Attention Deficit Hyperactivity Disorder (ADHD)

Description

Other Names

Attention deficit disorder, ADD

Diagnosis Coding

ICD-9

314.0, Predominantly inattentive type (if only sufficient symptoms for inattention have been met)

314.01, Predominantly hyperactive-impulsive type (if only sufficient symptoms of hyperactivity-impulsivity have been met) or combined type (if sufficient symptoms of both inattention and hyperactivity-impulsivity have been met)

See ADHD ICD9 (PDF Document 97 KB) for more detail and associated codes.

DSM-5 and ICD-10

F90.0, Predominantly inattentive type

F90.1, Predominantly hyperactive-impulsive type

F90.2, Combined type

ICD-10 Coding for ADHD provides further coding details.

Description

Attention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that begins in childhood and is characterized by some combination of hyperactivity, impulsivity, and/or inattention. These symptoms are present to such a degree that they significantly interfere in at least two areas of the child's life, such as in the home and classroom. Three major types of ADHD are currently recognized (predominantly inattentive, predominantly hyperactive-impulsive, and combined). Growing evidence suggests that at least one subtype of ADHD is caused by defects in the dopamine and norepinephrine transporter proteins within the nerve cell wall. [Vaidya: 2008] [Kollins: 2008] [Kim: 2006]

ADHD is a disorder that can be treated safely and with good efficacy. If undertreated or left untreated, it carries significant morbidity including an increased risk of substance abuse in adolescents. [Wilens: 2008] [Biederman: 2009] Some children who do not meet full criteria for diagnosis could respond to behavioral intervention and school support, and should not be treated with medications. [Wolraich: 2011] Children with ADHD often are affected by other conditions including emotional or behavioral disorders, developmental disabilities, and other medical conditions. [Wolraich: 2011]

Prevalence

ADHD is one of the most common chronic disorders of childhood. Approximately 7% of children in the U.S. meet criteria for ADHD diagnosis. [Wolraich: 2011] Boys are more than twice as likely as girls to have received a diagnosis of ADHD. [Visser: 2014]

Genetics

Although ADHD clearly runs in families, and twin and adoption studies support a strong genetic component, the genetic mechanisms are not yet well understood. [Smith: 2009] [Faraone: 2005] ADHD inheritability is complex; markers on at least 7 chromosomes and genes for dopamine and serotonin receptors, transporters, and associated enzymes have been found to be statistically associated with ADHD. Environmental factors are also shown to play a role in some cases. See [Pliszka: 2007] for a discussion.

Prognosis

Although many children show improvement in adolescence, many individuals may need support/treatment for this condition through adulthood. See [Shaw: 2012] for details.

Roles Of The Medical Home

Most children with ADHD can be treated by their medical home provider without subspecialty consultation/referral. Occasionally, additional expertise that includes psychologists, behavioral/developmental pediatricians, child psychiatrists, and/or educational specialists, may be needed, particularly if the child has a co-morbid condition. Even if children are referred elsewhere for diagnosis, ongoing evaluation and management should still be performed within the context of the medical home, and children with ADHD should be considered to have special health care needs. [Wolraich: 2011]

Ongoing communication with the child's parents and teachers is essential for appropriate management and response. Periodic visits, in addition to well-child exams and acute-care visits, are generally needed to discuss status and manage medications. The AAP suggests that the medical home should:
  • Periodically update and monitor family knowledge and understanding
  • Offer counseling on the family's response to the condition
  • Provide developmentally appropriate education for the child about ADHD, with updates as the child grows
  • Be available to answer family questions
  • Ensure coordination of health and other services
  • Help families set specific goals in areas related to the child's condition and its effects on daily activities
  • Link families with other families with children who have similar chronic conditions, as needed and available

Practice Guidelines

Algorithm for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD (AAP) (PDF Document 406 KB) provides supplemental information about implementing the 2011 Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD (listed below). Scroll to second page for algorithm of care process.

Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text

Salmeron PA.
Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications.
J Am Acad Nurse Pract. 2009;21(9):488-97. PubMed abstract / Full Text

Mahajan R, Bernal MP, Panzer R, Whitaker A, Roberts W, Handen B, Hardan A, Anagnostou E, Veenstra-VanderWeele J.
Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S125-38. PubMed abstract / Full Text

Helpful Articles

PubMed search on ADHD

Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother. 2013;. PubMed abstract / Full Text

Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry. 2013;70(7):740-9. PubMed abstract / Full Text

Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs. 2009;23(12):1057-83. PubMed abstract

Ghanizadeh A.
Atomoxetine for treating ADHD symptoms in autism: a systematic review.
J Atten Disord. 2013;17(8):635-40. PubMed abstract / Full Text

Clinical Assessment

Overview

With the release of the DSM-V in 2013, there are some minor changes to consider in the diagnosis of children and adolescents, including onset of symptoms before age 12 instead of age 7, and fewer symptom criteria are needed to diagnose adolescents than children. See ADHD Fact Sheet (APA) (PDF Document 279 KB) for 2 pages of DSM-5 updates.

Screening

For The Condition

Evaluation for ADHD should be initiated if the child presents with inattention, hyperactivity, impulsivity, low school achievement for the child's IQ, and/or behavior problems. [Wolraich: 2011] The evaluation will generally take a few visits and will require gathering information about school performance, school/daycare behavior, and functioning within the family and with friends. Gathering information from multiple areas can be done in a standardized manner by using specific ADHD checklists. Many of these checklists also screen for additional problems such as defiant behavior and learning concerns. It should be recognized that these measures are face valid, and subject to the biases of the people completing them. Specific ADHD checklists include: Screening tools and family educational handouts: ADHD (DB Peds) has information and checklists for ADHD screening as well as for other developmental and behavioral disorders.

