Attention Deficit Hyperactivity Disorder (ADHD)
Overview
Attention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that begins in childhood and is characterized by some combination of hyperactivity, impulsivity, and/or inattention. These symptoms are present to such a degree that they significantly interfere in at least 2 areas of the child's life, such as in the home and classroom. Three major types of ADHD are currently recognized (predominantly inattentive, predominantly hyperactive-impulsive, and combined). Growing evidence suggests that at least one subtype of ADHD is caused by defects in the dopamine and norepinephrine transporter proteins within the nerve cell wall. [Vaidya: 2008] [Kollins: 2008] [Kim: 2006]ADHD is a disorder that can be treated safely and with good efficacy. If undertreated or left untreated, it carries significant morbidity including an increased risk of substance abuse in adolescents. [Wilens: 2008] [Biederman: 2009] Some children who do not meet full criteria for diagnosis could respond to behavioral intervention and school support, and should not be treated with medications. [Wolraich: 2011] Children with ADHD often are affected by other conditions including emotional or behavioral disorders, developmental disabilities, and other medical conditions. [Wolraich: 2011]
Other Names & Coding
Attention deficit disorder
F90.0, predominantly inattentive type
F90.1, predominantly hyperactive-impulsive type
F90.2, combined type
ICD-10 Coding for ADHD provides further coding details.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2015] generally designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits our
including their codes or descriptions.
Prevalence
ADHD is one of the most common chronic disorders of childhood. Approximately 7% of children in the U.S. meet criteria for ADHD diagnosis. [Wolraich: 2011] Boys are more than twice as likely as girls to have received a diagnosis of ADHD. [Visser: 2014]Genetics
Although ADHD clearly runs in families, and twin and adoption studies support a strong genetic component, the genetic mechanisms are not yet well understood. [Smith: 2009] [Faraone: 2005] Markers on at least 7 chromosomes and genes for dopamine and serotonin receptors, transporters, and associated enzymes have been found to be statistically associated with ADHD. Environmental factors are also shown to play a role in some cases. [Pliszka: 2007]Prognosis
Many children show improvement in adolescence, yet individuals may need support and treatment for this condition through adulthood. [Shaw: 2012]Practice Guidelines

Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M,
Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder
in Children and Adolescents.
Pediatrics.
2011;128(5):1007-22.
PubMed abstract / Full Text
Roles of the Medical Home
Most children with ADHD can be treated by their medical home provider without subspecialty consultation or referral. Occasionally, additional expertise that includes psychologists, behavioral/developmental pediatricians, child psychiatrists, and educational specialists, may be needed, particularly if the child has a co-morbid condition. Even if children are referred elsewhere for diagnosis, ongoing evaluation and management should still be performed within the context of the medical home, and children with ADHD should be considered to have special health care needs. [Wolraich: 2011]Ongoing communication with the child's parents and teachers is essential for appropriate management. Periodic visits, in addition to well-child exams and acute-care visits, are generally needed to discuss status and manage medications. The AAP suggests that the medical home should:
- Monitor and update family knowledge and understanding of ADHD.
- Offer counseling on the family's response to the condition.
- Provide developmentally appropriate education for the child about ADHD and updates as the child grows.
- Be available to answer the family's questions.
- Ensure coordination of health and other services.
- Help families set specific goals in areas related to the child's condition and its effects on daily activities.
- When appropriate, connect families with other families who have children with similar chronic conditions.
Clinical Assessment
Pearls & Alerts for Assessment
Inattentive type may go undiagnosedChildren with inattentive presentation may go undiagnosed for longer than the hyperactive/impulsive presentation, presumably because the symptoms are less bothersome to others. Among girls, the inattentive type is more common, and may present simply as poor school performance that worsens when higher-level problem solving is required, typically in upper elementary grades.
Discrepancy between family and teacher symptom assessmentsWhen ratings of ADHD symptoms differ, additional sources, such as former teachers and coaches, may be helpful. Also consider the setting: A teacher in a very structured classroom may not note symptoms that are easily observed in a less structured classroom, or in a busy home. A child who expends a lot of effort to pay attention and behave appropriately at school may “fall apart” at home, and this can result in more severe parent ratings.
Re-evaluation neededFrequent re-evaluation to prevent under treatment may be needed. [Wolraich: 2011]
Cardiac screening before stimulant useThe American Heart Association proposes that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. The AAP recommends screening only when heart disease is suspected by a physician.
ADHD and autistic spectrum disorderChildren with autism may present with symptoms of ADHD during early elementary school, or earlier. If earlier, it may be difficult to differentiate from the autism symptoms. Children with autism spectrum disorder who present with significant hyperactivity, inattention, or impulsivity, despite adequate supports, should be evaluated for co-morbid ADHD.
Screening
For the Condition
Evaluation for ADHD should be initiated if the child presents with inattention, hyperactivity, impulsivity, low school achievement for the child's IQ, and/or behavior problems. [Wolraich: 2011] The evaluation will generally take a few visits and will require gathering information about school performance, school/daycare behavior, and functioning within the family and with friends by using specific ADHD checklists. Many of these checklists also screen for additional problems, such as defiant behavior and learning concerns. It should be recognized that these measures are subject to the biases of the people completing them. Specific ADHD checklists include:-
NICHQ Vanderbilt Assessment Scales - Parent & Teacher Initial and Follow-Up Scales with Scoring Instructions (
1.1 MB): Forms for initial and follow-up assessments for teacher and parent informants. Includes scoring instructions, no fee required.
