Attention deficit hyperactivity disorder

Last updated: November 20, 2023

Summarytoggle arrow icon

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and may persist into adulthood. It is characterized by inattention and/or impulsivity and hyperactivity resulting in functional impairment in social, occupational, and/or academic activities. ADHD is a clinical diagnosis made using the DSM-5 diagnostic criteria for ADHD, and evaluation should include an assessment for differential diagnoses of ADHD. Individuals with ADHD frequently have comorbidities such as anxiety disorder, major depressive disorder, and specific learning disorder. Management of ADHD differs based on the individual's age but typically consists of stimulant medications in combination with behavioral interventions. Untreated ADHD is associated with decreased academic and/or occupational success and an increased risk of developing substance use disorders.

Epidemiologytoggle arrow icon

  • Sex: : > [1]
  • Age of onset: usually before 12 years [2]
  • Prevalence: ∼ 10% [3]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

ADHD is a multifactorial disorder; pathogenesis is thought to be related to altered catecholamine metabolism.

Clinical featurestoggle arrow icon

Poor school performance in children with ADHD is usually due to inattention and/or impulsivity and hyperactivity rather than level of intelligence, which is not directly affected by the disorder. [6]

Diagnosticstoggle arrow icon

ADHD is a clinical diagnosis made using the DSM-5 diagnostic criteria for ADHD.

Approach [7][8][9]

Establishing the diagnosis of ADHD involves identifying comorbid disorders (e.g., learning disability, psychiatric disorders) as well as ruling out differential diagnoses of ADHD (e.g., hearing or visual impairment, thyroid disorders, sleep disorders). [7]

Diagnostic criteria

DSM-5 diagnostic criteria for ADHD [12]
ADHD, inattentive type ADHD, hyperactive type
  • Symptoms of inattention: ≥ 6 the following symptoms if 4–16 years of age or ≥ 5 symptoms if ≥ 17 years of age must be present.
    • Poor attention to detail
    • Struggles to maintain attention
    • Avoids activities that require uninterrupted focus or concentration
    • Easily distracted
    • Does not listen when directly spoken to
    • Inability to complete tasks or instructions
    • Forgetful
    • Loses items used for everyday tasks
    • Struggles with organization of tasks and activities
  • Behavior is not consistent with developmental level.
  • Symptoms of hyperactivity and impulsivity; ≥ 6 the following symptoms if 4–16 years of age or ≥ 5 symptoms if ≥ 17 years of age must be present.
    • Struggles to remain still
    • Fidgets, taps, or squirms when seated
    • Standing in situations in which they should be seated
    • Inappropriate running or climbing (or restlessness in adolescents and adults)
    • Unable to remain quiet during play or leisure activities
    • Excessive talking
    • Struggles with waiting for their turn
    • Intrudes upon others
    • Answers questions prematurely or for others
  • Behavior is not consistent with developmental level.
  • Present for ≥ 6 months in ≥ 2 settings (e.g., school, home, work) [7]
  • First noticed prior to 12 years of age
  • Associated with functional impairment (e.g., social, school, work) [13][14]
Exclusion of differential diagnoses
  • Symptoms do not solely occur during a psychotic episode (e.g., schizophrenia)
  • Symptoms cannot be better explained by another condition (e.g., another mental disorder, intoxication)

Differential diagnosestoggle arrow icon

Alternative causes of ADHD symptoms and common comorbidities include: [7][8][12]

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [7][8][11]

  • Consider specialist referral for individuals with: [14][17]
    • Unclear diagnosis
    • Comorbidities that are severe and/or may affect ADHD management (see “Differential diagnosis of ADHD”) [7][11]
    • Inadequate response to management [14][17]
    • Suspected ADHD if < 4 years of age or symptoms first manifest at > 12 years of age [17]
  • Initiate first-line management based on the individual's age. [7]
    • Children 4–5 years of age: behavioral interventions alone
    • Children ≥ 6 years of age and adults: pharmacotherapy with adjunctive behavioral interventions [7][18]
  • Educate patients and caregivers on ADHD. [8]
    • Children may be eligible for accommodations at school; caregivers should contact their school district. [7][19]
    • Ensure patients get regular physical activity and sufficient sleep.
  • Manage comorbid mental health conditions, e.g., anxiety, depression, substance use disorder.
  • Schedule regular follow-up for patients with ADHD.

