Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder typically diagnosed in childhood, with symptoms typically continuing to present into adulthood. According to the National Survey of Children’s Health, approximately 9.4% of youth ages 2 to 17 in the United States have been diagnosed with ADHD¹.

Types of ADHD

There are three different subtypes of ADHD²:

• ADHD, predominantly inattentive subtype: Often referred to as “ADD,” symptoms include inattention, disorganization, forgetfulness and being easily distracted.
• Parents may report their child can focus on desired activities, such as video games. This is common in children with ADHD, who can hyperfocus on activities of interest to them.
• ADHD, predominantly hyperactive/impulsive subtype: Symptoms include impulsivity, hyperactivity and talking excessively.
• ADHD, combined subtype: Youth has both inattentive and hyperactive/impulsive symptoms.

What causes ADHD in children?

A variety of factors have been identified as placing children at risk for ADHD. These include:

• Having a first degree biological relative with ADHD
• Premature birth or low birth weight
• Maternal smoking, alcohol use, or drug use during pregnancy
• Exposure to environmental toxins

Who gets ADHD?

ADHD is twice as likely to be diagnosed in boys versus girls. However, girls are more likely than boys to present primarily with inattentive symptoms.

Nearly two-thirds (64%) of children diagnosed with ADHD also have a comorbid emotional or behavioral disorder such as:

• Learning disabilities
• Anxiety
• Depression
• Behavior difficulties (e.g., Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder)

Screening for ADHD

Timely identification of youth with ADHD is critical, as poorly controlled ADHD symptoms can negatively impact their academic performance, peer relationships and self-esteem. Youth should first undergo a medical exam, including hearing and vision tests, to rule out other health conditions that can present similarly to ADHD.

Although there is no single test to diagnose ADHD, one screening measure that is commonly used when a provider suspects the presence of ADHD is the NICHQ Vanderbilt Assessment Scales.

Recommendations for treating ADHD in children

Medication is effective for ADHD and part of first line treatment for children 6 years and older. About 80% of children will show a clinically significant reduction in symptoms from one of the two major stimulant classes: methylphenidate or mixed amphetamine salts. For those who do not tolerate or respond to stimulants, nonstimulant medications such as atomoxetine, viloxazine, clonidine and guanfacine are still very effective. Advances in the pharmacology of medications for ADHD treatment have resulted in a bevy of options. These include improving the tolerability of the core two classes of stimulants, improved long-acting forms for stimulant and nonstimulant classes and a new nonstimulant option.

While complex schedules and off-label options may still have a role, hopefully, these will be increasingly needed less, especially in the primary care setting. Common resources listing FDA-approved ADHD medications include The ADHD Medication Guide and Children and Adults with Attention-Deficit/Hyperactivity Disorder. Despite the efficacy of ADHD medications, concurrent therapy and school support is recommended at any age.

Treatments by age group

A major development in current practice guidelines for ADHD is the tailored treatment recommendations for different age groups³.

• For children under 6, parent management training and school interventions are recommended as first line treatments. Those who do not adequately respond may be treated with low-dose methylphenidate. Of note, preschoolers are more susceptible to mood lability with methylphenidate than older children.
• For children ages 6 to 11 years, the “gold standard” treatment is a combination of medication and behavior therapy⁴. Behavior therapy supports parents and teachers in implementing strategies aimed at strengthening a child’s positive behaviors and eliminating problematic behaviors. These strategies may include strategic attention, reward systems, and effective consequences, all of which help motivate children to engage in appropriate behaviors. Collaboration with a child’s school is critical and can involve developing effective behavior management strategies in the classroom and providing additional supports, such as a 504 Plan or an Individualized Education Plan.
• For those 12 years and older, multimodal treatment remains first line; however, additional challenges to consider include increased risk of substance use, school interventions and accommodations may require more advocacy, and family interventions are likely to become more complicated. Despite these challenges, prescribers should seek to minimize providing medication monotherapy for ADHD.

ADHD should be treated as a lifelong disorder for any age, and the risk/benefit profile is important to consider. Overall, it remains true that multimodal treatment improves academic success and socioeconomic attainment. It reduces substance use, accidents and problem behaviors. Adverse events do occur and effects on appetite, growth and cardiovascular effects are part of routine management. Black box warnings are important to discuss, and their underlying rationale is important to consider. This includes diversion and abuse of stimulants and suicidality with atomoxetine and viloxazine.

Additional resources

Children’s Hospital Colorado, Pediatric Mental Health Institute provides evidence-based, family-focused comprehensive mental health services. For more information, providers can call 720-777-6200.

Colorado Pediatric Psychiatric Access and Consultation provides pediatric primary care providers access to peer consultation to assist with the assessment and treatment of pediatric mental health concerns presenting in the primary care setting.

Additional Colorado mental health services can be found at the Colorado Department of Human Services.

American Academy of Child and Adolescent Psychiatry provides parent medication guides, tools for clinical practice and continuing education opportunities.

Professional references

1. Danielson, ML, Bitsko, RH, Ghandour, RM, Holbrook, JR, Kogan, MD, & Blumberg, SJ (2018), Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment among U.S. Children and Adolescents, Journal of Clinical Child and Adolescent Psychology, 47(2), 199-212. American
2. Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
3. Wolraich ML, Hagan JF Jr, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), 2019-2528.
4. Evans S, Owens J, Bunford N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43(4):527-551.