What are the diagnostic criteria and treatment options for Attention Deficit Hyperactivity Disorder (ADHD)?

Diagnostic Criteria and Treatment Options for Attention Deficit Hyperactivity Disorder (ADHD)

Diagnostic Criteria

To diagnose ADHD, clinicians must verify that DSM-5 criteria are met, with symptoms causing impairment in more than one setting (home, school, social environments), based on information from multiple sources including parents, teachers, and other observers. 1, 2

Core Diagnostic Requirements

• ADHD evaluation should be initiated for any child or adolescent aged 4-18 years presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity 1, 2
• Symptoms must have been present before age 12 years and persist for at least 6 months 2
• Alternative causes for symptoms must be ruled out 1, 2
• Documentation of impairment must be present in more than one major setting (social, academic, or occupational) 1

DSM-5 ADHD Presentations

• Primarily inattentive presentation (ADHD/I) (314.00 [F90.0]) 1
• Primarily hyperactive-impulsive presentation (ADHD/HI) (314.01 [F90.1]) 1
• Combined presentation (ADHD/C) (314.01 [F90.2]) 1
• Other specified and unspecified ADHD (314.01 [F90.8]) 1

Information Gathering Process

• Obtain reports from multiple sources: parents/guardians, teachers, other school personnel, and mental health clinicians involved in the child's care 1, 2
• Use DSM-5-based rating scales to systematically collect information 2
• For adolescents, self-report becomes increasingly important 2
• Neuropsychological testing is not required for diagnosis in most cases but may help clarify learning strengths and weaknesses 1

Age-Specific Considerations

• For preschool-aged children (4-5 years): DSM-5 criteria can be applied; hyperactive symptoms often more prominent than inattentive symptoms 1, 2
• For school-aged children (6-12 years): Full DSM-5 criteria apply 1, 2
• For adolescents (12-18 years): Self-report becomes increasingly important; assess for substance use as a complicating factor 2, 3

Screening for Comorbid Conditions

• Essential to screen for common comorbid conditions that may alter treatment approach 1, 2:
  • Emotional/behavioral conditions (anxiety, depression, oppositional defiant disorder, conduct disorders, substance use) 1, 2
  • Developmental conditions (learning and language disorders, autism spectrum disorders) 1, 2
  • Physical conditions (tics, sleep disorders) 1, 2

Treatment Options

For children aged 4-5 years, evidence-based parent-administered behavior therapy is recommended as first-line treatment, while for children 6 years and older, FDA-approved medications are recommended as first-line therapy, preferably combined with behavioral interventions. 1

Age-Based Treatment Recommendations

Preschool-Aged Children (4-5 years)

• First-line: Evidence-based parent and/or teacher-administered behavior therapy 1
• If behavior interventions don't provide significant improvement with moderate-to-severe continuing disturbance: Consider methylphenidate 1
• Weigh risks of starting medication at early age against harm of delaying treatment 1

Elementary School-Aged Children (6-11 years)

• First-line: FDA-approved medications for ADHD, preferably combined with evidence-based behavioral therapy 1
• Strongest evidence supports stimulant medications (methylphenidate, amphetamines) 1, 4
• Alternative medications (in order of evidence strength): atomoxetine, extended-release guanfacine, extended-release clonidine 1

Adolescents (12-18 years)

• First-line: FDA-approved medications with the adolescent's assent 1
• May combine with behavioral therapy 1
• Consider risk of substance use when prescribing stimulants 3

Medication Options

Stimulants

• Most effective for core ADHD symptoms with generally acceptable side effect profiles 4
• Methylphenidate: Significantly reduces ADHD symptoms at home and school, improves social skills 5
• Amphetamines: Indicated for ADHD as part of a total treatment program 6
• Mechanism: Release of dopamine and norepinephrine in central nervous system 5

Non-Stimulants

• Atomoxetine: Effective but less so than stimulants; useful for patients with comorbid anxiety or substance use concerns 7, 4
• Other options: Guanfacine, clonidine, bupropion 4, 3

Behavioral Interventions

• Effective behavioral therapies include 1:
  • Behavioral parent training: Improves compliance with parental commands and parental understanding of behavioral principles 1
  • Behavioral classroom management: Improves attention to instruction, compliance with classroom rules, and work productivity 1
  • Behavioral peer interventions: Focus on peer interactions/relationships 1

Monitoring and Follow-up

• Titrate medication doses to achieve maximum benefit with minimum adverse effects 1
• Monitor height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence at follow-up visits 4
• Recognize ADHD as a chronic condition requiring ongoing care 1

Common Pitfalls to Avoid

• Failing to gather information from multiple sources and settings 1, 2
• Not screening for comorbid conditions that may complicate treatment 1, 2
• Relying solely on subjective assessments without systematic evaluation 8
• Delaying treatment in children with significant impairment 1
• Not considering age-specific treatment approaches 1