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

Diagnosing and Treating ADHD

For children ages 4-18 years presenting with academic or behavioral problems plus symptoms of inattention, hyperactivity, or impulsivity, initiate evaluation using DSM criteria with standardized rating scales from multiple informants, then treat preschoolers (4-5 years) with evidence-based behavior therapy first-line, and elementary-aged children (6-11 years) and adolescents (12-18 years) with FDA-approved stimulant medications and/or behavior therapy, preferably both. 1, 2

Diagnostic Approach

When to Initiate Evaluation

• Begin evaluation for any child 4-18 years presenting with academic or behavioral problems accompanied by symptoms of inattention, hyperactivity, or impulsivity 1, 2
• Use standardized rating scales from parents, teachers, and other clinicians involved in the child's care 1, 2

Establishing the Diagnosis

• Meet DSM criteria with documented impairment in more than one major setting (home, school, social environments) using information from parents/guardians, teachers, and mental health clinicians 1, 2
• Conduct a thorough clinical interview to verify DSM criteria, establish symptom onset, and document functional impairment across multiple settings 2
• Rule out alternative causes through clinical assessment 1

Critical caveat: Behavior rating scales combined with clinical interviews and multi-informant reports are required—questionnaires alone cannot diagnose ADHD 2

Screening for Comorbidities

• Screen for emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 2
• Screen for developmental conditions: learning disabilities, language disorders, autism spectrum disorder 1, 2
• Screen for physical conditions: tics, sleep apnea 1, 2

The majority of children with ADHD meet criteria for another mental disorder, and comorbid conditions may alter treatment approach 1

Treatment Approach by Age Group

Preschool-Aged Children (4-5 Years)

Prescribe evidence-based parent- and/or teacher-administered behavior therapy as first-line treatment 1, 2

• Behavior therapy has Grade A evidence quality for reducing ADHD-associated behaviors and improving function 1
• Behavioral parent training provides behavior-modification principles for home settings with median effect size of 0.55 1
• Behavioral classroom management provides behavior-modification principles for teachers 1

May prescribe methylphenidate if behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in function 1, 2

• In areas where evidence-based behavioral treatments are unavailable, weigh the risks of starting medication at an early age against the harm of delaying treatment 1

Elementary School-Aged Children (6-11 Years)

Prescribe FDA-approved medications for ADHD and/or evidence-based parent- and/or teacher-administered behavior therapy, preferably both 1, 2

Medication Hierarchy (by strength of evidence):

1. Stimulant medications (strongest evidence, Grade A) 1
2. Atomoxetine (sufficient but less strong evidence) 1
3. Extended-release guanfacine (sufficient but less strong evidence) 1
4. Extended-release clonidine (sufficient but less strong evidence) 1

• The school environment, program, or placement is part of any treatment plan 1

Adolescents (12-18 Years)

Prescribe FDA-approved medications for ADHD with the assent of the adolescent (Grade A strong recommendation) 1

May prescribe behavior therapy as treatment for ADHD (Grade C recommendation), preferably both medication and behavior therapy 1

• At minimum, assess adolescents with newly diagnosed ADHD for substance use, anxiety, depression, and learning disabilities 1
• Consider sequencing psychosocial and medication treatments to maximize impact on areas of greatest risk and impairment 1
• Monitor for stimulant abuse or suicidal ideation 1

Medication Dosing Specifics

Atomoxetine (Non-Stimulant)

Children and adolescents ≤70 kg:

• Initiate at 0.5 mg/kg/day total daily dose 3
• Increase after minimum 3 days to target of 1.2 mg/kg/day (single morning dose or divided morning/late afternoon doses) 3
• Maximum: 1.4 mg/kg or 100 mg daily, whichever is less 3

Children and adolescents >70 kg and adults:

• Initiate at 40 mg/day total daily dose 3
• Increase after minimum 3 days to target of 80 mg/day 3
• May increase to maximum 100 mg after 2-4 additional weeks if optimal response not achieved 3

Stimulants (Amphetamine/Methylphenidate)

• Indicated as integral part of total treatment program for ADHD in pediatric patients ages 3-16 years 4
• Titrate doses to achieve maximum benefit with minimum adverse effects 1

Chronic Disease Management

Manage ADHD as a chronic condition following chronic care model principles within a medical home 1, 2

• ADHD causes symptoms and dysfunction over long periods, even into adulthood 1
• Available treatments address symptoms and function but are usually not curative 1
• Longitudinal studies show treatments are frequently not maintained over time, and untreated ADHD increases risk for early death, suicide, psychiatric comorbidity (especially substance use), lower educational achievement, and increased incarceration rates 1

Ongoing Monitoring

• Periodically reevaluate long-term usefulness of medication for individual patients 3
• Maintain bidirectional communication with teachers, school personnel, and mental health clinicians 1
• Provide extra support for parents who also have ADHD to help maintain consistent medication schedules and behavioral programs 1

Important Precautions

Before Starting Treatment

• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating atomoxetine 3
• For adults, prioritize treatment of active substance use disorders before initiating stimulants 2
• Address severe mood symptoms requiring stabilization 2

Contraindications

• Atomoxetine is contraindicated in patients with known hypersensitivity to atomoxetine or other constituents 3

Dosing Adjustments

Hepatic impairment:

• Moderate hepatic insufficiency (Child-Pugh Class B): reduce atomoxetine dose to 50% of normal 3
• Severe hepatic insufficiency (Child-Pugh Class C): reduce atomoxetine dose to 25% of normal 3

CYP2D6 considerations:

• When using strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine) or in known CYP2D6 poor metabolizers, initiate atomoxetine at lower doses and increase only if symptoms fail to improve after 4 weeks with good tolerability 3