What are the recommended steps for diagnosing attention‑deficit/hyperactivity disorder and the first‑line pharmacologic and behavioral treatment options?

ADHD Diagnosis and Treatment

Diagnostic Approach

Initiate a comprehensive ADHD evaluation for any child or adolescent aged 4-18 years presenting with academic or behavioral problems plus symptoms of inattention, hyperactivity, or impulsivity, confirming DSM-5 criteria are met with documented impairment in multiple settings. 1, 2

Required Diagnostic Components

• Gather information from multiple sources including parents/guardians, teachers, and other involved clinicians to confirm the diagnosis 2
• Document specific DSM-5 symptoms: For inattentive type, at least 6 symptoms (careless mistakes, poor sustained attention, doesn't listen, fails to follow through, poor organization, avoids mental effort, loses things, easily distracted, forgetful); for hyperactive-impulsive type, at least 6 symptoms (fidgeting, leaving seat, inappropriate running/climbing, difficulty with quiet activities, "on the go," excessive talking, blurting answers, can't wait turn, intrusive) 1, 3
• Verify impairment exists in more than one major setting (home, school, social situations) 1, 2
• Screen for comorbid conditions including anxiety, depression, oppositional defiant disorder, conduct disorders, substance use disorders, learning and language disorders, autism spectrum disorders, tics, and sleep apnea 1, 2
• Rule out alternative causes for presenting symptoms 2
• Obtain developmental and family history to identify risk factors and patterns 4

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Treatment Algorithm by Age

Preschool-Aged Children (4-5 years)

Prescribe evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions as first-line treatment. 1, 2

• Consider methylphenidate only if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continued functional disturbance 1, 2
• Weigh the risks of starting medication before age 6 against the harm of delaying treatment when behavioral interventions are unavailable 1
• Other stimulants and nonstimulants have not been adequately studied in this age group 1

Elementary and Middle School Children (6-11 years)

Prescribe FDA-approved ADHD medications (methylphenidate or amphetamines) as first-line treatment, combined with PTBM and/or behavioral classroom interventions—preferably both. 1, 2

• The evidence is strongest for stimulant medications, with more than 70% of children responding to methylphenidate when a full range of doses is systematically tried 1
• More than 90% of patients respond beneficially to one of the psychostimulants when both methylphenidate and amphetamine/dextroamphetamine classes are tried 1
• Alternative medications include atomoxetine, extended-release guanfacine, and extended-release clonidine, in that order of evidence strength 1
• Educational interventions including IEP or 504 plan are necessary components of treatment 1

Adolescents (12-18 years)

Prescribe FDA-approved ADHD medications with the adolescent's assent, and screen for substance use before initiating treatment. 1, 2

• Encourage evidence-based training interventions and behavioral therapy when available 1
• Educational supports including IEP or 504 plan remain necessary 1
• Monitor for potential medication diversion through prescription drug monitoring programs 1

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Medication Management

Stimulant Titration Protocol

Start with immediate-release methylphenidate at the lowest dose and titrate systematically to achieve maximum benefit with tolerable side effects. 1, 2

• Titration schedule: Increase dose every 7 days (or as few as 3 days in urgent situations) 1
• Do not calculate dose by mg/kg as variations are not related to height or weight 1
• Trial multiple doses: Systematically try 4 different dose levels to identify optimal response 1
• Maximum doses: 1.4 mg/kg or 100 mg daily (whichever is less) for children/adolescents up to 70 kg; 100 mg daily for those over 70 kg and adults 3

Alternative Medications

For patients unable to tolerate stimulants or with specific comorbidities, consider atomoxetine, extended-release guanfacine, or extended-release clonidine. 1

• Atomoxetine dosing: Start at 0.5 mg/kg/day, increase after minimum 3 days to target of 1.2 mg/kg/day (maximum 1.4 mg/kg or 100 mg); for patients over 70 kg, start at 40 mg/day, increase to target of 80 mg/day (maximum 100 mg) 3
• Adjust dosing for hepatic impairment: 50% of normal dose for moderate impairment, 25% for severe impairment 3
• Adjust for CYP2D6 poor metabolizers or those on strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine) 3

Monitoring Requirements

Monitor regularly for efficacy, side effects, growth, blood pressure, and heart rate. 2

• Reassess treatment response and side effects at each visit 2
• The combination of medication and behavioral therapy allows lower stimulant dosages, potentially reducing adverse effects 1

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Behavioral and Educational Interventions

Behavioral Therapy Components

Implement behavioral parent training and classroom interventions that train adults to modify environmental contingencies and improve child behavior. 1

• Behavioral interventions address symptoms beyond ADHD's core features and show sustained positive effects with ongoing adherence 1
• Combined medication and behavioral therapy showed greater improvements in academic and conduct measures, particularly when ADHD is comorbid with anxiety or in lower socioeconomic environments 1
• Parents report significantly higher satisfaction with combined treatment approaches 1

School-Based Services

Ensure eligibility for 504 plan or IEP under "other health impairment" designation, and implement both skill-building interventions and accommodations. 1

• Skill-building interventions (first category): Daily report cards, point systems, academic remediation aimed at helping students independently meet expectations 1
• Accommodations (second category): Extended test time, reduced homework, ability to keep materials in class, provision of teacher's notes 1
• Critical distinction: Accommodations alone without skill-building interventions may lead to reduced expectations and perpetual need for support 1
• Maintain bidirectional communication with teachers and school personnel 2

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Chronic Care Management

Manage ADHD as a chronic condition following principles of the chronic care model and medical home. 1, 2

• Periodically reevaluate long-term medication usefulness for each patient 3
• Plan transition to adult care starting around age 14, with specific focus during the 2 years before high school completion 1
• Screen for bipolar disorder, mania, or hypomania (personal or family history) before initiating treatment 3
• Medications can be discontinued without tapering 3