Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, and one of the most encountered behavioral health conditions in children. ADHD is characterized by developmentally inappropriate levels of inattention, impulsivity and hyperactivity.  According to national data, ADHD affects about 9.4% of U.S. children ages 2-17; including 2.4% of children ages 2-5 and 4-12% of school-aged children. Boys are more than twice as likely as girls to be diagnosed with ADHD. While  initial diagnosis is generally made before age 12, ADHD symptoms may continue into adolescence and adulthood.

Early identification and treatment by a healthcare professional are vital, as untreated ADHD may have serious and long-term consequences, including school failure, delinquency, family stress and disruption, depression, conduct disorder, problems with relationships, substance abuse, accidental injuries and job failure.

When should we consider evaluation?

Increased activity, difficulty with focus and acting impulsively are often variations of normal behaviors. However, when these impair day to day functioning of youth and interfere with their ability to perform regular tasks or pose risk to their safety, further assessment is needed.

Assessment

ADHD is a clinical diagnosis often made by collecting information from multiple sources including youth, caregivers, teachers, and for older youth, workplace supervisors. A history and physical assessment are obtained to rule out medical conditions and/or to better understand psychosocial factors that may be impacting symptoms. A screening for ADHD symptoms may be completed using a combination of a clinical interview and standardized rating scales. The intent is to determine if those symptoms are contributing to an individual’s social, emotional, behavioral, academic, or work challenges. 

While there are several rating scales validated for screening and assessment of ADHD, such as Conner’s scale, Child Behavior Checklist (CBCL), and SNAP-IV; the Vanderbilt Assessment Scales are one of the most used tools to diagnose and monitor ADHD in children and adolescents. For initial diagnosis, the Vanderbilt Assessment Scales are obtained from parents and teachers. The assessment scales specifically ask about the child’s behavior within the past six months. Each section of the Vanderbilt Assessment Scales reflects the symptoms of ADHD, oppositional-defiant disorder, conduct disorder, mood concerns, academic performance, and classroom behavioral performance. Providers are encouraged to use the assessment for initial diagnosis, follow-up to monitor response to medication, and should utilize other objective data to optimize medication use.

Vanderbilt Assessment Scales

SNAP-IV

Diagnostic Features

The key feature of attention-deficit/hyperactivity disorder (ADHD) is persistent inattention and/or hyperactivity-impulsivity that interferes with typical functioning or normal development. Symptoms of ADHD are typically present before the age of 12 and persist for a period of at least six months and occur in two or more settings. 

Inattention refers to difficulty concentrating, lack of persistence with tasks, disorganization, and wandering off tasks. Hyperactivity refers to excessive motor activity, fidgeting, tapping, or extreme talkativeness. Impulsivity refers to decisions made in haste, often valuing immediate rewards over delayed gratification.

It is also important to consider other medical or mental health conditions before diagnosis of ADHD is established. See “Differential Diagnosis” for details.

Differential Diagnosis

Since many symptoms of ADHD resemble those of other behavioral health disorders, it is important to assess these to ensure an accurate diagnosis.  However, these disorders may co-occur with ADHD and need careful diagnosis for successful treatment outcomes. Some of the common differential diagnoses and distinguishing symptoms that present similarly to ADHD are listed below:

• Anxiety – Worry and rumination driving poor attention
• Autism – social disengagement and social isolation due to deficits in social communication, temper tantrums due to inability to tolerate a change from expected events
• Bipolar Disorder – Episodic increased activity, poor concentration, elevated mood, grandiosity, increased activity for several days
• Conduct Disorder – Elevated levels of impulsivity, is pattern of antisocial behavior
• Depression – Inability to concentrate, present during major depressive episodes 
• Disruptive Mood Disorder – Pervasive irritability and intolerance of frustration; impulsiveness and disorganized thought is not present
• Learning disorder – in the academic setting or during academic activities only
• Medication Induced – Bronchodilators, Isoniazid, neuroleptics, thyroid replacement medication
• Oppositional Defiant disorder – negativity, hostility, defiance, refusal to submit to others’ demands
• Personality Disorders – maladaptive features, self-injury, antisocial behavior, fear of abandonment, lack of empathy
• Substance Use Disorder – nicotine, alcohol, cannabis, opioids- onset of ADHD symptoms follow the onset of frequent use or abuse.

Treatment

Management strategies for ADHD include non-medication interventions and medication interventions.
Healthcare providers can select effective treatment strategies to promote resilience by assessing patient and family strengths and promoting patient and family engagement in treatment planning. 

