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Clinical Care Guidelines: Attention-Deficit/Hyperactivity Disorder (ADHD) For Children/Adolescents

An estimated 7.1 million children in the U.S. have ADHD while an estimated 6.5 million have a current diagnosis. (1) ADHD is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. (AAP). It has been shown that children with ADHD can have a lower independent functioning and may appear younger than their peers as well as experience learning disabilities and emotional regulation difficulties. In adolescence, it has been shown that patients with ADHD can struggle academically and experience increased risk for safety concerns regarding driving, substances, and sexual activity. (1) 

 

This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of ADHD in children and adolescents. 

 

Diagnostic Considerations for ADHD in Children and Adolescents

 

For the previous six months (or longer), has your client been experiencing a persistent pattern of inattention that may include 6 (for children) and/or 5 (17 years and older) of the following:

  • Difficulty attending to details
  • Challenges staying focused
  • Frequently distracted when listening to others
  • Difficulty staying organized 
  • Forgetful
  • Avoidance of tasks that require sustained mental energy
  • Does not follow through on instructions and fails to finish tasks
  • Loses things necessary for tasks/activities
  • Easily distracted by external stimuli

 

AND/OR

 

For the previous six months (or longer), has your client been experiencing a persistent pattern of  Hyperactivity and impulsivity that may include 6 (for children) and/or 5 (17 years and older) of the following:

  • Constant Fidgeting 
  • Feeling restless
  • Difficulty engaging in activities quietly
  • Hyperverbal
  • Frequent interrupting
  • Challenges with waiting 
  • Is always “on the go”
  • Leaves seat when should be remain seated i.e. office or workplace
  • Often blurts out answers before the question can be completed 



Key Points for Assessing and Treating ADHD in Children/Adolescents:

  • Early Onset: ADHD is a neurodevelopmental disorder and symptoms must be present before age 12, although full criteria may be met later.
    • Have the above symptoms been present in the patient’s life before age 12? Even if not formally diagnosed. 
  • Functional Impairments: Diagnosis requires impairments in at least two domains, which can begin at any age. 
    • Have the above symptoms negatively impacted the patient’s ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, losing things, etc)?
  • Medication Requests: Requesting stimulant medications as “performance enhancers” does not qualify for an ADHD diagnosis.
  • Comorbid Conditions: Other psychiatric diagnoses should be identified and treated before confirming an ADHD diagnosis. It’s important to note that the above symptoms and experiences may also be attributable to several alternative conditions, such as thyroid disease, mood disorders, anxiety, trauma, or the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if ADHD is the clinically indicated diagnosis. 
  • Collateral Reports: These can be helpful, particularly to verify symptoms before age 12.
  • Rating Scales: Imperative to use rating scales to include teacher and parent reports. 

 

For complete diagnostic criteria of Attention Deficit/Hyperactivity Disorder, consult the Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787.

 

When documenting care, be sure to include the specific symptoms of ADHD experienced by the patient including functional impairment and age of onset. This ensures your note reflects alignment with the diagnosis and demonstrates the medical necessity for the service.  

 

Symptom Screening and Monitoring

 

The use of Measurement-informed care is a critical component of treating ADHD in children, as it supports the establishment of a diagnosis, determination of treatment targets, and evaluation of treatment response. The Vanderbilt Rating Scale NICHQ Vanderbilt Assessment Scale can be used to screen children/adolescents for ADHD, as well as support symptom monitoring throughout treatment. The checklist consists of parent and teacher questionnaires which are consistent with DSM-IV-TR criteria and address the manifestations of ADHD symptoms in adults. 

 

Before considering medication for ADHD, specifically stimulants, certain medical screening questions need to be asked. 

  1. Does the patient have a family medical history of a first-degree family member with sudden cardiac death before age 50 or Wolff Parkinson’s white syndrome? 
  2. Does the patient have any cardiac conditions that would need closer follow-up i.e. Congenital heart defect, Conduction Defect, WPW, Long QT interval 
  3. Does the patient have any comorbid conditions including depression, anxiety, trauma, mania/hypomania, psychosis, or substance use? Consider treating any comorbid psychiatric conditions such as ODD, conduct disorder,  anxiety, depression, bipolar, PTSD, or SUD before starting a stimulant medication. Are there any psychiatric conditions that are contraindicated with stimulants i.e. psychosis?
  4. Note: If the Patient’s Medical History Is Unremarkable, Laboratory or Neurological Testing Is Not Indicated 

 

Monitoring Patients with ADHD who are on stimulants and non-stimulant medications:

  1. Monitor the CURES report before starting any controlled medications and throughout care when prescribing stimulant medications. (At least every 6 months) 
  2. If the patient is going to be prescribed a stimulant, ensure that the patient gets a copy of the stimulant medication agreement. After verbally reviewing it with the patient, you can attach it to the note in AMD. Please be sure to document consent from a legal guardian. 
  • You can view this agreement by clicking here.
  1. Obtain PCP information and an ROI so that we can obtain medical records.
  2. Assess and document if initial symptoms of ADHD are improving by providing examples from their day-to-day experience. 
  3. Monitor/Document the patient’s blood pressure and heart rate at the visit (ask the patient to please buy a BP cuff so that we can measure this for their safety)-get a baseline before starting medication and reassess regularly.
  4. Monitor/Document weight and height- baseline before starting medication and reassess regularly 
  • Is the patient losing weight or height blunted? 
  • Do you need to consider a drug holiday? Weigh the risks of a drug holiday considering social difficulties and increased chance of accidents including motor vehicle accidents in adolescents due to untreated symptoms.  
  1. If the patient has a hx of substance use check regularly on current use and discuss with the patient the monitoring plan which may include random or initial UDS.
  2. Assess for and document medication side effects including but not limited to restlessness, anxiety, tremors, decreased appetite, decreased sleep, psychosis, exacerbation of tics, picking, and tachycardia/palpitations.
  3. HEDIS (Healthcare Effectiveness Data Information Set) is a set of performance measures in the managed care industry. This is to ensure best practices with evaluation and follow-up with patients. For ways to improve the HEDIS score click here
    1. Initiation phase: following up with a psychiatric provider 30 days after the first stimulant prescription has been dispensed. 
    2. Continuation/Maintenance Phase: described as patients that continue on ADHD medications for at least 9 months and have had 2 follow-up appointments within that time frame. 

