Identifying and Treating ADHD in Children

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder typically diagnosed in childhood. Approximately 11.3% of youth (ages 5 to 17) in the United States have been diagnosed with ADHD. Providers have raised questions about the growing increase in the diagnosis rate of ADHD and whether this reflects a true increase in frequency, improved detection or diagnostic inflation. A recent systematic scoping review found evidence that ADHD is likely over diagnosed, particularly in youth with milder symptoms, and recommended providers use a stepped-diagnosis approach to improve the balance of benefit to harm in practice.

With all this in mind, it’s important for primary care providers to know how to recognize, diagnose and treat ADHD in their practices. Jessica Hawks, PhD, Clinical Director of our Pediatric Mental Health Institute and child and adolescent psychologist, and Anne Penner, MD, child and adolescent psychiatrist, share some guidance below.

What causes ADHD in children?

A variety of factors can place children at-risk for ADHD, according to the American Psychiatric Association. 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

Who gets diagnosed with ADHD?

• Boys (14.5%) are more likely to be diagnosed with ADHD than girls (8.0%).
• White (13.4%) youth are more likely to be diagnosed with ADHD than Black (10.8%) and Hispanic (8.9%) youth.
• The majority (78%) of youth diagnosed with ADHD have at least one co-occurring condition such as behavior concerns (44%), anxiety (39%), learning disability (37%), depression (19%) or autism spectrum disorder (14%).

Screening for and diagnosing 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. One screening measure providers commonly use to identify ADHD symptoms in youth is the National Institute of Children’s Health Equity Vanderbilt Assessment Scale. But there is no single test available to diagnose ADHD.

Youth with concerns of possible ADHD should first undergo a medical exam, including hearing and vision tests, to rule out other health conditions that can present similarly to ADHD. Providers should conduct a clinical interview to determine if the onset of ADHD symptoms occurred prior to age 12, have persisted for at least six months, are present in two or more settings, cause clinically significant impairment and aren’t better explained by another mental health disorder. The assessment should also include a review of developmental history, medical history, family psychiatric history, academic functioning and family and peer relationships.

The table below outlines pertinent symptoms of ADHD, categorized by the three main subtypes.

Subtype of ADHD	Symptoms
Predominantly Inattentive (Must have at least six symptoms)	Doesn’t pay attention to details/Makes careless mistakes Difficulty sustaining attention Doesn’t seem to listen when spoken to Doesn’t follow through with instructions/fails to finish tasks	Difficulty organizing Avoids tasks requiring sustained mental effort Loses things Easily distracted Forgetful
Predominantly Hyperactive/Impulsive (Must have at least six symptoms)	Fidgets/squirms Leaves seat when sitting is expected Runs/climbs in inappropriate situations Unable to play quietly	Is “driven by a motor” or restless Talks excessively Blurts out answers Difficulty waiting their turn Interrupts or intrudes on others
Combined	Meets criteria for both Inattentive and Hyperactive/Impulsive Criteria

ADHD treatment recommendations for children

Both behavioral therapy and medication can help children with ADHD and age is a critical determining factor in what providers may choose. Medication is very effective in treating core ADHD symptoms and there are currently three different categories of FDA approved medications for youth: stimulants, alpha-2 agonists and selective norepinephrine reuptake inhibitors (SNRIs).

Stimulant medications for ADHD

Stimulant medications, which fall into two major classes of methylphenidate and mixed amphetamine salts, have the largest effect sizes ranging from .8 to 1.2 in school-aged youth and .94 in teens. Researchers recommend methylphenidate products as a first-line treatment due to tolerability.

Alpha-2 agonist medications for ADHD

The extended-release alpha-2 agonist medications (clonidine and guanfacine) have treatment effect sizes of .5 to .7 in youth. Providers consider them when there is significant overactivity and impulsivity, or if there is comorbid trauma or anxiety or the child doesn’t tolerate stimulants. Consider alpha-2 agonists as monotherapy or in conjunction with stimulant medications where improved outcomes have been shown when combining a stimulant medication and extended release guanfacine (Intuniv).

SNRI medications for ADHD

SNRIs (atomoxetine and viloxazine) have effective sizes of .6 to .7 and are beneficial in youth with comorbid depression or anxiety and ADHD.

Other medication considerations

For all medications, careful dose titration and formulation selection are very important. Long-acting agents are often more effective as they provide a more “even” effect but an additional short-acting “booster” in the afternoon may help some children if its effects end too soon.

Side effects, while always something to monitor and respond to, are typically mild and don’t usually necessitate ending treatment. Often, providers can manage side effects with a dose adjustment or a change in the medication or class. If appetite suppression or growth are a concern, consider medication holidays or nutritional adjustments.

Treatment plans can be complex and vary based on current symptoms and family needs. The American Association of Child and Adolescent Psychiatry has a very helpful medication guide for families. For more information, the American Academy of Pediatrics’ Clinical Practice Guidelines now provide in-depth treatment recommendations for different age groups with ADHD.

Behavior therapy and other treatment for ADHD

Nonpharmacological treatment approaches are a critical component of an ADHD treatment plan. This often includes behavior therapy, such as parent management training (PMT), and school-based interventions. PMT focuses on working with caregivers to develop strategies aimed at strengthening a child’s positive behaviors and eliminating problematic behaviors. These strategies may include strategic attention, reward systems, effective consequences and other strategies known to help motivate children to engage in more 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. Individual treatment focused on improving a youth’s executive functioning and comorbid mental health conditions can also be helpful.

Age and ADHD treatment

• For children under age 6, mental health experts recommend behavior therapy as a first-line treatment.
• For children ages 6 to 11 years, the “gold standard” treatment is a combination of medication and behavior therapy. Youth-focused treatment can also be beneficial at this age.
• For youth ages 12 years and older, a multimodal treatment approach remains first-line; however, providers must consider unique circumstances in adolescent developmental including incorporating increased collaboration between parents and adolescent in developing behavioral contingencies, engaging in collaborative problem solving and improving parent-adolescent conflict and communication. Youth-focused treatment continues to be beneficial at this age.

Additional ADHD resources

Websites

• Additional resources for children’s healthcare professionals
• Mental health resources for parents
• American Academy of Child and Adolescent Psychiatry
• Colorado Pediatric Psychiatry Consultation and Access Program
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)

Books

• Taking charge of ADHD: The complete authoritative guide for parents by Russell Barkley, Ph.D.
• Your defiant child: 8 steps to better behavior by Russell Barkley, Ph.D. & Christine Benton.