Attention-Deficit/Hyperactivity Disorder (ADHD): Clinical Evaluation Learning Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with suspected ADHD
Physical Examination Guide
Systematic approach to examining a child with suspected ADHD
Diagnostic Approach
Initial Assessment
For a child presenting with symptoms suggestive of ADHD, the initial assessment should include:
- Comprehensive clinical interview with parents/caregivers and child
- Review of developmental history and milestones
- Assessment across multiple settings (home, school, other environments)
- Evaluation of functional impairment
- Screening for comorbid conditions
Diagnostic Criteria for ADHD
Diagnostic criteria based on DSM-5:
| Presentation | Required Symptoms | Key Features |
|---|---|---|
| Predominantly Inattentive | ≥6 inattention symptoms (≥5 for age ≥17) | Difficulty sustaining attention, poor organization, forgetfulness, distractibility |
| Predominantly Hyperactive-Impulsive | ≥6 hyperactivity-impulsivity symptoms (≥5 for age ≥17) | Fidgeting, excessive activity, inability to remain seated, interrupting, difficulty waiting turn |
| Combined Presentation | Meets criteria for both inattentive and hyperactive-impulsive | Exhibits significant symptoms in both domains |
Additional diagnostic requirements:
- Several symptoms present before age 12 years
- Symptoms present in ≥2 settings (e.g., home, school, with friends)
- Clear evidence of interference with functioning
- Symptoms not better explained by another disorder
- Duration of symptoms ≥6 months
Differential Diagnosis
| Category | Conditions | Distinguishing Features |
|---|---|---|
| Neurodevelopmental |
- Specific Learning Disorder - Autism Spectrum Disorder - Intellectual Disability - Language Disorder |
- Learning challenges in specific domains - Social communication deficits, restricted interests - Global cognitive delays - Primary language difficulties |
| Mental Health |
- Anxiety Disorders - Mood Disorders - Disruptive Behavior Disorders - Trauma-Related Disorders |
- Inattention due to worry, hypervigilance - Mood as primary feature, episodic course - Primarily oppositional behavior - Symptoms linked to traumatic experiences |
| Medical/Neurological |
- Seizure Disorders - Sleep Disorders - Thyroid Dysfunction - Hearing/Vision Impairment |
- Episodic attention lapses, postictal states - Daytime sleepiness, fatigue - Additional metabolic symptoms - Sensory-related attention difficulties |
| Environmental |
- Inadequate Sleep - Chaotic Home Environment - Educational Mismatch - Neglect/Maltreatment |
- Symptoms improve with adequate sleep - Symptoms primarily in specific contexts - Improves with appropriate educational support - History of adverse childhood experiences |
| Substance/Medication |
- Medication Side Effects - Lead Exposure - Prenatal Substance Exposure |
- Temporal relationship to medication use - History of environmental exposure - Known maternal substance use history |
Assessment Tools
Standardized assessment tools to support diagnosis:
| Assessment Type | Examples | Clinical Utility |
|---|---|---|
| Rating Scales - Parent |
- ADHD Rating Scale-5 - Conners Parent Rating Scale-3 - Vanderbilt ADHD Parent Rating Scale - Child Behavior Checklist (CBCL) |
- Quantifies symptom severity - Evaluates behavior across settings - Screens for comorbidities - Monitors treatment response |
| Rating Scales - Teacher |
- Conners Teacher Rating Scale-3 - Vanderbilt ADHD Teacher Rating Scale - Teacher Report Form (TRF) |
- Evaluates classroom behavior - Assesses academic functioning - Compares to same-age peers - Documents impairment at school |
| Self-Report (Older Children) |
- Conners Self-Report Scale - ADHD Self-Report Scale - Youth Self Report (YSR) |
- Provides child's perspective - Assesses insight into symptoms - Evaluates subjective distress - Particularly useful in adolescents |
| Direct Observation |
- Classroom observation - Structured office observation - Behavior coding systems |
- Provides objective data - Compares to peer behavior - Identifies environmental triggers - Documents response to structure |
| Cognitive/Neuropsychological |
- Continuous Performance Test - Wisconsin Card Sorting Test - Cogmed Working Memory Test - Behavior Rating Inventory of Executive Function (BRIEF) |
- Assesses sustained attention - Evaluates executive functioning - Measures working memory - Not diagnostic alone but provides supporting data |
Laboratory and Other Studies
Generally used to rule out other conditions:
| Test | Clinical Utility | When to Consider |
|---|---|---|
| Thyroid Function Tests | Rule out hypo/hyperthyroidism | Growth concerns, fatigue, other thyroid symptoms |