Shared decision-making can encourage children, teens, and caregivers to have a voice in their care.  The Ohio Minds Matter Shared Decision-Making Toolkit is a guide for youth and families to take an active role in their treatment, prepare for their appointment, consider treatment options, document their symptoms, and describe their goals.

Shared Decision Making

Non-Medication Interventions

Beyond medication, management of ADHD includes psychosocial interventions, which can be implemented both at home and at school. 

Behavior Therapy

The goal of behavioral therapy is to encourage positive behaviors and discourage negative behaviors. For younger children, this form of therapy typically includes teaching caregivers and teachers how to provide support and structure. For older children it involves recognizing negative behaviors and managing responses.

Clinical Pearl: Academic Performance

Behavioral therapy for ADHD can have significant impact on reducing impairment in specific domains of functioning, such as academic performance is due to deficits in executive functioning

Standardized parent training programs can be helpful in reducing disruptive behaviors. 
Some examples include:

• Parent Child Interaction Therapy (PCIT)
• Triple P Positive Parenting Program
• The Incredible Years
• Helping the Noncompliant Child
• Parent Management Training (for older children)

These programs have been proven effective for improving the parent-child relationship, reducing problem behaviors, and increasing desired behavioral outcomes. Training focuses on enhancing parent responsiveness to developmentally appropriate signals and providing parents with skills to promote compliance with instruction. More specific tips, which may be included within some BPT training programs, include: 

• create a routine
• manage distractions
• offer few choices at one time to reduce overstimulation
• clear and specific communication
• help your child plan
• use goals and rewards to track positive behaviors
• discipline effectively
• provide an overall healthy lifestyle for your child

Teachers can also use behavioral therapy strategies in the classroom. The behavioral classroom management approach encourages a student’s positive behaviors in the classroom, through a reward system or a daily report card, and discourages their negative behaviors. The National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.

Diet and ADHD Symptoms

Both scientists and caregivers have long been interested in the relationship between diet and ADHD symptoms. Many studies have been conducted to try to understand if a significant relationship exists and, if so, what it may mean for preventing or controlling ADHD symptoms. For instance, in the 1970s, it was proposed that artificial colors and flavors caused hyperactivity in children. These preliminary findings have not held up to experimental replication and at the current time there is not a clear relationship between diet and ADHD symptoms in most children. 

Some patients, families, and providers may see diets which eliminate certain ingredients and additives as unlikely to harm, and therefore worthwhile even if the chance of benefit is small. Providers can be helpful to caregivers by helping emphasize the evidence base of using well-established treatment for ADHD, both nonpharmacological and pharmacological, and the importance of interventions such as school accommodations, as mainstays of caring for individuals with ADHD. If a family has limited time, energy, and money to devote to helping a child with ADHD, the primary care provider can help emphasize those interventions that are most likely to be beneficial. 

Medication

The two main classes of medications used for treatment of ADHD include stimulants and non-stimulants.

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

Stimulant Prescribing Principles

Before considering a stimulant medication, obtain cardiac history, including sudden cardiac death in first degree relative under age 50, history of congenital heart defect, or conduction defect. 

Prescribers may start with a first line stimulant medication from the methylphenidate or dextroamphetamine-amphetamine class, depending on age and ability to swallow solid dosage forms. Long-acting stimulant medications are generally preferred for school-age children.

Dosages

Although the weight and size of patients can give clues about what doses of stimulant medications will be appropriate to treat ADHD symptoms, there is enough variation in effective doses that a general principle of starting with dosages at or near the bottom end of the dose range is a good practice.

Maximize the dosing of one agent before moving to the next. If ineffective or side effects develop, switch classes within first line options, then move to second- or third-line medication, if needed. Maximize dosing of long-acting stimulant before adding an immediate release formulation medication. It is important to recognize that increasing the dose of the long-acting stimulant does not increase duration of action, but rather tempers symptomatology. 

Fortunately, both the beneficial and adverse effects of stimulant medications are usually seen within a few days of starting the medication allowing for relatively rapid determination of stimulant dose effectiveness and tolerability. This means that with a few reliable data points combining patient self-report, observation from caregivers, and information from collateral sources (such as teachers), decisions about increasing, decreasing, or maintaining a medication dosage can be made. Often, increments of 1-2 weeks are a good interval to allow for observations to be collected.
 

Clinical Pearl: Sharing information with School Staff

Although some caregivers think it may be best not to share medication changes with school staff, thinking this may bias their observations, in many cases informing school staff and proactively soliciting their observations yields better information for refining the treatment plan.

