Attention/activity level DTW

ADHD Basic Care


ADHD has 3 core symptoms = Distractibility, Impulsivity, and Hyperactivity[note] which must be relative to peers and causing difficulties.

Key Points

Assessment requirements:

Not indicated:

Recommended stimulants work equally well
Children who fail to respond to one stimulant medication may respond to another.

For 3-5 year old children with symptoms, consider other diagnoses before ADHD (See: Differential Diagnosis) but treat as ADHD if appropriate.

Look for common comorbid conditions initially and at follow up Including Oppositional Defiant Disorder, Conduct Disorder, Anxiety, Depression, and Learning Disorders (See: Comorbid Conditions).

Latest research on ADHD


  1. ADHD Basic Care
    1. Definitions
    2. Key Points
    3. Management
  2. Definitions
    1. Variations
    2. Problems
    3. Disorders
  3. Key Points
  4. Differential Diagnosis and Comorbidity
  5. Management
  6. Appendices
    1. Medication Table
    2. Clinical Placebo Trial for Stimulant Medication
    3. Non-stimulant Medication Options for ADHD
    4. Non-medical Treatment Options for ADHD
    5. Results of Large ADHD MTA Study
    6. Tips For Teachers for Children with ADHD
    7. Parent Training Groups Citations
    8. ADHD Follow-Up Visit Goals
    9. Daily Report Cards
  7. Citations


According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (Wolraich, M. (Ed.) 1996) the following are the definitions for Impulsive/Hyperactive or Inattentive Behavior variations and problems.


V65.49 Hyperactive/Impulsive Variation

Young children in infancy and in the preschool years are normally active and impulsive and may need constant supervision to avoid injury. Their constant activity may be stressful to adults who do not have the energy or patience to tolerate the bahavior.

During school years and adolescence, activity may be high in play situations and impulsive behaviors may normally occur, especially in peer pressure situations.

High levels of hyperactive/impulsive behavior do not indicate a problem or disorder if the behavior does not impair function.

V65.49 Inattention Variation

A young child will have a short attention span that will increase as the child matures. The inattention should be appropriate for the child's level of development and not cause any impairment.


V40.3 Hyperactive/Impulsive Behavior Problem

These behaviors become a problem when they are intense enough to begin to disrupt relatipnships with others or begine to affect the acquisition of age-appropriate skills. The child displays some of the symptoms listed for the ADHD predominantly hyperactive/impulsive type. However, the behaviors are not sufficiently intense to qualify for a behavioral disorder such as ADHD, or of a mood disorder or anxiety disorder.

A problem degree of this behavior is also likely to be accompanied by other behaviors such as negative emotional behaviors or agressive/oppositional behaviors.

V40.3 Inattention Problem

A problem exists when some of the symptoms for the ADHD predominantly inattentive type are present and they create some difficulties for the child's parents and teachers and begin to affect some areas of academic and social functioning. However, the behaviors are not sufficiently intense to qualify for a behavioral disorder.


Attention Deficit Hyperactivity Disorders

  1. Either (1) or (2):
    1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:


      1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      2. often has difficulty sustaining attention in tasks or play activities
      3. often does not seem to listen when spoken to directly
      4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace ( not due to oppositional behavior or failure to understand instructions)
      5. often has difficulty organizing tasks and activities
      6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. often loses thing necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. is often easily distracted by extraneous stimuli
      9. is often forgetful in daily activities
    2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:


      1. often fidgets with hands or feet or squirms in seat
      2. often leaves seat in classroom or in other situations in which remaining seated is expected
      3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
      4. often has difficulty playing or engaging in leisure activities quietly
      5. is often "on the go" or often acts as if "driven by a motor"
      6. often talks excessively


      1. often blurts out answers before questions have been completed
      2. often has difficulty awaiting turn
      3. often interrupts or intrudes on others (e.g., butts into conversations or games)
  2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type

If Criterion A2 is met but Criterion A1 is not met for the past 6 months.

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

314.9 Attention-Deficit/ Hyperactivity Disorder Not Otherwise Specified

This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.

