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Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder

Mary K. Colvin, PhD, and Theodore A. Ste​rn, MD

Psychology Assessment Center, Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston (Dr Colvin), and Psychiatric Consultation Service, Massachusetts General Hospital, and the Depar​tme​nt of Psychiatry, Harvard Medical School, Boston (Dr Stern)

Have you ever tried to dete​rmine whether a patient's inattention and cognitive impairment reflected an acute situational reaction or a life-long struggle? Have you wondered how you could reliably make a diagnosis of attention-deficit/hyperactivity disorder (ADHD) and differentiate it from a learning disorder or another psychiatric condition? Have you been uncertain about the value of neuropsychological testing in this endeavor? If you have, then the following case vignette and discussion should prove useful in your evaluation and management of patients and their families.

Johnny A, a 13-year-old, right-handed boy, was seen because of long-standing concerns regarding his inattentiveness, possible learning difficulties, and encopresis (the involuntary passage of feces). His psychosocial history was complex and problematic; both of his biological parents suffered from polysubstance abuse, and, as a result, the care he received from his primary caregivers was frequently disrupted during his early years. Since Johnny was 7 years old, his grandfather has been his legal guardian. At age 10 years, elimination difficulties developed (although he had achieved full bladder and bowel control as a toddler) in the context of a custody dispute. He was subsequently diagnosed with ADHD; treatment with both medication and therapy was initiated.

What is inattention?

From a cognitive processing perspective, attention operates at the boundaries of consciousness. The fundamental roles of attentional processes are to orient the individual to an external stimulus and then to hold that stimulus in awareness to support further cognitive processing. This complicated sequence of events involves several different types of attentional processes (including orienting the individual, detecting and filtering stimuli, and shifting and sustaining vigilance).1 These processes are regulated by widespread and integrated neural systems described in greater detail below.

Selective deficits in attentional processing can occur, and, as a result, inattention can manifest in myriad ways. For example, if the brain has difficulties regulating arousal levels, then the individual may fail to orient to an external stimulus. If sensory thresholds are altered, or if the brain has difficulty filtering information in a crowded field, then the individual may fail to fully detect the stimulus’s salience or relevance. If difficulties occur in sustaining attention in the face of competition from other stimuli, then an individual may struggle to filter irrelevant stimuli or be pulled quickly to a novel stimulus. Alternatively, the individual may have difficulty disengaging from a stimulus and then struggle to shift to something new. Finally, limitations in attentional capacity can create difficulty in attending to more than 1 stimulus at a time.

What neural systems are involved in attention?

Recent neuroimaging studies, combined with lesion studies, have identified multiple brain networks involved in the regulation of attention.2–4 Conceptually, these networks have been divided into “top-down” networks, which are involved in the executive control of attention, and “bottom-up” networks, which are involved in detecting the salient features of a stimulus. Top-down attention is regulated by regions of the prefrontal cortex, which is critical for controlling inhibition, sustaining attention, dividing attention, and shifting attention. Bottom-up networks involve the inferior temporal cortices, which integrate the perception of an object’s basic visual properties and salience (the “what” pathway), and the posterior parietal cortices, which are involved in orienting the person to an object’s location in space (the “where” pathway).5–7 These pathways have extensive interconnections that provide a foundation for the feedback and feedforward loops that regulate the attentional systems.8 These neural circuits are predominantly regulated by catecholamines, specifically dopamine and noradrenaline.9

How does inattention impact everyday functioning?

Behaviorally, inattention can manifest in a variety of different ways that leave an individual particularly vulnerable to underperforming in multiple functional domains (for example, at school, at work, and in interpersonal interactions). Inattentive individuals may miss new information as it is being presented. They may fail to notice something important, particularly if the stimulus did not trigger narrow sensory thresholds or appear personally relevant. Inattentive individuals may have difficulty appropriately shifting attention. They may move too quickly to the next stimulus, or they may become “stuck” or hyperfocused on a stimulus. They may have difficulty regulating their level of arousal and require more sensory stimulation to sustain attention (ie, they may become easily bored). As a result, these individuals may have difficulties initiating and completing tasks and are at risk for making careless errors. They may also appear forgetful, but, in inattentive individuals, memory difficulties reflect inadequate processing of to-be-learned material rather than the actual forgetting of learned information.

How is ADHD defined and diagnosed?

