Pediatrics (System-Integrated)

ADHD in children: diagnosis and treatment

Clinical Overview and When to Suspect ADHD

— Prevalence ~9–11% of US school-age children (CDC); M:F ~2:1 in childhood, narrowing in adolescence

— Strongly heritable (h² ~0.7–0.8); first-degree relatives have 4–5× risk

— Frequent comorbidities: oppositional defiant disorder (~40%), anxiety, learning disorders, depression, tic disorders, autism spectrum

— Predominantly inattentive (often girls, missed until later grades)

— Predominantly hyperactive-impulsive (younger children, preschool)

— Combined (most common referral pattern)

— Teacher or parent complaints of "can't sit still," "doesn't finish work," "careless mistakes," "loses things," "blurts out"

— Declining grades despite preserved intelligence

— Frequent disciplinary referrals, peer rejection, accidents/injuries

— Sleep complaints, screen overuse, or anxiety masking underlying ADHD

— Evaluate any child 4–18 years presenting with academic or behavioral problems AND symptoms of inattention, hyperactivity, or impulsivity

— Use DSM-5 criteria as the diagnostic gold standard; ADHD is a clinical diagnosis, not a lab or imaging diagnosis

Board pearl: A child whose teacher reports inattention but whose parents report no issues at home does not meet ADHD criteria — pursue learning disorder, vision/hearing deficit, or classroom-specific problem.

Step 3 management: First step when ADHD is suspected is to obtain standardized rating scales (Vanderbilt, Conners) from both parents and teachers before initiating any treatment or referral.

Definition: ADHD is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, with onset of several symptoms before age 12.

Epidemiology:

Three DSM-5 presentations:

When to suspect in primary care:

AAP screening guidance (2019):

Functional impairment is required: symptoms must be present in ≥2 settings (home, school, extracurricular, peer relationships) and cause measurable dysfunction.

Presentation Patterns and Key History

— Careless mistakes, difficulty sustaining attention, doesn't seem to listen

— Fails to finish tasks/chores, poor organization, avoids sustained mental effort

— Loses items (homework, jackets), easily distracted, forgetful in daily activities

— Fidgets, leaves seat, runs/climbs inappropriately, "on the go"

— Talks excessively, blurts answers, can't wait turn, interrupts

— Several symptoms present before age 12

— Symptoms in ≥2 settings

— Clear evidence of interference with academic, social, or occupational functioning

— Not better explained by another mental disorder

— Preschool (4–5): aggression, injuries, expulsion from daycare; defer stimulants if possible, start with parent training

— School-age (6–11): academic underachievement, homework battles, peer conflict

— Adolescents: procrastination, risk-taking, driving violations, substance use risk, declining executive function as demands rise

— Prenatal (maternal smoking/alcohol, prematurity, low birth weight)

— Developmental milestones, head injury, lead exposure

— Sleep history (snoring → OSA mimics ADHD), screen time

— Family history of ADHD, tics, mood disorders, sudden cardiac death

— School records, IEP/504 status, prior psychoeducational testing

— Vanderbilt (AAP-preferred, free, includes comorbidity screening)

— Conners-3, SNAP-IV, ADHD-RS-5

— Collect from ≥2 informants in ≥2 settings

Key distinction: Symptoms confined to one rigid, boring environment (e.g., only at school during math) suggest a learning disorder or anxiety, not ADHD — ADHD is pervasive.

Board pearl: A required positive family cardiac history item (sudden death <35, arrhythmia, long QT, HCM) is what triages whether a screening ECG is needed before stimulants.

Inattentive symptoms (need ≥6 for <17 yr, ≥5 if ≥17):

Hyperactive-impulsive symptoms (need ≥6 / ≥5):

DSM-5 thresholds:

Developmental context — age-specific clues:

Targeted history must include:

Validated rating scales:

Physical Exam Findings and Cardiovascular Assessment

— Baseline HR and BP plotted on pediatric percentiles (stimulants raise both modestly)

— Height, weight, BMI on growth chart — stimulants can blunt growth velocity

— Document baseline before any pharmacotherapy

— Auscultate for murmurs (HCM), check for Marfanoid habitus, femoral pulses

— Family history red flags: sudden cardiac death <35, unexplained drowning/MVC, long QT, HCM, arrhythmogenic cardiomyopathy, pacemaker/ICD in young relative

— Observe for tics (motor or vocal) — important baseline; stimulants can unmask

— Soft signs, coordination; gross focal deficits warrant neurology referral

— Dysmorphic features → consider fetal alcohol spectrum, fragile X, 22q11

— Tonsillar hypertrophy, mouth breathing, allergic shiners → screen for OSA (a classic ADHD mimic)

— Vision and hearing screen — uncorrected deficits masquerade as inattention

Step 3 management: Routine ECG before stimulant initiation is NOT recommended (AHA/AAP joint statement) in an asymptomatic child with normal cardiac history and exam. Obtain ECG only if there is personal cardiac history, concerning family history, exam findings (murmur, abnormal pulses), or symptoms (syncope, exertional chest pain, palpitations).

