9.1 ADHD Assessment & Management
Key Takeaways
- DSM-5-TR ADHD is a ≥6-month pattern of inattention and/or hyperactivity-impulsivity with onset before age 12, two or more settings, and clear impairment — not a single parent checklist
- NICHQ Vanderbilt parent and teacher scales are the usual primary-care tools; also consider mimics: sleep apnea, hearing loss, anxiety, trauma, learning disability, lead, and thyroid disease
- AAP 2019: ages 4–5 start with evidence-based parent training in behavior management; do not open with medication in preschool without a behavioral attempt
- From age 6, pair an FDA-approved medication with behavioral therapy; approved classes are methylphenidate, amphetamines, atomoxetine, extended-release guanfacine, and extended-release clonidine
- Before stimulants, take a cardiac history and examination; monitor blood pressure, heart rate, growth, sleep, and appetite; recheck about 2–4 weeks after a start or dose change and include 504/IEP supports
Developmental, behavioral, and mental health is clinical category #1 by exam volume on the PNCB CPNP-PC outline. ADHD is the diagnosis you will see most often in that bucket. Domain II wants a valid assessment. Domain III wants a primary-care management plan: behavioral therapy, FDA-approved medication when the guideline says so, school supports, and monitoring. You are not writing a child-psychiatry consult. You are deciding whether DSM-5-TR is met, whether something else is mimicking ADHD, and what the AAP 2019 clinical practice guideline does at this age.
DSM-5-TR: a pattern, not a personality
ADHD is a neurodevelopmental pattern of inattention and/or hyperactivity-impulsivity. DSM-5-TR names three presentations:
| Presentation | What you document |
|---|---|
| Predominantly inattentive | ≥6 inattention symptoms (5 if age 17 or older): careless mistakes, seeming not to listen, poor organization, losing things, distractibility, forgetfulness, avoiding sustained mental effort |
| Predominantly hyperactive-impulsive | ≥6 hyperactive-impulsive symptoms (5 if 17 or older): fidgeting, leaving the seat, running/climbing or inner restlessness, talking excessively, blurting, difficulty waiting, interrupting |
| Combined | Thresholds met in both clusters |
Duration is ≥6 months. Several symptoms were present before age 12. Symptoms occur in two or more settings (home, school, after-school care, activities). There is clear functional impairment — grades, friendships, safety, or family life. The picture is not better explained by another disorder.
Onset after 12, symptoms only during a custody change, or a perfect school day with chaos only at one parent's house is not ADHD until you explain the setting mismatch. Combined presentation is common in school-age referrals. Inattentive presentation is easy to miss in quiet children who "daydream" and fall behind in writing.
Vanderbilt is multi-informant, not a parent form
The NICHQ Vanderbilt ADHD Diagnostic Rating Scale is the usual primary-care instrument. You need parent and teacher versions. Each covers DSM symptom counts plus performance (reading, writing, math, classroom behavior, peer relations) and screens oppositional, conduct, anxiety, and depression items.
A single parent checklist is not a diagnosis. Teachers see peer comparison and academic demand. If the teacher scale is negative and school function is fine, pause — anxiety, insufficient sleep, or a home-only behavior problem may be driving the parent form. If school is collapsing and the parent minimizes, the teacher scale still counts as a second setting.
Repeat Vanderbilt (or the follow-up version) after treatment so you are tracking symptoms, not only "a parent says the medicine works."
Mimics you must think about before you prescribe
ADHD is common, and comorbidity is the rule. Before you lock the label, look for conditions that imitate inattention or hyperactivity.
| Mimic | Why it looks like ADHD | What the CPNP-PC actually does |
|---|---|---|
| Obstructive sleep apnea / short sleep | Inattention, irritability, "hyper" when exhausted | Ask snoring, gasping, adenoidal facies, obesity, a screen in the bedroom; restore sleep opportunity; refer sleep or ENT when OSA is likely |
| Hearing loss | "Does not listen" | Audiology — do not start a stimulant for an untested language-delay child |
| Anxiety | Restlessness, poor concentration | Worry, avoidance, somatic complaints, school-morning pattern |
| Trauma | Hypervigilance, concentration failure | Trauma history, nightmares, startle; do not treat PTSD as ADHD first |
| Learning disability | Off-task only in reading or math | Psychoeducational testing and academic supports |
| Lead | Irritability, inattention | Housing, pica, blood lead when indicated |
| Thyroid disease | Activity and attention change | Growth, goiter, constipation or diarrhea, family history |
You do not order a full endocrine panel on every fidgety 8-year-old. You do take a sleep, hearing, trauma, mood, and academic history, and you do not skip the teacher.
Clinic vignette. A 7-year-old's parent Vanderbilt is sky-high. He snores nightly, mouth-breathes, and has never had an audiogram. School calls him tired and spacey. Treat the airway and hearing question before you commit to combined-type ADHD and a stimulant.