ADHD is the most common neuropsychiatric disorder treated in children, with recent studies suggesting that ADHD affects approximately 5% to 12% of school-aged children.10–14 Current diagnostic criteria, defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),15 cluster symptoms into 2 broad categories: inattention and hyperactivity/impulsivity. Inattentive symptoms (which in children and adolescents are most often associated with ADHD) include making careless mistakes, seeming forgetful, not seeming to listen when spoken to, not following through on instructions, having difficulty organizing tasks, avoiding activities that require sustained mental effort, losing things necessary for tasks or activities, having excessive distractibility, and having impairments of sustained attention. Symptoms of hyperactivity include increased restlessness and movement (eg, fidgeting, often leaving one’s seat in the classroom, having difficulty playing quietly, often being on the go), along with excessive talking. Impulsive symptoms include having trouble waiting one’s turn and frequently interrupting others.

To meet DSM-5 diagnostic criteria for ADHD, at least 6 of the 9 symptoms from either or both of the 2 broad categories (inattention or hyperactivity/impulsivity) must be present (AV 1).15 Thus, 3 subtypes of ADHD exist: 1) predominantly inattentive (at least 6 of 9 inattentive symptoms endorsed); 2) predominantly hyperactive/impulsive (at least 6 of 9 hyperactive/impulsive symptoms endorsed); and 3) the combined type (at least 6 of 9 inattentive symptoms endorsed and at least 6 of 9 hyperactive/impulsive symptoms endorsed). By definition, ADHD is a developmental disorder; DSM-5 diagnostic criteria also require that significant ADHD symptoms must have been present in childhood (prior to the age of 12 years). In addition, ADHD symptoms must cause functional impairment in at least 2 environmental settings (eg, at home and at school) for at least 6 months.

AV 1. DSM-5 Criteria for ADHD (00:36)

Based on American Psychiatric Association15

Children and adolescents are more commonly diagnosed with ADHD by pediatricians and family physicians than by mental health professionals.16,17 Several standardized tools are available to assist health care providers in making a diagnosis of ADHD in a child or an adult (eg, Brown ADD Rating Scales, Conners Rating Scales, Swanson Nolan and Pelham questionnaire–fourth edition [SNAP-IV ], Vanderbilt ADHD Diagnostic Scales ).18 To make the diagnosis in children, clinicians often ask the parents and teachers to complete these questionnaires to determine whether functional impairment occurs in at least 2 domains (such as at home and at school). While these tools may help to determine the presence of symptoms of ADHD, they should not be used in isolation to make a diagnosis. The results of questionnaires can be influenced by response biases.19

As will be discussed in greater detail below, in the diagnosis of children and adolescents, clinicians must rule out the presence of psychiatric conditions (such as anxiety or depression) and neurodevelopmental conditions (eg, specific learning disorders, autism spectrum disorders) that may cause symptoms that mimic ADHD, and clinicians must also consider potential comorbidities.15 In addition, several medical conditions (for example, sleep disorders and seizure disorders) can contribute to inattentive symptoms and should be ruled out.20,21 For these reasons, current diagnostic and treatment guidelines18 from the American Academy of Child and Adolescent Psychiatry recommend that clinicians conduct a thorough evaluation of perinatal history, psychiatric history, medical history, and developmental milestones and that neuropsychological evaluations should be requested if the patient’s history is suggestive of global cognitive delay or low academic achievement. However, limitations exist in securing payment for such evaluations from third-party payers on the basis of their being education-related and not health-related.22

What interventions can improve attention difficulties?

Although the popular press has reported that ADHD may be overdiagnosed in children, recent epidemiologic studies have suggested that only about 60% of children with ADHD receive treatment.23 In children and adolescents, ADHD symptoms are most commonly treated with pharmacologic interventions, specifically stimulants (eg, methylphenidate).24 All medications that are prescribed to treat ADHD enhance dopaminergic and adrenergic function.24 A major advantage of stimulant medication is the availability of multiple delivery mechanisms and release times (immediate, intermediate, and extended); these choices allow clinicians to tailor prescriptions to an individual’s need.24 Stimulants have been shown to be highly effective in treating symptoms of ADHD (effect size of approximately 1.0).22 Nonstimulants, which are sometimes prescribed when contraindications to stimulant medication exist, also work quite well (effect size of approximately 0.7).22

