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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SORT: KEY RECOMMENDATIONS FOR PRACTICE

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

C

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

C

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

B

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

B

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

B

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

C

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 https://www.aafp.org/afpsort.

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: jennifer.g.chang.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Danielson ML, Bitsko RH, Ghandour RM, et al. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199–212....

2. Wolraich ML, Hagan JF Jr, Allan C, et al.; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents [published correction appears in Pediatrics. 2020;145(3):e20193997]. Pediatrics. 2019;144(4):e20192528.

3. Hinshaw SP. Attention deficit hyperactivity disorder (ADHD): controversy, developmental mechanisms, and multiple levels of analysis. Annu Rev Clin Psychol. 2018;14:291–316.

4. Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Mol Psychiatry. 2019;24(4):562–575.

5. Slobodin O, Davidovitch M. Gender differences in objective and subjective measures of ADHD among clinic-referred children. Front Hum Neurosci. 2019;13:441.

6. Rucklidge JJ. Gender differences in attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2010;33(2):357–373.

7. Posner K, Melvin GA, Murray DW, et al. Clinical presentation of attention-deficit/hyperactivity disorder in preschool children: the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS). J Child Adolesc Psychopharmacol. 2007;17(5):547–562.

8. Allotey J, Zamora J, Cheong-See F, et al. Cognitive, motor, behavioural and academic performances of children born preterm: a meta-analysis and systematic review involving 64,061 children. BJOG. 2018;125(1):16–25.

9. Franz AP, Bolat GU, Bolat H, et al. Attention-deficit/hyperactivity disorder and very preterm/very low birth weight: a meta-analysis. Pediatrics. 2018;141(1):e20171645.

10. Huang L, Wang Y, Zhang L, et al. Maternal smoking and attention-deficit/hyperactivity disorder in offspring: a meta-analysis. Pediatrics. 2018;141(1):e20172465.

11. Maher GM, O'Keeffe GW, Kearney PM, et al. Association of hypertensive disorders of pregnancy with risk of neurodevelopmental disorders in offspring: a systematic review and meta-analysis. JAMA Psychiatry. 2018;75(8):809–819.

12. Nikkelen SW, Valkenburg PM, Huizinga M, et al. Media use and ADHD-related behaviors in children and adolescents: a meta-analysis. Dev Psychol. 2014;50(9):2228–2241.

13. Donzelli G, Carducci A, Llopis-Gonzalez A, et al. The association between lead and attention-deficit/hyperactivity disorder: a systematic review. Int J Environ Res Public Health. 2019;16(3):382.

14. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013.

15. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894–921.

16. Kaiser ML, Schoemaker MM, Albaret JM, et al. What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the literature. Res Dev Disabil. 2015;36C:338–357.

17. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90(7):456–464. Accessed February 18, 2020. https://www.aafp.org/afp/2014/1001/p456.html

18. Posner J, Polanczyk GV, Sonuga-Barke E. Attention-deficit hyperactivity disorder. Lancet. 2020;395(10222):450–462.

19. Verkuijl N, Perkins M, Fazel M. Childhood attention-deficit/hyperactivity disorder. BMJ. 2015;350:h2168.

20. Barbaresi WJ, Campbell L, Diekroger EA, et al. The Society for Developmental and Behavioral Pediatrics clinical practice guideline for the assessment and treatment of children and adolescents with complex attention-deficit/hyperactivity disorder: process of care algorithms. J Dev Behav Pediatr. 2020;41(suppl 2S):S58–S74.

21. Wigal S, Chappell P, Palumbo D, et al. Diagnosis and treatment options for preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2020;30(2):104–118.

22. Gaba P, Giordanengo M. Attention deficit/hyperactivity disorder: screening and evaluation. Am Fam Physician. 2019;99(11):712. Accessed February 17, 2020. https://www.aafp.org/afp/2019/0601/p712.html

23. Cianchetti C, Faedda N, Pasculli M, et al. Predictive validity for the clinical diagnosis of a new parent questionnaire, the CABI, compared with CBCL. Clin Child Psychol Psychiatry. 2020;25(2):507–519.

24. Chang LY, Wang MY, Tsai PS. Diagnostic accuracy of rating scales for attention-deficit/hyperactivity disorder. Pediatrics. 2016;137(3):e20152749.

25. DuPaul GJ, Gormley MJ, Laracy SD, et al. School-based interventions for elementary school students with ADHD. Child Adolesc Psychiatr Clin N Am. 2014;23(4):687–697.

26. Chan E, Fogler JM, Hammerness PG. Treatment of attention-deficit/hyperactivity disorder in adolescents: a systematic review. JAMA. 2016;315(18):1997–2008.

27. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline [NG87]. March 14, 2018. Accessed February 15, 2020. https://www.nice.org.uk/guidance/ng87

28. Schatz NK, Aloe AM, Fabiano GA, et al. Psychosocial interventions for attention-deficit/hyperactivity disorder: systematic review with evidence and gap maps. J Dev Behav Pediatr. 2020;41(suppl 2S):S77–S87.