| Lead Level | Identify lead toxicity | High-risk environment, pica, developmental regression |
| EEG | Evaluate for seizure disorder | History of staring spells, episodic behavior, seizure risk factors |
| Sleep Study | Assess for sleep disorders | Snoring, daytime sleepiness, restless sleep, suspected apnea |
| Genetic Testing | Identify genetic syndromes | Dysmorphic features, family history, developmental delays |
| Hearing/Vision Screen | Rule out sensory impairments | All children with attention concerns |
Comprehensive Assessment Process
A systematic approach to ADHD diagnosis:
- Screening - Brief parent/teacher questionnaires to identify concerns
- Clinical Interview - Detailed history from multiple informants
- Rating Scales - Standardized measures from parents and teachers
- Psychoeducational Assessment - If academic difficulties present
- Medical Evaluation - Physical exam and targeted medical tests
- Functional Analysis - Assessment of impairment across domains
- Comorbidity Screening - Evaluation for commonly co-occurring conditions
- Synthesis - Integration of all data to establish diagnosis and severity
- Treatment Planning - Collaborative development of intervention approach
Management Strategies
General Approach to Management
Key principles in managing ADHD in children:
- Multimodal approach: Combination of behavioral, educational, and sometimes pharmacological interventions
- Developmentally appropriate: Interventions tailored to child's age and developmental level
- Family-centered: Parents as partners in treatment planning and implementation
- Target functional impairment: Focus on improving daily functioning across settings
- Long-term perspective: ADHD as a chronic condition requiring ongoing support
- Regular monitoring: Systematic follow-up to assess effectiveness and side effects
Behavioral and Psychosocial Interventions
| Intervention | Description | Evidence Level |
|---|---|---|
| Parent Behavior Management Training |
- Structured training for parents - Positive reinforcement strategies - Consistent discipline approaches - Behavior contingency management |
High; numerous RCTs demonstrate efficacy, especially for children under 12 |
| Behavior Therapy - School-Based |
- Daily report cards - Token economy systems - Classroom behavior management - Contingency contracting |
High; significant evidence for improving classroom behavior and academic performance |
| Organizational Skills Training |
- Time management techniques - Materials organization - Planning and prioritizing - Task completion strategies |
Moderate to high; especially effective for inattentive presentation |
| Social Skills Training |
- Peer relationship skills - Conversational techniques - Emotional regulation - Problem-solving strategies |
Moderate; most effective when delivered in natural settings with peers |
| Cognitive Behavioral Therapy |
- Self-monitoring skills - Cognitive restructuring - Problem-solving training - Self-instruction techniques |
Moderate; more effective for older children and adolescents, especially with comorbidities |
Educational Interventions
| Intervention | Approach | Implementation Considerations |
|---|---|---|
| Classroom Accommodations |
- Preferential seating - Extended time for assignments/tests - Reduced homework load - Frequent breaks |
- May be implemented through 504 Plan - Should be specific to child's needs - Regular review and adjustment - Teacher education on ADHD |
| Individualized Education Program (IEP) |
- Specialized instruction - Related services (counseling, OT) - Modified curriculum - Behavioral intervention plan |
- Requires documentation of educational impact - Formal evaluation process - Annual goals and objectives - Progress monitoring |
| Classroom Management Strategies |
- Clear, concise directions - Visual schedules and reminders - Structured transitions - Immediate feedback systems |
- Teacher training and support - Consistency across school day - Positive behavioral approaches - Regular communication with parents |
| Executive Function Support |
- Organizational systems - Study skills training - Use of planners/agendas - Technology supports |
- Direct instruction in executive skills - Scaffolded approach with gradual independence - Consistent routines - Visual supports |
Pharmacological Management
| Medication Class | Examples | Dosing Considerations | Common Side Effects |
|---|---|---|---|
| Stimulants - Methylphenidate |
- Immediate release (Ritalin) - Extended release (Concerta, Ritalin LA) - Transdermal (Daytrana patch) |
- Start low, titrate slowly - Duration varies by formulation (3-12 hours) - Typical range: 0.3-1.0 mg/kg/day - Usually given once or twice daily |
- Decreased appetite - Sleep difficulties - Headache - Increased heart rate/BP - Irritability/rebound |