Despite the known efficacy of psychopharmacologic treatment, many parents have reservations about initiating medications (for instance, the potential impact on a child’s developmental trajectory and health). In children, negative side effects of stimulants include decreased appetite, abdominal pain, headaches, and difficulties with sleep initiation. Rarely, stimulant use may precipitate psychotic symptoms and sudden cardiac death.22 For some children and adolescents, especially those with comorbid conduct problems, concerns about diversion of stimulant medication for misuse and abuse may exist.25

In recent years, the focus on developing evidence-based psychotherapeutic treatments for ADHD has increased (perhaps due in part to medication concerns). Behavior therapy focuses on teaching strategies to shape a child’s behavior. At a fundamental level, behavior therapy aims to consistently and effectively reinforce desired behaviors while decreasing the frequency and intensity of unwanted behaviors.22,26 For treatment of childhood ADHD, behavior modification techniques are taught to both parents and teachers to address the impact of the child’s symptoms both at home and at school. Similar strategies have been used to help a child learn skills to navigate peer relationships. In recent years, studies have also shown that cognitive-behavioral therapy (CBT) is effective in helping adolescents with ADHD to learn to manage their symptoms.27 For children with comorbid conduct problems or mood disorders, a specialized CBT program known as collaborative problem solving has shown particular promise.28

When implemented appropriately, behavior therapy is highly effective. A recent meta-analysis26 found that behavioral interventions (implemented in the home, school, or peer setting) resulted in a substantial improvement in functioning (unweighted effect size of 0.83 for between-group studies). Behavior therapy may also have a greater influence on improving family functioning and parent-child relationships than medication treatment. Parents who are engaged in behavior therapy, especially at high intensity, report confidence in their ability to manage their child’s ADHD symptoms.29 Such changes to a child’s psychosocial environment may be an important protective factor for a child’s long-term development.

The active development of effective behavior therapy treatment programs contributed to a shift in the American Academy of Pediatrics treatment guidelines for childhood ADHD. Once viewed as a second-line or adjuvant treatment for ADHD, behavior therapy is now recommended as first-line treatment for preschool-aged children.22 For older children and adolescents, the combination of medication and therapy appears to be most effective for improving both core symptoms and functional outcomes30 and is recommended.22 The combination of medication and therapy may also allow for use of lower dosages of stimulants, which can reduce the risk of adverse side effects.22

Continue to Case Vignette: Part 2

Despite pharmacologic and psychotherapeutic treatment, Johnny A’s difficulties at school increased, and a school evaluation was conducted. The school's assessment raised the possibility that Johnny had an intellectual disability. His psychiatrist referred him for neuropsychological testing, which revealed normal intellectual functioning and specific learning disorders in reading and written expression, as well as selective difficulties in attention and executive functions (consistent with ADHD). Neuropsychological testing also raised concerns about an emerging depressive disorder and suggested that Johnny was achieving minimal benefit from the medications used to treat his ADHD symptoms. The psychiatrist and neuropsychologist worked together to provide feedback and recommendations regarding school placement and appropriate special education services. The psychiatrist also made adjustments to his medication regimen and therapeutic goals, resulting in significant improvement in the patient's level of functioning.

When should you suspect that an individual with ADHD also has a learning disorder?

ADHD alone is a risk factor for academic underachievement. In the classroom setting, children with attentional difficulties often miss new information as it is being presented, struggle to exhibit consistent effort and/or complete assignments, forget to complete or turn in assignments, and make careless errors. Children with symptoms of hyperactivity and impulsivity may have difficulty meeting classroom behavioral expectations (eg, sitting still or staying in line, keeping quiet during work times, waiting to be called on) and, as a result, are more likely to be disciplined or to receive negative feedback than children without ADHD. As such, the fact that ADHD is associated with general academic underachievement is unsurprising. Children with ADHD earn lower grades and score lower on standardized achievement tests than those without ADHD.31 They also have significantly higher rates of special education placement, grade retention, and school dropout.13,32

The risk of academic underachievement in childhood ADHD is compounded when children also have specific learning disorders, which have a high rate of comorbidity with ADHD. Learning disorders should be suspected when a gap is reported or observed between a child’s apparent level of cognitive functioning and his or her academic performance. The possibility of a comorbid learning disorder should also be explored when a child is acquiring academic skills at different rates (with isolated concerns about reading, writing, or math). This consideration is especially important if the child also has a history of developmental delays in aspects of language acquisition (early concerns regarding language development, including articulation) and/or the development of fine motor skills. Learning disorders are distinct from the learning difficulties that occur in the context of an intellectual disability, in that a child with a learning disorder has many intact cognitive abilities.