Board pearl: A child with loud snoring, witnessed apneas, and daytime inattention needs a polysomnogram before an ADHD label — treating OSA (adenotonsillectomy) often resolves the "ADHD."

General principle: Physical exam in ADHD is usually normal; its purpose is to (1) screen for mimics, (2) establish a cardiovascular baseline before stimulants, and (3) document growth parameters.

Vital signs and growth:

Cardiovascular exam:

Neurologic exam:

HEENT and pulmonary:

Skin: café-au-lait spots (NF1), hypopigmented macules (tuberous sclerosis)

Mental status: mood, affect, thought content — screen for depression, anxiety, suicidality, especially in adolescents

Diagnostic Workup — Initial Evaluation and Screening

— DSM-5 symptom count from ≥2 settings via validated rating scales

— Direct clinical interview with child and caregiver

— Review of school records, report cards, prior testing, IEP/504

— Functional impairment documentation

— Screening for coexisting conditions (mandatory, not optional)

— Oppositional defiant disorder, conduct disorder

— Anxiety disorders, depression, suicidality (use PHQ-A in teens)

— Learning disorders (request psychoeducational testing through school)

— Autism spectrum, tic disorders, Tourette

— Substance use in adolescents (CRAFFT)

— Sleep disorders (OSA, restless legs, delayed sleep phase)

— CBC, ferritin if pica, restless legs, or poor diet (low ferritin worsens inattention/RLS)

— TSH if goiter, weight change, tachycardia, family thyroid disease

— Lead level in children <6 with risk factors (older housing, pica)

— Toxicology if substance use suspected in adolescents

Key distinction: Absence seizures present as brief staring spells with behavioral arrest, often inducible by hyperventilation, and show 3-Hz spike-and-wave on EEG — easily mistaken for inattention.

Board pearl: Insurance or school requests for a "brain scan to confirm ADHD" should be declined — there is no validated imaging biomarker; recommend rating scales and school-based evaluation instead.

ADHD is a clinical diagnosis: No laboratory test, imaging study, EEG, or neuropsychological test is required or diagnostic. The diagnosis rests on DSM-5 criteria applied to multi-informant data.

Required diagnostic elements (AAP 2019):

Comorbidity screening targets (~⅔ of ADHD kids have ≥1):

Targeted labs — only if indicated:

Imaging: No neuroimaging unless focal neurologic findings, seizures, micro/macrocephaly, or atypical features.

EEG: Only if seizures suspected (staring spells must be distinguished from inattention).

Diagnostic Workup — Advanced and Confirmatory Studies

— Suspected learning disorder (reading, math, written expression) despite controlled ADHD symptoms

— Discrepancy between cognitive potential and academic achievement

— Atypical presentation, treatment-resistant cases, or medicolegal/educational documentation needs

— Tests: WISC-V (IQ), WIAT-4 (achievement), executive function batteries (BRIEF, NEPSY)

— Measure sustained attention and impulsivity

— Supportive, not diagnostic — normal CPT does not rule out ADHD; abnormal CPT does not confirm it

— Polysomnography if snoring, witnessed apneas, restless sleep, obesity, large tonsils, or refractory ADHD

— Actigraphy or sleep diary for circadian/insomnia patterns

— Reserved for dysmorphic features, intellectual disability, regression, or family history suggesting a syndrome (fragile X, 22q11, fetal alcohol)

— Chromosomal microarray if global developmental delay or autism features coexist

— Triggered by personal cardiac symptoms (syncope, exertional chest pain, palpitations), abnormal exam, or red-flag family history

— Long QT, HCM, WPW, CPVT must be excluded before stimulant if suspected

— Request in writing for IEP (specific learning disability) or 504 plan (accommodations only)

— Pediatrician should advocate; document medical necessity

Step 3 management: When a school refuses to evaluate a struggling child, instruct parents to submit a written request for evaluation; under federal law (IDEA), the district must respond within 60 days.

CCS pearl: Ordering "MRI brain" or "EEG" on a routine ADHD CCS case will waste time/score — order Vanderbilt scales, hearing/vision screen, and schedule a follow-up visit instead.

Psychoeducational/neuropsychological testing — when to order:

Continuous Performance Tests (CPT, TOVA, IVA):

Sleep evaluation:

Genetic and metabolic testing:

Cardiology consult and ECG:

School-based evaluation (free under IDEA):

Adolescent-specific: Substance use assessment with CRAFFT, depression screen with PHQ-A, and driving safety counseling.