 

Evidence-Based Approaches to Treatment 

 

Identifying and treating ADHD can have a dramatic and rapid improvement in the lives of the patient, as well as in the lives of those around them. Treatment recommendations for children and adolescents can vary by age. The MTA study, which is the most extensive empirical comparison of psychosocial and psychopharmacological intervention showed that adding psychosocial treatment did not yield a superior outcome to medication alone, but this was not true for all subgroups so it is important to individualize treatment. (3)

 

Psychotherapy

It is generally recommended that children under 6 years of age should start with behavioral therapy and/or classroom interventions; however, medications can be considered as well in this age group. (2) For children over the age of 6 years old, it is generally recommended to start medications as well as behavioral therapy. (2) 

 

Therapy modalities used to treat ADHD in children/adolescents include 

  • Behavioral therapy - helps control aggression and social behavior
  • Parent education - learn management skills 
  • Cognitive behavioral therapy (CBT) - reduce negative thoughts, improve problem-solving skills, and build self-esteem
  • Educational interventions and IEPs- classroom placement behavioral supports, and school environment can help with coexisting learning disabilities and behavioral problems

 

Medication

Currently, two classes of FDA-approved medications are used for the treatment of ADHD: stimulants and non-stimulants. (AAFP) (4) Please look at this guide for more in-depth practicing guidelines depending on age Safer Use of Psychotropic Medications in Children and Adolescents Guideline.

 

Stimulants: Methylphenidate (such as Ritalin and Concerta) and amphetamine (such as Adderall and Vyvanse.) This class is considered the first line in treating ADHD in children/adolescents. 

 

Non-Stimulants: Atomoxetine (Strattera), Guanfacine ER  (Intuniv), Clonidine ER (Kapvay), and Viloxazine (Qelbree) are currently the non-stimulants approved by the FDA for the treatment of ADHD in children/adolescents. Usually, these are not first-line treatments in children/adolescents but can be helpful in patients with symptoms of ODD specifically the alpha 2a agonists. Non-stimulants should not be used in children under 6 years of age. 

 

Start at a low dose of the chosen medication and titrate doses of medication for ADHD to achieve maximum benefit with tolerable side effects. 

 

 
As a reminder, it is important to consider all aspects when deciding what medication to prescribe to the patient. We must take into consideration medical history, family history, substance use history, and comorbid disorders i.e. ODD, conduct disorder, anxiety, depression, bipolar, SUD, etc before making a decision on medication management with stimulants vs. non-stimulants. Keep in mind the age of the child as well when deciding a treatment plan. 



What resources are available to our patients? 

 

It is important to give support/resources to our patients as well as their parents to help them understand and manage their diagnosis. Here are some resources that could be considered for your patients:

 

When should I refer my client to neurological psychiatric testing for ADHD?

In general, we do not require our patients to be sent for neuropsych testing for the diagnosis of ADHD as there are limitations to this which include cost/insurance as well as availability. It may be appropriate to send for neuropsych testing if the patient has co-existing learning disabilities and/or have them evaluated in the school system so that an IEP or 504 plan can be created for the patient to help them thrive. 



Assessing Risk and  Higher Level of Care Needs

 

The American Academy of Children and Adolescent Psychiatry identified that with ADHD it is a risk to found that with ADHD are at greater risk of experiencing other comorbid mental health conditions including elevated rates of ODD, conduct disorder, impulsivity, depression, anxiety, substance abuse, and self-harm. Persistent ADHD has also been associated with poor social outcomes, impacting emotional support and leading to higher rates of unemployment or disengagement from education. (3) Psychiatric providers need to engage in (and document) regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, Group therapy, etc) if clinically indicated. 

 

Rula’s team of care coordinators is available to support your patient in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC).

 

Cultural Considerations  

 

Cultural and social perspectives often play a significant role in the diagnosis of ADHD. The expression of symptoms is often influenced by cultural contexts, including perceptions of symptoms, culture, gender, racial and religious identification values, and stigma. Moreover, it has been shown that untreated ADHD leads into adulthood in many cases adults with ADHD may have learned throughout their lives to compensate for ADHD symptoms and may appear to function well, however, they may expend excessive amounts of energy to overcome impairments, leading to marked distress and often accompanying mental health concerns. (5) As a result, it is important to always consider the social and cultural contexts of a patient's treatment needs as part of the diagnostic process. 

 

When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes. (NAMI)



Tools/Resources for child/adolescent ADHD:


References

 

1. CHADD. https://chadd.org/about-adhd/general-prevalence/ 

2. American Academy of Pediatrics (AAP)

Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder

Pediatrics, October 2019    https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?autologincheck=redirected

3. American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters

Journal of the American Academy of Child and Adolescent Psychiatry, 46:7, 894-921, 2007  https://www.jaacap.org/article/S0890-8567(09)62182-1/pdf

4. American Academy of Family Physicians. https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit/treatment-and-management.html (AAFP)

5. Journal of Attention Disorders https://journals.sagepub.com/doi/10.1177/1087054711435360




















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