Periodic repetition of behavior scales completed by parents and teachers can be helpful to track response to medication and behavioral interventions. These are often completed every 6-12 months. It is important to pick a time during the school year when the teacher has had some exposure to the student. Subjective reports can also be very helpful.

For Complications

If treatment does not seem to be effective, consider using a validated screening tool to identify and help diagnose co-morbid conditions such as anxiety, depression, oppositional-defiant disorder, conduct disorder, substance use or abuse, learning disorders, mood disorders, language disorders, sleep problems including sleep apnea, tics, other neurological disorders including autism, and trauma.

The following screening tools may be helpful:

Presentations

Presentation may vary considerably based on form of ADHD ( predominantly inattentive, predominantly hyperactive-impulsive, combined), developmental age, severity, environment, co-morbid conditions, and other factors. Young children with the inattentive type may have significant difficulty attending to the reading of a picture book, whereas adolescents may have difficulty finishing homework and performing required tasks. Inattentive students may not be noticed until they start falling behind in school, often in the upper elementary grades when problem solving becomes more complex. Preschoolers with the hyperactive/impulsive type may be constantly physically active, running in circles, and climbing on furniture, whereas adolescents with this type may engage in risky behaviors and sports. Hyperactive children are typically noticed earlier due to disrupting their classrooms or getting into trouble at home. It is important to consider developmental age when deciding whether the level of inattentiveness and/or hyperactivity is abnormal. A child with the cognitive level of a 5 year old, although he may be twice that age, usually has the activity level and attention span of a 5 year old. It is also important to take a history about the symptoms over time, as children who start out with symptoms of hyperactivity in preschool may present with more inattentive/impulsive symptoms in adolescence.

Diagnostic Criteria

DSM-5 Criteria for ADHD [American: 2013]
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:
  1. Inattention: Six or more symptoms of inattention for children up to age 16, o 5 or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
    • Often has trouble holding attention on tasks or play activities
    • Often does not seem to listen when spoken to directly
    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked)
    • Often has trouble organizing tasks and activities
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period (such as schoolwork or homework)
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
    • Is often easily distracted
    • Is often forgetful in daily activities
  2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or 5 or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
    • Often fidgets with or taps hands or feet, or squirms in seat
    • Often leaves seat in situations when remaining seated is expected
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
    • Often unable to play or take part in leisure activities quietly
    • Is often "on the go" acting as if "driven by a motor"
    • Often talks excessively
    • Often blurts out an answer before a question has been completed
    • Often has trouble waiting his/her turn
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years
  • Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities)
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning
  • The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
  • Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
  • Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
  • Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months
Presentation may change over time. Obtaining information from two sources (such as home and daycare or preschool) for preschool-aged children to make a diagnosis of ADHD may be difficult, but is necessary. [Wolraich: 2011]

Clinical Classification

As defined by DSM-V:
  • ADHD predominantly inattentive presentation
  • ADHD predominantly hyperactive-impulsive presentation
  • ADHD combined type

Differential Diagnosis

Other diagnoses that should be considered include: (Links lead to diagnosis and management information.)
  • Seizures, particularly absence seizures. See the Portal's modules on Seizures/Epilepsy and Childhood Absence Epilepsy for diagnosis and management information.
  • Middle ear infections, causing hearing loss or auditory processing disorder, may contribute to inattention. Evaluation for hearing deficits should be triggered by any suspicious symptoms or findings. See the Portal's modules on Hearing Loss and Deafness for diagnosis and management information.
  • Sleep disturbances may cause daytime difficulties such as hyperactivity and inattention. Consider further evaluation if history and physical exam (e.g., large tonsils) suggest obstructive sleep apnea. Further information can be found at Sleep Problems.
  • Vision problems, including visual processing disorders may present as inattention. An ophthalmological exam is warranted if there is any concern, or if the child has any difficulty passing screening tests. Visual Impairment provides further clinical information.
  • Tourette Syndrome could lead to speaking out inappropriately or repetitive noses, which could be confused with the impulsiveness or repetitive noises seen with ADHD.
  • Learning disabilities may be the etiology of poor school performance and may accompany ADHD. If these are a concern, refer for psychological testing. Children with learning disabilities will often score significantly higher on IQ testing compared to achievement testing.
  • Anxiety or depression, or similar psychiatric problems may occur with ADHD or may cause symptoms of ADHD that may resolve when the primary disorder is treated. If there are concerns, consider a referral to child psychiatry or psychology. Inquire about life changes causing anxiety or difficulty concentrating, such as a parent's death, divorce, etc. The Portal's Depression and Anxiety (Medical Home Newsletter) contains referral, screening, treatment, and family support information for medical home providers treating children who may be experiencing depression or anxiety.
  • Children with Autism Spectrum Disorders may have characteristics of ADHD including difficulties with focus on non-preferred activities, and ADHD and autism spectrum disorder may be genetically linked. [Rommelse: 2010] Children with ADHD may also present with social skill deficits. [Kotte: 2013]
  • Substance Abuse
  • Side effects of medication
  • Trauma/childhood adverse events can lead to hypervigilance and arousal that can be mistaken for ADHD, or can overlap with actual ADHD. [Kaya: 2008] Screening for adverse events in childhood can help in the differential diagnosis as well as provide insight into ways to tailor support for struggling families. See Foster Care module for more information.

Medical Conditions Causing Attention Deficit Hyperactivity Disorder (ADHD)

Medical conditions causing ADHD include:
  • Fetal alcohol spectrum disorders
  • Traumatic Brain Injury or post-concussive attention problems
  • Hyperthyroidism

Comorbid Conditions

Many children with ADHD have co-morbid conditions including: (Links lead to further diagnosis and management information.) The clinician should suspect a co-morbid condition under the following conditions:
  • Lack of improvement in behavioral symptoms despite appropriate treatment/services for ADHD
  • Persistent school underachievement or school avoidance
  • Parental concern for a comorbid condition
  • Low self-esteem, anxiety, irritability, sleep disturbance, and/or sadness
  • Negative/oppositional behaviors
  • Substance abuse
Comorbid conditions vary somewhat by the developmental stage of the child. For a detailed discussion, see [Pliszka: 2006].