-
NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) (
3.9 MB) and NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) (
3.6 MB): Spanish (with English translation) forms for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required.
- Conners 3rd Edition ADHD Assessment (Pearson): Administered to parents and teachers of children and adolescents 6–18 years old; self-report, 8–18 years old. Available for a fee.
- ADHD Rating Scale—IV (for Children and Adolescents) (ADHD-RS): Containing 18 items, the scale is linked directly to DSM-IV diagnostic criteria for ADHD. Available for a fee.
Periodic repetition of behavior scales completed by parents and teachers can be helpful to track response to medication and behavioral interventions. These are often completed every 6-12 months. It is important to pick a time during the school year when the teacher has had some exposure to the student. Subjective reports can also be very helpful.
For Complications
If treatment does not seem to be effective, consider using a validated screening tool to identify and help diagnose co-morbid conditions, such as anxiety, depression, oppositional-defiant disorder, conduct disorder, substance use or abuse, learning disorders, mood disorders, language disorders, sleep problems including sleep apnea, tics, other neurological disorders including autism, and trauma.The following screening tools may be helpful:
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Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) (
218 KB): Child self-assessment with 41 (brief) questions that have fill-in circles for possible answers. Contains scoring information, no fee required.
-
Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) (
47 KB): Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.
-
Patient Health Questionnaire-9 (PHQ-9) (
40 KB): Nine-question depression screen with scoring information that can be used with adolescents. Questions are based on DSM-IV diagnostic criteria for major depressive disorder, no fee required.
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Severity Measure for Depression - Ages 11–17 (
228 KB): Adolescent-focused, 9-question, depression screen with scoring information. No fee required.
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Center for Epidemiological Studies Depression Scale for Children (CES-DC) (
37 KB): Depression screening tool, with 20 questions, that takes about 10 minutes to complete. No fee required.
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DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) (
367 KB) and DSM-5 Self-Rated Level 1 Symptom Measure—Age 11–17 (APA) (
250 KB): Free, 25-question assessments for initial patient interview and for monitoring treatment progress. Includes scoring instructions.
-
Achenbach Child Behavior Checklists (Ages 1 1/2-5) (Ages 6-18) (Ages 11-18): A variety of screening tools are available for a fee. (Child Behavior Checklist for Ages 6-18 (Screen Sample) (
40 KB))
- SEEK Parent Screening Questionnaire (PSQ-R) (University of Maryland): Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions; free to download in English, Chinese, Spanish, and Vietnamese.
- Behavior Assessment System for Children, Second Edition (BASC-2): Screen for children 2-21 years of age that takes about 15 minutes to complete; available for purchase.
- CRAFFT: A 6-question behavioral health screening tool recommended by the American Academy of Pediatrics' Committee on Substance Abuse to screen adolescents for high-risk alcohol and other drug use disorders. Available for free download in 13 languages.
Presentations
Presentation may vary considerably based on form of ADHD (predominantly inattentive, predominantly hyperactive-impulsive, combined), developmental age, severity, environment, co-morbid conditions, and other factors. Young children with the inattentive type may have significant difficulty attending to the reading of a picture book, whereas adolescents may have difficulty finishing homework and performing required tasks. Inattentive students may not be noticed until they start falling behind in school, often in the upper elementary grades when problem solving becomes more complex.Preschoolers with the hyperactive/impulsive type may be constantly physically active, running in circles, and climbing on furniture, whereas adolescents with this type may engage in risky behaviors and sports. Hyperactive children are typically noticed earlier due to disrupting their classrooms or getting into trouble at home.
It is important to consider developmental age when deciding whether the level of inattentiveness and/or hyperactivity is abnormal. A child with the cognitive level of a 5-year-old, although he may be twice that age, usually has the activity level and attention span of a 5-year-old. It is also important to take a history about the symptoms over time, as children who start out with symptoms of hyperactivity in preschool may present with more inattentive/impulsive symptoms in adolescence.
Diagnostic Criteria
When DSM-5 was updated in 2013, minor changes were made to diagnosis criteria for ADHD, including onset of symptoms before age 12 instead of age 7, and fewer symptom criteria needed to diagnose adolescents than children. (See ADHD Fact Sheet (APA) (
DSM-5 Criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Based on types of symptoms, 3 presentations of ADHD can occur:
- Predominantly inattentive presentation: Six or more symptoms of inattention (listed below) for children up to age 16, or 5
or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they
are inappropriate for developmental level:
- Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
- Has trouble holding attention on tasks or play activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked)
- Has trouble organizing tasks and activities
- Avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period (such as schoolwork or homework)
- Loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
- Is easily distracted
- Is forgetful in daily activities
- Predominantly hyperactive-impulsive presentation: Six or more symptoms of hyperactivity-impulsivity (listed below) for children
up to age 16, or 5 or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present
for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
- Fidgets with or taps hands or feet, or squirms in seat
- Leaves seat in situations when remaining seated is expected
- Runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
- Is unable to play or take part in leisure activities quietly
- Is "on the go" acting as if "driven by a motor"
- Talks excessively
- Blurts out an answer before a question has been completed
- Has trouble waiting his/her turn
- Interrupts or intrudes on others (e.g., butts into conversations or games)
- ADHD combined type: If enough symptoms of both inattention and hyperactivity-impulsivity criteria were present for the past 6 months
- Several inattentive or hyperactive-impulsive symptoms were present before age 12 years
- Several symptoms are present in 2 or more settings (e.g., at home, school or work; with friends or relatives; in other activities)
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning
- The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Clinical Classification
Presentations: [American: 2013]- ADHD predominantly inattentive presentation
- ADHD predominantly hyperactive-impulsive presentation
- ADHD combined type
- Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
- Moderate: Symptoms of functional impairment between "mild" and "severe" are present.