Risk Stratification and First-Line Management Logic

— Ages 4–5 (preschool): Parent training in behavior management (PTBM) AND/OR classroom behavioral interventions = first line; methylphenidate only if behavior therapy fails AND impairment is moderate-to-severe

— Ages 6–11: FDA-approved medication (stimulant preferred) AND behavioral therapy + school interventions (504/IEP) — combination beats either alone (MTA study)

— Ages 12–18: FDA-approved medication with patient assent + behavioral/educational interventions; address driving, substance use, transition planning

— Parent training (Triple P, Incredible Years, PCIT for younger)

— Classroom behavior management, daily report cards

— Organizational skills training for older children

— Social skills training when peer dysfunction prominent

— Identify 3–6 specific target outcomes with family (e.g., homework completion, fewer outbursts, improved grades, peer relationships, safety)

— Reassess outcomes at each visit using rating scales

— Stimulants (methylphenidate, amphetamine) — first line; effect size ~0.9–1.1

— Non-stimulants (atomoxetine, guanfacine ER, clonidine ER, viloxazine) — when stimulants contraindicated, ineffective, poorly tolerated, or comorbid tic/anxiety/substance use

— Discuss benefits, side effects, growth/appetite monitoring, controlled-substance status, school storage of medications

Board pearl: The landmark MTA study showed combined medication + behavioral therapy was superior to either alone for functional outcomes; medication alone beat behavioral therapy alone for core symptoms.

Step 3 management: In a 4-year-old with ADHD symptoms, prescribing a stimulant first is wrong — refer for parent behavior training; reserve medication for failure or severe impairment.

Treatment is age-stratified per AAP 2019 guideline:

Behavioral interventions (evidence-based):

Goal-setting framework:

Medication selection rationale:

Shared decision-making elements:

Pharmacotherapy — Stimulants (First-Line)

— Methylphenidate (MPH): preferred starting class in children <6 and often first try in 6–11

— Amphetamine (AMP): mixed amphetamine salts, lisdexamfetamine, dextroamphetamine

— Short-acting MPH (Ritalin, 3–4 h) — useful for titration, afternoon "boost"

— Long-acting MPH (Concerta, Ritalin LA, Focalin XR, Daytrana patch, Quillivant liquid) — 8–12 h

— Short-acting AMP (Adderall IR, Dexedrine)

— Long-acting AMP (Adderall XR, Vyvanse, Mydayis, Dyanavel XR)

— Start low, titrate every 1–3 weeks based on rating scales and tolerability

— Reassess with parent and teacher Vanderbilt scales after each titration

— If first stimulant fails or intolerable → switch to the other class before declaring stimulants ineffective (~85% respond to one of the two)

— Decreased appetite, weight loss, growth velocity reduction (~1–2 cm over years)

— Insomnia (give earlier, avoid late-afternoon dosing)

— Headache, abdominal pain, irritability/"rebound" as dose wears off

— Modest ↑ HR (~3–5 bpm) and BP (~2–4 mm Hg)

— Tic exacerbation (usually transient; not absolute contraindication)

— Rare: psychosis/mania, priapism (MPH), Raynaud-like vascular events

Board pearl: Lisdexamfetamine (Vyvanse) is a prodrug activated by RBC hydrolysis — lower abuse potential, smoother onset/offset, FDA-approved for binge-eating disorder in adults.

Step 3 management: A child losing weight on stimulants — give medication after breakfast, add calorie-dense snacks, consider drug holidays on weekends/summer if growth is affected.

Two stimulant classes — equally effective, try both before declaring failure:

Mechanism: Block dopamine and norepinephrine reuptake (MPH); AMP also promotes presynaptic release.

Common formulations:

Dosing strategy:

Adverse effects:

Contraindications: Symptomatic cardiovascular disease, structural cardiac defect (HCM), severe hypertension, hyperthyroidism, glaucoma, current MAOI, history of stimulant-induced psychosis.

Controlled substance: Schedule II — no refills; monthly prescriptions; counsel on diversion in adolescents.

Pharmacotherapy — Non-Stimulants and Combination Strategies

— Stimulant intolerance, non-response to both MPH and AMP

— Coexisting tics, anxiety, insomnia, or substance use risk

— Family preference to avoid controlled substances

— Need for 24-hour coverage (evenings, mornings)

— Selective NE reuptake inhibitor; not a controlled substance

— Dose: 0.5 mg/kg/day × 1–2 wk, then 1.2 mg/kg/day (max 1.4 mg/kg or 100 mg)

— Full effect in 4–6 weeks (slower than stimulants)

— Black box: suicidal ideation in children/adolescents — monitor closely first 1–2 months

— Side effects: GI upset, somnolence, ↑ HR/BP, rare hepatotoxicity

— FDA-approved as monotherapy or adjunct to stimulants

— Help with hyperactivity, impulsivity, sleep onset, tics, emotional lability

— Side effects: sedation, hypotension, bradycardia, dry mouth; taper to discontinue (rebound HTN)

— Check baseline HR/BP; ECG not required but reasonable if cardiac concern

— NE modulator, FDA-approved 2021 for ages 6+

— Once-daily; side effects: somnolence, decreased appetite, irritability

— Suicidality black box

— Stimulant + alpha-2 agonist for residual hyperactivity, sleep, or aggression

— Stimulant + atomoxetine occasionally for partial response

— Confirm diagnosis → reassess adherence, dose, timing → switch stimulant class → trial non-stimulant → consider psychiatric referral and reassess for missed comorbidity (anxiety, mood, learning disorder)

Key distinction: Guanfacine ER is more selective for prefrontal α2A receptors → less sedation than clonidine; clonidine is more sedating → useful for sleep-onset insomnia from stimulants.

