Psychiatry/Behavioral · PANCE / PANRE

Attention-Deficit/Hyperactivity Disorder (ADHD)

Persistent inattention and/or hyperactivity-impulsivity present before age 12 with cross-setting impairment.

Also known as: ADHD, attention deficit, ADD, hyperactivity

Overview

A neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity interfering with functioning or development, with several symptoms present before age 12 and across >=2 settings.

Epidemiology

Childhood prevalence ~5-7%; adult prevalence ~2.5-4%. Male-to-female ratio ~2:1 in childhood; narrows in adulthood. Highly heritable (~75%).

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Risk factors

Family history (first-degree relative ~5x risk)
Prenatal exposure: nicotine, alcohol, prematurity, low birth weight
Lead exposure, traumatic brain injury
Male sex (in childhood diagnostic samples)

Pathophysiology

Frontostriatal and frontoparietal dysfunction with reduced dopaminergic and noradrenergic signaling. Delayed cortical maturation in prefrontal regions. Reduced default-mode suppression during attention tasks.

Clinical presentation

Symptoms

Inattention: careless mistakes, difficulty sustaining attention, doesn't listen, fails to follow through, organization difficulties, avoids sustained mental effort, loses things, easily distracted, forgetful
Hyperactivity-impulsivity: fidgets, leaves seat, runs/climbs inappropriately, can't engage quietly, 'on the go', talks excessively, blurts answers, can't wait turn, interrupts
Adults: internal restlessness, procrastination, difficulty with time management, executive dysfunction

Signs / physical exam

Restlessness or distractibility evident in interview
Collateral history from parent/teacher/partner is essential — ADHD is a cross-setting diagnosis

Differential diagnosis

Anxiety disorder — Concentration deficits secondary to worry; symptoms newer, situational
MDD / bipolar depression — Episodic; mood disturbance predominates
Substance use disorder — Symptoms in temporal relationship to use; especially stimulants, cannabis
Hyperthyroidism — Tremor, weight loss, suppressed TSH
Learning disability — Domain-specific academic deficit without pervasive inattention
Autism spectrum disorder — Social communication deficits and restricted/repetitive behaviors; often co-occurs with ADHD
OSA / poor sleep — Daytime inattention from sleep fragmentation; screen with sleep history

Diagnostic workup

Diagnostic criteria

DSM-5-TR: (A) >=6 inattention and/or >=6 hyperactivity-impulsivity symptoms for >=6 months in children, or >=5 for individuals age 17 and older; (B) Several symptoms present before age 12; (C) Present in >=2 settings; (D) Clear interference with functioning; (E) Not better explained by another disorder. Specify combined, predominantly inattentive, or predominantly hyperactive-impulsive presentation. Validated rating scales: Vanderbilt (children), ASRS (adults), Conners.

Labs

TSH, CBC if suggested by history
Pre-stimulant: BP, HR; cardiac history including family history of sudden death; ECG only if cardiac concerns
Urine drug screen if substance use suspected

Imaging

Not routinely indicated

Diagnostic algorithm

Class	Examples	Pearls
Stimulant — methylphenidate	methylphenidate IR/ER, dexmethylphenidate	First-line; titrate weekly; monitor BP/HR/sleep
Stimulant — amphetamine	lisdexamfetamine, mixed amphetamine salts, dextroamphetamine	First-line; lisdexamfetamine prodrug with lower abuse potential
Non-stimulant SNRI	atomoxetine, viloxazine	Useful with anxiety, tics, SUD history; 4-6 wks to effect
Alpha-2 agonist	guanfacine ER, clonidine ER	Adjunct or monotherapy; helps sleep onset, tics; watch sedation/BP

ADHD pharmacotherapy classes and selection considerations.

Treatment

First-line

Behavioral parent training and classroom interventions — first-line in preschool age (4-5 years) and adjunct at all ages
Stimulant — methylphenidate, lisdexamfetamine, mixed amphetamine salts (first-line pharmacotherapy school-age and older); titrate to effect over weeks
School accommodations (IEP/504); psychoeducation; sleep regularity; exercise
Adults: CBT for ADHD; coaching; organizational supports

Second-line / adjunct

Non-stimulant: atomoxetine (selective norepinephrine reuptake inhibitor, NRI), viloxazine; useful in tic disorder, anxiety, SUD history
Alpha-2 agonist: extended-release guanfacine, clonidine — adjunct or monotherapy in children, especially with sleep onset issues or tic disorder
Bupropion — off-label in adults with comorbid depression
Avoid prescribing immediate-release stimulants to patients with active SUD; use long-acting or non-stimulants and consider diversion risk

Complications

Academic underachievement, occupational instability
Increased risk of motor vehicle crashes, injuries
Substance use disorders, especially when untreated
Comorbid mood, anxiety, learning, and oppositional defiant disorders
Stimulant side effects: appetite suppression, growth slowing, insomnia, modest BP/HR increases, rare cardiac events in those with structural heart disease
Misuse and diversion

PANCE pearls

Cross-setting and pre-age-12 symptoms are required — recent onset in adulthood should prompt search for other causes (substance use, mood, sleep, cognitive decline).
Stimulants are more efficacious than non-stimulants but require monitoring for BP/HR, appetite, sleep, and growth.
Reassess every 6-12 months — many children continue to benefit into adulthood; some achieve symptom remission and may taper.
Routine pre-treatment ECG is not required in low-risk children per AAP; obtain ECG/cardiology referral with positive cardiac history or exam.

References

AAP 2019 — AAP Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents (2019)
AACAP / APA — AACAP Practice Parameter for the Assessment and Treatment of ADHD; APA guidance for adult ADHD
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
MTA Study — The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for ADHD. Arch Gen Psychiatry 1999

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