AAP 2019: age changes first-line therapy
The AAP clinical practice guideline (Wolraich et al., 2019) is the management spine. ADHD is a chronic condition in a medical home. Treatment is age-banded.
| Age | First-line AAP approach |
|---|---|
| 4–5 years | Evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions. Medication is not first-line. If function remains moderately to severely impaired after behavioral therapy, methylphenidate may be considered, weighing a smaller pediatric evidence base and adverse effects. |
| 6–11 years | FDA-approved medication AND PTBM and/or behavioral classroom interventions. Stimulants have the strongest evidence. |
| 12–18 years | FDA-approved medication with the adolescent's assent, plus encouraged behavioral interventions. Screen substance use. Titrate to benefit with tolerable effects. |
Preschool trap: starting a stimulant because a parent is exhausted, without a PTBM attempt (Incredible Years, Triple P, Parent-Child Interaction Therapy, or an equivalent evidence-based program). If PTBM is scarce in your community, document the barrier, still give office-based behavioral guidance, and do not treat unavailability as permission to skip the concept on the exam.
School-age trap: a pill without any behavioral or school plan. From age 6 the guideline is medication with behavioral treatment, not a prescription that replaces parent training and classroom supports.
FDA-approved medications — classes, not a milligram encyclopedia
Start low, titrate to effect, and know which agents are FDA-approved for ADHD:
- Methylphenidate products (immediate- and extended-release; methylphenidate and dexmethylphenidate)
- Amphetamine products (mixed amphetamine salts, lisdexamfetamine, dextroamphetamine)
- Atomoxetine (norepinephrine reuptake inhibitor; not a stimulant)
- Extended-release guanfacine and extended-release clonidine (alpha-2 adrenergic agonists)
The ADHD FDA approvals for alpha-2 agonists are the extended-release forms. Stimulants remain first-line by evidence for most school-age children without a contraindication. Atomoxetine is useful when substance misuse is a concern, when tics or anxiety dominate, or when a nonstimulant is preferred; onset is measured in weeks, not a weekend. Alpha-2 agonists help as monotherapy or adjunct, especially with tics, sleep-onset difficulty, or residual hyperactivity; they can lower blood pressure and cause sedation.
You do not need every milligram row. You do need: start low, avoid large adult-style opening doses in small children, and know that "any ADHD medicine" is not the same as "FDA-approved for this age."
Before the first stimulant: cardiac history, not a reflex ECG
Take a cardiac history and examination before stimulants: exertional chest pain, unexplained syncope, palpitations, dyspnea, and family history of sudden unexplained death, cardiomyopathy, Wolff-Parkinson-White, or long QT. Examine heart rate, blood pressure, and the precordium. If history and examination are normal, a routine ECG is not required by AAP. Abnormal history or examination — do not start the stimulant until cardiology has cleared the child.
Stimulants carry a boxed warning for high potential for abuse and dependence: lock the bottle, count pills with adolescents, and screen for diversion. Atomoxetine carries a boxed warning for suicidal ideation; counsel and follow mood after start. A boxed warning is not a "never use" stamp.
Monitoring, school, follow-up
At baseline and on treatment, track blood pressure, heart rate, height, weight, sleep, and appetite. Stimulants commonly suppress appetite and delay sleep. Dose after breakfast, protect calories with an afternoon snack, and keep the evening dose from wrecking sleep. A flattening height or weight curve is a reason to adjust timing, discuss a structured holiday, or change agents — not a reason to ignore the growth chart.
See the child about 2–4 weeks after a stimulant start or dose change (sooner if severe adverse effects). Once stable, chronic-care visits still include vitals, growth, school function, and a side-effect review.
Section 504 accommodations (extra time, preferential seating, movement breaks, reduced distractions) often suffice when ADHD is the main educational issue. An IEP under IDEA is specialized instruction when ADHD — commonly coded as Other Health Impairment — adversely affects educational performance. Write school letters that describe function and needed supports. You do not "prescribe" an IEP; you document impairment and partner with the school.
Clinic vignette. An 8-year-old meets combined-type criteria on parent and teacher Vanderbilt scales, sleeps 10 hours without snoring, hears well, and is failing writing because he cannot stay in the seat. AAP-consistent care is a stimulant and a behavioral classroom/parent plan, a 504 discussion, cardiac history, and a 2-to-4-week follow-up for blood pressure, heart rate, appetite, and sleep — not a six-month "call if there are problems" send-off.
Exam traps
- Diagnosing from one parent checklist.
- Starting medication in a 4- or 5-year-old without a behavioral-therapy attempt.
- Medication without behavioral and school supports from age 6.
- Skipping cardiac history — or ordering a reflex ECG on every healthy child.
- Never plotting growth after a stimulant starts.
- Treating OSA, hearing loss, or trauma as ADHD because inattention items lit up.
Pattern, two settings, mimics, age-banded AAP therapy, then monitor. That is ADHD on this exam.
A 5-year-old has eight months of hyperactivity and impulsivity at home and preschool. Parent and teacher Vanderbilt scales are positive, sleep and hearing are adequate, and there is no trauma history. What is the AAP 2019 first-line management step?
Which set of findings supports a DSM-5-TR ADHD diagnosis in primary care rather than a single-setting or acute problem?
An 8-year-old meets combined-type ADHD criteria on parent and teacher Vanderbilt scales. Cardiac history and examination are normal. You start a methylphenidate product with a behavioral school plan. Which monitoring plan matches AAP primary-care practice?