Side Effects

Common adverse effects of stimulant medication are lowered appetite, sleep disruption, feeling nervous or jittery, adverse changes in mood or behavior (either when the medicine is active or when it wears off), headaches, stomachaches, and mild increases in heart rate or blood pressure. Adverse effects are usually, but not always, dose-related, with dose reduction often leading to resolution. Because stimulant medications have a specific duration of activity, one of the most helpful pieces of information to gather about adverse effects is their timing and severity throughout the day (e.g., about an hour after taking a stimulant dose, suggesting a direct adverse effect of the medication, or about 8 hours after taking a long-acting stimulant, suggesting an adverse effect related to when the medicine wears off). This will help guide medication adjustments to address adverse effects. 

Reduced appetite from stimulant medications can sometimes be managed by thoughtfully prioritizing adequate nutrition in the morning before the medicine is taken or kicks in, and in the evening when the medicine is wearing off or has worn off. While the appetite may be low at lunchtime, when the stimulant is active, the nutritional intake at other times may compensate, making it adequate over the course of the day.

Clinical Pearl: Side effects and tolerability

Patients receiving stimulant pharmacotherapy may experience increased irritability in two distinct patterns: increased irritability soon after the medication kicks in, indicating poor tolerability of that agent/dose, or increased irritability much later after the medication begins to wear off, indicating a difficulty due to a sharp drop-off of the medication, which in some cases can be addressed with a short-acting stimulant “booster” dose later in the day

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Adding extended release guanfacine to stimulant treatment which has been partially effective but limited by side effects can improve symptom control without the adverse effects of increasing the stimulant dose

Clinical Pearl: Medication-naive patients

For medication-naïve patients, it is often useful to trial methylphenidate/dexmethylphenidate first due to somewhat decreased incidence of adverse effects compared with amphetamine.

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For additional Psychotropic Medication Prescribing Principles see Prescribing Principles of Psychotropic Medication

Stimulant Medications

Methylphenidate

Dexmethylphenidate

Amphetamine Derivatives

Tips for Combining Medication

Common Side Effects for Stimulant Medications

Reduced appetite/weight loss, insomnia, nervousness, stomachaches, headaches, mild irritability as medicine kicks in, mild irritability as medicine wears off, mild social withdrawal, mild increases in heart rate or blood pressure

Serious Side Effects for Stimulant Medications (Rare)

Severe mood problems, serious aggression, hallucinations, severe social withdrawal, severe tics, large increases in heart rate or blood pressure

Tips for Follow-Up Medication Management

When a stimulant medication is well-tolerated but ineffective, the dose can be increased. Improvements are often seen right away, so with good data from caregivers and schools about symptoms/response to the current dose, this titration could occur after a brief time (e.g., one week).

Obtaining information about the timing of when the medicine wears off and when side effects are seen is an important part of medication follow-up. For instance, patients receiving stimulant pharmacotherapy may experience increased irritability in two distinct patterns: increased irritability soon after the medication kicks in, indicating poor tolerability of that agent/dose, or increased irritability much later after the medication begins to wear off, indicating a difficulty due to a sharp drop-off of the medication, which in some cases can be addressed with a short-acting stimulant “booster” dose later in the day.

Patients who tolerate methylphenidate without significant side effects but do not seem to experience benefit may be trialed on an amphetamine stimulant such as mixed amphetamine salts or lisdexamfetamine, which sometimes shows efficacy in those who do not respond to methylphenidate, although the likelihood of stimulant-related side effects with amphetamine is modestly higher.

Nonstimulant Medication Prescribing Principles

Although non-stimulant medications for ADHD have a lower effect size, they can be a good choice for individuals who do not tolerate stimulant medications.

Nonstimulant ADHD medications, as a group, improve ADHD symptoms in fewer patients and to a smaller degree than stimulant medications. However, they may be a good choice for some patients, either alone or in combination with stimulant medications. The prototypical patient for whom nonstimulant ADHD medications are helpful is one who has not been able to tolerate adverse effects of stimulant medication. Nonstimulant medications are used as an alternative for patients whose caregivers are averse to stimulant medication. Sometimes those caregivers can be reassured that stimulant medications are some of the best- and longest-studied medications for youth, and that we have a large amount of clinical experience to demonstrate that they are generally safe and effective.

FDA-approved nonstimulant ADHD medications can be divided into two basic groups: alpha agonist medications (guanfacine and clonidine) and norepinephrine reuptake inhibitors (atomoxetine and viloxazine). Among the alpha agonists, guanfacine has more specificity for the brain targets of ADHD therapy, so it generally has fewer adverse effects compared with clonidine. However, both can cause sedation, lightheadedness (especially when standing up), orthostatic hypotension, and headache). For norepinephrine reuptake inhibitors, common adverse effects are gastrointestinal side effects, reduced appetite (although usually milder than seen with stimulant medications), and mild changes in mood and irritability.