How are learning disorders defined and diagnosed?

Learning disorders are defined as a failure to learn despite adequate teaching and intact cognitive functioning. Formal diagnosis of a learning disorder requires psychological assessment to document both a child’s overall level of cognitive functioning (IQ) and his or her level of academic achievement.15,18 Traditionally, if a child had a significant gap between cognitive aptitude and academic achievement, then a learning disorder was diagnosed. This discrepancy model approach to defining learning disorders has been criticized, as it can result in missed diagnoses (false negatives) in children with below-average cognitive ability and false positives in children with higher-than-average cognitive ability. It has also been associated with instability of diagnosis over time.33,34 However, the discrepancy model approach is the one described in the DSM-5.15

The DSM-5 defines 3 specific learning disorders: impairment in reading, impairment in mathematics, and impairment in written expression (AV 2). When clear evidence of a specific learning disorder is lacking but the patient has well-defined learning issues, the diagnoses of Other Specified Neurodevelopmental Disorder or Unspecified Neurodevelopmental Disorder may apply.15

AV 2. DSM-5 Criteria for Specific Learning Disorder (00:34)

Based on American Psychiatric Association15

Impairment in reading. Reading disorders occur in approximately 5% to 10% of the population and have a high rate of comorbidity with ADHD.35 Between 25% and 40% of children with either disorder also have the other disorder.36 Developmental dyslexia is the most commonly recognized reading disorder and is believed to arise from deficits in phonological processing that initially interfere with the acquisition of early reading skills. A young child with dyslexia will struggle to appropriately map orthography (written letters) onto the elemental sounds of spoken language (phonemes); this skill quickly becomes automatic in children without dyslexia. As a result, children with dyslexia have particular difficulty accurately reading words that they do not visually recognize and typically also have difficulty with spelling, especially for irregular words. With intensive phonics-based instruction, a dyslexic child can explicitly learn to effectively decode single words, but difficulties achieving reading fluency often persist.37 Comorbid attentional issues can exacerbate difficulties with reading fluency and reading comprehension, especially if a child has additional weaknesses in higher-order language skills.38

Impairment in mathematics. Math disorder, also referred to as developmental dyscalculia, occurs in 5% to 6% of children.39 Among children with dyscalculia, approximately 26% also have ADHD, and 17% also have dyslexia.40 Approximately 18% of children with ADHD also have a diagnosis of a math disability.41 Young children with dyscalculia may have difficulty mastering counting skills and struggle to understand relational quantities (such as “more” or “less”). As they grow older, difficulties achieving automaticity with math facts is common (for example, they may have difficulty learning multiplication facts). They may also make inattentive errors (eg, use the wrong sign, misplace digits while “carrying” or “borrowing”). In early grades, a child will require intensive remedial instruction focused on boosting math fluency and quantitative reasoning skills, but academic accommodations may be required throughout the child’s years of formal schooling.39

Impairment in written expression. Writing disorder, or developmental dysgraphia, has not been as well defined as dyslexia and dyscalculia. This likely reflects the complex nature of writing; fluent writing requires the seamless integration of graphomotor and expressive language skills. Children with dyspraxia may struggle with the motor demands of writing in the absence of higher-order language disorders. By extension, children with language delays and weaknesses in executive functions may struggle with the retrieval and organization of their verbal output, both orally and/or in writing.42 They may require interventions aimed at improving their fine motor skills or speech and language therapy aimed at improving the retrieval and organization of language.

How often do individuals with ADHD have other psychiatric disorders (especially anxiety and depression)?

ADHD is highly comorbid with other psychiatric disorders. In children and adolescents with ADHD, about two-thirds have at least one other psychiatric condition.32,43 The rates of anxiety and mood disorders in ADHD youth are particularly high. The relative risk of a comorbid anxiety disorder is more than 7 times greater than for those without an ADHD diagnosis, and the risk of comorbid depression is 8 times greater.32 The rates of anxiety and mood disorders as well as eating disorders are increased in girls with ADHD relative to those without ADHD.44 Childhood ADHD has also been associated with bipolar disorder.45

The considerable overlap between ADHD and other psychiatric disorders suggests commonalities in the genetic and neuroanatomical factors that contribute to their emergence.46 Functionally, the presence of ADHD symptoms can also create environmental circumstances that might be expected to increase the risk of anxiety and depression. For example, if a child with ADHD is underperforming in school, he or she may subsequently become anxious about his or her ability to meet task demands, eventually internalizing feelings of self-doubt and expecting failure. Such environmental factors may be potent triggers in children who have some underlying genetic predisposition to the development of anxiety or mood disorders.

