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Attention-Deficit/Hyperactivity Disorder (ADHD)

Last reviewed: August 2024

Attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, and one of the most frequently 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 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 tends to lead to lower esteem and a sense of failure. Youth with ADHD struggle not only educationally but also with their relationships with adults and peers which may have serious and long-term consequences, including school failure, delinquency, and involvement in the criminal justice system, family stress and disruption, depression or anxiety, defiant behavior, problems with relationships, substance abuse, accidental injuries, and job failure.

Medication is one of the most effective tools in treating ADHD. According to the CDC, stimulant medication reduces symptoms of ADHD in 70-80% of children allowing them to thrive in all aspects of their lives.

When should we consider evaluation?

Increased activity, difficulty with focus and acting impulsively are often variations of normal behaviors. However, when these behaviors 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. It is also important to note that symptoms may appear later in life and look different in girls compared to boys. Girls often present with inattentive symptoms rather than hyperactivity which may make it more difficult to diagnose.

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Meet Jack

Jack is a 7-year-old male with unremarkable medical and psychiatric history who presents with disruptive behavior at school. He is frequently wandering around the classroom, interrupting other children while they are working, and is unable to sit still. Over the past year Jack has been missing more and more assignments and teachers report that though Jack appears to understand the material, he simply cannot complete it.

Medications

Albuterol inhaler, as needed for asthma.

Psychosocial

Jack lives with his mother, father, and 3-year-old sister. There is no history of trauma or CPS involvement.

Myths vs Facts About ADHD

Fact: While pharmacotherapy can be an important part of the treatment regimen for ADHD, ADHD is a chronic condition and symptoms may return when medication is stopped.

Fact: While social factors are important to any child’s wellbeing, research shows that ADHD has a strong genetic and biological basis.

Fact: Left untreated, ADHD symptoms can persist into teen years and even adulthood. In fact, 70% of untreated children with ADHD show symptoms throughout their teens, and 50% of untreated children with ADHD present symptoms in adulthood, although some of the symptom features may change over time.

Fact: Treating ADHD with stimulants has shown to be protective against the development of substance use disorders.

Fact: Stimulants can sometimes cause extreme hyperfocus, especially when a dose is too high or a medication is not right for an individual. People on the right dose of the right medication should not feel any changes to their personalities.

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 assessing the patient, it can also be beneficial to gather information on family history of ADHD. Families who have adults with untreated ADHD may need additional resources to best support their child’s treatment.

While there are several rating scales validated for screening and assessment of ADHD, such as Conner’s scale, and Child Behavior Checklist (CBCL); the Vanderbilt Assessment Scales are one of the most commonly 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 and follow-up to monitor response to medication.

 

Vanderbilt Assessment Scales

 

The Vanderbilt Assessment scale consists of two clusters of symptoms and allows for parents and teachers to check off for each of the symptoms that are present and rate if they are a problem or not. It identifies areas within the diagnostic criteria that are a potential problem that a provider can inquire more about the symptoms and the impairment they are causing.

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Jack

Vanderbilt scales were distributed to Jack’s parents and teachers. When interviewed, the parents agree with the teacher’s assessment. The symptoms are consistent with ADHD. Symptoms from both the hyperactive/impulsive cluster and the inattentive cluster are strongly present indicating a diagnosis of ADHD, combined type.

Jack’s Parent Vanderbilt Scales:

The Vanderbilt completed by Jack’s parents were positive for the following items. Jack is forgetful in daily activities and loses things that are needed for tasks or activities. He doesn’t seem to listen when spoken to directly and is not able to follow through when given directions. He fails to finish things and is easily distracted by noises or other things. Finally, he does not pay attention to details or makes careless mistakes on things such as his homework.

Jack’s Teacher Vanderbilt Scales:

When reviewing the Vanderbilt completed by Jack’s teacher, it’s noted that they noticed similar symptoms highlighted in the parent’s assessment. Additionally, Jack’s teacher notes that Jack leaves his seat when he is supposed to stay seated, he often seems like he is on the go or acts like he is driven by a motor. Jack also interrupts or bothers others when they are talking or playing games. He fidgets with his hands or feet and squirms in his seat. Jack has difficulty waiting his turn and blurts out answers even before the question has been completed.