Clinical Pearl: ADHD Nonstimulant Medication Overview

Both clonidine extended release and guanfacine extended release can cause sedation and orthostatic hypotension, but this side effect is less common in guanfacine because its activity at receptors is more selective

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Patients receiving atomoxetine may take a long time to achieve the full effect of the medicine (a mean time to optimal response of 14 weeks)

Nonstimulant Medications

Methylphenidate

Guanfacine and clonidine are alpha agonists; atomoxetine and viloxazine are norepinephrine reuptake inhibitors.

Common Side Effects for Alpha Agonists (guanfacine and clonidine)

Lightheadedness/dizziness, especially when sitting up or standing up; mild sedation; headache.

Serious Side Effects for Alpha Agonists (Rare)

Syncope (fainting); large decreases in heart rate or blood pressure.

Common Side Effects for Norepinephrine Reuptake Inhibitors (atomoxetine and viloxazine)

Gastrointestinal side effects: upset stomach, diarrhea, nausea, vomiting, reduced appetite, mild increases in irritability.

Common Side Effects for Norepinephrine Reuptake Inhibitors (Rare)

Large increases in irritability, suicidal ideation, liver problems.

Ongoing Management

While medications and psychosocial treatments can be effective for symptom management, ongoing dialogue about symptoms and side effects is important. Healthcare providers should schedule frequent follow up visits to determine whether treatment goals are being met.

• Assess symptom changes in multiple domains (home and school)
• Monitor for medication side effects
• Monitor appetite, height, and weight
• Monitor sleep hygiene
• Reinforce use of resources for families and youth
• Refer to support groups, peer groups, education sources
• To promote shared decision making, a decision-making tool kit and video have been developed. The use of the toolkit can empower children, teens, and caregivers to have a voice in their care. The toolkit includes pages for “how to prepare for your visit,” “treatment options and plans,” “tools to help rate your symptoms”, and blank areas for notes.  
   

Resources

Resources for families

ADHD Resource Center  

NIMH ADHD Disorder in Children and Teens: What You Need to Know  

Chadd Parenting PDF  

Ways to Help Your Child With ADHD Succeed at School  

Treatment of ADHD  

Behavior Therapy for Children with ADHD

Resources for youth

Youth Resources

ADHD for Teens

References

1. American Academy of Pediatrics. (2017). Behavior therapy for children with ADHD. https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Behavior-Therapy-Parent-Training.aspx

2. Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R., & GLAD-PC STEERING GROUP. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141(3), e20174082. https://doi.org/10.1542/peds.2017-4082

3. Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2020). ADHD quick facts: Behavior management in ADHD treatment. https://chadd.org/about-adhd/adhd-quick -facts-behavior-management-in-adhd-treatment/

4. Cigna. (2021). ADHD myths and facts. https://www.cigna.com/individuals-families/health -wellness/hw/adhd-myths-and-facts-hw164660

5. Del-Ponte, B., Quinte, G. C., Cruz, S., Grellert, M., & Santos, I. S. (2019). Dietary patterns and attention deficit/hyperactivity disorder (ADHD): A systematic review and meta-analysis. Journal of affective disorders, 252, 160–173. https://doi.org/10.1016/j.jad.2019.04.061

6. Heilskov Rytter, M. J., Andersen, L. B., Houmann, T., Bilenberg, N., Hvolby, A., Mølgaard, C., Michaelsen, K. F., & Lauritzen, L. (2015). Diet in the treatment of ADHD in children - A systematic review of the literature. Nordic journal of psychiatry, 69(1), 1–18. https://doi.org/10.3109/08039488.2014.921933

7. Owens, J., Hustus, C., Everly, E., Evans, S., & Margherio, S. (2020). Attention deficit hyperactivity disorder: Evidence-based assessment and treatment for children and adolescents. In G. J. G. Asmundson (Ed.), Comprehensive Clinical Psychology (2nd ed.) (2nd ed., pp. 395–411). Elsevier. https://doi.org/10.1016/B978-0-12-818697-8.00029-7

8. Pellow, J., Solomon, E. M., & Barnard, C. N. (2011). Complementary and alternative medical therapies for children with attention-deficit/hyperactivity disorder (ADHD). Alternative medicine review: A journal of clinical therapeutics, 16(4), 323–337

9. Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R., Laraque, D., & GLAD-PC STEERING GROUP. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3), e20174081. https://doi.org/10.1542/peds.2017-4081