Pearls & Alerts

Inattentive type of ADHD

Children with ADHD, inattentive presentation may go undiagnosed for longer than the hyperactive/impulsive presentation, presumably because the symptoms are less bothersome to others. Among girls, the inattentive type is more common, and may present simply as poor school performance that worsens when higher-level problem solving is required, typically in upper elementary grades.

Discrepancy between family and teacher symptom assessment

When ratings of ADHD symptoms differ, additional sources (e.g., former teachers, coaches, etc.) may be helpful. Also consider setting - a teacher in a very structured classroom may not note symptoms that are easily observed in a less structured classroom or in a busy home; a child who expends a lot of effort to pay attention and behave appropriately at school may “fall apart” at home and this can result in more severe parent ratings.

Re-evaluation needed

Under treatment may be harmful and frequent re-evaluation may be needed. [Wolraich: 2011]

Cardiac screening before stimulant use

The American Heart Association proposes that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. The AAP recommends screening only when heart disease is suspected by a physician.

ADHD and autistic spectrum disorder

Children with autism may present with symptoms of ADHD during early elementary school, or earlier (if earlier, it may be difficult to differentiate from the autism symptoms). Children with autism spectrum disorders who present with significant hyperactivity, inattention, or impulsivity despite adequate supports should be evaluated for co-morbid ADHD.

History & Examination

Evaluation of the child with possible ADHD requires time, the use of checklists, and more than one information source, for instance parents and teachers. Many children will require more than one visit, the first to discuss the diagnosis and the second to go over the information gathered and to begin treatment, if necessary. If the child has a complicated clinical picture and referral for a diagnostic evaluation is made to a specialist, follow-up should be performed back in the medical home. [Wolraich: 2011]

Critical components of ongoing assessment include current functioning at home and school and success, and/or side effects of treatment methods (behavioral and medication-based).

Family History

Ask about a family history of ADHD, associated conditions, cardiovascular disease, sudden death, and mental health disorders including bipolar disorder and psychosis. There is growing evidence suggesting that risk of cardiovascular disease and sudden cardiac death is extremely low with the use of both stimulant and non-stimulant ADHD medications. [Martinez-Raga: 2013]

Pregnancy Or Perinatal History

Inquire about any pregnancy or perinatal problems that may contribute to poor intellectual and behavioral functioning.

Current & Past Medical History

Take a full medical history that includes heart problems, and motor and vocal tics. Ask about:
  • Previous illnesses or accidents that may contribute to development of attention problems
  • Recent medical problems, growth, appetite, and possible side effects of medication for ADHD
  • Mood, interactions with peers
  • Adherence to prescribed medication or therapies
  • Staring, brief eye-blinking or other automatisms - consider absence seizures if “spacing out” events are occurring many times per day with clear interruptions of activity (speaking, walking, drinking, etc.)
  • Sleep onset and duration, as well as the presence of snoring or restless sleep
  • Toileting and elimination

Developmental & Educational Progress

Assess developmental milestones and intellectual and social functioning in family and day care/school settings. Be sure to inquire about fine and gross motor skills, as many children with ADHD have poor coordination and possibly a developmental coordination disorder. [Wolraich: 2011] School performance and testing reports may be very helpful in assessing the impact of the attention deficit and will provide a baseline to measure response to treatment. Age and interest level will affect children's ability to attend to tasks; video games and other highly stimulating activities are not good indicators of a child's ability to attend. Assessment should include documentation of:
  • ADHD DSM-V criteria (inattention and hyperactivity-impulsivity) by parent interview or by use of a specific checklist, such as the Vanderbilt ADHD Parent Rating Scale (PDF Document 72 KB)
  • Age at which the problem behaviors began, the settings in which the behaviors occur, and to what degree the child is impaired by the symptoms
School assessment should also include documentation of the specific symptoms by use of a checklist, such as Vanderbilt ADHD Teacher Rating Scale (PDF Document 53 KB). Obtain past schoolwork and report cards; a teacher narrative that discusses behavior; a learning assessment; degree of impairment; and the teacher's interventions to deal with the problems. Ask families to bring current school records to evaluate success of treatment. Periodic use of checklists and/or rating scales can assist in guiding therapy adjustments.

Social & Family Functioning

Inquire about:
  • Recent changes in the family that may be causing anxiety or depression.
  • Functioning within the family and with others (e.g., church, or extracurricular activities)
  • Behavior and functioning in the home setting and consistency or changes of medication
  • Use of complementary/alternative treatments
  • Parenting challenges

Physical Exam

General

Assess general appearance and interaction with the environment.

Vital Signs

HR | RR | BP - resting tachycardia and/or hypertension may indicate hyperthyroidism or other hypermetabolic state that may present with hyperactivity. Increased heart rate may occur with stimulant use; however, hypertension is less likely to occur as a result of medication use. [Hailpern: 2014] Use of alpha agonists such as guanfacine or clonidine can lower blood pressure, and can cause rebound hypertension if discontinued abruptly. [Committee: 2001]

Growth Parameters

Ht | Wt | BMI - because stimulant medications may cause appetite suppression, follow weight closely. Although stimulants may slow height to some extent when first started, this effect appears to decrease over time. Recent studies have found that use of stimulants by children does not prevent them from obtaining their full adult height. [Harstad: 2014] It is still prudent to regularly measure children’s height and weight while on medications.