- Severe: Many symptoms in excess of those required to make diagnosis, or severe symptoms that are particularly severe and result in marked impairment in social or school functioning.
Differential Diagnosis
Other diagnoses that should be considered are listed below:- Seizures/Epilepsy, particularly Childhood Absence Epilepsy
- Hearing Loss and Deafness, including middle ear infections causing hearing loss or auditory processing disorder, may contribute to inattention. Evaluation for hearing deficits should be triggered by any suspicious symptoms or findings.
- Sleep Issues may cause daytime difficulties, such as hyperactivity and inattention. Consider further evaluation if history and physical exam (e.g., large tonsils) suggest obstructive sleep apnea.
- Visual impairment, including visual processing disorders may present as inattention. An ophthalmological exam is warranted if there is any concern, or if the child has any difficulty passing screening tests.
- Tourette Syndrome could lead to speaking out inappropriately or repetitive noises, which could be confused with the impulsiveness or repetitive noises seen with ADHD.
- Learning disabilities may be the etiology of poor school performance and may accompany ADHD. If these are a concern, refer for psychological testing. Children with learning disabilities will often score significantly higher on IQ testing compared to achievement testing.
- Depression or anxiety are similar psychiatric problems that may occur with ADHD or cause symptoms of ADHD that may resolve when the primary disorder is treated. If concerned, consider a referral to child psychiatry or psychology. Ask about life changes causing anxiety or difficulty concentrating, such as a parent's death, divorce, etc.
- Autism Spectrum Disorder may present like ADHD, including difficulties with focus on non-preferred activities. Children with ADHD may also present with social skill deficits. [Kotte: 2013] ADHD and autism spectrum disorder may be genetically linked. [Rommelse: 2010]
- Substance Use Disorders
- Side effects of medication
- Trauma/childhood adverse events can lead to hypervigilance and arousal that can be mistaken for ADHD, or can overlap with actual ADHD. [Kaya: 2008] Screening for adverse events in childhood can help in the differential diagnosis as well as provide insight into ways to tailor support for struggling families. See Toxic Stress Screening and the Foster Care module for more information.
Medical Conditions Causing Condition
Medical conditions causing ADHD include:- Fetal alcohol spectrum disorders
- Traumatic Brain Injury or post-concussive attention problems
- Hyperthyroidism
Comorbid & Secondary Conditions
Co-morbid conditions include:- Tourette Syndrome
- Oppositional Defiant Disorder/Conduct Disorder and ADHD
- Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD)
- Mood Disorders and ADHD
- Specific Learning Disability (SLD) and ADHD
- Coordination Disorders and ADHD
- Lack of improvement in behavioral symptoms despite appropriate treatment and services for ADHD
- Persistent school underachievement or school avoidance
- Parental concern for a comorbid condition
- Low self-esteem, anxiety, irritability, sleep disturbance, or sadness
- Negative/oppositional behaviors
- Substance Use Disorders
History & Examination

Current & Past Medical History
Take a full medical history that includes heart problems, and motor and vocal tics. Ask about:- Previous illnesses or accidents that may contribute to attention problems
- Recent medical problems, growth, appetite, and possible side effects of medication for ADHD
- Mood, interactions with peers
- Adherence to prescribed medication or therapies
- Staring, brief eye-blinking, or other automatisms - consider absence seizures if “spacing out” events are occurring multiple times per day with a clear interruptions of activity, such as speaking, walking, or drinking
- Sleep onset and duration, as well as the presence of snoring or restless sleep
- Toileting and elimination
Family History
Ask about a family history of ADHD, associated conditions, cardiovascular disease, sudden death, and mental health disorders including bipolar disorder and psychosis. Growing evidence suggests that risk of cardiovascular disease and sudden cardiac death is extremely low with the use of both stimulant and non-stimulant ADHD medications. [Martinez-Raga: 2013]Pregnancy/Perinatal History
Ask about any pregnancy or perinatal problems that may contribute to poor intellectual and behavioral functioning.Developmental & Educational Progress
Assess developmental milestones and intellectual and social functioning in family and day care or school settings. Assessment should include documentation of:- ADHD DSM-5 criteria by parent interview or by use of a specific checklist, such as the Vanderbilt ADHD Parent Rating Scale (
72 KB)
- Specific symptoms by use of a checklist, such as Vanderbilt ADHD Teacher Rating Scale (
53 KB)
- Age at which the problem behaviors began, the settings in which the behaviors occur, and to what degree the child is impaired by the symptoms
Age and interest level will affect children's ability to attend to tasks; video games and other highly stimulating activities are not good indicators of a child's ability to attend.
