Attention-deficit/hyperactivity disorder.

Epidemiology Common. ADHD is the most common behavioral disorder in school-age children – a U.S. community prevalence of 6-8% that is more common in boys [C]. In at least 30% of diagnosed children ADHD continues into adulthood, with 3-4% of adults meeting criteria for ADHD [C]. Primary care provider. Most children with ADHD receive care through primary care physicians. Diagnosis Types. Diagnosis is based on the DSM-IV-TR criteria (see Table 1) [D]. The three main types are primary hyperactive, primary inattentive, and combined. Multiple sources. No specific test can make the diagnosis. Input from both parents and teachers or other source is required. Some psychological rating tools are useful but are not diagnostic (e.g., Vanderbilt, Conners; see Figure 1, Tables 1 & 2, and Appendix A1). If a learning problem is suspected, consider neuropsychiatric testing for intelligence testing (IQ) and learning disorders. Confused and associated conditions. Diagnosis is complicated by overlapping symptoms or cooccurrence of other disorders (e.g., anxiety disorders, bipolar disorder, obstructive sleep apnea, fetal alcohol syndrome, major depressive disorders, learning disorders, oppositional defiant disorder, post traumatic stress disorder, reactive attachment disorder; see Appendices B1 & B2). Treatment (See Table 4) Drug treatment  Stimulants are the first line treatment and have proven benefit to most people. If one class of stimulant fails or has unacceptable side effects then another should be tried (Tables 5-7) [IA*].  Atomoxetine is a secondary choice [IA]. (One reported side effect is suicidal thinking.)  Other medications may be used alone or in combination depending upon the ADHD type, response to therapy or comorbidity profile: e.g., Alpha-II agonists (clonidine, guanfacine) with hyperactivity or impulsivity; bupropion (over age 8) with co-morbid depression; risperidone (atypical antipsychotic) for aggression (see Table 7) [IIA].  Comorbid conditions may require additional treatment (e.g., for depression) and consideration of referral to a mental health specialist. Non-pharmacologic interventions  Age-appropriate behavioral interventions at home: education and support [IB]; parent interventions including routines, clear limits and positive reinforcement for target behaviors (for children); consider family therapy; cognitive behavioral techniques for adults [IIB] (see Table 8 and Appendix A2).  School interventions: children with ADHD may qualify for a 504 education plan or special education services with individualized education plan (IEP) [ID] (see Appendices A3 & A4).