HEENT

Check for middle ear fluid, which, if persistent, may cause conductive hearing loss. Assess tonsillar size and potential for obstruction and sleep disturbance. Also, check thyroid size, consistency.

Neurologic Exam

Children with ADHD should have normal neurologic exams, although so-called "soft neurologic signs," such as clumsiness or motor overflow, may be present.

Testing

Sensory Testing

Routine vision screening and, if indicated, hearing screening.

Laboratory Testing

Not indicated unless there are specific concerns from the medical history, such as lead exposure or symptoms of hyperthyroidism. Consider checking a ferritin as a marker of iron deficiency, as this can be associated with disordered sleep, which in turn can negatively impact daytime attention and behavior. [Abou-Khadra: 2013] [Cortese: 2009] If malnutrition is suspected to play a role in the child’s performance, specific nutritional markers could be tested as well.

Imaging

Rarely, children with absence epilepsy may present with ADHD signs. EEG is necessary only if there is a clear pattern of seizures.

Genetic Testing

None indicated.

Other Testing

Testing for intelligence: Usually performed by the school, an IQ test such as the Wechsler Intelligence Scale for Children [WISC]) and a learning disability test such as the Woodcock-Johnson may be helpful when there seems to be a discrepancy between ability and performance.

Echocardiogram and EKG: In 2008, the American Heart Association recommended that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. [Vetter: 2008] However, the 2011 clinical practice guidelines published by the AAP recommends using clinical judgment regarding screening when there are cardiac symptoms or there is a significant cardiac or sudden death history in the family. [McPherson: 2004] See Stimulants and cardiovascular monitoring (AAP) for further discussion.

Subspecialist Collaborations & Other Resources

Developmental Pediatrics (see Services below for relevant providers)

Consult for expert assessment in diagnosing complicated cases, such as for discriminating symptoms related to developmental delay, or for diagnosis of younger children.

Psychiatrist, Child-18 (see Services below for relevant providers)

Consult to help with diagnosis and management of situations complicated by underlying medical issues, such as a history of traumatic brain injury, co-morbid psychiatric conditions such as mood or anxiety disorders, or for children who fail to respond to standard therapies.

Psychologist, Child-18 (see Services below for relevant providers)

Refer for testing if learning disabilities or low intelligence may be contributing to the child's problems. A child psychologist may be available to perform this testing through the child's school district if the condition impacts school participation. Child psychologists are also helpful when the diagnosis is unclear, or multiple comorbid conditions are suspected. Some psychologists specialize in diagnostic testing for learning disabilities or cognitive impairment, while others focus on therapeutic approaches such as behavior training.

Neuropsychology (see Services below for relevant providers)

Consult when full psychological testing is not available through the school district and/or if learning disabilities are suspected. May also be helpful in designing and implementing behavioral plans and therapies.

Pediatric Cardiology (see Services below for relevant providers)

Consult if there are concerns about a child's cardiac status that would affect treatment and management decisions.

Treatment & Management

Overview

Management principles vary with the age of the individual. [Wolraich: 2011] Preschool age children (4-5) should first receive parent- and/or teacher-administered behavior therapy. If this is not successful and function continues to be moderately to severely impaired, methylphenidate may be considered. For school-aged children 6-11 years, behavior therapy and school placement optimization, plus stimulants, or to a lesser extent atomoxetine, extended-release guanfacine, and extended-release clonidine are recommended. For adolescents, similar treatments are recommended, but the consent of the individual should be obtained before medicating. Long-acting guanfacine, atomoxetine, or clonidine, or stimulants that have lower abuse potential such as lisdexamfetamine (Vyvanse), OROS extended-release methylphenidate (Concerta), or dermal methylphenidate may be preferred. [Wolraich: 2011]

Barriers to treatment of ADHD may include lack of insurance and other systemic barriers, including language and access to medication. [Rushton: 2004] Consequences of non-treatment include poor achievement, decreased self-esteem, poor relationships, increased morbidity from accidents, and increases in co-morbid problems such as conduct and mood disorder. [Biederman: 2009] Medical home providers should be watchful for unsuccessful or inadequate therapy, or improvement that is not sustained. If there is inadequate response, the dosage and family follow-through should be examined. Also, consider using a validated screening tool to identify and help diagnose co-morbid conditions. See Screening for Co-Morbid conditions, above, for screening tools. The following Portal pages provide diagnosis and management information for co-morbid conditions and ADHD:

Pearls & Alerts

Stimulant use & cardiac events

The current AAP guidelines indicates that evidence does not clearly demonstrate an increased risk of serious cardiovascular events (such as MI, QT prolongation, sudden death, ventricular arrhythmias) in children using stimulant medication.

Tics, Tourette syndrome, and stimulant use

Recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics.

Stimulant drug misuse

Frequent or early requests for stimulant refills may suggest misuse or that they are being sold for non-medical consumption. Prescribers should carefully monitor their prescription refill requests.

Systems

Pharmacy & Medications

Stimulant medications are known to decrease symptoms of ADHD [Chavez: 2009] and are recommended as first-line treatment for children 6 years of age and older by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. [Wolraich: 2011] [Pliszka: 2007] Stimulants work on dopamine and norepinephrine receptors in the brain. Approximately 75% of children with ADHD will respond to stimulant treatment if dosing is correct. Start at a low dose in either stimulant class (methylphenidates and amphetamines), and then every few days increase the dose until the optimum effect is achieved, the maximum dose is reached for the child's age, or the side effects intervene. Consider using a longer-acting stimulant for school-aged children to avoid re-dosing at school. A short-acting stimulant can be given if a longer-acting formulation wears off too early to complete homework or other activities after school. If one stimulant is not effective at the highest dose possible, try another stimulant in the other class. Most children will respond favorably to either the first or second stimulant class. Stimulants may be prescribed for some children for school days or during the school year only, depending on circumstances and child or family preference.