Be sure to inquire about fine and gross motor skills, as many children with ADHD have poor coordination and possibly a developmental coordination disorder. [Wolraich: 2011]
Social & Family Functioning
Inquire about:- Recent changes in the family that may be causing anxiety or depression
- Behavior and functioning within the family and elsewhere (e.g., church or during extracurricular activities)
- Consistency or changes of medication
- Use of complementary/alternative treatments
- Parenting challenges
Physical Exam
Vital Signs
HR | RR | BP - Resting tachycardia or hypertension may indicate hyperthyroidism or another hypermetabolic state that may present with hyperactivity. Increased heart rate may occur with stimulant use; however, hypertension is less likely to occur as a result of medication use. [Hailpern: 2014] Use of alpha agonists such as guanfacine or clonidine can lower blood pressure and can cause rebound hypertension if discontinued abruptly. [Committee: 2001]Growth Parameters
Ht | Wt | BMI - Because stimulant medications may cause appetite suppression, follow weight closely. Although stimulants may slow height to some extent when first started, this effect appears to decrease over time. Recent studies have found that use of stimulants by children does not prevent them from obtaining their full adult height [Harstad: 2014]; it is still prudent to regularly measure children’s height and weight while on medications.Testing
Laboratory Testing
Lab testing is not indicated unless there are specific concerns from the medical history, such as lead exposure or symptoms of hyperthyroidism. Consider checking ferritin as a marker of iron deficiency, as this can be associated with disordered sleep, which in turn can negatively impact daytime attention and behavior. [Abou-Khadra: 2013] [Cortese: 2009] If malnutrition is suspected to play a role in the child’s performance, specific nutritional markers could be tested as well.Imaging
Rarely, children with absence epilepsy may present with ADHD signs. EEG is necessary only if there is a clear pattern of seizures.Other Testing
Testing for intelligence: Usually performed by the school, an IQ test, such as the Wechsler Intelligence Scale for Children [WISC], and a learning disability test, such as the Woodcock-Johnson, may be helpful when there seems to be a discrepancy between ability and performance.Echocardiogram and EKG: In 2008, the American Heart Association recommended that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. [Vetter: 2008] However, the 2011 clinical practice guidelines published by the AAP recommends using clinical judgment regarding screening when there are cardiac symptoms, or there is a significant cardiac or sudden death history in the family. [McPherson: 2004] See Stimulants and Cardiovascular Monitoring (AAP) for further discussion.
Specialty Collaborations & Other Services
Developmental - Behavioral Pediatrics (see UT providers [9])
Consult for expert assessment in diagnosing complicated cases, such as for discriminating symptoms related to developmental delay, or for diagnosis of younger children.
Psychiatry/Medication Management (see UT providers [62])
Consult to help with diagnosis and management of situations complicated by underlying medical issues, such as a history of traumatic brain injury, co-morbid psychiatric conditions such as mood or anxiety disorders, or for children who fail to respond to standard therapies.
General Counseling Services (see UT providers [450])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Neuropsychiatry/Neuropsychology (see UT providers [14])
Consult when full psychological testing is not available through the school district or if learning disabilities are suspected. May also be helpful in designing and implementing behavioral plans and therapies.
Pediatric Cardiology (see UT providers [7])
Consult if there are concerns about a child's cardiac status that would affect treatment and management decisions.
Treatment & Management
Overview
Management principles vary with the age of the individual: [Wolraich: 2011]- Preschool age children (4-5years old) should first receive parent- and/or teacher-administered behavior therapy. If this is not successful and function continues to be moderately to severely impaired, methylphenidate may be considered.
- For school-aged children 6-11 years old, behavior therapy and school placement optimization, plus stimulants, or to a lesser extent atomoxetine, extended-release guanfacine, and extended-release clonidine are recommended.
- For adolescents, similar treatments are recommended, but the consent of the individual should be obtained before medicating. Long-acting guanfacine, atomoxetine, or clonidine, or stimulants that have lower abuse potential, such as lisdexamfetamine (Vyvanse), OROS extended-release methylphenidate (Concerta), or dermal methylphenidate may be preferred. [Wolraich: 2011]
Consider using a validated screening tool to identify and help diagnose co-morbid conditions. See Screening for Co-Morbid conditions, above, for screening tools. The following Portal pages provide diagnosis and management information for co-morbid conditions and ADHD:
Pearls & Alerts for Treatment & Management
Stimulant use & cardiac eventsAAP guidelines indicate that evidence does not clearly demonstrate an increased risk of serious cardiovascular events, such as MI, QT prolongation, sudden death, or ventricular arrhythmias, in children using stimulant medication.
Tics, Tourette syndrome, and stimulant useRecent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics.
Stimulant drug misuseFrequent or early requests for stimulant refills may suggest misuse. Prescribers should carefully monitor their prescription refill requests.
Systems
Pharmacy & Medications
Prescribers should carefully monitor their prescription refill requests; frequent or early requests for stimulant refills may suggest misuse. Stimulants with relatively less abuse potential include lisdexamfetamine (Vyvanse), methylphenidate patch (Daytrana), or OROS extended-release methylphenidate (Concerta). Non-stimulant medications, such as atomoxetine (Strattera), extended-release clonidine (Kapvay), and guanfacine (Intuniv) may also be considered.
Extended-release guanfacine, extended-release clonidine, and atomoxetine offer alternatives for treatment. The AAP recommends their use if stimulants (one from each class) have been tried and are not successful. Atomoxetine is a selective norepinephrine reuptake inhibitor, and can cause nausea and sleepiness. Guanfacine and clonidine are norepinephrine receptor type alpha 2 agonists that can cause sedation and hypotension (more so in clonidine), and both are available in short and long-acting formulations. These medications need to be used on a daily basis without medication holidays. Extended-release guanfacine and clonidine have been shown to have efficacy as add-on therapies with stimulants. These non-stimulant medications for ADHD can take several weeks for full effect.
Side effects for both classes of stimulant medications include mild stomachaches and headaches, depressed appetite and weight loss, difficulty sleeping, increased blood pressure and heart rate, and irritability/anxiety. Cautions and contraindications to stimulant use include presence of a cardiac abnormality or condition; significant side effects (e.g., decreased appetite, insomnia, and poor growth); and significant tic exacerbation. (See Pearls and Alerts section, above.) Rare side effects can also occur; the FDA warns that methylphenidates and atomoxetine can cause priapism, and that atomoxetine can cause suicidality. Rarely, psychiatric symptoms, such as manic symptoms, paranoia, and hallucinations may occur. For more information, see Medications for ADHD Safety Information (FDA).