In addition to anxiety and mood disorders, children with ADHD are also at increased risk for social difficulties and substance abuse. At a young age, children with ADHD have difficulty relating to their peers and are likely to experience peer rejection and to exhibit social withdrawal. Some research suggests that social difficulties stem from core deficits in emotion perception and regulation.47 Over time, this pattern of negative interactions may contribute to the development of maladaptive patterns of relating to others. By adolescence, children with ADHD are more likely than other children to develop and exhibit antisocial behaviors.48 Similarly, children with ADHD are at increased risk of developing substance use disorders. ADHD youth are particularly likely to develop nicotine dependence, which is associated with an increased risk of alcohol and drug abuse.48–50

How does age affect ADHD and comorbid psychiatric disorders?

ADHD symptoms, especially the hyperactive-impulsive symptoms, decline as children move through adolescence.51 By late adolescence, a little less than 50% of children continue to manifest significant ADHD symptoms.52 By adulthood, the rate of ADHD drops to about 4%,53 or approximately one-third of those who met ADHD criteria in childhood.54 However, the functional impairment associated with childhood ADHD may continue to affect many individuals who no longer meet ADHD criteria.51

The high rates of psychiatric comorbidity with ADHD persist into adulthood, especially in individuals with the combined subtype.55 Less than one-fourth of adults with ADHD have no comorbid psychiatric disorders.55,56 Adults with ADHD are more likely than those without ADHD to have anxiety disorders (including generalized anxiety disorder, agoraphobia, social phobia, specific phobias, posttraumatic stress disorder, and panic disorder) and mood disorders (ie, major depressive disorder, dysthymia, bipolar disorder).53

Given the high rate of psychiatric comorbidity with ADHD, clinicians must thoroughly assess patients prior to the initiation of psychopharmacologic treatment for ADHD to avoid adverse effects. For example, stimulants may exacerbate anxiety symptoms, and combination pharmacotherapy may be needed for successful management of the anxiety symptoms (perhaps sequencing the anxiety treatment to precede treatment for ADHD).13 Similarly, combination pharmacotherapy may be needed to treat comorbid ADHD and depression, but clinicians may wish to consider certain classes of antidepressants to treat both conditions.13

What is the role of neuropsychological testing in refining a differential diagnosis?

Neuropsychological evaluations are recommended to assist with differential diagnosis when learning disorders are suspected.18 A comprehensive neuropsychological evaluation assesses 3 domains of functioning: 1) cognitive development, 2) social, emotional, and behavioral functioning, and 3) academic functioning.57 A neuropsychologist also takes a comprehensive developmental history and reviews educational and medical records. This information is then integrated to address any concerns of clinicians, patients, and family members. At the end of the evaluation, the neuropsychologist will be able to describe an individual’s strengths and weaknesses, to determine the need for and type of intervention services, to establish a baseline by which to assess developmental progress and treatment efficacy, and to assist with creation of a differential diagnosis.

Recommendations will be targeted to address all aspects of an individual’s life (school, work, the development of life skills) and may include further evaluation (such as a medical evaluation) and treatment (eg, psychopharmacology, psychotherapy, occupational therapy, speech and language therapy). In addition, the neuropsychologist should offer individualized feedback, often in conjunction with treatment providers. For children and adolescents, these feedback sessions may be family-focused so that the parents and their child have a greater understanding of their current functioning and understand the recommendations that were made.