Board pearl: Atomoxetine is the non-stimulant of choice when ADHD coexists with active substance use or strong diversion concern — no abuse potential.

Indications for non-stimulants:

Atomoxetine (Strattera):

Alpha-2 agonists (guanfacine ER / clonidine ER):

Viloxazine ER (Qelbree):

Bupropion, tricyclics, modafinil: Off-label; reserved for specialist use.

Combination therapy:

Treatment failure algorithm:

Special Populations — Hepatic, Renal, and Cardiac Considerations

— Atomoxetine requires dose reduction:

— Moderate (Child-Pugh B): 50% of normal

— Severe (Child-Pugh C): 25% of normal

— Rare idiosyncratic hepatotoxicity — discontinue immediately if jaundice, dark urine, ↑ transaminases, unexplained flu-like illness; do not rechallenge

— Stimulants — no specific hepatic dose adjustment; routine LFTs not required

— Guanfacine ER and clonidine ER — use caution; titrate slowly, monitor BP

— Lisdexamfetamine in severe renal impairment (GFR 15–<30): max 50 mg/day; ESRD: max 30 mg/day

— Methylphenidate — minimal renal adjustment needed

— Structural heart disease, HCM, long QT, WPW, arrhythmias → cardiology clearance before stimulants

— Mild well-controlled hypertension is not an absolute contraindication, but prefer alpha-2 agonist or atomoxetine

— Monitor HR and BP at every visit; persistent HR >110 or BP >95th percentile warrants dose reduction or switch

— CYP2D6 poor metabolizers have higher atomoxetine levels — start lower, titrate slower; more side effects

— Atomoxetine + strong CYP2D6 inhibitors (fluoxetine, paroxetine, bupropion) → ↑ levels, similar dose adjustment

— Stimulants are generally safe if seizures are well controlled

— Bupropion lowers seizure threshold — avoid

Step 3 management: In a teen on fluoxetine for depression who is started on atomoxetine, halve the atomoxetine target dose because of CYP2D6 inhibition; counsel about additive risk of suicidal ideation and serotonergic side effects.

Board pearl: New jaundice or RUQ pain in a child on atomoxetine → stop drug, check LFTs/bilirubin, do not rechallenge regardless of recovery.

Hepatic impairment:

Renal impairment:

Cardiac comorbidity:

Pharmacogenomic considerations:

Seizure disorders:

Thyroid disease: Correct hyperthyroidism before stimulants; ADHD-like symptoms may resolve.

Anemia/iron deficiency: Low ferritin (<30 ng/mL) worsens inattention and restless legs — supplement iron; reassess symptoms before/after.

Special Populations — Preschoolers, Adolescents, and Pregnancy

— First-line: parent training in behavior management (PTBM) for 8–12 sessions; classroom behavioral interventions if in preschool

— Diagnose only if symptoms persist ≥9 months across settings with clear impairment

— If PTBM fails AND moderate-severe impairment → methylphenidate is the only stimulant with adequate evidence (PATS trial); start 2.5 mg BID, titrate slowly

— Higher rate of side effects (irritability, appetite loss, sleep)

— Obtain assent in addition to parental consent

— Discuss diversion: ~10–35% of teens with stimulant prescriptions report being asked to sell/share — counsel on safe storage, single-day dispensing, prefer lisdexamfetamine or osmotic-release MPH (Concerta) for tamper-resistance

— Driving safety: untreated ADHD ↑ MVC risk 2–4×; ensure medication coverage during driving hours

— Transition planning: by age 18, transfer to adult provider; teach self-management, refills, college disability services

— Screen depression, anxiety, substance use at every visit

— Stimulants: limited data, possible small ↑ risk of preeclampsia, preterm birth, low birth weight; weigh risk/benefit; many continue if functional impairment severe

— Atomoxetine: limited data; generally avoided

— Behavioral therapy preferred during pregnancy when feasible

— Lactation: methylphenidate has low milk transfer and is generally compatible

— Document diagnosis for disability services

— Provide longer-acting formulations to reduce dosing in dorm/class settings

Key distinction: A young child with hyperactivity AND a history of trauma, neglect, or foster placement may have PTSD or reactive attachment disorder, not ADHD — trauma-focused therapy is first line.

Board pearl: In adolescents, prefer lisdexamfetamine or OROS-methylphenidate (Concerta) to reduce abuse and diversion potential.

Preschoolers (4–5 years):

Adolescents:

Pregnancy and lactation (relevant to adolescent patients):

College transition:

Foster care, adoption, trauma history: Higher ADHD prevalence; rule out PTSD, attachment disorder, fetal alcohol spectrum before labeling.