Frequent or early requests for stimulant refills may suggest misuse or that they are being sold for non-medical consumption. Prescribers should carefully monitor their prescription refill requests. Stimulants with relatively less abuse potential include lisdexamfetamine (Vyvanse), methylphenidate patch (Daytrana), or OROS extended-release methylphenidate (Concerta). Non-stimulant medications such as atomoxetine (Strattera), extended-release clonidine (Kapvay), and guanfacine (Intuniv) may also be considered.

Extended-release guanfacine, extended-release clonidine, and atomoxetine offer alternatives for treatment, but are viewed by the AAP as second line to be used if stimulants (one from each class) have been tried and are not successful. Atomoxetine is a selective norepinephrine reuptake inhibitor, and can cause nausea and sleepiness. Guanfacine and clonidine are norepinephrine receptor type alpha 2 agonists that can cause sedation and hypotension (more so in clonidine), and both are available in short and long-acting formulations. These medications need to be used on a daily basis without medication holidays. Extended-release guanfacine and clonidine have been shown to have efficacy as add-on therapies with stimulants. These non-stimulant medications for ADHD can take several weeks for full effect.

Side effects are similar between both classes of stimulant medications and include mild stomachaches and headaches, depressed appetite and weight loss, difficulty sleeping, increased blood pressure and heart rate, and irritability/anxiety. Cautions and contraindications to stimulant use include presence of a cardiac abnormality, significant side effects (e.g., decreased appetite, insomnia, and poor growth), some cardiac conditions, and significant tic exacerbation. (See Pearls and Alerts section, above.) Rare side effects can also occur; for example, the FDA has issued warnings that methylphenidates and atomoxetine can cause priapism, and that atomoxetine can cause suicidality. Rarely, psychiatric symptoms, such as manic symptoms, paranoia, and hallucinations may occur. For more information, see Medications for ADHD Safety Information (FDA).

Effects of stimulants on co-morbid conditions needs further study. Some of what is known is as follows:
  • Cardiac problems: Stimulant drug packaging includes the following statement, “Stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.” The AAP and AHA offer further insights into medication use in these special groups. [AAP: 2008] [Perrin: 2008]
  • Fetal alcohol syndrome disorder (FASD): Children with fetal alcohol spectrum disorder (FASD) commonly have problems with attention and impulsivity that may respond to stimulant treatment or may be worsened.
  • Tics/Tourette syndrome: FDA package labeling for stimulants indicates that tics are a contraindication to use of these medications, so use of stimulants for children with tics is considered “off-label.” However, recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people [Tourette's: 2002] and may reduce tics. [Roessner: 2006] Untreated ADHD may be more troubling to the child than the tics themselves. [Erenberg: 2005] However, monitoring of tics before and after starting stimulants is warranted due to individual variation. [Tourette's: 2002] For more information about relevant studies, see [Murphy: 2013] and [Pringsheim: 2011].
  • Autism: Despite concerns about using stimulants in children with autism, recent information suggests that they may be helpful. Cautious monitoring for unexpected effects on the child's functioning (e.g., an increase in anxiety symptoms) should be maintained. [Posey: 2007]. There is growing evidence that ADHD and autism spectrum disorder may be linked genetically. [Rommelse: 2010] Children with autism spectrum disorders have a decreased response rate to ADHD medications with increase in reported side effects. See Evaluation and Medication Choice for ADHD Disorder Symptoms in Autism Spectrum Disorders (AAP) for treatment of co-morbid ADHD and autism spectrum disorders. [Mahajan: 2012]
  • Other neurologic conditions: ADHD symptoms are often observed in children with neurologic conditions, such as neural tube defects, muscular dystrophy, cerebral palsy, intellectual disability, and various genetic syndromes. Stimulants are often helpful for these symptoms in children with intellectual disability [Aman: 2003], but not necessarily in children with velocardiofacial syndrome (22q11.2 Deletion Syndrome). [Antshel: 2007] Treatment for ADHD symptoms in neurologic and other conditions should be accompanied by close monitoring to assure response and limit side effects.
For preschool-age children, the only stimulant approved for use in is dextroamphetamine, which is not recommended in this age group by the AAP in the latest guidelines. [Wolraich: 2011] Depending on the functioning of the child and symptoms of ADHD, some providers will use stimulant medications "off-label" for younger children. There is some evidence that short-term treatment of preschool-age children with methylphenidate may be helpful [Ghuman: 2008], although controlled safety and efficacy trials are not available. Parent- or teacher-guided behavior therapy is recommended as a first-line therapy, and medications should be used only if not successful. None of the non-stimulant medications is currently licensed for use in preschoolers.

Off-label medications are occasionally used to manage ADHD, particularly in patients with comorbidities such as depression, include bupropion (Wellbutrin), modafinil (Provigil or Nuvigil), and tricyclic antidepressants such as desipramine (Norpramin), and imipramine (Tofranil). [American: 2013]

Medication tables with dosing information for stimulants and non stimulants can be found at: If treatment fails, consider:
  • Under-treatment - Medications should be titrated to maximum doses without adverse side effects instead of relying on milligram-per-kilogram recommendations to ensure adequate treatment of symptoms.
  • Noncompliance with medication - This may be more common in families where parents also have symptoms of ADHD. [Wolraich: 2011]
  • A co-morbid condition
For more information and updates on FDA-approved medications for ADHD, see FDA Approved Drugs by Condition (CenterWatch) and scroll to bottom of the page. ADHD: Parents' Medication Guide (PDF Document 1.1 MB) may be helpful for parents. Medications used for ADHD, along with dosing guidelines and pharmacokinetics can be found at Algorithm for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD (AAP) (PDF Document 406 KB) on page 13/S113.