Effects of stimulants on co-morbid conditions needs further study. Some of what is known is as follows:
- Cardiac problems: Stimulant drug packaging includes the following statement, “Stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.” The AAP and AHA offer further insights into medication use in these special groups. [AAP: 2008] [Perrin: 2008]
- Fetal alcohol spectrum disorders (FASD): Children with FASD often have problems with attention and impulsivity; stimulant treatment may help, or it could make symptoms worse.
- Tics/Tourette syndrome: FDA package labeling for stimulants indicates that tics are a contraindication to use of these medications, so use of stimulants for children with tics is considered “off-label.” However, recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics. [Tourette's: 2002] [Roessner: 2006] Untreated ADHD may be more troubling to the child than the tics themselves. [Erenberg: 2005] However, monitoring of tics before and after starting stimulants is warranted due to individual variation. [Tourette's: 2002] For more information about relevant studies, see [Murphy: 2013] and [Pringsheim: 2011].
- Autism: Children with autism spectrum disorder have a decreased response rate to ADHD medications and an increased rate of reported side effects. Despite these concerns, recent information suggests that medication may be helpful. Cautious monitoring for unexpected effects on the child's functioning (e.g., an increase in anxiety symptoms) should be maintained. [Posey: 2007]. There is growing evidence that ADHD and autism spectrum disorder may be linked genetically. [Rommelse: 2010] See Evaluation and Medication Choice for ADHD Disorder Symptoms in Autism Spectrum Disorders (AAP) for treatment of co-morbid ADHD and autism spectrum disorder. [Mahajan: 2012]
- Other neurologic conditions: ADHD symptoms are often observed in children with neurologic conditions, such as neural tube defects, muscular dystrophy, cerebral palsy, intellectual disability, and various genetic syndromes. Stimulants are often helpful for these symptoms in children with intellectual disability [Aman: 2003], but not necessarily in children with velocardiofacial syndrome (22q11.2 Deletion Syndrome). [Antshel: 2007] Treatment for ADHD symptoms in neurologic and other conditions should be accompanied by close monitoring to assure response and limit side effects.
Off-label medications are occasionally used to manage ADHD, particularly in patients with comorbidities, such as depression, include bupropion (Wellbutrin), modafinil (Provigil or Nuvigil), and tricyclic antidepressants, such as desipramine (Norpramin) and imipramine (Tofranil). [American: 2013]
Medication tables with dosing information for stimulants and non-stimulants can be found at: If treatment fails, consider:
- Under-treatment - Medications should be titrated to maximum doses without adverse side effects instead of relying on milligram-per-kilogram recommendations to ensure adequate treatment of symptoms.
- Noncompliance with medication - This may be more common in families where parents also have symptoms of ADHD. [Wolraich: 2011]
- A co-morbid condition


Specialty Collaborations & Other Services
Developmental - Behavioral Pediatrics (see UT providers [9])
Consult for guidance on managing more complex cases, such as for children who have comorbid conditions, intellectual disability, or difficult-to-treat ADHD.
Psychiatry/Medication Management (see UT providers [62])
Consult to help with diagnosis and management of situations complicated by underlying medical issues.
Mental Health/Behavior
Most children with ADHD respond to more structure and fewer distractions in the environment. Behavior management takes advantage of this and includes the use of time-outs, a token economy, and daily school report cards while teaching the parents to respond consistently to a child's misbehavior. For instance, when a child comes home from school, a parent should inquire about homework, set a time and place for the child to do the homework, keep external noise (e.g., television) to a minimum, and then check that the homework is completed. Parents should be reminded that the long-acting preparations of stimulant medication are beginning to wear off in the afternoon, and homework attempted sooner rather than later, will probably be more successful. Classes are often available locally, through school systems, mental health, or other agencies, to train parents in achieving the goals of directed supervision and in managing behavioral problems.
Before starting medications, work with parents and school to identify 3 to 6 target behaviors or outcomes based on the needs and strengths of the child. The goals should be realistic and measurable. These may include: [Wolraich: 2011]
- Improvements in relationships with parents, siblings, teachers, and peers
- Decreased disruptive behaviors
- Improved academic performance, particularly in volume of work, efficiency, completion, and accuracy
- Increased independence in self-care or homework
- Improved self-esteem
- Enhanced safety in the community, such as in crossing streets or riding bicycles
The medical home should then collaborate with the family to develop a comprehensive treatment plan, which might include stimulant medication and behavioral management, as well as treatment of associated conditions.
Specialty Collaborations & Other Services
General Counseling Services (see UT providers [450])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Pediatric Neurology (see UT providers [5])
Referral may be helpful in managing ADHD, particularly if there are concerns about head injury or other neurologic conditions, such as seizures.
Learning/Education/Schools
The school will usually conduct an evaluation to determine if the child qualifies for special education services. If so, the school, with parental input, will develop an individualized education program (IEP). If the child does not qualify for special education services, he or she may qualify for a 504 plan for children with disabilities.
The medical home may be involved in planning and evaluating the child's school services. Direct communication is often very helpful for both the provider and the school. A signed consent from the parents should be in place before these conversations or meetings take place.
Teachers can help the child with ADHD by setting clear goals, decreasing distractions, offering subtle reminders to stay on task, and providing more structure. A daily or weekly "report card" or "contract" system with positive reinforcement for reaching goals can also help. For some children, a 504 plan may provide for desired classroom adaptations, such as preferential seating and decreased workload. See Education & Schools in the Portal's For Physicians & Professionals section for more detail on IEPs and 504 plans. Letter Requesting Assessment from Teacher (AAP) is a sample of a request for a teacher to complete a behavior assessment for their student. ADHD for Educators may also be helpful.