Complications and Adverse Outcomes

— Academic underachievement, grade retention, lower educational attainment

— Increased risk of MVCs, unintentional injuries, ED visits

— Higher rates of substance use disorder, especially nicotine and cannabis

— Adolescent risk-taking: unplanned pregnancy, STIs

— Comorbid depression, anxiety, suicidality (especially in girls and inattentive type)

— Occupational underperformance, relationship instability into adulthood

— Criminal justice involvement (untreated conduct disorder comorbidity)

— Growth: stimulants reduce height gain ~1–2 cm cumulative; usually attenuates over years; drug holidays controversial

— Cardiovascular: small ↑ HR/BP; rare sudden cardiac events almost exclusively in those with undiagnosed structural disease

— Psychiatric: new-onset psychosis or mania (~0.1%), worsening anxiety, emotional blunting; atomoxetine/viloxazine — suicidal ideation black box

— Sleep: insomnia (dose timing), nightmares, rebound hyperactivity

— Tics: may emerge or worsen; usually transient; can switch to non-stimulant

— Appetite suppression → weight loss → growth concern

— Misuse and diversion: especially in adolescents and college students

— Declining grades despite "good response," new mood symptoms, suicidal ideation, school avoidance, social withdrawal

— Suspect emerging depression, anxiety, learning disorder, or substance use

— Stimulant shortages — counsel families on flexibility, alternative formulations

— Insurance prior authorizations — long-acting branded products often require step therapy

Step 3 management: A child with controlled ADHD whose grades suddenly drop — don't reflexively increase stimulant dose; reassess for emerging depression, learning disorder, bullying, substance use, or sleep disorder.

Board pearl: Treated ADHD is associated with reduced rates of substance use disorder vs untreated ADHD — stimulant treatment is protective, not causative.

Untreated ADHD — long-term consequences:

Medication-related complications:

Functional warning signs requiring re-evaluation:

Health systems issues:

When to Escalate Care — Specialty Referral and Inpatient Triage

— Age <6 years with persistent severe symptoms after PTBM trial

— Diagnostic uncertainty or atypical presentation

— Treatment failure after adequate trials of both stimulant classes and a non-stimulant

— Significant psychiatric comorbidity: bipolar disorder, psychosis, severe anxiety, OCD, suicidality, autism spectrum

— Substance use disorder in adolescent with ADHD

— Tic disorder/Tourette with functional impairment

— Significant aggression, conduct disorder, or safety concerns

— Complex medical comorbidity (epilepsy, cardiac disease, intellectual disability)

— Personal history of syncope, exertional chest pain, palpitations

— Murmur, abnormal pulses, hypertension on exam

— Family history of sudden death <35, HCM, long QT, arrhythmia, ICD/pacemaker in young relative

— Pre-existing congenital heart disease before stimulant initiation

— Request IEP evaluation for specific learning disability or "Other Health Impairment" classification

— 504 plan for accommodations (extended time, preferential seating, frequent breaks)

— Active suicidal ideation with plan/intent → ED for safety assessment

— New-onset psychosis or mania on stimulants → discontinue, urgent psychiatry

— Stimulant overdose/toxicity (agitation, hyperthermia, hypertensive emergency, seizures) → ED, benzodiazepines, supportive care

CCS pearl: A teen presenting with new psychotic symptoms after starting amphetamine — stop the stimulant, admit if safety concerns, consult psychiatry, and do not restart that class.

Refer to child psychiatry, developmental-behavioral pediatrics, or neurology when:

Refer to cardiology when:

Refer to sleep medicine: snoring/witnessed apnea, refractory ADHD with poor sleep

Refer to neuropsychology: suspected learning disorder, complex executive dysfunction, atypical cognitive profile

School-based referral:

Emergency/inpatient escalation:

Adult transition: Begin transition planning by age 16; transfer by 18–21 with summary letter, current regimen, comorbidities, and accommodation needs.

Key Differentials — Other Neurodevelopmental and Psychiatric Causes

— Inattention from worry and rumination, restlessness from physiologic arousal

— Look for somatic complaints, avoidance, sleep disturbance, family history

— May coexist with ADHD (30–40%); treat both — SSRIs + stimulant often needed

— Concentration difficulty, low energy, irritability (especially adolescents)

— Anhedonia, sleep/appetite changes, hopelessness distinguish from ADHD

— ADHD symptoms are lifelong; depression has episodic course

— Episodic mood elevation, grandiosity, decreased need for sleep, hypersexuality

— Family history strongly suggestive

— Critical: Stimulants may precipitate mania — stabilize mood first

— Social communication deficits, restricted/repetitive behaviors, sensory sensitivities

— Coexists with ADHD in ~30–50%; DSM-5 allows dual diagnosis

— Defiance and rule-breaking — often comorbid with ADHD, not differential

— Inattention is task-specific (reading, math) rather than pervasive

— Psychoeducational testing distinguishes

— Cognitive testing reveals global deficits

— ADHD symptoms judged against developmental, not chronological, age

— Often coexist; choose non-stimulant or use cautious stimulant trial

— Trauma history, hypervigilance, dissociation, nightmares

— Foster care and adopted children at high risk

— Recent stressor (divorce, move, loss); symptoms time-limited

Key distinction: Bipolar disorder vs ADHD — bipolar mood elevation is episodic with discrete onset; ADHD symptoms are continuous from early childhood. Decreased need for sleep with high energy points to bipolar.

