What are the key considerations for assessing and treating a new patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Key Considerations for Assessing and Treating a New ADHD Patient

A comprehensive assessment for ADHD must include screening for comorbid conditions, as identifying these conditions is critical for developing the most appropriate treatment plan that will improve morbidity, mortality, and quality of life outcomes. 1

Diagnostic Assessment

• Initiate an evaluation for ADHD for any child or adolescent age 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity 1
• Ensure DSM-5 criteria are met, including documentation of symptoms and impairment in more than one major setting (social, academic, or occupational) 1
• Obtain information from multiple sources including parents/guardians, teachers, other school personnel, and mental health clinicians involved in the patient's care 1
• Rule out alternative causes for symptoms before confirming ADHD diagnosis 1

Essential Screening for Comorbid Conditions

Emotional/Behavioral Conditions

• Screen for anxiety disorders, depression, oppositional defiant disorder, conduct disorders, and substance use 1
• For adolescents specifically, assessment for substance use is critical as they are at higher risk for substance abuse, especially when untreated 1

Developmental Conditions

• Evaluate for learning disabilities, language disorders, autism spectrum disorders, and other neurodevelopmental disorders 1
• Assessment of learning problems is particularly important as they frequently co-occur with ADHD and require specific educational interventions 1

Physical Conditions

• Screen for tics, sleep disorders (particularly sleep apnea), and seizures 1
• Sleep disorders can both mimic and exacerbate ADHD symptoms, making their identification crucial for effective treatment 1

Age-Specific Considerations

Preschool-Aged Children (4-5 years)

• DSM-5 criteria can be appropriately applied to preschool-aged children 1
• First-line treatment should be evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions 1
• Methylphenidate may be considered if behavioral interventions do not provide significant improvement and there is moderate-to-severe continued disturbance in functioning 1

Elementary and Middle School-Aged Children (6-12 years)

• Prescribe FDA-approved medications for ADHD along with PTBM and/or behavioral classroom interventions (preferably both) 1
• Educational interventions and individualized instructional supports are necessary components of the treatment plan 1

Adolescents (12-18 years)

• Prescribe FDA-approved medications for ADHD with the adolescent's assent 1
• Behavioral therapy may also be prescribed, with combined treatment being preferable 1
• Specifically assess for substance use, anxiety, depression, and learning disabilities, as these are common comorbidities that affect treatment approach 1

Treatment Approach

• Recognize ADHD as a chronic condition and manage patients following principles of the chronic care model and medical home 1
• For medication management, titrate doses to achieve maximum benefit with minimum adverse effects 1
• When using atomoxetine, be aware of the FDA black box warning regarding increased risk of suicidal ideation in children and adolescents 2
• Monitor patients started on medication therapy closely for suicidality, clinical worsening, or unusual changes in behavior 2

Special Considerations

• Parents with ADHD themselves may benefit from extra support to help them follow consistent schedules for medication and behavioral programs 1
• Longitudinal studies indicate ADHD treatments are frequently not maintained over time, and impairments often persist into adulthood 1
• Untreated ADHD is associated with increased risk for early death, suicide, increased psychiatric comorbidity, lower educational achievement, and increased rates of incarceration 1

Common Pitfalls to Avoid

• Failing to screen for comorbid conditions, which can alter treatment approach 1
• Misdiagnosing comorbid conditions, leading to inappropriate care 1
• Not recognizing ADHD as a chronic condition requiring ongoing management 1
• Discontinuing treatment prematurely, which places individuals at risk for adverse outcomes 1
• Using medication as the sole intervention without incorporating behavioral and educational supports 2