Parents should be encouraged to meet with the child's teacher early in the year to discuss the child's diagnosis, needs, and what has worked or failed in the past. This is particularly true if the family is changing school districts or if the child is transitioning to middle or high school. Ongoing meetings, not necessarily at the time of parent-teacher conferences, may also be helpful. Families should know that many colleges and universities have programs to support students with various disabilities through their years in higher education.
Specialty Collaborations & Other Services
School Districts (see UT providers [55])
The medical home provider can work with the school to ensure appropriate services are provided to qualifying students, as well as to obtain periodic feedback on how treatment interventions are affecting the child’s school participation and performance. Contact the district officials if the school is unable or unwilling to offer needed services. The child’s family should authorize a release of information to allow two-way communication between the school and the physician’s office.
Funding & Access to Care
Specialty Collaborations & Other Services
Medical Care Expense Assistance (see UT providers [95])
There are a variety of organizations that either provide health care or help find or fund it.
Health Insurance Counseling and Advocacy (see UT providers [30])
Organizations that can help families find insurance and healthcare options based on their individual situations.
CHIP, State Children's Health Insur Prog (see UT providers [27])
The Children's Health Insurance Program, or CHIP, is a state health insurance plan for children. Depending on income and family size, working Utah families who do not have other health insurance may qualify for CHIP.
Medicaid (see UT providers [41])
A combined federal and state program administered by the state that provides medical benefits for individuals and families with limited incomes who fit into an eligibility group that is recognized by federal and state law.
Prescription Drug Patient Assistance Programs (see UT providers [42])
Many organizations can provide information on and links to prescription assistance programs, or discounts and/or support toward prescription costs.
Financial Assistance, Other (see UT providers [52])
Local and national organizations and programs can help families receive financial support to help with their child’s chronic conditions.
Complementary & Alternative Medicine
Food elimination diets are controversial. Mainstream western medicine tends to discount this approach, indicating that only a few individuals may benefit from specific food elimination diets. However, analysis of the 2011 Impact of Nutrition on Children with ADHD (INCA) study suggests that a strictly supervised food elimination trial may be an approach to consider; use of IgG blood levels to prescribe diets is not advised, though. [Pelsser: 2011] European guidelines would indicate no evidence for elimination diets unless there are GI symptoms. There is some evidence for removal of dyes.
Dr. Sanford Newmark, a physician at the UCSF Pediatric Integrative Neurodevelopmental Clinic, in his presentation at the 2014 AAP National Conference, recommended these safe mind-body approaches to help with attention and self-regulation: yoga, exercise (martial arts), EEG neurofeedback, and a healthy diet consisting of whole grains, fruits and vegetables, and lean protein sources. Less well studied is adherence to organic diets. Avoidance of unnecessary food dyes and chemicals and maintaining fairly even blood sugar and insulin levels by eating frequent, smaller meals with complex carbohydrates and healthy proteins and fats, are reasonable approaches. Although there is some support for use of neurofeedback for ADHD, this therapy is often not covered by insurance, has significant out-of-pocket expenses for the family, and its effects are not maintained once treatment has been discontinued. There is evidence to support use of high dose omega-3 and omega-6 fatty acids for treatment of ADHD, although the effect seen was not as great as with treatment with stimulants.
For a more in-depth review of dietary approaches to managing ADHD, see The Diet Factor in ADHD (AAP) and Complementary Medicine and ADHD (Medscape), which is available with from Medscape with a free account.
Issues Related to Attention Deficit Hyperactivity Disorder (ADHD)
Clinical Assessment
Coordination Disorders and ADHDLearning/Education/Schools
Specific Learning Disability (SLD) and ADHDMental Health/Behavior
Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD)Mood Disorders and ADHD
Oppositional Defiant Disorder/Conduct Disorder and ADHD
Ask the Specialist
Although clinical practice guidelines recommend starting with stimulant medications for first-line therapy, when would you be more likely to treat with something else first (and what would you use)?
The alpha 2 agonists can be very useful in children with developmental disabilities, such as autism spectrum disorder, because of a lower side effect profile and higher tolerability in children with co-morbid conditions like tics, anxiety, or sleep problems.
Which stimulant medications are the least likely to be abused or sold illegally?
Long-acting stimulant medications, such as Vyvanse and Concerta, have lower abuse potential because of their mechanism of release; the Daytrana patch is also a good stimulant option to use when there are concerns about abuse. Non-stimulant options, such as Intuniv, Kapvay, and Strattera, can also be useful when concerned about the potential misuse of stimulant medications.
Is there any special guidance on management of ADHD in children with autism?
Children with autism have a poorer response to stimulant medications with more side effects than typically developing children with ADHD. Starting with lower doses and titrating up slowly is very important in this group of patients. Non-stimulant medications, such as the alpha 2 agonists, may also be a good option. See the 2012 guidelines for treatment of ASD and ADHD at [Mahajan: 2012] for more information.
Why is my patient having such difficulty with tantrums? Should I be worried about an additional diagnosis?
If there are significant behavioral concerns despite adequate supports and/or medication management, it is important to consider additional or alternative diagnoses including oppositional defiant disorder, conduct disorder, mood or anxiety disorder, and autism spectrum disorder. However, children with ADHD can also have significant difficulties with executive functioning, which not only can affect organization and planning, but also can affect an individual's ability to shift between tasks, self-regulate, and adapt to new information or situations. Executive functioning skills only show mild improvement with medication management, and require behavioral interventions and supports.
