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This is a corrected version of the article that appeared in print.

Am Fam Physician. 2020;102(9):592-602

Patient information: A handout on this topic is available at https://familydoctor.org/condition/attention-deficit-hyperactivity-disorder-adhd/.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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.

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 CExpert 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 CExpert 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 BConsensus 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 BConsensus 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 BConsistent 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 CConsensus guidelines, large retrospective cohort showing no significant increased incidence of serious cardiovascular events

What Are the Risk Factors for ADHD?

The etiology of ADHD involves a complex interaction of genetic, social, and environmental factors, including prenatal and childhood exposures.3

EVIDENCE SUMMARY

Research among families, twins, and children who are adopted support substantial heritability (74%) for ADHD.4 The search to identify specific genes responsible for ADHD implicates a complex polygenic mechanism.3,4 Males are diagnosed with ADHD at nearly two times the rate of females1,5; however, differences in presentation between sexes may result in missed or delayed diagnosis in females.5,6 Males present with more recognizable externalizing symptoms and behaviors (e.g., impulsivity, defiant conduct), whereas females present with inattention and possibly impaired cognitive function.57

Children born preterm (before 37 weeks' gestation) are diagnosed with ADHD two times as often as children born at term (odds ratio [OR] = 1.6; 95% CI, 1.3 to 1.8; 74 studies; N = 64,061]),8 and risk of ADHD diagnosis or symptoms may increase with the severity of prematurity or low birth weight.9 The risk of ADHD is greater for children whose mothers smoked during pregnancy (OR = 1.60; 95% CI, 1.45 to 1.76; N = 50,044)10 and had hypertensive disorders in pregnancy (OR = 1.29; 95% CI, 1.22 to 1.36; six studies; N = 1,395,605).11 Despite ongoing public concern and scientific inquiry, the evidence is inconsistent in supporting direct links between ADHD and exposure to digital or “screen” media12 or chemical toxins,3 including lead.13

When and How Should Physicians Evaluate a Child for ADHD?

Primary care physicians should initiate evaluation for ADHD when parents or caregivers present with concerns about a child's academic or behavior problems, including symptoms of inattention, hyperactivity, or impulsivity in children between four and 17 years of age.2

EVIDENCE SUMMARY

ADHD is diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (Table 114 ) after a comprehensive history and physical examination, with attention to family, birth, and early childhood development2,1416 (Table 22,1517 ). The assessment of symptoms should explore the duration and context in which they occur and the effects on function or development.2,15 The dysfunction classified in ADHD must occur in more than one setting; therefore, clinicians should seek evaluations from other adults with whom the child interacts outside of the home (e.g., educators, school counselors, coaches).2,18 Routine laboratory tests, genetic testing, and neuroimaging are not recommended unless specific concerns result from the history or examination.15,19

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