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.

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Jack

After an exam and review of family, health, and school history, it was determined that Jack’s symptoms were consistent with ADHD. No underlying medical or developmental factors were found that could be causing these symptoms. A diagnosis of ADHD, combined type, was made.

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. It is important to recognize that many patients with ADHD have at least one comorbid condition and need careful diagnosis for successful treatment of 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 – Increased activity which is episodic rather than always present, elevated or euphoric mood, grandiosity, decreased need for sleep while still having excess energy (and not just difficulty sleeping), and thoughts which are not just slightly scattered but racing and extremely loosely connected, sometimes called “flight of ideas”
  • Conduct Disorder – Pervasive pattern of serious violations of rules or laws, destruction of property, theft, or frequently initiating fights or engaging in other aggression to people and animals
  • Depression – Inability to concentrate, present during major depressive episodes 
  • Disruptive Mood Dysregulation Disorder – Pervasive irritability and intolerance of frustration; impulsiveness and disorganized thought is not present
  • Learning disorder – Avoidant, disruptive, or seemingly inattentive behaviors which occur only in the academic setting or during academic activities can be indicative of an undiagnosed learning disorder or intellectual disability
  • Oppositional Defiant disorder – negativity, hostility, defiance, refusal to submit to others’ demands
  • Substance Use Disorder – Use of nicotine, alcohol, cannabis, opioids when an onset of ADHD symptoms follow the onset of frequent and problematic 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.

 

Preparing for your appointment

 

Treatment Guide

 

Medication Management

 

Non-Medication Interventions

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

Behavior Therapy

Standardized parent training programs, sometimes called behavioral parent training or BPT, can be helpful in reducing disruptive behaviors.

The goal of behavioral therapy is to encourage positive behaviors and discourage negative behaviors, which can be helpful for children with disruptive behavior whether or not ADHD is present. Behavior therapy can be effective at helping children with ADHD succeed in school, at home, and in peer relationships. Psychotherapies targeting impairments due to ADHD symptoms include a significant component of parent involvement, especially for younger children. For younger children, this form of therapy may include 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:

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
  • set consistent boundaries, expectations, and consequences for behaviors
  • avoid ineffective methods of discipline such as corporal punishment
  • promote an overall healthy lifestyle for your child

If a family has adults who have untreated ADHD, encourage them to seek treatment for their own symptoms as well.

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. Additionally, accommodations through a 504 Plan or Individualized Educational Plan (IEP) for students with ADHD in academic setting can include flexible or preferential seating, providing support for learning organizational strategies, and extra time and ability to complete assessments in a quiet space. The National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.

Behavior therapy such as parent management training may be recommended as an initial treatment for children under 6 years of age if the ADHD symptoms are mild with minimal impairment or if the diagnosis of ADHD is uncertain.

Both therapy and medication interventions are recommended for older children. These include maintaining a daily schedule, minimizing distractions, and using charts and checklists to keep the child on track. Positive behavior should be rewarded, and parents should be careful that they are not unintentionally reinforcing negative behaviors. It is also helpful to set small, achievable goals for the child and to find activities in which they can be successful. The child should also be evaluated for an IEP or 504 plan, which can offer additional support with these interventions in the school setting.

Individual psychotherapy and family therapy can be helpful for comorbidities such as anxiety and depression.

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. 

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Jack

Jack was evaluated at school for an IEP to help with organization, test-taking, and limiting distractions. His parents also implemented a daily schedule for Jack at home with a token economy system to reward him for positive behaviors.

Medication

While behavioral therapy is important, medication treatment for ADHD is considered a vital component of a full treatment plan. It has been proven highly effective for many individuals with ADHD who are of school age and older. The two main classes of medications used for treatment of ADHD include stimulants and non-stimulants. Please note that availability from pharmacies and insurance coverage of stimulant medication may vary and present significant barriers to treatment planning.

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

For additional resources, visit the Ohio Medicaid Pharmacy Program.

 

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 should choose a stimulant depending on age, ability to swallow solid dosage forms, and duration of action.

Stimulant 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.