Board pearl: Children with autism + ADHD may have blunted stimulant response and more irritability — start at lower doses and titrate cautiously.

Anxiety disorders:

Major depressive disorder:

Bipolar disorder:

Autism spectrum disorder:

Oppositional defiant disorder / conduct disorder:

Specific learning disorders:

Intellectual disability:

Tic disorders / Tourette syndrome:

PTSD / reactive attachment disorder:

Adjustment disorder:

Key Differentials — Medical and Environmental Mimics

— Snoring, witnessed apneas, restless sleep, mouth breathing, morning headaches

— Adenotonsillar hypertrophy on exam

— Polysomnography confirms; adenotonsillectomy often resolves daytime inattention

— Uncorrected → appears as inattention, poor classroom performance

— Always screen at diagnostic visit

— Restlessness, irritability, weight loss, tachycardia, tremor, heat intolerance

— Check TSH if any suggestive findings

— Inattention, restless legs, pica

— Check CBC and ferritin; supplement if ferritin <30 ng/mL

— Pre-1978 housing, peeling paint, pica

— Cognitive, behavioral, attentional symptoms; check lead level in at-risk young children

— Brief staring spells with behavioral arrest, automatisms, no postictal state

— Induced by hyperventilation in clinic; EEG shows 3-Hz generalized spike-wave

— Dysmorphic facies (smooth philtrum, thin vermillion, short palpebral fissures), growth restriction, prenatal alcohol exposure

— Albuterol, antihistamines (sedation → inattention), antiepileptics (phenobarbital, topiramate), corticosteroids (mood, behavior)

— Cannabis, alcohol, stimulant misuse, vaping → screen with CRAFFT

— Chronic sleep deprivation (late screen use), bullying, abuse, neglect, food insecurity, chaotic home, learning environment mismatch

Step 3 management: Before initiating stimulants in a young child with new ADHD-like symptoms in a pre-1978 home with peeling paint — obtain a venous lead level.

Board pearl: A school-age child who snores loudly with daytime inattention — order polysomnography and ENT referral; adenotonsillectomy may obviate the need for ADHD medication.

Obstructive sleep apnea:

Hearing or vision impairment:

Hyperthyroidism:

Iron deficiency anemia / low ferritin:

Lead poisoning:

Absence seizures:

Fetal alcohol spectrum disorder:

Medication side effects:

Substance use in adolescents:

Environmental/social:

Long-Term Plan, Medication Continuation, and Secondary Prevention

— Continue as long as benefits outweigh risks and functional impairment persists

— Periodic (annual) re-evaluation of need — consider brief structured trial off medication during low-demand periods (summer) for older children if family wishes; not mandatory

— ~50–60% will need continued treatment into adulthood

— Maintain 504 plan or IEP with annual review

— Organizational coaching, executive function therapy, parent support

— Sleep hygiene, screen time limits, exercise (≥60 min/day — improves core symptoms)

— Structured routines, visual schedules, homework systems

— Injury prevention: helmet use, supervised swimming, MVC counseling for teens

— Substance use prevention: counsel at every adolescent visit; treated ADHD ↓ SUD risk

— Mental health: screen for depression, anxiety, suicidality at every visit

— Driving: ensure medication coverage during driving hours; consider longer-acting agents

— Annual vision, hearing, dental

— Maintain immunizations; ADHD does not alter schedules

— Monitor BMI percentile, growth velocity

— Provide written treatment summary, current dose, comorbidities, accommodations

— Connect with adult primary care or psychiatry; college disability office

— Teach prescription self-management, recognition of side effects

Step 3 management: At an annual ADHD follow-up, repeat Vanderbilt scales from parent and teacher, plot height/weight/BP/HR, screen for mood/anxiety/substance use, and review 504/IEP status — every year.

Board pearl: Drug holidays are not required — discuss with family; data show modest growth recovery but symptom worsening and possible academic/social cost.

ADHD is a chronic condition — AAP classifies it as such; apply the chronic care model with planned longitudinal visits, written care plans, and family self-management support.

Duration of pharmacotherapy:

Behavioral and educational scaffolding (continue lifelong as needed):

Secondary prevention of complications:

Health maintenance integration:

Transition to adult care (by age 18–21):

Follow-Up, Monitoring Parameters, and Counseling

— Titration phase: every 2–4 weeks until target response and tolerable side effects

— Maintenance: every 3 months for first year, then every 3–6 months

— More frequent if comorbidities, dose changes, or adolescent transitions

— Vanderbilt/Conners scores from parent and teacher (every 3–6 months)

— Height, weight, BMI plotted on growth chart

— Heart rate, blood pressure

— Sleep, appetite, mood, tics, side effects

— Academic progress (report cards), peer/family functioning

— Medication adherence, missed doses, weekend use

— Adolescents: substance use, driving, sexual health, mood/suicidality

— Weight loss > 2 kg or crossing percentiles → dietary counseling, dose timing, calorie-dense foods, consider drug holiday or non-stimulant

