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

ADHD Diagnostic Criteria and Treatment Options

ADHD diagnosis requires meeting DSM-5 criteria with documentation of symptoms and impairment in more than one major setting (social, academic, or occupational), with information obtained from multiple sources including parents, teachers, and other observers. 1, 2

Diagnostic Criteria for ADHD

• 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 2
• Diagnosis requires verification that DSM-5 criteria are met, including:
  • An ongoing pattern of inattention and/or hyperactivity-impulsive symptoms for at least 6 months 1
  • Multiple symptoms (5 or more for age 17+ years; 6 or more for <17 years) 1
  • Symptom onset before age 12 years 2
  • Symptoms present in 2 or more settings (e.g., home, school, work) 1
  • Evidence that symptoms interfere with or reduce quality of functioning 1
  • Symptoms not better explained by another mental disorder 1

ADHD Presentations According to DSM-5

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

Symptom Categories

Inattentive Symptoms

• Poor attention to detail 1
• Difficulty concentrating or sustaining attention on tasks 1
• Seems preoccupied, difficulty shifting focus even when spoken to directly 1
• Difficulty completing tasks (gets distracted/side-tracked) 1
• Organizational challenges 1
• Reluctance to engage in tasks requiring sustained mental effort 1
• Difficulty keeping track of belongings/items 1
• Easily distracted 1

Hyperactive-Impulsive Symptoms

• Frequent fidgeting 1
• Difficulty sitting still for prolonged periods 1
• Feeling of inner restlessness or agitation 1
• Often loud and disruptive 1
• Always "on the go" 1
• Often talks excessively 1
• Frequently interrupts others 1
• Highly impatient 1

Diagnostic Assessment Approach

• Obtain comprehensive behavioral information from multiple sources using DSM-5-based ADHD rating scales 3, 2
• For adults, use validated screening tools such as the Adult ADHD Self-Report Scale (ASRS-V1.1) - a positive screen occurs when a patient checks "often" or "very often" for 4 or more of the 6 questions 1, 4
• For children, use standardized rating scales completed by parents and teachers to document symptoms across multiple settings 3, 2
• Rule out alternative causes of symptoms through comprehensive evaluation 1, 5
• The American Academy of Pediatrics does not recommend routine laboratory or neurological testing unless specific medical conditions are suspected 3

Special Considerations by Age Group

• Preschool-aged children (4-6 years): Conduct clinical interview with parents, examine and observe the child, and obtain information from parents and teachers through DSM-based rating scales 1
• School-aged children and adolescents: Gather information from multiple sources including parents, teachers, and self-reports 1, 2
• Adults: Comprehensive clinical history and evaluation, patient symptom and function assessment (e.g., Adult ADHD Self-Report Scale, Conners Adult ADHD Rating Scales), and gathering of collateral information 4

Screening for Comorbid Conditions

• Screen for emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 3, 2
• Evaluate for developmental conditions: learning disorders, language disorders, autism spectrum disorders 3, 2
• Consider physical conditions that may impact attention: sleep disorders, tics 3, 2
• Adults with ADHD often have concurrent anxiety/stress, mood, personality, impulse control, and substance use disorders 4, 6

Treatment Options

For Children Aged 4-5 Years

• Evidence-based parent-administered behavior therapy is recommended as first-line treatment 2
• Parent training in behavior management (PTBM) is recommended even before confirming ADHD diagnosis 1

For Children 6 Years and Older

• FDA-approved medications are recommended as first-line therapy, preferably combined with behavioral interventions 2
• Behavioral interventions include behavioral parent training, behavioral classroom management, and behavioral peer interventions 2

For Adolescents (12-18 Years)

• First-line treatment includes FDA-approved medications with the adolescent's assent, which may be combined with behavioral therapy 2

For Adults

• Clinical guidelines recommend amphetamine and methylphenidate stimulants as first-line pharmacotherapy 4
• For adults unable to take stimulants or with concurrent anxiety/depression, options include atomoxetine, viloxazine, and bupropion 4
• Atomoxetine has demonstrated efficacy in doses of 60 to 120 mg/day (mean final dose approximately 95 mg/day) 7

Common Pitfalls to Avoid

• Failing to gather information from multiple sources and settings 2
• Not screening for comorbid conditions that may complicate treatment 2, 6
• Overlooking inattentive symptoms in girls, who are more likely to present with predominantly inattentive symptoms rather than hyperactive symptoms 3
• Not considering age-specific treatment approaches 2
• Failing to recognize that ADHD is a chronic condition requiring ongoing care and monitoring 2, 8