract

Salmeron PA.
Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications.
J Am Acad Nurse Pract. 2009;21(9):488-97. PubMed abstract / Full Text

Vaidya CJ, Stollstorff M.
Cognitive neuroscience of Attention Deficit Hyperactivity Disorder: current status and working hypotheses.
Dev Disabil Res Rev. 2008;14(4):261-7. PubMed abstract

Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother. 2013. PubMed abstract / Full Text

Thomas R, Sanders S, Doust J, Beller E, Glasziou P.
Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis.
Pediatrics. 2015;135(4):e994-1001. PubMed abstract

Clinical Tools

Assessment Tools/Scales

Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( PDF Document 1.1 MB)
Helps to diagnose ADHD in children between the ages of 6 and 12; also screens for anxiety, depression, oppositional-defiant, and conduct disorders. Includes questionnaires for the initial and follow-up assessments for teachers and parents - and scoring instructions. No fee is required.

NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) ( PDF Document 3.9 MB)
Spanish (with English translation) online fillable, self-calculating form for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required; NICHQ

NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) ( PDF Document 3.6 MB)
Spanish (with English translation) follow-up forms for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required; NICHQ

NICHQ Vanderbilt ADHD Primary Care Initial Evaluation Form ( PDF Document 1.7 MB)
2-page evaluation template includes scoring for the initial Vanderbilts, plus checkboxes for relevant medical history, physical examination, diagnostic assessment and plan, and related screenings; American Academy of Pediatrics.

Conners 3rd Edition
Screens for ADHD and comorbid disorders such as oppositional defiant disorder and conduct disorder. Administered to parents and teachers of children and adolescents age 6-18 and self-report for youth ages 8-18, English and Spanish. Updated for DSM-5. Proprietary/for purchase.

ADHD Rating Scale-5 for Children and Adolescents
Child and adolescent versions with parent and teacher questionnaires, ages 5-17, the scales take <5 minutes to complete. Scoring is linked directly to DSM-5 diagnostic criteria for ADHD. Available for purchase.

Achenbach System of Empirically Based Assessment (ASEBA)
A variety of screening tools are available for a fee.

Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) ( PDF Document 47 KB)
Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.

DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) ( PDF Document 367 KB)
Free, 25-question assessment for initial patient interview and for monitoring treatment progress. Includes scoring instructions; American Psychiatric Association.

Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.

Care Processes & Protocols

Medication Guides

ADHD Medication Tables ( PDF Document 152 KB)
Provides information about different classes of medications, dosing options, estimated duration of effect, and timing of immediate vs. longer-acting medication release (when available). It also includes formulations, such as chewable, liquid, patch, capsules with contents that can be sprinkled, and tablets that can be divided, flavors, generic and brand options for prescribing, and FDA-approval status; Medical Home Portal, last updated April 2020.

Stimulant Equivalency Table (UACAP) ( PDF Document 505 KB)
One-page table of key differences in stimulant medications used to treat ADHD. Author Matt Swenson, MD; Utah Academy of Child & Adolescent Psychiatry.

Toolkits

Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Ed. (AAP)
his framework of tools and forms, templates, scales, and coding references is a complementary resource to the 2019 American Academy of Pediatrics (AAP) Clinical Practice Guideline, to enable and empower the clinician to provide needed care to children with ADHD from birth to adulthood. Available for purchase from the AAP.

Caring for Children with ADHD Toolkit, 3rd Ed. (AAP)
This links to some free resources associated with the older edition of the American Academy of Pediatrics (AAP)'s toolkit, including commonly used screening tools, treatment and monitoring guidance, and parent information.

Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit (AAP)
Toolkit for pediatric care providers delivering comprehensive mental health care. Now in a new online format; available for a fee from American Academy of Pediatrics.

mehealth for ADHD
This integrated assessment and treatment-planning tool is an evidence-based, comprehensive, and easy-to-use online platform for improving the quality of ADHD care. Efficacy is proven by randomized controlled research. This quality improvement tool provides a means of communication between the clinician, family, and teachers to assess, monitor interventions, and guide behavioral supports, and it integrates Vanderbilt screens (2nd Edition). Free if participating in their NIH-funded research study; subscription required otherwise; Cincinnati Children’s Hospital Medical Center.