Key Points

  • Etiology/Epidemiology
  • See Clinical Guide Algorithm

    Latest research on ADHD

    Differential Diagnosis and Comorbidity


    Overarching Principles ( [broken reference] )

    Initial Visit

    Follow-up Visit:


    Medication Table

    Medication Table
    Forms Duration Dosage Comments
    d-isomer Immediate release tablets
    (Focalin) 2.5, 5, 10 mgs.
    3 - 4 hours Half regular dose or 0.15 - .3 mg/kg/dose -usually 3x/day
    d-isomer Extended release capsules
    (Focalin XR) 5, 10, 20 mgs.
    8 hours Equivalent to two immediate release tablets of d-isomer. Half the extended release Ritalin dosage. Can sprinkle on apple sauce. Acts like two immediate release tablets with two peaks 4 hours apart.
    Immediate release Regular (Riltalin) 5, 10, 20 mgs. 3 - 4 hours 0.3 - .6 mg/kg/dose -usually 3x/day
    Chewable Immediate release
    (Methylin) 2.5, 5, 10 mgs
    3-4 hours 0.3 - 0.6 mg/kg -3x/day Should wash down with liquid to avoid choking. Note Feb/ 2005 The FDA began a recall of 2.5-, 5-, and 10-mg methylphenidate HCl chewable tablets (Methylin CT) due to the potential for superpotent and subpotent lots. Expected to resume in March of 2006. High fat meals delay onset by 1 hour.
    Oral Solution Immediate release
    (Methylin) 5 and 10 mg/5 cc
    3-4 hours 0.3 - 0.6 mg/kg -3x/day High fat meals delay onset by 1 hour.
    Sustained-release (SR) 20 mgs. 2 - 8 hours Variable 2x Ritalin dose or .6 - 1.2 mg/kg/dose -usually 1x/day
    Spansule capsules (Metadate CD) 20 mgs. 6 hours Variable 2x Ritalin dose -usually 1x/day; Before breakfast Beads are 30% short and 70% long acting; food can delay early peak by one hour
    Osmotic pump (Concerta) 18, 27, 54 mgs. 12 hours 3x Ritalin dose or 0.9 - 1.8 mg/kg/dose -usually 1x/day Occasional sleep problems; Capsule is nondeformable and should not be administered to someone with intestinal narrowing; absorption not affected by food
    Transdermal Patch (Daytranna)
    Patch Sizes 12.5 cm2 18.75cm2 25cm2 37.5cm
    2 hour onset delay until at least 3 hours after patch removed See Table Below More nausea, anorexia, and insomnia than Concerta.
    Probably should be reserved for children who cannot take oral medication because of potential rare sensitizing to future oral methylphenidate if child develops a rash to the transdermal.
    Patch size (cm2) Mg/hr Mg/ 9 hrs Mg/patch Concerta Equivalent
    12.5 1.1 10 27.5 18 mg
    18.75 1.6 15 41.3 27 mg
    25 2.2 20 55 36 mg
    37.5 3.3 30 82.5 54 mg
    Forms Duration Dosage Comments
    Regular (Dextrostat)
    5, 10 mg.
    4 - 5 hours 0.15-0.25mg/kg/dose up to .4 mg/kg/dose 2 - 3 x/day
    Spansule capsules (Dexedrine)
    10, 15 mg.
    6 - 8 hours 0.3 - 0.5mg/dose 1x/day Occasional sleep problems
    (Vyvanse) capsules Lisdexamfetamine dimesylate (l-lysine plus dextroamphetamine This 'pro-drug' combination rapidly breaks down in GI tract) 20, 30, 40, 50, 60, 70 mg 12 hours Titrate by 20 mg per week until reaching optimized dose; Some children may need the highest recommended 'adult dose' of 70 mg The advantage of the 'pro-drug' is that without being digested the dextroamphetamine is not active and therefore is not of use to substance users through the IV or nasal route; can be taken with our without food and can be opened and poured onto applesause
    Mixed Amphetamine Salts
    Forms Duration Dosage Comments
    Regular (Adderall)
    5, 7.5, 10, 12.5, 15, 20, 30 mgs
    6 - 8 hours 0.15--.25mg/kg/dose up to .4/kg/dose
    Spansule capsules (Adderall XR)
    10, 15, 20, 25, 30 mgs.
    9 - 12 hours 0.3 - 0.5mg/dose 1x/day Can open capsule and pour beads in applesauce

    Clinical Placebo Trial for Stimulant Medication

    Non-stimulant Medication Options for ADHD


    1. 1-4 mg/kg /2-3 doses/day
    2. EKG monitoring


    1. 4-5 microgram/kg/day
    2. Alternative: Guanfacine (Tenex) long acting, especially for aggression and when sedation
    3. HS needed
    4. CVS concerns

    Bupropion (Wellbutrin)