My patient has been diagnosed with sensory processing disorder/sensory integration disorder, and has significant difficulties with attention and hyperactivity. Can this all be explained by the sensory processing disorder, or do they also have ADHD?
Although many children have sensory processing difficulties that affect their day-to-day lives, sensory processing disorder is not a recognized stand-alone diagnosis, and the AAP recommends screening for co-morbid conditions including autism spectrum disorder, ADHD, developmental coordination disorder, and childhood anxiety disorders. For a child that presents with sensory concerns and symptoms of ADHD, it is important to diagnose ADHD and address the sensory components as part of their behavior support. [Zimmer: 2012]
Resources for Clinicians
On the Web
National Resource Center on ADHD (NRC)
A clearinghouse for the latest evidence-based information on ADHD; funded by the Centers for Disease Control and Prevention,
National Center on Birth Defects and Developmental Disabilities.
Attention-Deficit Hyperactivity Disorder, Third Edition: A Handbook for Diagnosis and Treatment
Presents extensive knowledge on the nature, diagnosis, assessment, and treatment of ADHD; by Barkley R (2005), published
by the Guilford Press (3rd. ed.).
Helpful Articles
PubMed search for ADHD in children, last 1 year.
Ghanizadeh A.
Atomoxetine for treating ADHD symptoms in autism: a systematic review.
J Atten Disord.
2013;17(8):635-40.
PubMed abstract / Full Text
Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry.
2013;70(7):740-9.
PubMed abstract / Full Text
Mahajan R, Bernal MP, Panzer R, Whitaker A, Roberts W, Handen B, Hardan A, Anagnostou E, Veenstra-VanderWeele J.
Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism
spectrum disorders.
Pediatrics.
2012;130 Suppl 2:S125-38.
PubMed abstract / Full Text
Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs.
2009;23(12):1057-83.
PubMed abstract
Salmeron PA.
Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications.
J Am Acad Nurse Pract.
2009;21(9):488-97.
PubMed abstract / Full Text
Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother.
2013.
PubMed abstract / Full Text
Clinical Tools
Assessment Tools/Scales
NICHQ Vanderbilt Assessment Scales - Parent & Teacher Initial and Follow-Up Scales with Scoring Instructions ( 1.1 MB)
Helps to diagnose ADHD in children between the ages of 6 and 12; also screens for anxiety, depression, oppositional-defiant,
and conduct disorders. Includes questionnaires for the initial and follow-up assessments for teachers and parents - and scoring
instructions. No fee is required.
NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) ( 3.9 MB)
Spanish (with English translation) online fillable, self-calculating form for assessing and quantifying the impact of attention
problems at home. Includes scoring instructions, no fee required; NICHQ
NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) ( 3.6 MB)
Spanish (with English translation) follow-up forms for assessing and quantifying the impact of attention problems at home.
Includes scoring instructions, no fee required; NICHQ
Conners 3rd Edition ADHD Assessment (Pearson)
Screens for ADHD and comorbid disorders such as oppositional defiant disorder and conduct disorder. Administered to parents
and teachers of children and adolescents age 6-18 and self-report for youth ages 8-18, English and Spanish. Updated for DSM-5.
Proprietary/for purchase.
ADHD Rating Scale—IV (for Children and Adolescents) (ADHD-RS)
Containing 18 items, the scale is linked directly to DSM-IV diagnostic criteria for ADHD. Available for a fee.
Achenbach Child Behavior Checklists (Ages 1 1/2-5) (Ages 6-18) (Ages 11-18)
A variety of screening tools are available for a fee.
Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) ( 218 KB)
A child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders, including
general anxiety disorder, separation anxiety disorder, panic disorder, and social and school phobia. Free to download, or
link to on-line Excel worksheet that calculates the score. Translations in Arabic, Chinese, French, German, Italian, Spanish,
Tamil (Sri Lanka), and Thai.
Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB)
Ages 12 to 18; 6th grade reading level; Spanish version available; 20 items, 5 to 10 minutes to complete. No fee required.
Severity Measure for Depression - Ages 11–17 ( 228 KB)
Adolescent-focused, 9-question, depression screen with scoring information. No fee required.
Patient Health Questionnaire-9 (PHQ-9) ( 40 KB)
Nine-question depression screen in many languages with scoring information that can be used with adolescents 13-17 years old.
Questions based on DSM-IV diagnostic criteria for major depressive disorder. Select a language and "Go to Selected Screener"
for a PDF download; developed with a grant from Pfizer Inc, no fee required.
Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) ( 47 KB)
Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist
for parents or youth to complete, and scoring instructions. No fee required.
Behavior Assessment System for Children, Second Edition (BASC-2)
Screen for children 2-21 years of age that takes about 15 minutes to complete; available for purchase.
DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) ( 367 KB)
Free, 25-question assessment for initial patient interview and for monitoring treatment progress. Includes scoring instructions;
American Psychiatric Association.
SEEK Parent Screening Questionnaire (PSQ-R) (University of Maryland)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions; scroll to bottom of the
page for links to free to download in English, Chinese, Spanish, Swedish, and Vietnamese.
CRAFFT
The CRAFFT 2.0/2.1 is an updated substance use brief screening tool for use with youth ages 12-21 and is recommended by the
American Academy of Pediatrics. A clinician-administered version and a self-report version are provided. The screen and scoring
instructions are available in 17 languages and can be downloaded or printed for free upon request; Boston Children's Hospital
and Harvard Medical School Teaching Hospital.