Subspecialist Collaborations & Other Resources

Behavioral Pediatrics (see Services below for relevant providers)

Consult for guidance on managing more complex cases, such as for children who have comorbid conditions, intellectual disability, or difficult-to-treat ADHD.

Developmental Pediatrics (see Services below for relevant providers)

Consult for guidance for managing more complex cases, such as for children who have comorbid conditions, intellectual disability, or difficult-to-treat ADHD.

Psychiatrist, Child-18 (see Services below for relevant providers)

Consult to help with diagnosis and management of situations complicated by underlying medical issues.

Mental Health/Behavior

Although stimulant medications are the mainstay of ADHD treatment, behavior therapy, parent training, and classroom behavior interventions have an evidence-based role in managing ADHD. In some cases, behavior therapy is recommended as first line in mild-to-moderate cases of ADHD in children, when the family prefers not to use medications, or in children younger than 6 years old. In general, for ADHD without comorbid conditions, training parents in behavior therapy is considered more effective than putting the child into therapies to better understand their feelings or thought processes. See [Wolraich: 2011] pg. S116; also see [Brimble: 2009] and [Atkinson: 2010] for more information.

Most children with ADHD respond to more structure and fewer distractions in the environment. Behavior management takes advantage of this and includes the use of time-outs, a token economy, and daily school report cards while teaching the parents to respond consistently to a child's misbehavior. For instance, when a child comes home from school, a parent should inquire about homework, set a time and place for the child to do the homework, keep external noise (e.g., television) to a minimum, and then check that the homework is completed. Parents should be reminded that the long-acting preparations of stimulant medication are beginning to wear off in the afternoon and homework attempted sooner rather than later in the afternoon/evening will probably be more successful. Classes are often available locally through school systems, mental health, or other agencies to train parents in achieving the goals of directed supervision, as well as in managing behavioral problems.

Before starting medications, work with parents and school to identify 3 to 6 target behaviors/outcomes based on the needs and strengths of the child. The goals should be realistic and measurable. These may include: [Wolraich: 2011]
  • Improvements in relationships with parents, siblings, teachers, and peers
  • Decreased disruptive behaviors
  • Improved academic performance, particularly in volume of work, efficiency, completion, and accuracy
  • Increased independence in self-care or homework
  • Improved self-esteem
  • Enhanced safety in the community, such as in crossing streets or riding bicycles
For example, for a child who is not finishing homework, a goal might be to finish 75% of homework. For another child, three days without fighting with siblings might be a goal.
The medical home should then collaborate with the family to develop a comprehensive treatment plan, which might include stimulant medication and behavioral management, as well as treatment of associated conditions.

Subspecialist Collaborations & Other Resources

Psychologist, Child-18 (see Services below for relevant providers)

Refer for parent training in behavior management skills and for children with co-morbid disorders, e.g. anxiety disorders, who may benefit from therapy and counseling.

Pediatric Neurology (see Services below for relevant providers)

Referral may be helpful in managing ADHD, a neurobehavioral condition, particularly if there are concerns about head injury or other neurologic conditions such as seizures.

Licensed Professional Counselor (LPC, CMHC) (see Services below for relevant providers)

Counselors who have experience working with children who have educational problems may be helpful, particularly in working with teachers on classroom interventions. Referral also can help the family work together to create shared goals and interventions to support successful management of the patient's inattention and impulsivity in the home and community.

Learning/Education/Schools

The school will usually conduct an evaluation to determine if the child qualifies for special education services. If so, the school, with parental input, will develop an individualized education program (IEP). If the child does not qualify for special education services, he or she may qualify for a 504 plan for children with disabilities.

The medical home may be involved in planning and evaluating the child's school services. Direct communication is often very helpful for both the provider and the school. A signed consent from the parents should be in place before these conversations or meetings takes place. See Education & Schools in the Portal's For Physicians & Professionals section for more detail on IEPs and 504 plans.

Teachers can help the child with ADHD by setting clear goals, decreasing distractions, offering subtle reminders to stay on task, and providing more structure. A daily or weekly "report card" or "contract" system with positive reinforcement for reaching goals can also help. For some children, a 504 plan may provide for desired classroom adaptations such as preferential seating and decreased workload.

To avoid potential pitfalls, parents should be encouraged to meet with the child's teacher early in the year to discuss the child's diagnosis, needs, and what has worked or failed in the past. This is particularly true if the family is changing school districts or if the child is transitioning to middle or high school. Ongoing meetings, not necessarily at the time of parent-teacher conferences, may also be helpful. Families should know that many colleges and universities have programs to support students with various disabilities through their years in higher education.

Subspecialist Collaborations & Other Resources

School Districts (see Services below for relevant providers)

The medical home provider can work with the school to ensure appropriate services are provided to qualifying students, as well as to obtain periodic feedback on how treatment interventions are affecting the child’s school participation and performance. Contact the district officials if the school is unable or unwilling to offer needed services. The child’s family should authorize a release of information to allow two-way communication between the school and the physician’s office.

Complementary & Alternative Medicine

Clinicians should ask families about any alternative therapies they are using to manage symptoms of ADHD. Popular practices include special diets, herbal supplements, homeopathic treatments, vision therapy, chiropractic adjustments, yeast infection treatments, anti–motion-sickness medication, metronome training, auditory stimulation, applied kinesiology (realigning bones in the skull), and brain wave neurobiofeedback. Many of these approaches are not proven effective, or are detrimental to the child's health.

Food elimination diets are controversial. Mainstream western medicine tends to discount this approach, indicating that only a few individuals may benefit from specific food elimination diets. However, analysis of the 2011 Impact of Nutrition on Children with ADHD (INCA) study suggests that a strictly supervised food elimination trial may be an approach to consider; use of IgG blood levels to prescribe diets is not advised, though. [Pelsser: 2011] European guidelines would indicate no evidence for elimination diets unless there are GI symptoms. There is some evidence for removal of dyes.

