Menu
Video Chapters
Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.
Yavuz Ince, M.D., Child & Adolescent Psychiatrist, University of Michigan
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that manifests with inattention, impulsivity, and/or hyperactivity. It is developmentally atypical and remains relatively persistent over time, resulting in impairment across multiple settings and life activities. It is usually first diagnosed in childhood and often lasts into adulthood.
ADHD occurs due to genetic and environmental influences with multifactorial contributors. ADHD is frequently comorbid with Oppositional Defiant Disorder (ODD) (40%), Anxiety Disorders (34%), Conduct Disorder (14%), Tic Disorder (11%), and Mood Disorders (4%).
The diagnostic process includes ruling out any other potential medical or psychiatric explanations that better explain the current presentation. Physical health conditions such as iron deficiency anemia, lead poisoning, obstructive sleep apnea, epilepsy, and migraine, or psychiatric conditions such as post-traumatic stress disorder (PTSD), anxiety, depression, Autism Spectrum Disorder (ASD), and learning disabilities are some conditions which may manifest similarly to ADHD.
Once the diagnosis of ADHD has been established, there are broadly two classes of psychopharmacological options to treat ADHD: psychostimulants and non-psychostimulants. According to the Multimodal Treatment of ADHD (MTA) study (1999), combined treatment of psychostimulants and psychotherapy demonstrates greater benefit than medication management alone for ADHD. Most side effects associated with psychostimulant medications are rare and temporary, often responding to adjustments in dosage or timing. Non-stimulant options that are generally well-tolerated include guanfacine, clonidine, and atomoxetine. Side effects to consider with alpha-2 agonists, such as guanfacine and clonidine, are sedation, blood pressure, and heart rate changes. Side effects are generally mild with the dosing range used to manage ADHD.
Additional medication strategies can be considered to target commonly co-occurring anxiety, sleep problems, aggression, and tics. Psychotherapies may be considered as an additional treatment after optimization of medication. Behavioral therapies also may help with medication adherence. In addition to this, family therapy and motivational interviewing can have a role, especially in adolescents. If there are comorbidities such as ODD or CD, parent management training (PMT) and wraparound services can be considered.
Resources
Screening Tools
CDC. Attention-Deficit / Hyperactivity Disorder (ADHD). Attention-Deficit / Hyperactivity Disorder (ADHD) https://www.cdc.gov/adhd/index.html (2024).
Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. (American Psychiatric Association Publishing, 2022).
Kim, J. H. et al. Environmental risk factors, protective factors, and peripheral biomarkers for ADHD: an umbrella review. Lancet Psychiatry 7, 955–970 (2020).
Ayano, G., Demelash, S., Gizachew, Y., Tsegay, L. & Alati, R. The global prevalence of attention deficit hyperactivity disorder in children and adolescents: An umbrella review of meta-analyses. J Affect Disorder 339, 860–866 (2023).
Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C. & Rohde, L. A. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol 43, 434–442 (2014).
A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry 56, 1073–1086 (1999).
Beauchaine, T. P., Hinshaw, S. P. & Pang, K. L. Comorbidity of Attention-Deficit/Hyperactivity Disorder and Early-Onset Conduct Disorder: Biological, Environmental, and Developmental Mechanisms. Clinical Psychology: Science and Practice 17, 327–336 (2010).
Özgen, H. et al. [International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder]. Z Kinder Jugendpsychiatr Psychother 50, 54–67 (2021).
Chang, Z. et al. Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry 55, 878–885 (2014).
Humphreys, K. L., Eng, T. & Lee, S. S. Stimulant Medication and Substance Use Outcomes: A Meta-analysis. JAMA Psychiatry 70, 740–749 (2013).
Salazar, F. et al. Co-occurring Psychiatric Disorders in Preschool and Elementary School-Aged Children with Autism Spectrum Disorder. J Autism Dev Disorder 45, 2283–2294 (2015).
Attention deficit hyperactivity disorder (ADHD) in adults with intellectual disability (CR230)| Royal College of Psychiatrists. www.rcpsych.ac.uk https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2021-college-reports/ADHD-in-adults-with-intellectual-disability-CR230.
Cohen, S. C. et al. Meta-Analysis: Risk of Tics Associated With Psychostimulant Use in Randomized, Placebo-Controlled Trials. J Am Acad Child Adolesc Psychiatry 54, 728–736 (2015).
Greenhill, L. L., Pliszka, S. & Dulcan, M. K. Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents, and Adults. Journal of the American Academy of Child & Adolescent Psychiatry 41, 26S-49S (2002).
Cortese, S. et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. The Lancet Psychiatry 5, 727–738 (2018).
Croxtall, J. D. Clonidine extended-release: in attention-deficit hyperactivity disorder. Paediatric Drugs 13, 329–336 (2011).
Elbe, D. & Reddy, D. Focus on Guanfacine Extended-release: A Review of its Use in Child and Adolescent Psychiatry. J Can Acad Child Adolesc Psychiatry 23, 48–60 (2014).
Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)