What is the recommended process for screening and treating Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Screening and Treatment Protocol

Primary care clinicians should initiate an evaluation for ADHD in any child 4-18 years of age presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity, using a structured approach that includes DSM-5 criteria assessment, screening for comorbidities, and age-appropriate treatment recommendations. 1

Diagnostic Process

Initial Screening and Evaluation

• Evaluation should be initiated for children ages 4-18 years who present with:
  • Academic or behavioral problems
  • Symptoms of inattention, hyperactivity, or impulsivity 1
• Gather information from multiple sources:
  • Parents/guardians
  • Teachers/school personnel
  • Mental health clinicians involved in the child's care 1
• Use standardized rating scales:
  • Vanderbilt ADHD Rating Scale (completed by both parents and teachers) 2
  • Document symptoms in more than one major setting (home, school, social) 1

Diagnostic Criteria

• Determine if DSM-5 criteria are met:
  • Inattentive Presentation: ≥6 inattention symptoms, <6 hyperactivity/impulsivity symptoms
  • Hyperactive/Impulsive Presentation: <6 inattention symptoms, ≥6 hyperactivity/impulsivity symptoms
  • Combined Presentation: ≥6 symptoms in both categories 2
• Verify symptoms cause functional impairment
• Rule out alternative causes for symptoms 1

Comorbidity Screening

• Screen for emotional/behavioral conditions:
  • Anxiety disorders
  • Depression
  • Oppositional defiant disorder
  • Conduct disorders
  • Substance use (especially in adolescents) 1, 2
• Screen for developmental conditions:
  • Learning and language disorders
  • Autism spectrum disorders 1, 2
• Screen for physical conditions:
  • Tic disorders
  • Sleep disorders (including sleep apnea)
  • Seizure disorders 1, 2

Treatment Recommendations by Age Group

Preschool Children (4-5 years)

1. First-line treatment: Evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions 1
2. Consider methylphenidate only if:
   • Behavioral interventions don't provide significant improvement
   • Moderate-to-severe disturbance in functioning persists
   • In areas where evidence-based behavioral treatments aren't available, weigh risks of medication against harm of delayed treatment 1

Elementary and Middle School Children (6-11 years)

1. Prescribe FDA-approved ADHD medications 1
   • Strongest evidence for stimulant medications
   • Alternative medications in order of evidence strength: atomoxetine, extended-release guanfacine, extended-release clonidine 1
2. Implement parent and/or teacher-administered behavior therapy 1
3. Preferably use both medication and behavioral interventions 1
4. Include educational interventions and supports as part of treatment plan 1

Adolescents (12-18 years)

1. Prescribe FDA-approved ADHD medications with adolescent's assent 1
2. Consider behavioral therapy as additional treatment 1
3. Include educational interventions and supports 1
4. Specifically screen for substance use, anxiety, depression, and learning disabilities 2

Medication Management

• Titrate medication doses to achieve maximum benefit with minimum adverse effects 1
• Monitor response to treatment regularly
• Be alert to potential for stimulant misuse in adolescents 2

Ongoing Management

• Recognize ADHD as a chronic condition requiring long-term management 1
• Follow principles of the chronic care model and medical home approach 1
• Maintain bidirectional communication with:
  • School personnel
  • Mental health clinicians involved in care 1
• Monitor for persistence of symptoms and functional impairment over time 1

Common Pitfalls to Avoid

• Relying solely on parent or teacher reports without cross-verification 2
• Failing to screen for comorbid conditions 2
• Diagnosing based on response to medication trials 2
• Using screening tools alone without comprehensive clinical evaluation 2
• Overlooking age-specific manifestations of symptoms 2
• Discontinuing treatment prematurely, which increases risk for:
  • Motor vehicle crashes
  • Substance use disorders
  • Depression
  • Academic underachievement
  • Legal issues 1

By following this structured approach to ADHD screening, diagnosis, and treatment, clinicians can provide evidence-based care that addresses the specific needs of children and adolescents with ADHD while monitoring for comorbidities and optimizing long-term outcomes.