On neuropsychological testing, individuals with ADHD commonly demonstrate selective weaknesses in aspects of executive functions. These aspects are higher-order cognitive skills involved in responding appropriately to novel and complex situations.58 Individuals with ADHD tend to exhibit weakness on measures of response inhibition, vigilance, spatial working memory, and planning and organization but may also have impaired processing speed and set-shifting.59 However, among children with ADHD, considerable variation occurs in the degree of executive dysfunction shown on neuropsychological testing. In other words, the extent of ADHD symptomatology is only modestly correlated with performance on measures of executive function.60 This modest correlation probably, at least in part, reflects the heterogeneity of the disorder—for example, children with only symptoms of inattention may have neuropsychological profiles different from those of children who also have symptoms of hyperactivity or impulsivity. In fact, recent genetic studies have moved toward defining neuropsychological endophenotypes of ADHD, such as grouping individuals who exhibit weakness in inhibition.59,61 Thus, neuropsychological assessment allows for the identification of specific deficits in executive functions, as these cannot be predicted from a diagnosis of ADHD alone.

A neuropsychological assessment typically also assists the referring clinician in determining whether the patient has additional comorbid psychiatric or neurodevelopmental conditions.57 For example, a clinical neuropsychologist can identify symptoms of anxiety and depression and their potential impact on cognitive functioning, as well as identify whether ADHD symptoms exist in the context of more widespread developmental conditions such as autism.

When should an inattentive child be referred for a neurological assessment or for further medical evaluation?

Current diagnostic and treatment guidelines18 recommend that the physician who is considering a diagnosis of ADHD rule out possible medical conditions that may contribute to inattention. It is important to carefully assess the history and course of inattentive symptoms. In most cases of straightforward ADHD, inattentive symptoms are longstanding (dating to early childhood) and have a relatively stable course. Inattentive symptoms that wax and wane and are associated with altered states of awareness are more suggestive of seizure disorders, especially if the patient also has stereotyped patterns of behavior (eg, automatisms). However, many children with seizure disorders also meet diagnostic criteria for ADHD and benefit from stimulant medication.62

Clinically significant symptoms of ADHD are also quite common in the context of autism spectrum disorder (ASD).15 Accurate identification of children with mild ASD symptoms can be difficult, especially in the context of a routine check-up. Referral to a developmental pediatrician, a neurologist specializing in ASD, and/or a neuropsychologist is warranted if the clinician has significant concerns about social communication skills and/or peer relationships, especially if the patient has a history of developmental delays in or atypical patterns of language and/or motor skills. A more comprehensive evaluation is especially important as children with ASD are also at increased risk of learning disorders, seizure disorders, and psychiatric disorders.63–65 In these complex cases, a neuropsychological evaluation is particularly important in clarifying a child’s strengths and weaknesses and helping to monitor the effectiveness of treatment interventions and developmental course.

Estimates suggest that 25% to 50% of children with ADHD experience sleep-related difficulties.66 Assessment and management of sleep difficulties are important as these difficulties can exacerbate ADHD symptoms and serve as a significant source of family stress. Children with ADHD have longer sleep-onset latency. Sleep is also likely to be more fragmented and less efficient. Contributing factors to this may be increased movement during sleep and disordered sleep-breathing.67 Indeed, up to 44% of children with ADHD have been found to have restless legs syndrome.66 Children with ADHD may also be at increased risk of nocturnal enuresis.68 Given these abnormal sleep patterns, it is perhaps not surprising that children with ADHD are often sleepier during the day.67 Thus, when assessing a child with ADHD, the practitioner should ask about sleep behaviors and consider formal assessment (such as overnight polysomnography).66 Regarding treatment, in patients with adenotonsillar hypertrophy and obstructive sleep disordered breathing as well as ADHD, adenotonsillectomy has been associated with a reduction of ADHD symptoms.69 Use of melatonin has been associated with decreased sleep-onset latency and increased sleep duration in children with ADHD.70 Use of stimulants has been associated with resolution of nocturnal enuresis in youths diagnosed with ADHD.71 Finally, behavior therapy may improve sleep-related behaviors and help reduce parents’ anxiety about their child’s sleep but does not change ADHD symptoms.72

Children with ADHD are also at increased risk for movement disorders, including developmental coordination disorder, motor stereotypies, and tics.73,74 Occupational therapy evaluations can be helpful in determining the functional impact of motor delays on everyday function, especially in school. Neurological evaluations and neuropsychological evaluations are also often warranted for children who meet diagnostic criteria for Tourette’s Disorder. These children are at increased risk for anxiety (typically presenting as symptoms of obsessive-compulsive disorder) and learning disabilities, and they may have social difficulties that overlap with ASD symptoms.75 Their neuropsychological profiles are often remarkable for more severe cognitive deficits than would be expected of children with ADHD alone.76

Does effective and early treatment of ADHD improve long-term prognosis?

