What are the guidelines for diagnosing and treating a patient with suspected Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Diagnosis and Treatment Guidelines

Primary care clinicians should initiate an ADHD evaluation for any child or adolescent aged 4-18 years presenting with academic or behavioral problems plus symptoms of inattention, hyperactivity, or impulsivity, using DSM-5 criteria with multi-informant documentation of impairment across multiple settings. 1, 2

Diagnostic Process

Core Requirements for Diagnosis

The diagnosis requires meeting all DSM-5 criteria with documented functional impairment in at least two major settings (home, school, work, social). 1, 3

• Symptoms must have been present before age 12 years and persist for at least 6 months 3
• For Inattentive Type: at least 6 symptoms including lack of attention to details, poor sustained attention, poor listening, failure to follow through, poor organization, avoidance of sustained mental effort, losing things, easy distractibility, forgetfulness 4
• For Hyperactive-Impulsive Type: at least 6 symptoms including fidgeting, leaving seat inappropriately, inappropriate running/climbing, difficulty with quiet activities, being "on the go," excessive talking, blurting answers, inability to wait turn, intrusiveness 4
• For Combined Type: both inattentive and hyperactive-impulsive criteria must be met 4

Information Gathering Strategy

Use standardized DSM-based rating scales (such as Vanderbilt ADHD Rating Scales) from parents AND teachers, combined with clinical interviews—questionnaires alone cannot diagnose ADHD. 2, 3

• Obtain parent-completed and teacher-completed Vanderbilt scales for children ages 6-12 years 3
• For adolescents with multiple teachers, gather information from several instructors 3
• Conduct thorough clinical interview to verify DSM criteria, establish symptom onset, and document functional impairment 2
• Rule out alternative causes through clinical assessment 2, 3

Neuropsychological testing does not improve diagnostic accuracy in most cases, though it may clarify learning strengths and weaknesses. 1

Mandatory Comorbidity Screening

Screen systematically for comorbid conditions that alter treatment approach, including emotional/behavioral conditions (anxiety, depression, oppositional defiant disorder, conduct disorders, substance use), developmental conditions (learning and language disorders, autism spectrum disorders), and physical conditions (tics, sleep apnea). 1, 3

• For adolescents specifically, assess at minimum for substance use, anxiety, depression, and learning disabilities 1
• The majority of children with ADHD meet criteria for another mental disorder 1
• Comorbid conditions may require sequencing of psychosocial and medication treatments 1

Treatment Algorithm by Age

Preschool Children (Ages 4-5 Years)

Evidence-based parent-administered behavior therapy is first-line treatment; methylphenidate may be prescribed if behavioral interventions fail to provide significant improvement. 1, 3

• Parent training in behavior management (PTBM) is Grade A recommendation 1
• Medication is Grade B recommendation for this age group 1

Elementary School Children (Ages 6-11 Years)

FDA-approved medications are first-line treatment, preferably combined with evidence-based behavioral interventions including parent training and behavioral classroom management. 1, 2, 3

• Stimulants (methylphenidate and amphetamine) are most effective with Grade A recommendation 1, 5
• 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
• Atomoxetine is an alternative nonstimulant option with no abuse potential, initiated at 0.5 mg/kg/day and increased after minimum 3 days to target dose of 1.2 mg/kg/day, not exceeding 1.4 mg/kg/day or 100 mg/day 4

Adolescents (Ages 12-18 Years)

Prescribe FDA-approved medications with the adolescent's assent, combined with evidence-based behavioral interventions when available. 1, 3

• Educational interventions and individualized instructional supports (IEP or 504 plan) are necessary components 1
• Consider sequencing treatments to address areas of greatest risk and impairment 1
• Monitor for stimulant abuse and suicidal ideation given higher comorbidity rates 1

Medication-Specific Considerations

Stimulants (methylphenidate and amphetamine) have the strongest efficacy evidence and acceptable safety profiles. 5, 6

• Amphetamine is indicated as integral part of total treatment program for ages 3-16 years with behavioral syndrome characterized by moderate to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity 5
• Atomoxetine carries black box warning for increased risk of suicidal ideation in children and adolescents (0.4% vs 0% placebo); requires close monitoring for suicidality, clinical worsening, or unusual behavioral changes 4
• Titrate medication doses to achieve maximum benefit with tolerable side effects 1

Chronic Care Management

Manage ADHD as a chronic condition following chronic care model principles within a medical home framework. 1, 2, 7

• ADHD causes symptoms and dysfunction over long periods, often into adulthood 1
• Available treatments address symptoms and function but are usually not curative 1
• Establish continuous, coordinated care with systematic follow-up 7
• Develop communication systems with schools and other personnel 7
• Monitor height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence at follow-up visits 6

Critical Pitfalls to Avoid

• Never diagnose based solely on rating scale scores without clinical interview and multi-informant data 3
• Never fail to document impairment in more than one setting 3
• Never skip comorbidity screening, as this fundamentally alters treatment approach 1, 3
• Never delay treatment in children with significant impairment 3
• Parents with ADHD themselves may need extra support to maintain consistent medication and behavioral program schedules 1