| Stimulants - Amphetamine |
- Mixed amphetamine salts (Adderall, Adderall XR) - Lisdexamfetamine (Vyvanse) - Dextroamphetamine (Dexedrine) |
- Start low, titrate slowly - Duration varies by formulation (4-14 hours) - Typical range: 0.1-0.5 mg/kg/day - Usually given once or twice daily |
- Decreased appetite - Sleep difficulties - Headache - Increased heart rate/BP - Irritability/rebound |
| Non-Stimulants - Alpha-2 Agonists |
- Guanfacine XR (Intuniv) - Clonidine XR (Kapvay) |
- Slower onset of action (1-2 weeks) - Guanfacine: 1-4 mg/day - Clonidine: 0.1-0.4 mg/day - Taper when discontinuing |
- Sedation - Dizziness - Dry mouth - Decreased BP - Irritability |
| Non-Stimulants - Selective NRI | - Atomoxetine (Strattera) |
- Gradual titration - Full effect may take 4-6 weeks - Typical dose: 0.5-1.4 mg/kg/day - Given daily or divided BID |
- Decreased appetite - Nausea - Fatigue - Mood changes - Slight increase in BP/HR |
| Other Medications (Off-label) |
- Bupropion - Modafinil - Tricyclic antidepressants |
- Generally third-line options - Consider for specific comorbidities - Refer to guidelines for dosing - Closer monitoring needed |
- Variable by medication - See specific drug information - Monitor for unique risks - Consider drug interactions |
Medication Monitoring
| Parameter | Frequency | Assessment Method |
|---|---|---|
| Height and Weight | Every 3-6 months | Accurate measurement, plot on growth chart, monitor for concerning trends |
| Blood Pressure and Heart Rate | At baseline and follow-up visits | Compare to age-based norms, monitor for persistent elevations |
| Side Effects | Each follow-up visit | Structured assessment, review of common and concerning symptoms |
| Treatment Response | 2-4 weeks after initiation/dose change | Rating scales, parent/teacher feedback, direct assessment |
| Academic Performance | Quarterly | School reports, grades, teacher feedback, homework completion |
| Psychiatric Symptoms | Every visit | Assess for mood changes, anxiety, tics, or other concerns |
Management of Comorbid Conditions
| Comorbidity | Management Approach | Special Considerations |
|---|---|---|
| Learning Disorders |
- Educational interventions - Specific skill remediation - Accommodations - Assistive technology |
- Comprehensive psychoeducational testing - Address learning needs first or concurrently - May require specialized instruction - Monitor medication impact on learning |
| Anxiety Disorders |
- CBT for anxiety - Consider SSRI if moderate-severe - Relaxation techniques - Address environmental triggers |
- Stimulants may worsen or improve anxiety - Consider non-stimulants if significant anxiety - May need combination therapy - Monitor for compounding effects on sleep |
| Mood Disorders |
- Mood-focused therapy - Consider mood stabilizers/antidepressants - Family psychoeducation - Close monitoring |
- Risk of stimulant-induced mood lability - Evaluate risk/benefit of ADHD medication - Often need specialist consultation - May need to treat mood first |
| Disruptive Behavior Disorders |
- Parent management training - Individual behavior therapy - School-based interventions - Consider alpha-2 agonists |
- Intensive parent training often essential - Address family dynamics - Stimulants may improve oppositionality - Monitor for stimulant rebound effects |
| Autism Spectrum Disorder |
- Structured behavioral approaches - Social skills interventions - Lower medication doses initially - Environmental modifications |
- May be more sensitive to medication side effects - Consider irritability when choosing medications - Focus on concrete behavioral strategies - Address sensory needs |
Parent and Family Support
- Parent education: About ADHD causes, course, and management
- Support groups: Connection with other families managing ADHD
- Stress management: Techniques for managing parenting challenges
- Advocacy training: How to effectively advocate in educational settings
- Family therapy: When family dynamics are significantly affected
- Respite care: Options for parental breaks when needed
Long-term Monitoring and Transition Planning
- Regular follow-up: Scheduled monitoring of symptoms, functioning, and treatment response
- Developmental transitions: Re-evaluation and treatment adjustment at key transitions (elementary to middle school, etc.)
- Treatment holidays: Consideration of planned medication breaks to assess continued need
- Self-management skills: Progressive development of self-monitoring and self-advocacy
- Transition to adult care: Planning for adolescents moving to adult healthcare systems
- Career/vocational planning: Supporting appropriate educational and vocational choices