Dr. Sanford Newmark, a physician at the UCSF Pediatric Integrative Neurodevelopmental Clinic, in his presentation at the 2014 AAP National Conference, recommended these safe mind-body approaches to help with attention and self-regulation: yoga, exercise (martial arts), EEG Neurofeedback, and a healthy diet consisting of whole grains, fruits and vegetables, and lean protein sources. Less well studied is adherence to organic diets. Avoidance of unnecessary food dyes and chemicals and maintaining a fairly even blood sugar and insulin levels (such as by eating frequent, smaller meals with complex carbohydrates and healthy proteins and fats) are both reasonable approaches. Although there is some support for use of neurofeedback for ADHD, this therapy is often not covered by insurance and has significant out of pocket expenses for the family, and effects are not maintained once treatment has been discontinued. There is evidence to support use of high dose Omega 3 and 6 fatty acids for treatment of ADHD, although the effect seen was not as great as that seen with treatment with stimulants.

For a more in-depth review of dietary approaches to managing ADHD, see The Diet Factor in ADHD (AAP) and Complementary Medicine and ADHD, which is available with from Medscape with a free account.

Frequently Asked Questions

Although clinical practice guidelines recommend starting with stimulant medications for first-line therapy, when would you be more likely to treat with something else first (and what would you use)?

The alpha 2 agonists can be very useful in children with developmental disabilities such as autism spectrum disorders because of a lower side effect profile and higher tolerability in children with co-morbid conditions like tics, anxiety, or sleep problems.

Which stimulant medications are the least likely to be abused or sold illegally?

Long-acting stimulant medications such as Vyvanse and Concerta have lower abuse potential because of their mechanism of release; the Daytrana patch is also a good stimulant option to use when there are concerns about abuse. Non-stimulant options such as Intuniv, Kapvay, and Straterra can also be useful when concerned about the potential misuse of stimulant medications.

Any special guidance on management of ADHD in children on the autism spectrum?

Children with autism spectrum disorders have a poorer response to stimulant medications with more side effects then typically developing children with ADHD; more patients/parents stopping medications because of adverse reactions Starting with lower doses and titrating up slowly is very important in this group of patients. Non-stimulant medications such as the alpha 2 agonists may also be a good option in this group of patients because of the difficulty with side effects. Please see the 2012 guidelines for treatment of ASD and ADHD at [Mahajan: 2012].

Why is my patient having such difficulty with tantrums? Should I be worried about an additional diagnosis?

If there are significant behavioral concerns despite adequate supports and/or medication management, it is important to consider additional or alternative diagnoses including oppositional defiant disorder, conduct disorder, mood or anxiety disorder, and autism spectrum disorders. However, children with ADHD can also have significant difficulties with executive functioning, which not only can affect organization and planning, but also can affect an individual's ability to shift between tasks, self-regulate, and adapt to new information or situations. Executive functioning skills only show mild improvement with medication management, and require behavioral interventions and supports.

My patient has been diagnosed with sensory processing disorder/sensory integration disorder, and has significant difficulties with attention and hyperactivity. Can this all be explained by the sensory processing disorder, or do they also have ADHD?

Although there are many children that have sensory processing difficulties that affect their day-to-day lives, sensory processing disorder is not a recognized stand-alone diagnosis and the AAP recommends screening for co-morbid conditions including autism spectrum disorder, ADHD, developmental coordination disorder, and childhood anxiety disorders. For a child that presents with sensory concerns and symptoms of ADHD, it is important to diagnose ADHD and address the sensory components as part of their behavior support. [Zimmer: 2012]

Issues Related to Attention Deficit Hyperactivity Disorder (ADHD)

Clinical Assessment

Coordination Disorders and ADHD

Resources

Information for Clinicians

ADHD Information (Natl. Resource Center on ADHD)
Information about all aspects of ADHD; provides responses to questions that are e-mailed in; a cooperative venture of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and the Centers for Disease Control and Prevention (CDC).

Attention-Deficit Hyperactivity Disorder, Third Edition: A Handbook for Diagnosis and Treatment
Presents extensive knowledge on the nature, diagnosis, assessment, and treatment of ADHD; by Barkley R (2005), published by the Guilford Press (3rd. ed.).

Helpful Articles

PubMed search on ADHD

Ghanizadeh A.
Atomoxetine for treating ADHD symptoms in autism: a systematic review.
J Atten Disord. 2013;17(8):635-40. PubMed abstract / Full Text

Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry. 2013;70(7):740-9. PubMed abstract / Full Text

Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs. 2009;23(12):1057-83. PubMed abstract

Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother. 2013;. PubMed abstract / Full Text

Clinical Tools

Assessment Tools/Scales

Vanderbilt ADHD Parent Rating Scale (PDF Document 72 KB)
A 40-questions assessment designed to identify behavior problems and performance impairments at home; contains scoring information.

Vanderbilt ADHD Parent Rating Scale (Spanish) (PDF Document 228 KB)
Spanish (with English translation) version of a tool for assessing and quantifying the impact of attention problems at home; contains scoring information.

Vanderbilt ADHD Teacher Rating Scale (PDF Document 53 KB)
A 40-questions assessment designed to identify behavior problems and performance impairments in schoolchildren; contains scoring information.

Vanderbilt ADHD Teacher Rating Scale (Spanish) (PDF Document 285 KB)
Spanish (with English translation) version of the 40-questions assessment designed to identify behavior problems and performance impairments in schoolchildren; contains scoring information.

Conners 3rd Edition ADHD Assessment (Pearson)
Administered to parents and teachers of children and adolescents 6–18 years old; Self-report, 8–18 years old. May be obtained from this and other websites, usually at some cost.

Achenbach Child Behavior Checklist
A variety of screening tools are available, including the basic checklist forms.

