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Attention Deficit/Hyperactivity Disorder (ADHD), Pediatric

Basics

  • Neurodevelopmental disorder presenting in early childhood with distractibility, impulsivity, hyperactivity, and/or inattention.
  • Three subtypes: predominantly hyperactive (ADHD-H), predominantly inattentive (ADHD-I), combined (ADHD-C).
  • Affects nervous system.

Epidemiology

  • Onset typically before age 12, persists into adolescence and adulthood.
  • Male > female ratio ~2:1; ADHD-I more common in females.
  • Prevalence: 9–15% among children aged 4 to 17 years.

Etiology and Pathophysiology

  • Not fully understood; proposed imbalance of catecholamine metabolism and structural brain differences.
  • Environmental factors controversial.

Risk Factors

  • Family history (genetic predisposition).
  • Medical influences: prenatal tobacco exposure, prematurity.

Commonly Associated Conditions

  • Mood disorders: depression, anxiety.
  • Behavior disorders: oppositional defiant disorder, conduct disorder.
  • Autism spectrum disorder.
  • Sleep disorders, tics.
  • Learning disabilities, developmental coordination syndrome, language disorder.
  • Substance use disorders.

Diagnosis

Diagnostic Criteria (DSM-5-TR)

  • For children <17 years: ≥6 symptoms of inattention and/or hyperactivity-impulsivity.
  • Symptoms present >6 months, before age 12, in ≥2 settings, excessive for developmental level, impair social/scholastic function.
  • Not better explained by other mental disorders.

Inattention Symptoms

  • Careless mistakes, difficulty sustaining attention/organizing.
  • Does not listen, fails to finish tasks.
  • Avoids tasks needing sustained mental effort.
  • Loses things, forgetful, distracted.

Hyperactivity/Impulsivity Symptoms

  • Fidgets, difficulty remaining seated.
  • Runs/climbs excessively, difficulty playing quietly.
  • "Driven by motor," talks excessively.
  • Blurts out answers, difficulty waiting turn, interrupts.

History

  • Birth/developmental history.
  • Psychosocial home evaluation.
  • School performance, absences.
  • Psychiatric and cardiac history.

Physical Exam

  • Baseline weight, heart rate, blood pressure.
  • Neurologic signs (tics, clumsiness).
  • Hearing and vision assessment.

Differential Diagnosis

  • Age-appropriate activity level.
  • Dysfunctional family, abuse.
  • Learning disabilities (dyslexia).
  • Hearing, vision, language disorders.
  • Autism spectrum disorders.
  • Oppositional defiant or conduct disorders.
  • Seizure disorder.
  • Neurodevelopmental syndromes (fragile X).
  • Lead poisoning.
  • CNS infection/trauma sequelae.
  • Medication effects.

Diagnostic Tests

  • Behavioral rating scales (Vanderbilt ADHD forms) by parents, caregivers, teachers before and after therapy.
  • Testing for learning disabilities (school).
  • Lead level if indicated.
  • ECG prior to stimulant therapy if family history of premature cardiovascular disease.

Treatment

General Measures

  • Develop behavioral plan with parents, school.
  • Identify treatment goals prioritizing most harmful behaviors.
  • Coordinate school and home interventions.
  • Ages 4–5 years: behavioral interventions first line.
  • Ages 6–17 years: behavioral interventions plus medication if needed.
  • Behavioral counseling for child and parents (parent training, academic/social training).
  • Behavioral modifications: positive reinforcement, limit negative comments, reward systems, environmental changes.

Medication

First Line: Stimulants

  • Methylphenidate (short, intermediate, long acting formulations).
  • Dexmethylphenidate.
  • Amphetamines (immediate and extended release).
  • Lisdexamfetamine (prodrug).
  • Monitor for side effects: anorexia, insomnia, growth delay, headache, CV effects; rare priapism, psychosis, tics, suicidal ideation.

Precautions

  • Assess compliance and consider alternate diagnosis if no response.
  • Avoid abrupt withdrawal; consider afternoon short-acting dose to prevent rebound.
  • Monitor growth, HR, BP.
  • Avoid drug holidays unless indicated.
  • Stimulants are abuse-prone; monitor carefully.

Second Line: Nonstimulants

  • Atomoxetine (SNRI), Viloxazine (Qelbree).
  • Alpha-2 agonists (Clonidine XR, Guanfacine XR).
  • Carry black box warning for suicidality; monitor closely.
  • Similar side effects to stimulants.

Issues for Referral

  • Additional mental health or developmental concerns.
  • Poor medication response.

Complementary & Alternative Medicine

  • Frequently used by families (20–60%) but lack robust evidence.
  • Includes herbal therapies, video games, trigeminal nerve stimulation.

Ongoing Care

Follow-Up

  • Monitor treatment response (grades, rating scales, social/family interactions).
  • Monitor growth, HR, BP regularly.

Patient Education

  • Resources:
  • http://www.parentsmedguide.org
  • ADDitude toolkit for parents and teachers

Prognosis

  • Deficits in academic/social function may persist into adulthood.
  • Encourage career choices allowing autonomy and mobility.

Complications

  • Untreated ADHD increases risks of school failure, parental conflict, social isolation, low self-esteem, substance abuse, accidents, injuries.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed. 2022.
  2. Felt BT, Biermann B, Christner JG, et al. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90(7):456-464.
  3. National Institute for Children's Health Quality. Caring for children with ADHD: resource toolkit. https://www.nichq.org/resource/caring-children-adhd-resource-toolkit-clinicians

ICD10 Codes

  • F90.2 Attention-deficit hyperactivity disorder, combined type
  • F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type
  • F90 Attention-deficit hyperactivity disorders

Clinical Pearls

  • Identify treatment goals before intervention.
  • Behavioral therapy coordinated with school and parents is essential.
  • AAP recommends behavioral interventions ages 4–5, plus stimulants for ages 6–17 if needed.
  • Titrate stimulants carefully with monitoring for efficacy and side effects.