Other

Letter Requesting Assessment from Teacher (AAP)
Sample letter requesting that a teacher complete a behavior assessment for their student. The AAP suggests that a release of information form, signed by parent, accompanies this letter; American Academy of Pediatrics.

Monarch eTNS (external Trigeminal Nerve Stimulation) System
This medical device, approved in 2019 for treatment of ADHD in children ages 7-12 who are not taking prescription ADHD medication, delivers low-level electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. Prescription required.

EndeavorRx
EndeavorRx™ is the first-and-only prescription treatment of ADHD, delivered through a video game. Evidence-based, it was cleared by the FDA in 2020.

Patient Education & Instructions

ADHD: Parents Medication Guide (AACAP) ( PDF Document 1.1 MB)
Forty-five page booklet that helps youngsters and their families better understand the treatments for ADHD; prepared by the American Academy of Child & Adolescent Psychiatry and American Psychiatric Association (2013).

Behavior Therapy for Children with ADHD
Printable information for families about behavioral interventions and therapy for children with attention deficit/hyperactivity disorder; HealthyChildren.org/AAP.

Resources for Patients & Families

Books ADHD 3rd Edition: What Every Parent Needs to Know (AAP)
This book provides reliable information about how ADHD is defined and diagnosed, as well as the most current behavioral, developmental, educational, and medical therapies. Topics covered align with the DSM-5 updates. Paperback and eBook versions available for purchase; American Academy of Pediatrics.

Attention Deficit Hyperactivity Disorder (ADHD) (FAQ)

Information on the Web

ADHD (MedlinePlus)
Information for families that includes description, frequency, causes, inheritance, other names, and additional resources; from the National Library of Medicine.

ADHD (HealthyChildren)
Links to more than 90 articles that discuss aspects of ADHD evaluation and management; developed by the American Academy of Pediatrics.

Attention-Deficit/Hyperactivity Disorder (NIMH)
Overview and links to more information from the National Institute of Mental Health

National & Local Support

Children & Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
A national nonprofit organization with numerous local chapters that provides education, advocacy, and support for ADHD. Includes e-training for parents and teachers, information, advocacy, support, podcasts, newsletters, and more.

Understood for Learning & Attention Issues
An organization providing resources to young adults, parents, and teachers of children with different learning styles and attention disorders. Focusses on inclusive workplaces by developing and implementing best-in-class disability inclusion programs so they can hire, advance, and retain people with disabilities.

Studies/Registries

Mental Health Clinical Trials (NIMH)
Links to descriptions of clinical trials related to numerous mental health conditions, including ADHD, anxiety, and depression; National Institute of Mental Health.

Clinical Trials in ADHD (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in New Mexico (NM)

Service Categories	NM	NW		NV	RI
CHIP, State Children's Health Insur Prog			2		4
Developmental - Behavioral Pediatrics	2	1	3	12	9
Family Counseling	1		23	44	67
Financial Assistance, Other	19	8	41	20	27
General Counseling Services	10	1	211	30	260
Health Insurance Counseling and Advocacy	5	1	14	3	48
Medicaid	8	3	25	6	10
Medical Care Expense Assistance	39	32	56	36	46
Neuropsychiatry/Neuropsychology	1		3	9	5
Outpatient Mental Health Care	35		42	16	168
Pediatric Cardiology	3		4	17	4
Pediatric Neurology	5		5	18	8
Prescription Drug Assistance	20	19	38	23	39
Psychiatry/Medication Management	3		37	80	55
School Districts	90		4	64	42

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: October 2013; last update/revision: September 2020

Current Authors and Reviewers:

Author:	Jennifer Goldman, MD, MRP, FAAP
Reviewer:	Kelly Irons, MD, FAAP

Authoring history

2015: update: Jennifer Goldman, MD, MRP, FAAP^SA; Robyn Nolan, MD^R

2013: first version: Lynne M. Kerr, MD, PhD^A

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

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