Clinical Checklists & Visit Tools
NICHQ Vanderbilt ADHD Primary Care Initial Evaluation Form ( 1.7 MB)
2-page evaluation template includes scoring for the initial Vanderbilts, plus checkboxes for relevant medical history, physical
examination, diagnostic assessment and plan, and related screenings; American Academy of Pediatrics.
Medication Guides
ADHD Medication Tables ( 133 KB)
Medication tables with dosing information for stimulants and non-stimulants; Medical Home Portal, last updated October 2015.
Toolkits
Caring for Children with ADHD Toolkit (AAP)
Contains 40 practical tools (some in Spanish), symptom checklists for use by parents and teachers, guidance on selecting
appropriate therapy, forms for teacher reports, and examples of written management plans; available for a fee from the American
Academy of Pediatrics (2011).
ADHD Resources (Intermountain Healthcare)
ADHD-related tools, forms, and patient education materials; a part of Intermountain Healthcare's Mental Health Integration
Clinical Program.
Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes
a variety of resources, checklists, intake and assessment forms, and patient education materials.
Patient Health Questionnaire Screeners
Free screening tools to be used by clinicians to help detect mental health disorders: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS,
Brief PHQ, PHQ-4. All PHQ, GAD-7 screeners and translations are downloadable from this website and no permission is required
to reproduce, translate, display, or distribute them.
Other
Letter Requesting Assessment from Teacher (AAP)
Sample letter requesting that a teacher complete a behavior assessment for their student. The AAP suggests that a release
of information form, signed by parent, accompanies this letter; American Academy of Pediatrics.
Patient Education & Instructions
ADHD: Parents' Medication Guide (AACAP) ( 1.1 MB)
Forty-five page booklet that helps youngsters and their families better understand the treatments for ADHD; prepared by the
American Academy of Child & Adolescent Psychiatry and American Psychiatric Association (2013).
Resources for Patients & Families
Information on the Web
ADHD (MedlinePlus)
Provides links to high-quality sources of information about ADHD; a service of the National Library of Medicine and National
Institutes of Health.
ADHD (HealthyChildren)
Links to more than 90 articles that discuss aspects of ADHD evaluation and management; developed by the American Academy of
Pediatrics.
What is ADHD? (KidsHealth)
Health information for parents, kids, and teens. This is the parent's page on ADHD, see the tabs at the top for the pages
focused on kids and teens; sponsored by Nemours Foundation.
The Diet Factor in ADHD (AAP)
A comprehensive overview of the role of dietary methods for treatment of children with ADHD when pharmacotherapy has proven
unsatisfactory or unacceptable; American Academy of Pediatrics.
ADHD Information (AAP)
List of publications for parents of children with ADHD; American Academy of Pediatrics.
ADHD Information (NIMH)
Overview and links to more information from the National Institute of Mental Health
Early Behavior Therapy Found to Aid Children With A.D.H.D. (New York Times)
A news story about a new study that finds children with attention-deficit problems improve faster when the first treatment
they receive is behavioral: New York Times, Feb.
National & Local Support
Children and Adults with ADHD (CHADD)
A national non-profit organization, with numerous local chapters, that provides education, advocacy, and support for individuals
with ADHD; Children and Adults with Attention Deficit/Hyperactivity Disorder.
Understood for Learning & Attention Issues
A collaboration between 15 non-profit agencies to provide resources to parents of children with learning and attention disorders.
Studies/Registries
Mental Health Clinical Trials (NIMH)
Links to descriptions of clinical trials related to numerous mental health conditions, including ADHD, anxiety, and depression;
National Institute of Mental Health.
Clinical Trials in ADHD (clinicaltrials.gov)
Trial listings for ADHD with "completed," "recruiting," and "active" status noted.
Services for Patients & Families in Utah (UT)
Service Categories | # of providers* in: | UT | NW | Other states (5) (show) | | ID | MT | NM | NV | RI |
---|---|---|---|---|---|---|---|---|---|---|
CHIP, State Children's Health Insur Prog | 27 | 1 | 23 | 2 | 9 | 3 | 1 | |||
Developmental - Behavioral Pediatrics | 9 | 1 | 3 | 9 | 3 | 4 | 11 | |||
Family Counseling | 59 | 67 | 10 | 290 | 24 | 16 | ||||
Financial Assistance, Other | 52 | 17 | 126 | 51 | 248 | 47 | 24 | |||
General Counseling Services | 450 | 216 | 150 | 109 | 169 | 33 | ||||
Health Insurance Counseling and Advocacy | 30 | 3 | 22 | 4 | 43 | 25 | 5 | |||
Medicaid | 41 | 2 | 67 | 5 | 203 | 45 | 7 | |||
Medical Care Expense Assistance | 95 | 41 | 100 | 41 | 305 | 79 | 47 | |||
Neuropsychiatry/Neuropsychology | 14 | 3 | 3 | 7 | 6 | |||||
Outpatient Mental Health Care | 479 | 1 | 7 | 4 | 90 | 69 | 11 | |||
Pediatric Cardiology | 7 | 1 | 4 | 17 | 32 | 5 | 17 | |||
Pediatric Neurology | 5 | 2 | 15 | 33 | 6 | 11 | ||||
Prescription Drug Patient Assistance Programs | 42 | 26 | 49 | 35 | 90 | 47 | 26 | |||
Psychiatry/Medication Management | 62 | 20 | 17 | 17 | 40 | 78 | ||||
School Districts | 55 | 116 | 130 | 21 | 47 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
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Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M,
Stein MT, Visser S.
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Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive
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