A growing body of evidence indicates that early treatment of ADHD symptoms may result in a better long-term prognosis, although interventions do not bring about functioning equivalent to that of youths without ADHD.77 Pharmacologic treatment of ADHD symptoms in children and adolescents has been associated with a reduced risk of later development of major depressive disorder,78,79 disruptive behavior disorders, and anxiety disorders.79 ADHD treatment has also been shown to have a protective effect against the development of substance use80,81; children with ADHD who are treated with stimulants are at decreased risk for cigarette smoking, alcohol use, and drug use.25,82–84

Treatment of childhood ADHD may mitigate some future functional impairment. Adults who had ADHD in childhood have a greater likelihood of being financially dependent on parents or, if they are financially independent, of having a lower socioeconomic status than those who never had ADHD, despite receiving treatment at some point.48 ADHD has also been associated with decreased educational achievement compared with no ADHD,48 but some evidence suggests that children who receive stimulant treatment for ADHD have less grade repetition than those not treated.79 Additionally, teenagers and young adults with ADHD are more likely to have motor vehicle accidents and to exhibit reckless driving behaviors than those without ADHD,85 but treatment with stimulants has been shown to reduce these behaviors. In general, however, people with ADHD have an increased risk of unintentional injuries or trauma.86 Altogether, these findings indicate that effective treatment of ADHD symptoms is needed to improve long-term prognosis and quality of life.

How can health care providers help to coordinate medical/educational care and improve family function?

Primary care health providers are often the first line of contact for families who have children with ADHD. Providers are also likely to have more contact with these families than with other families, as childhood diagnosis of ADHD is associated with greater use of health and education services, especially if comorbid conditions are present.32,87,88 High rates of systemic stress and family conflict occur in families of children with ADHD.89 Mothers of children with ADHD report more marital problems and depressive symptoms than mothers whose children do not have ADHD.90,91

Effective treatment of the child may be an important first step in improving family functioning. However, assessing the function of individual parents and the family system is important to determine whether treatment at those levels is also necessary. Because ADHD has a high rate of heritability, at least one parent may also have symptoms of the disorder. Children who have both ADHD and conduct problems or oppositional defiant disorder are more likely than children with just ADHD to have parents who are dependent on stimulants or cocaine, have alcohol problems, and have psychological disorders such as mood and anxiety disorders.91 Such children are clearly at high risk for worse functional outcomes than other children, especially if the systemic issues are not adequately addressed. Parent guidance training, family therapy, and/or treatment of the parent’s mental health issues may all be necessary treatment components, and, in most cases, these issues will first come to the attention of a primary care provider.

Conclusion

ADHD is the most common neuropsychiatric disorder treated in children, and primary care physicians are often in the position of diagnosing and treating ADHD. Effective treatment may combine medication and psychotherapeutic options, which have been shown to mitigate functional impairment. However, treatment decisions should be made after a thorough evaluation that considers a child’s developmental history, medical history, academic performance, and psychosocial functioning (ie, relationships to family members and peers). Comorbid psychiatric conditions and learning disorders, which are common, must be ruled out, as these may complicate treatment. In cases of suspected developmental delay, learning disorders, and/or psychiatric dysfunction, a comprehensive neuropsychological evaluation can be particularly helpful in elucidating comorbidity, developing a comprehensive treatment plan, and establishing a baseline to monitor future developmental progress.

Clinical Points

​​​​​​​​​​​​​​​​​​​​​​​​​
  • Standardized tools can help clinicians diagnose ADHD (eg, Brown ADD Rating Scales, Conners Rating Scales)
  • Medication and psychotherapy can help children with ADHD; parents and teachers may both need to assist with behavior modification
  • Neuropsychological assessment for a learning disorder is needed when a gap is observed between a child’s cognitive functioning and academic performance or when a child is acquiring academic skills at different rates
  • Patients with ADHD should be screened and treated for comorbid conditions
  • Parents of children with ADHD should be screened for psychiatric conditions and for family dysfunction that requires treatment

Drug Names

methylphenidate (Daytrana, Ritalin, and others)

Abbreviations

ADHD = attention-deficit/hyperactivity disorder
ASD = autism spectrum disorder
CBT = cognitive-behavioral therapy
DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

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