ADHD Clinical Practice Guidelines
Evidence-Based Recommendations from Major Medical Organizations

Key Recommendations:

Assessment & Diagnosis:

Treatment Recommendations:

Medication Management:

• Stimulants (methylphenidate, amphetamine): First-line pharmacotherapy, 70-80% response rate
• Non-stimulants (atomoxetine, guanfacine, clonidine): Second-line or adjunct
• Titration: Start low, increase gradually to optimal dose
• Monitoring: Height, weight, blood pressure, heart rate, appetite, sleep, mood
• Duration: Continue treatment as long as symptoms and impairment persist

Comorbidity Management:

• ADHD + Anxiety: Treat ADHD first; if anxiety persists, add anxiety-specific treatment
• ADHD + Depression: Consider SSRI + ADHD medication; CBT
• ADHD + ODD/Conduct: Behavioral parent training essential; medication alone insufficient
• ADHD + Autism: Stimulants effective but monitor for increased irritability

Key Recommendations:

For Primary Care Pediatricians:

Treatment Algorithm:

Medication Safety Monitoring:

• Baseline: Height, weight, blood pressure, heart rate
• Ongoing: Monitor at every visit (typically every 3-4 months)
• Cardiac: No routine ECG required unless history of cardiac disease
• Growth: Plot on growth chart; usually normalizes after initial suppression

Shared Decision-Making:

AAP emphasizes involving families in treatment decisions, discussing risks/benefits of all options, and supporting families who prefer non-medication approaches initially.

Key Recommendations:

Assessment Principles:

• Holistic approach: Consider psychological, social, and educational factors
• Multi-informant: Information from parents, teachers, and young person
• Differential diagnosis: Rule out attachment disorders, trauma, sleep disorders
• Comorbidity assessment: Screen for autism, learning disabilities, mood/anxiety disorders

Stepped Care Approach:

Medication Sequence:

1. First-line: Methylphenidate (immediate or modified-release)
2. Second-line: Lisdexamfetamine or dexamphetamine (if methylphenidate ineffective/intolerable)
3. Third-line: Atomoxetine (if stimulants ineffective/contraindicated)
4. Alternative: Guanfacine (if other options unsuccessful)

Monitoring Requirements:

• Pre-treatment: Height, weight, blood pressure, heart rate, ECG (if cardiac risk factors)
• During titration: Weekly (pulse, BP) until stable dose
• Maintenance: 3-monthly (height, weight) + 6-monthly (BP, heart rate)
• Annual review: Comprehensive assessment of symptoms, side effects, need for continuation

Drug Holidays:

NICE recommends considering planned breaks from medication (e.g., school holidays) to assess ongoing need and monitor growth, but only if clinically appropriate.

DSM-5-TR Diagnostic Criteria (2022):

Criterion A - Symptoms:

• Inattention: 6+ symptoms (5+ for adults age 17+) persisting ≥6 months
• Hyperactivity-Impulsivity: 6+ symptoms (5+ for adults) persisting ≥6 months

Criterion B - Age of Onset:

Several inattentive or hyperactive-impulsive symptoms present before age 12.

Criterion C - Pervasiveness:

Symptoms present in two or more settings (home, school, work, social situations).

Criterion D - Impairment:

Clear evidence symptoms interfere with or reduce quality of functioning.

Criterion E - Differential:

Symptoms not better explained by another mental disorder.

Specifiers:

• Combined Presentation: Criteria met for both inattention and hyperactivity-impulsivity
• Predominantly Inattentive: Inattention criteria met, hyperactivity-impulsivity not met
• Predominantly Hyperactive-Impulsive: Hyperactivity-impulsivity met, inattention not met

Severity:

• Mild: Few symptoms beyond required for diagnosis, minor impairment
• Moderate: Symptoms or impairment between mild and severe
• Severe: Many symptoms beyond required, marked impairment

Key Recommendations (for low-resource settings):

Assessment:

• Screen for behavioral and developmental problems in children
• Assess for inattention, hyperactivity, impulsivity using ICD-10 criteria
• Evaluate functional impairment in school, home, social settings
• Rule out other causes (hearing/vision problems, intellectual disability, trauma)

Management:

• Psychoeducation: Explain ADHD to parents and teachers
• Behavioral strategies: Teach parents behavioral management techniques
• School interventions: Work with teachers on classroom strategies
• Medication: Consider stimulants (methylphenidate) if available and severe impairment

ICD-10 vs ICD-11:

Note: WHO transitioned to ICD-11 in 2022. ICD-11 aligns more closely with DSM-5, using "Attention Deficit Hyperactivity Disorder" with presentations rather than separate disorders.