ADHD in Children: Common Questions and Answers


Attention-deficit/hyperactivity disorder (ADHD) is a multidimensional chronic neurodevelopmental condition that affects 8.4% of U.S. children between two and 17 years of age and may pose long-term morbidity if untreated. The evaluation for ADHD begins when parents or caregivers present to primary care physicians with concerns about behavior problems or poor school or social function. A comprehensive history and physical examination should assess for comorbid or other conditions that can mimic ADHD. The combination of Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria and validated screening tools completed by parents, teachers, or other adults can aid in establishing the diagnosis. The goals of treatment include symptom reduction and improved social and cognitive function. Psychosocial interventions are the recommended first-line treatment for preschool children (four to five years) and can improve overall function when used as an adjunct therapy in elementary school children (six to 11 years of age) and adolescents (12 to 17 years of age). Stimulant medications are well-established as an effective treatment for reducing symptoms of ADHD in elementary school children and adolescents. Nonstimulant medications are less effective but reasonable as adjunct or alternative therapy when stimulants are ineffective or not tolerated. Regular follow-up is key in the management of ADHD and should assess symptoms, overall function, presence of comorbidities, adverse effects of treatment, and medication use.

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental condition in U.S. children, and it affects 8.4% of children between two and 17 years of age (greater than 5 million).1 Of the children who are affected, 62% are treated with medication, less than one-half have received behavioral treatment, and nearly one-fourth have not received treatment.1 Children with ADHD are at risk of long-term morbidities, including poor academic performance, low self-esteem, difficult relationships, substance use, injury, and other maladaptive behaviors.2 This article presents evidence-based answers to common questions about the evaluation and management of childhood ADHD.

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Clinical recommendationEvidence ratingComments

Children four years and older and adolescents with poor attention, distractibility, hyperactivity, impulsiveness, poor academic performance, or behavior problems at home or at school should be evaluated for ADHD.2,27


Expert opinion, consensus guideline in the absence of clinical trials

The evaluation for ADHD should include a comprehensive history, physical examination, use of a validated ADHD assessment tool with input from multiple raters and consideration of coexisting or alternative diagnoses.2,15,1719,27


Expert opinion, consensus guideline in the absence of clinical trials

Medications should be offered as first-line treatment for ADHD in children six years and older.2,27,43,44,5155


Consensus guidelines, systematic reviews of small and large randomized controlled trials showing improved ADHD symptom scores; single retrospective cohort study showing long-term improvement

Psychosocial interventions should be first-line treatment for ADHD in preschool children (four to five years) and should be offered as an adjunct to medications in children six years and older.2,26,27,29,30,32


Consensus guidelines, systematic review of small or medium-sized clinical trials with mixed results or methodologic limitations

Stimulant medications are recommended as the most effective therapy for reducing ADHD symptoms.43,5153,55


Consistent results from small double-blind randomized controlled trials comparing stimulants to placebo or nonstimulant medications

Electrocardiography is not recommended before starting stimulants or second-line medications if the cardiovascular examination is normal and there is no increased cardiovascular risk based on other medical conditions or family history.2,27,45


Consensus guidelines, large retrospective cohort showing no significant increased incidence of serious cardiovascular events

ADHD = attention-deficit/hyperactivity disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

The Authors

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JENNIFER G. CHANG, MD, is the family medicine clerkship director and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

FRANCESCA M. CIMINO, MD, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

WEYINSHET GOSSA, MD, MPH, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Jennifer G. Chang, MD, Uniformed Services University of the Health Sciences, Department of Family Medicine, 4301 Jones Bridge Rd., Ste. A-1038, Bethesda, MD 20814 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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