Guideline sources The following summarized guidelines for the evaluation and management of attention deficit and hyperactivity disorder are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2019), the American Academy of Neurology (AAN 2016), and the American Association of Family Physicians (AAFP 2012). 1 2 4 5 5 5 6 Definition ADHD is a common psychiatric disorder characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity according to DSM-V. 5 Epidemiology ADHD is caused by biological (genetics, brain structure and their influence on neuropsychology) and environmental (pregnancy or birth complications, exposure to environmental toxins, chaotic parenting, and diet) factors. 5 Disease course The interplay of environmental, genetic factors, and dysfunction in the frontal cortex, basal ganglia, corpus callosum, and cerebellum results in ADHD, which results in clinical manifestations of inattention, hyperactivity, and impulsivity. ADHD is associated with poor motor coordination, https://web.pathway.md/diseases/recpbVKrWa0Tdeebd 1/4 6/23/23, 3:15 AM Attention deficit and hyperactivity disorder Pathway impaired academic functioning, unintentional physical injury, sleep disturbances, and poor quality of life. 5 Prognosis and risk of recurrence ADHD is not associated with an increased risk of natural-cause mortality. 6 Calculator Calculator DSM 5 diagnostic criteria for AD DSM 5 diagnostic criteria for AD Guidelines 1. Screening and diagnosis Indications for testing: evaluate for ADHD in any pediatric patient 4-18 years old presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. B Diagnostic criteria: diagnose ADHD according to the DSM-5 criteria, including documentation of symptoms and impairment in 1 major setting (social, academic, or occupational), relying on information drawn primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians involved in the patient's care. Rule out any alternative cause. B 2. Diagnostic investigations Screening for comorbid conditions: Assess for other conditions that might coexist with ADHD, including: Situation Guidance Anxiety, depression, oppositional defiant disorder, conduct disorders, substance use Emotional or behavioral conditions Learning and language disorders, autism spectrum disorders Developmental conditions Tics, sleep apnea. B Physical conditions Electroencephalography: inform patients with suspected ADHD and their families that EEG should not be used to confirm an attention deficit hyperactivity disorder diagnosis or to support https://web.pathway.md/diseases/recpbVKrWa0Tdeebd 2/4 6/23/23, 3:15 AM Attention deficit and hyperactivity disorder Pathway further testing after a clinical evaluation, unless such diagnostic assessments take place in the context of a research study. B 3. Medical management General principles: manage pediatric patients with ADHD similar to the care of pediatric patients with special healthcare needs, following the principles of the chronic care model and the medical home. B Medical therapy (indications): Offer United States FDA-approved medications along with parent training in behavior management and/or behavioral classroom intervention, preferably both, in pediatric patients 6- 12 years old (elementary and middle school-aged) with ADHD. B Offer United States FDA-approved medications in adolescent patients 12-18 years old with ADHD. B Medical therapy (dose titration): titrate doses of medications for ADHD to achieve maximum benefit with tolerable side effects. B Medical therapy (methylphenidate): consider offering methylphenidate in pediatric patients 4-5 years old if behavioral interventions do not provide significant improvement and there is moderate- to-severe continued disturbance in the patient's functioning. Weigh the risks of initiating medication before the age of 6 years against the harm of delaying treatment in areas where evidence-based behavioral treatments are not available. C 4. Nonpharmacologic interventions Behavioral therapy: as per AAP 2019 guidelines, offer evidence-based parent training in behavior management and/or behavioral classroom interventions as first-line therapy, if available, in pediatric patients 4-6 years old (preschool-aged) with ADHD. B Show 2 more Educational interventions: Include the following educational interventions and individualized instructional supports in any treatment plan of pediatric patients 6-18 years old with ADHD: school environment class placement instructional placement behavioral supports individualized education program rehabilitation plan (504 plan). B 5. Specific circumstances https://web.pathway.md/diseases/recpbVKrWa0Tdeebd 3/4 6/23/23, 3:15 AM Attention deficit and hyperactivity disorder Pathway Adult patients: recognize that various rating scales are available and are appropriate diagnostic tools for adult patients with ADHD. B Show 3 more 6. Follow-up and surveillance Indications for referral: refer patients with comorbid conditions to an appropriate subspecialist for treatment, or consider initiating treatment if trained or experienced in diagnosing such conditions. Refer patients with possible comorbid conditions to an appropriate subspecialist for diagnosis and treatment if not trained or experienced in diagnosing or treating such conditions. B References 1. Mark L Wolraich, Joseph F Hagan Jr, Carla Allan et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019 Oct;144 4):e20192528. Open 2. Robert E Post, Stuart L Kurlansik. Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. Am Fam Physician. 2012 May 1;85 9 890 6. Open 3. Brieger D, Amerena J, Attia JR et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Med J Aust. 2018 Oct 15;209 8 356 362. Open 4. Gloss D, Varma JK, Pringsheim T et al. Practice advisory: The utility of EEG theta/beta power ratio in ADHD diagnosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2016 Nov 29;87 22 2375 2379. Open 5. Ajay Singh, Chia Jung Yeh, Nidhi Verma et al. Overview of Attention Deficit Hyperactivity Disorder in Young Children. 2015 Apr 13;3 2 2115.2015 Apr 13;3 2 2115. Open 6. Vincent Chin-Hung Chen, Hsiang-Lin Chan, Shu-I Wu et al. Attention-Deficit/Hyperactivity Disorder and Mortality Risk in Taiwan. JAMA Netw Open. 2019 Aug 2;2 8):e198714. Open 7. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M et al. ADHD clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011 Nov;128 5 1007 22. Open 8. David Coghill, Sarah Seth. Do the diagnostic criteria for ADHD need to change? Comments on the preliminary proposals of the DSM 5 ADHD and Disruptive Behavior Disorders Committee. Eur Child Adolesc Psychiatry. 2011 Feb;20 2 75 81. Open https://web.pathway.md/diseases/recpbVKrWa0Tdeebd 4/4