Screen for Child Anxiety Related Disorders (SCARED) CHILD Version (PDF Document 218 KB)
Child self-assessment with 41 (brief) questions that have fill-in circles for possible answers; developed by Boris B, M.D., et al. Western Psychiatric Institute and Clinic, University of Pittsburgh (October, 1995).

Depression Scale for Children (Bright Futures) (PDF Document 37 KB)
Free depression screening tool with 20 items that take about 10 minutes to complete; Center for Epidemiological Studies.

Patient Health Questionnaire-9 (PHQ-9) (PDF Document 40 KB)
A 9-question depression screen copyrighted by Pfizer with free access at the Pfizer site.

Pediatric Symptom Checklist (PSC) and PSC - Youth Report (PDF Document 47 KB)
Free psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a checklist for parents or youth to complete and scoring instructions.

Behavior Assessment System for Children, Second Edition (BASC-2)
Fifteen-minute screen for children 2 - 21 year old; available for purchase.

Medication Guides

ADHD Medication Tables (MHP) (PDF Document 254 KB)
Medication tables with dosing information for stimulants and non stimulants; Medical Home Portal.

Patient Education & Instructions

ADHD Information Booklet (NIMH)
A 28-page booklet with comprehensive information for parents and other caregivers about ADHD; National Institute of Mental Health (2012).

ADHD: Parents' Medication Guide (PDF Document 1.1 MB)
Forty-five page booklet that helps youngsters and their families better understand the treatments for ADHD; prepared by the American Academy of Child & Adolescent Psychiatry and American Psychiatric Association (2013).

Toolkits

Caring for Children with ADHD Toolkit (AAP)
A fee-based toolkit that contains: Diagnosis - checklists for teachers and parents, and diagnostic tools for clinical use. Treatment - guidelines for therapy plans, setting treatment goals, medication dosing. Parent Information and Support - "Understanding ADHD" booklet, information about school issues, other parenting resources; American Academy of Pediatrics. Resources - Information on coding, billing, and reimbursement, Internet resources for parents, teachers, and clinicians.

ADHD Resources (IHC)
ADHD-related tools, forms, and patient education materials; a part of Intermountain Healthcare's Mental Health Integration Clinical Program.

Bright Futures in Practice: Mental Health—Volume II, Tool Kit (Bright Futures)
A comprehensive selections of mental health tools for health professionals and families; American Academy of Pediatrics.

Patient Health Questionnaire Screeners
Free screening tools to be used by primary care providers to help detect mental health disorders: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4. All PHQ, GAD-7 screeners and translations are downloadable from this website and no permission is required to reproduce, translate, display, or distribute them.

Information & Support for Families

Family Diagnosis Page

Information on the Web

ADHD (Medline Plus)
Provides links to high-quality sources of information about ADHD; a service of the National Library of Medicine and National Institutes of Health.

ADHD (Healthy Children)
Links to more than 90 articles that discus various aspects of ADHD evaluation and management; developed by the American Academy of Pediatrics.

What is ADHD? (KidsHealth)
Health information for parents, kids, and teens. This is the parent's page on ADHD, see the tabs at the top for the pages focused on kids and teens; sponsored by Nemours Foundation.

The Diet Factor in ADHD (AAP)
A comprehensive overview of the role of dietary methods for treatment of children with ADHD when pharmacotherapy has proven unsatisfactory or unacceptable; American Academy of Pediatrics.

ADHD information (AAP)
List of publications by the American Academy of Pediatrics for parents of children with ADHD.

Support National & Local

Children and Adults with ADHD (CHADD)
A national non-profit organization, with numerous local chapters, that provides education, advocacy, and support for individuals with ADHD; Children and Adults with Attention Deficit/Hyperactivity Disorder.

Understood for Learning & Attention Issues
A collaboration between 15 non-profit agencies to provide resources to parents of children with learning and attention disorders.

Studies/Registries

Mental Health Clinical Trials (NIMH)
Links to descriptions of clinical trials related to numerous mental health conditions, including ADHD, anxiety, and depression; National Institutes of Mental Health.

Clinical Trials in ADHD (clinicaltrials.gov)
Trial listings are filterable by completed, recruiting, active but not recruiting, etc.

Services for Patients & Families

Behavioral Pediatrics

See all Behavioral Pediatrics services providers (5) in our database.

Developmental Pediatrics

See all Developmental Pediatrics services providers (5) in our database.

Family Support, General

See all Family Support, General services providers (69) in our database.

Licensed Professional Counselor (LPC, CMHC)

See all Licensed Professional Counselor (LPC, CMHC) services providers (232) in our database.

Mental Health, Other Services

See all Mental Health, Other Services services providers (28) in our database.

Neuropsychology

See all Neuropsychology services providers (39) in our database.

Parent/Family Education

See all Parent/Family Education services providers (165) in our database.

Pediatric Cardiology

See all Pediatric Cardiology services providers (2) in our database.

Pediatric Neurology

See all Pediatric Neurology services providers (5) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (22) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (146) in our database.

School Districts

See all School Districts services providers (51) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Author: Lynne M Kerr, MD, PhD - 10/2013
Reviewing Author: Robyn Nolan, MD - 4/2015
Content Last Updated: 4/2015

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ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text

Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S.
Implementing the Key Action Statements: An Algorithm and Explanation for Process of Care for Evaluation, Diagnosis, Treatment, and Monitoring of ADHD in Children and Adolescents.
Pediatrics. 2011;128(5).
Appendix to ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

Zimmer M, Desch L.
Sensory integration therapies for children with developmental and behavioral disorders.
Pediatrics. 2012;129(6):1186-9. PubMed abstract / Full Text
Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan for children with developmental and behavioral disorders. Pediatricians and other clinicians should discuss the limitations of these therapies with parents.