— HR persistently >110 or BP > 95th percentile → reduce dose, switch class, consider cardiology

— New tics → reassure if transient; if persistent/functional, switch to non-stimulant or add guanfacine

— Mood changes → screen for depression; consider atomoxetine black box if applicable

— Medication is a tool, not a cure — combined behavioral + educational support remains essential

— Storage in locked location; never share medications

— School communication and 504/IEP advocacy

— Setting realistic, specific goals; celebrating small wins

— Screen time (AAP recommendation ≤2 h recreational), physical activity, sleep hygiene

CCS pearl: On a CCS follow-up visit, orders should include "Vanderbilt parent and teacher rating scales," "plot height/weight," "measure HR and BP," and "screen for mood and side effects" — these score the management phase.

Board pearl: A consistent gap in stimulant effect (e.g., afternoon homework crash) — add short-acting MPH or amphetamine in early afternoon rather than escalating the long-acting morning dose.

Visit cadence:

At every visit document:

Specific monitoring concerns:

Counseling families on:

Telehealth: appropriate for stable maintenance visits; controlled-substance e-prescribing rules vary by state.

Ethical, Legal, and Patient Safety Considerations

— Parent/guardian provides consent for minors; assent from the child should be obtained, especially ≥7 years

— Discuss risks (growth, CV, psychiatric, abuse potential), benefits, alternatives (including no treatment), and reasonable expectations

— Document discussion in chart

— Schedule II — no refills, written or e-prescription required, monthly limits

— Counsel families on safe storage (locked) and diversion risk — up to ⅓ of teens with prescriptions report being asked to share/sell

— Be alert to early refill requests, lost prescriptions, multiple-prescriber patterns; check state PDMP per local law

— Adolescents heading to college: discuss diversion pressure, secure storage in dorm

— If history suggests child abuse, neglect, or unsafe home environment → mandated report to CPS; do not delay

— Foster care youth: coordinate with case worker for consent (state-specific rules)

— IDEA (special education) and Section 504 (accommodations) — pediatrician should write supporting letters; schools must respond to written evaluation requests within mandated timelines

— Avoid signing off on unilateral school-driven medication recommendations — diagnosis must follow clinical evaluation, not a teacher's directive

— At age 18, prescription authority passes to the patient; gaps in care common

— Provide written summary, medication list, and warm handoff to adult provider before patient leaves pediatric practice

— Untreated ADHD significantly ↑ MVC risk — counsel teens and document

— ADHD is underdiagnosed in girls and minority children, and overdiagnosed in young-for-grade children; consider relative age effect

— Discuss limits; mental health and substance use disclosures often have state-specific confidentiality protections

Step 3 management: A college-bound 18-year-old asks for early stimulant refills "for exams" — review PDMP, counsel on diversion and misuse, document, and consider lisdexamfetamine for tamper-resistance; do not reflexively refill.

Board pearl: A teacher pressuring parents to "get your child on medication" is not a diagnostic basis — formal multi-informant evaluation is required before any prescription.

Informed consent and assent:

Controlled substance prescribing:

Mandatory reporting and child welfare:

School advocacy and federal law:

Transition of care risk:

Driving safety:

Disparities:

Confidentiality in adolescents:

High-Yield Associations and Rapid-Fire Clinical Facts

— 4–5: PTBM ± methylphenidate

— 6–11: medication + behavioral therapy + school support

— 12–18: medication + behavioral support + assent

Board pearl: "Several symptoms before age 12, in two or more settings, with functional impairment" — these are the three highest-yield DSM-5 criteria for ADHD on Step 3.

Step 3 management: When in doubt, order Vanderbilt scales from parent and teacher and a follow-up appointment — the highest-yield Step 3 first move.

Prevalence ~9–11% US school-age; M:F 2:1 in childhood, near 1:1 by adulthood

Heritability ~70–80% — one of the most heritable psychiatric conditions

DSM-5: age <12 onset, ≥2 settings, ≥6 symptoms (≥5 if ≥17), functional impairment

Three presentations: inattentive, hyperactive-impulsive, combined

Comorbidity is the rule, not exception (~⅔): ODD, anxiety, depression, LD, tics, autism

AAP first-line by age:

MTA study: combined treatment > medication alone > behavioral alone for function

Stimulants effect size ~0.9–1.1; non-stimulants ~0.5–0.7

Try both stimulant classes (MPH and AMP) before declaring stimulant failure — ~85% respond to one

Routine pre-stimulant ECG not recommended in asymptomatic child with normal cardiac history

Lisdexamfetamine is a prodrug → activated by RBC hydrolysis → lower abuse potential

Atomoxetine: NE reuptake inhibitor, full effect 4–6 weeks, suicidality black box, hepatotoxicity warning, CYP2D6 metabolism

Guanfacine ER vs clonidine ER: guanfacine less sedating, clonidine more sedating (helps sleep)

Iron deficiency (ferritin <30) worsens inattention and restless legs — supplement

Adenotonsillar hypertrophy + snoring → OSA mimics ADHD; treat OSA first

Absence seizures mimic inattention — 3-Hz spike-wave on EEG

Stimulants are protective against substance use disorder when ADHD treated effectively

Drug holidays optional, not required; growth reduction usually 1–2 cm cumulative

Stimulants modestly ↑ HR (~3–5 bpm) and BP (~2–4 mm Hg)

Foster/adopted children — rule out PTSD, fetal alcohol spectrum before ADHD diagnosis

Girls more often inattentive type, frequently underdiagnosed

Relative age effect: youngest-in-grade children overdiagnosed

Untreated ADHD ↑ MVC risk 2–4×

Board Question Stem Patterns

— "8-year-old boy with declining grades, loses homework, fidgets, blurts answers; teacher and parents report similar symptoms for 2 years."