29. Goode AP, Coeytaux RR, Maslow GR, et al. Nonpharmacologic treatments for attention-deficit/hyperactivity disorder: a systematic review. Pediatrics. 2018;141(6):e20180094.

30. Storebø OJ, Andersen ME, Skoog M, et al. Social skills training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev. 2019;(6):CD008223.

31. Shrestha M, Lautenschleger J, Soares N. Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review. Transl Pediatr. 2020;9(suppl 1):S114–S124.

32. Pelham WE Jr, Fabiano GA, Waxmonsky JG, et al. Treatment sequencing for childhood ADHD: a multiple-randomization study of adaptive medication and behavioral interventions. J Clin Child Adolesc Psychol. 2016;45(4):396–415.

33. Hiscock H, Sciberras E, Mensah F, et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health. BMJ. 2015;350:h68.

34. Zang Y. Impact of physical exercise on children with attention deficit hyperactivity disorders. Medicine (Baltimore). 2019;98(46):e17980.

35. Cagigal C, Silva T, Jesus M, et al. Does diet affect the symptoms of ADHD? Curr Pharm Biotechnol. 2019;20(2):130–136.

36. Gillies D, Sinn JK, Lad SS, et al. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2012;(7):CD007986.

37. Nigg JT, Lewis K, Edinger T, et al. Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry. 2012;51(1):86–97.e8.

38. Li S, Yu B, Zhou D, et al. Acupuncture for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2011;(4):CD007839.

39. Accorsi A, Lucci C, Di Mattia L, et al. Effect of osteopathic manipulative therapy in the attentive performance of children with attention-deficit/hyperactivity disorder. J Am Osteopath Assoc. 2014;114(5):374–381.

40. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD [published correction appears in J Am Acad Child Adolesc Psychiatry. 2007; 46(1):141]. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293.

41. McGough JJ, Faraone SV. Estimating the size of treatment effects: moving beyond p values. Psychiatry (Edgmont). 2009;6(10):21–29.

42. Vitiello B, Lazzaretto D, Yershova K, et al. Pharmacotherapy of the Pre-school ADHD Treatment Study (PATS) children growing up. J Am Acad Child Adolesc Psychiatry. 2015;54(7):550–556.

43. Newcorn JH, Kratochvil CJ, Allen AJ, et al.; Atomoxetine/Methylphenidate Comparative Study Group. Atomoxetine and osmotically released methylphenidate for the treatment of attention deficit hyperactivity disorder: acute comparison and differential response. Am J Psychiatry. 2008;165(6):721–730.

44. Hirota T, Schwartz S, Correll CU. Alpha-2 agonists for attention-deficit/hyperactivity disorder in youth: a systematic review and meta-analysis of monotherapy and add-on trials to stimulant therapy. J Am Acad Child Adolesc Psychiatry. 2014;53(2):153–173.

45. Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011;365(20):1896–1904.

46. Adesman A. The ADHD medication guide. Cohen Children's Medical Center, NorthWell Health. Accessed January 29, 2020. http://www.adhdmedicationguide.com/

47. Prescriber's Digital Reference. Drug information. Accessed February 4, 2020. https://www.pdr.net/browse-by-drug-name

48. Swanson JM, Elliott GR, Greenhill LL, et al. Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1015–1027.

49. Swanson JM, Arnold LE, Molina BSG, et al.; MTA Cooperative Group. Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry. 2017;58(6):663–678.

50. Pliszka SR. Pharmacologic treatment of attention-deficit/hyperactivity disorder: efficacy, safety and mechanisms of action. Neuropsychol Rev. 2007;17(1):61–72.

51. Barbaresi WJ, Katusic SK, Colligan RC, et al. Modifiers of long-term school outcomes for children with attention-deficit/hyperactivity disorder: does treatment with stimulant medication make a difference? Results from a population-based study. J Dev Behav Pediatr. 2007;28(4):274–287.

52. Wigal SB, Greenhill LL, Nordbrock E, et al. A randomized placebo-controlled double-blind study evaluating the time course of response to methylphenidate hydrochloride extended-release capsules in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2014;24(10):562–569.

53. Wigal S, Lopez F, Frick G, et al. A randomized, double-blind, 3-way crossover, analog classroom study of SHP465 mixed amphetamine salts extended-release in adolescents with ADHD. Postgrad Med. 2019;131(3):212–224.

54. Kratochvil CJ, Milton DR, Vaughan BS, et al. Acute atomoxetine treatment of younger and older children with ADHD: a meta-analysis of tolerability and efficacy. Child Adolesc Psychiatry Ment Health. 2008;2(1):25.

55. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018;5(9):727–738.

56. Ibrahim K, Donyai P. Drug holidays from ADHD medication: international experience over the past four decades. J Atten Disord. 2015;19(7):551–568.

57. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47(1):21–31.

58. Garnock-Jones KP, Keating GM. Atomoxetine: a review of its use in attention-deficit hyperactivity disorder in children and adolescents. Paediatr Drugs. 2009;11(3):203–226.

59. Rader R, McCauley L, Callen EC. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 2009;79(8):657–665. Accessed July 28, 2020. https://www.aafp.org/afp/2009/0415/p657.html

 

 

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