 
Stimulant Side Effects

Adverse effects are usually, but not always dose-related. Dose reduction often leads to resolution. Since stimulant medications have a specific duration of activity, gathering specific information about timing and severity can help guide how to address adverse effects. For example, if a patient is experiencing effects 1 hour after a stimulant dose is taken, it suggests that it is the effect of the medication but if they experience the effect 8 hours after a long-acting stimulant is taken, it suggests the effect is related to when the medication is wearing off. 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.

If a patient is experiencing reduced appetite, it can be managed by thoughtfully prioritizing adequate nutrition. Having meals in the morning before the medicine is taken or kicks in and in the evening after the medicine is wearing off or has worn off can help provide total daily nutrition and compensate for low nutrition intake during lunch time when appetite may be affected by the stimulant being active in their system. Serious side effects are rare and include severe mood problems, serious aggression, hallucinations, severe social withdrawal, severe tics, or large increases in heart rate or blood pressure.

For more information on stimulant medication, visit the ADHD Stimulant Medication Aid.

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

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.

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

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Jack

In addition to the non-medication interventions that Jack’s family and teachers implemented in the previous vignette, Jack was prescribed a low dose of stimulant medication, which he tolerated well and the medication was titrated to an effective dose. In the next few months, teachers and parents noticed a great reduction in disruptive behaviors. Jack’s grades improved and by the end of the year, he was excelling academically.

Nonstimulant 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

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)

For more information on nonstimulant medication, visit the ADHD Nonstimulant Medication Aid.

Ongoing Management

Managing ADHD in primary care is akin to managing a chronic condition. It demands ongoing treatment and follow-up care. In the initial stages, our focus often revolves around providing effective medication treatment. This involves fine-tuning medication doses within therapeutic ranges and keeping a close eye on medication compliance, symptom progress, and any potential side effects. After symptoms are stabilized, ongoing treatment includes monitoring medication response and for emergence for side effects over time. Especially in the early phases of treatment, regular follow-up visits play a pivotal role. They serve a dual purpose: ensuring the individual's journey toward improved well-being and promptly recognizing any signs of symptom deterioration. Typically, this close monitoring continues for around 6 to 12 months.
 
Caregivers and family members play an important role in supporting youth navigating the challenges of ADHD. 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 toolkit has been developed to serve as 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.

In some cases, adding a bit more structure to the home environment can be quite beneficial. This might involve setting reasonable boundaries on the use of social media and gaming. It's also important for caregivers to make it a priority to attend regularly scheduled visits with the primary care provider. Staying informed and actively involved in the treatment process is key.

Promoting a healthy lifestyle is another essential part of caregiving. This encompasses encouraging healthy eating habits, regular physical activity, and good sleep practices. Additionally, caregivers can work with the youth on developing resilience and equipping them with the skills they need to better handle life's challenges. To explore more about these resilience-building skills, you can visit the Ohio Minds Matter Resilience page.

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Jack

Jack's primary care provider continued to see Jack and his parents for ongoing monitoring. He continued to tolerate the medication well without significant side effects and maintained his improvements in the classroom. His appointments for ADHD management occurred about every three months. At the end of the school year, Jack's parents met with his teacher to discuss how to help Jack be successful with a new teacher who was familiar with his 504 plan. Jack's teacher agreed that maintaining the classroom accommodation of preferential seating would be beneficial.

Frequently Asked Questions (FAQs)

Yes. A large majority of individuals with ADHD have a co-occurring condition, frequently related to mood, behavior, sleep, or substance use. Youth with ADHD are also more likely to be overweight or obese.

While a healthy diet can be beneficial to any child, there has been no evidence that restricting certain foods or nutrients will significantly reduce ADHD symptoms. Evidence-based medication and behavioral therapies are recommended treatments for managing ADHD.

Parents may question that their child has ADHD due to their ability to sustain focus on certain tasks, but these are often favored tasks that hold particular interest. Since ADHD is due to a limitation in executive functioning skills, children may be able to complete some tasks while still experiencing deficits in emotional regulation, planning and organizing skills that should be addressed.

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. 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
  5. 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
  6. 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
  7. 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
  8. 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