— Next step: Vanderbilt rating scales from parents and teachers → diagnose → start stimulant + behavioral therapy + 504 plan

— "5-year-old expelled from two preschools for hyperactivity and aggression; pediatrician's first recommendation?"

— Answer: Parent training in behavior management (PTBM) — not stimulants

— "9-year-old, normal exam, no cardiac symptoms or family history. What workup before MPH?"

— Answer: No ECG needed; baseline HR, BP, height, weight

— "Child develops motor tics on methylphenidate."

— Answer: switch to atomoxetine or alpha-2 agonist; or reassure if mild/transient

— "Adolescent with ADHD and cannabis use; family worried about diversion."

— Answer: Atomoxetine or lisdexamfetamine (prodrug, lower abuse potential)

— "Child on stimulants has crossed two weight percentiles down."

— Answer: give meds after meals, calorie-dense snacks, consider drug holidays or switch to non-stimulant

— "Inattentive 7-year-old with snoring, large tonsils, obesity."

— Answer: polysomnogram + ENT referral before ADHD label

— "Teen on fluoxetine started on atomoxetine."

— Answer: reduce atomoxetine dose (CYP2D6 inhibition); monitor suicidality

— "Teacher insists child needs stimulants."

— Answer: perform multi-informant evaluation; do not prescribe based on teacher request

— Answer: reassess for depression, substance use, learning disorder, sleep issue — not automatic dose increase

— "4-year-old with hyperactivity in pre-1978 housing with peeling paint."

— Answer: venous lead level

— "Episodic mood elevation, decreased sleep need, grandiosity, family history of bipolar."

— Answer: stabilize mood first; stimulants may precipitate mania

Board pearl: When the stem mentions snoring or large tonsils, the answer is sleep study/ENT — not ADHD treatment.

CCS pearl: Initial CCS orders for new ADHD visit: Vanderbilt scales (parent and teacher), hearing/vision screen, height/weight/HR/BP, schedule 2-week follow-up — avoid imaging and EEG.

Stem 1 — Classic diagnosis:

Stem 2 — Preschooler:

Stem 3 — Pre-stimulant cardiac evaluation:

Stem 4 — Tic emergence:

Stem 5 — Substance use risk:

Stem 6 — Growth concern:

Stem 7 — OSA mimic:

Stem 8 — Atomoxetine + fluoxetine:

Stem 9 — School pressure:

Stem 10 — Sudden grade decline on stable regimen:

Stem 11 — Lead exposure:

Stem 12 — Bipolar vs ADHD:

One-Line Recap

ADHD is a clinical, DSM-5-based diagnosis requiring developmentally inappropriate inattention and/or hyperactivity-impulsivity present before age 12, in ≥2 settings, with functional impairment — managed by age-stratified combination of behavioral therapy, school supports (504/IEP), and stimulant-first pharmacotherapy with longitudinal monitoring.

— 4–5 yr: parent training first, methylphenidate only if PTBM fails with severe impairment

— 6–11 yr: stimulant + behavioral therapy + school plan (MTA evidence base)

— 12–18 yr: medication with assent, address driving, substance use, transition planning

Board pearl: The three-word Step 3 mnemonic for ADHD diagnosis — "before 12, two settings, real impairment" — captures the DSM-5 essentials; the three-word management mnemonic — "scales, school, stimulant" — captures the AAP-aligned plan.

Diagnosis: Vanderbilt or Conners scales from parents and teachers; rule out OSA, hearing/vision deficits, iron deficiency, lead, absence seizures, anxiety, trauma, learning disorder; no routine imaging, EEG, or ECG.

Treatment by age:

Pharmacology pearls: Try both stimulant classes (MPH and AMP) before declaring failure (~85% respond to one); non-stimulants (atomoxetine, guanfacine ER, clonidine ER, viloxazine) for stimulant intolerance, tics, anxiety, or substance use risk; lisdexamfetamine is a prodrug with lower abuse potential; routine pre-stimulant ECG is not required without red flags.

Monitoring: every 3–6 months — Vanderbilt scales, height/weight/BMI, HR/BP, sleep, appetite, mood, tics, side effects, adherence, school progress, substance use (teens); treated ADHD reduces substance use risk and MVC risk; counsel on safe storage and diversion; advocate for IEP/504; plan adult-care transition by 18–21.