Key Considerations for Assessing and Treating a New ADHD Patient

Diagnostic Assessment

The American Academy of Pediatrics recommends initiating an evaluation for ADHD for any child or adolescent age 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity 2
The diagnostic assessment should ensure DSM-5 criteria are met, including documentation of symptoms and impairment in more than one major setting (social, academic, or occupational) 2
Information from multiple sources including parents/guardians, teachers, other school personnel, and mental health clinicians involved in the patient's care should be obtained 2
Alternative causes for symptoms should be ruled out before confirming ADHD diagnosis 2

Screening for anxiety disorders, depression, oppositional defiant disorder, conduct disorders, and substance use is recommended 3, 1
For adolescents, assessment for substance use is critical as they are at higher risk for substance abuse, especially when untreated 4
Evaluation for learning disabilities, language disorders, autism spectrum disorders, and other neurodevelopmental disorders is necessary 3, 1
Assessment of learning problems is particularly important as they frequently co-occur with ADHD and require specific educational interventions 5
Screening for tics, sleep disorders (particularly sleep apnea), and seizures is also recommended 3, 1
Sleep disorders can both mimic and exacerbate ADHD symptoms, making their identification crucial for effective treatment 5

For preschool-aged children (4-5 years), DSM-5 criteria can be appropriately applied, and first-line treatment should be evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions 6, 7
For elementary and middle school-aged children (6-12 years), FDA-approved medications for ADHD should be prescribed along with PTBM and/or behavioral classroom interventions (preferably both) 2
For adolescents (12-18 years), FDA-approved medications for ADHD should be prescribed with the adolescent's assent, and behavioral therapy may also be prescribed, with combined treatment being preferable 7
Specifically, assess for substance use, anxiety, depression, and learning disabilities in adolescents, as these are common comorbidities that affect treatment approach 1

Recognize ADHD as a chronic condition and manage patients following principles of the chronic care model and medical home 1, 8
For medication management, titrate doses to achieve maximum benefit with minimum adverse effects 7
Parents with ADHD themselves may benefit from extra support to help them follow consistent schedules for medication and behavioral programs 1, 8
Longitudinal studies indicate ADHD treatments are frequently not maintained over time, and impairments often persist into adulthood 8
Untreated ADHD is associated with increased risk for early death, suicide, increased psychiatric comorbidity, lower educational achievement, and increased rates of incarceration 8

Failing to screen for comorbid conditions, which can alter treatment approach 5, 3
Misdiagnosing comorbid conditions, leading to inappropriate care 3
Not recognizing ADHD as a chronic condition requiring ongoing management 1
Discontinuing treatment prematurely, which places individuals at risk for adverse outcomes 8