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

ADHD Diagnosis and Treatment

The diagnosis of ADHD requires meeting DSM-5 criteria with at least 6 symptoms of inattention and/or hyperactivity-impulsivity persisting for at least 6 months, documented functional impairment in more than one setting (home, school, work), symptoms present before age 12, and systematic screening for comorbid conditions, followed by FDA-approved stimulant medications as first-line treatment for children ≥6 years (combined with behavioral interventions) and behavioral parent training as first-line for ages 4-5 years. 1, 2, 3

Diagnostic Criteria

Core Requirements

• At least 6 symptoms of inattention and/or hyperactivity-impulsivity must be present for ≥6 months 2, 3
• Symptom onset before age 12 years must be documented or reported, even if diagnosis occurs in adolescence or adulthood 1, 2
• Functional impairment in ≥2 major settings (social, academic, occupational) must be documented using information from multiple sources 1, 2, 3
• Alternative causes must be ruled out through clinical interview and examination 3, 4

Information Gathering Process

• Obtain standardized rating scales from both parents AND teachers - the Vanderbilt ADHD Rating Scales are specifically recommended by the American Academy of Pediatrics for ages 6-12 years 3, 4
• Collect behavioral information from multiple observers including parents, teachers, and other relevant adults who see the child in different contexts 1, 2, 4
• Review school records for academic performance patterns and behavioral concerns 4
• Conduct clinical interview focusing on specific symptom examples, timing of onset, and functional impact across settings 3, 4

Critical Diagnostic Pitfall

Rating scales are screening tools that systematically collect symptom information—they do NOT diagnose ADHD by themselves. Diagnosis requires comprehensive clinical evaluation beyond questionnaire scores. 3, 4

Mandatory Comorbidity Screening

Essential Screens (Alter Treatment Approach)

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 3
• Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 1, 3
• Physical conditions: sleep disorders (especially sleep apnea), tics 1, 3

Adolescent-Specific Screening (Ages 12-18)

At minimum, assess ALL adolescents for: substance use, anxiety, depression, and learning disabilities—these four conditions are common comorbidities that fundamentally affect treatment sequencing 1

• Increased risk for: mood disorders, risky sexual behaviors, intentional self-harm, suicidal behaviors 1
• Substance use considerations: marijuana and other substances can mimic ADHD symptoms; adolescents may feign symptoms to obtain stimulants for performance enhancement 1

Gender-Specific Consideration

Girls are more likely to present with predominantly inattentive symptoms rather than hyperactive symptoms, leading to underdiagnosis, and have higher rates of comorbid anxiety and depression compared to boys 4

Treatment Algorithm by Age

Preschool-Aged Children (4-5 Years)

First-line: Evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions 1, 3

• Methylphenidate may be considered ONLY if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continued functional disturbance 1
• Behavioral interventions do not require a specific diagnosis to benefit the family 1

Elementary/Middle School Children (6-11 Years)

First-line: FDA-approved stimulant medications PLUS behavioral interventions (preferably both parent training AND classroom interventions) 1, 3

• Stimulants include methylphenidate and amphetamine formulations 5, 6
• Behavioral parent training improves compliance with parental commands and parental understanding of behavioral principles 3
• Behavioral classroom management improves attention to instruction, compliance with classroom rules, and work productivity 3

Adolescents (12-18 Years)

First-line: FDA-approved stimulant medications with the adolescent's assent, which may be combined with behavioral therapy 1, 3

• Sequence treatments to maximize impact on areas of greatest risk and impairment while monitoring for stimulant abuse or suicidal ideation 1

Medication Management Principles

• Titrate doses to achieve maximum benefit with minimum adverse effects 1, 3
• Atomoxetine is effective at doses of 1.2-1.8 mg/kg/day, with the 1.8 mg/kg/day dose providing no additional benefit over 1.2 mg/kg/day 5
• Atomoxetine can be administered once daily in the morning or as divided doses 5
• For patients unable to take stimulants or with concurrent anxiety/depression, consider atomoxetine, viloxazine, or bupropion 7

Chronic Care Management

ADHD must be managed as a chronic condition following the chronic care model and medical home principles 1

• Treatments address symptoms and function but are usually not curative 1, 8
• Longitudinal studies show ADHD treatments are frequently not maintained over time and impairments persist into adulthood 1
• Patients with ADHD face increased risk for early death, suicide, and psychiatric complications whether treated or not 1

Laboratory and Neurological Testing

The American Academy of Pediatrics does NOT recommend routine laboratory or neurological testing for diagnosing ADHD—order tests only when specific medical conditions are suspected based on history or physical examination findings 4

Common Diagnostic Pitfalls to Avoid

• Failing to gather information from multiple sources and settings before making diagnosis 2, 3
• Not screening for comorbid conditions that may complicate or alter treatment 2, 3
• Relying solely on questionnaire scores without comprehensive clinical interview and multi-informant data 3
• Underdiagnosing girls who present with predominantly inattentive symptoms 2, 4
• Delaying treatment in children with significant documented impairment 3