Refer individuals with ADHD and a history of substance use disorder to a psychiatrist. Consider treatment with medications that have a low potential for addiction (e.g., nonstimulants). [7]

Behavioral interventions [7][16]

  • Parent training in behavioral management (PTBM) [7]
    • Indication: caregivers with children 4–11 years of age with problematic behaviors (e.g., ADHD) [7]
    • Goals: reinforce preferred behaviors and reduce problematic behaviors
  • Classroom interventions: behavioral intervention plan (organized via the school district) [7][19]
  • Cognitive behavioral therapy (CBT): may be considered as adjunctive therapy for adults with ADHD [11][16][18]

PTBM can also be utilized for children who do not meet the full criteria for ADHD. [7]

Pharmacotherapy [8][11][20]

  • Options include stimulant and nonstimulant therapy.
  • Stimulant therapy is usually first-line treatment for children ≥ 6 years of age and adults. [7][8][21]
  • Nonstimulants are preferred for individuals with: [7][21]
    • Contraindications to or potential for serious adverse effects with stimulants [11]
    • A preference for nonstimulants
    • Certain comorbidities [22]

Stimulant therapy [20]

Methamphetamine has FDA approval for the treatment of ADHD but is rarely prescribed because of its high potential for misuse. [30]

Initiation of stimulant therapy

  • Review state and federal laws relevant to prescribing controlled substances (stimulants are Schedule II drugs). [7]
  • Consider implementing a controlled substance agreement. [7][11][16]
  • Obtain an ECG if either of the following are present: [7][31]
  • Inform individuals that effects may be noticed within 2–3 days of initiation. [21]
  • Start on a low dose and slowly titrate medication as necessary, e.g.:
    • Children: every 1–4 weeks [8]
    • Adults: every 4–6 weeks [11]
  • Arrange regular follow-up for patients with ADHD to monitor the effects of pharmacotherapy. [11][22]

Examples of stimulant medications used to treat ADHD [8][11][32]

Methylphenidate analogues

Amphetamine analogues


(8–12-hour duration)


(6–8-hour duration)

  • Methylphenidate long-acting (LA) or controlled delivery (CD) capsules [8]

Short-acting (i.e., immediate-release; 3–6-hour duration)

Stimulants are Schedule II controlled drugs because of their high risk of misuse; consider implementing a controlled substance agreement before prescribing. [7][11][33]

Long-acting stimulants are preferred because of increased adherence and reduced risk of misuse compared to short-acting stimulants. [8][34]

Nonstimulant therapy

Patients and caregivers should be informed that it may take 4–6 weeks for nonstimulants to reach maximum efficacy. [22]

Selective norepinephrine reuptake inhibitors [7][8][11]

SNRIs are not addictive or Schedule II drugs and therefore may be preferred for individuals with a history of substance use disorder. [35]

Atomoxetine has a black box warning for increased suicidal ideation in children and adolescents. Monitor individuals closely, especially during the first few weeks of treatment. [7]

Alpha-2 adrenergic agonists [26]

  • Indications: children 6–17 years of age with either of the following. [11]
    • Contraindications to stimulants [7]
    • Preference for nonstimulants
    • Inadequate response to stimulants alone (i.e., adjunctive therapy) [7]
  • Options: guanfacine ; extended-release or clonidine extended-release [7][8]

To avoid rebound hypertension, do not abruptly stop alpha-2 adrenergic agonists; taper gradually. [7]

Antidepressants [11]

Follow-up for patients with ADHD

  • Educate patients and caregivers on how to manage ADHD; see also “Chronic disease management.”
  • For patients on pharmacotherapy:
    • Advise patients and/or caregivers that several different medications and dosages may need to be trialed. [20]
    • Arrange regular scheduled follow-up appointments. [26]
      • Monthly until treatment is optimized
      • Every 3 months for at least the first year
      • Once stable, every 6 months
    • At every visit, assess vital signs and inquire about adverse effects. [26]
    • Laboratory studies are not routinely required. [26]
    • If the response is insufficient or significant adverse effects occur, consider medication adjustments.
    • Periodically reassess if medication is still required. [37]
  • For patients not on pharmacotherapy, arrange follow-up to: [7]
    • Reassess symptoms
    • Determine if medication is now indicated

In children, routine laboratory studies to monitor for medication adverse effects are generally not recommended. [26]

Prognosistoggle arrow icon

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Referencestoggle arrow icon

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