    1. Antidepressant with stimulant action (beta noradrenergic receptors and prefrontal lobe)
    2. Significant effect on ADHD but less effect size than first line stimulants
    3. Better than nicotine patch for smoking cessation ("Zyban")
    4. Dosage: 3-6mg/kg (</=300/day); 75, 100, & 150mgSR
    5. Side-effects (especially if increase fast)
      1. a. Increased seizure threshold (rate = .06%)
      2. b. Agitation, insomnia

    Non-medical Treatment Options for ADHD

    Results of Large ADHD MTA Study

    Reference: NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit Disorder. The MTA Cooperative Group. Arch. Gen. Psychiatry. 1999; 56: 1088-1096

    Tips For Teachers for Children with ADHD

    1. Avoid Embarrassment
    2. Reduce Distracters, increase salience
      1. Keep desk free from extraneous stuff
      2. Use novel things/topics or ways of teaching
      3. Try to intersperse things of low-interest to child with things of high interest
      4. Organize child's tasks into small manageable sections
    3. Keep them engaged-ask for immediate recall of information just presented
    4. Clearly display classroom rules; give instruction visually as well as verbally.
      1. Have child repeat the instruction out loud and softly to himself while completing the task.
    5. Teacher can use subtle techniques to cue his/her attention
      1. Closing classroom door
      2. Flashing classroom lights.
      3. Lightly tapping/touching child's desk
    6. Swift, frequent, and immediate delivery of consequences
    7. Varied and rich incentive for appropriate behavior
    8. Consistent routine
      1. Advise ADHD children of the day's schedule as early as possible in the day
    9. Structure-ADHD children need reminders, previews, repetition, and direction
    10. Organization-they need help in how to organize their lives. These can be helpful
      1. Clipboard
      2. Post-it notes for marking pages
      3. Large 3-ring notebook
      4. Color coded dividers
      5. Highlighters for marking notes
      6. Index cards
    11. Environmental concerns-An ADHD child should be seated where the following are minimized:
      1. Excessive noise
      2. Temperature fluctuations
      3. Visual stimulation (windows to look out of)
      4. Doors
      5. Traffic
    12. ADHD children can benefit from doing some work on computers. This helps to hold their attention-especially when exercises are interactive

    Parent Training Groups Citations

    Anastopoulos, A. D., Shelton, T., DuPaul, G. J., & Guevremont, D. C. (1993). Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning. Journal of Abnormal Child Psychology, 21, 581-596.

    Firestone, P. & Witt, J.E. (1982). Characteristics of families completing and prematurely discontinuing a behavioral parent training program. Journal of Pediatric Psychology, 7, 209-222.

    Pisterman, S., Firestone, P. McGrath, P., Goodman, J. T., Webster, I., Mallory, R., & Goffin, B. (1992). The role of parent training in treatment of preschoolers with ADD-H. American Journal of Orthopsychiatry, 62, 397-408.

    ADHD Follow-Up Visit Goals

    Daily Report Cards

    1. Parent should set up a meeting with teacher.
    2. They should set 3-5 daily goals for the child (phrased in positive terms).
      1. Examples of goals
      2. academic performance
      3. having necessary classwork materials (coming to class prepared)
      4. remembering to bring in homework(regardless of accuracy)
      5. completing tasks accurately (regardless of speed)
      6. completing and returning homework.
      7. Remains seated
      8. Raises hand and waits to be called on to speak.
    3. Once the goals have been identified, the parent and teacher can decide how many "yes's" the child need have to get certain privileges at home.
      1. Rewards need to be selected carefully so that the child will want to work hard to meet those goals.
      2. In addition to daily rewards, children often do well when they can work up to weekly or monthly rewards, too.
      3. Parents will need to be continually involved in this process if it is to be successful. Goals need to be frequently reviewed and modified.
    4. If parents can't navigate this on their own, they may want to get a consultant or therapist to help them set up such an arrangement with the school.

    Note: There is limited research on the effectiveness of these daily report cards. However, research (Fuchs & Fuchs, 1989) suggests that if they are not carefully monitored they are often ineffective. (chapter by Pelham & Waschbusch (1999) entitled "Behavioral intervention in ADHD" in the Handbook of Disruptive Behavior Disorders (Edited by Quay & Hogan)]


    1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
    2. Aylward, E.H., Reiss, A.L., Reader, M.J., Singer, H.S., Brown, J.E., Denckla, M. B. (1996). Basal Ganglia Volumes in Children with ADHD. .
    3. Barkley, R.A. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment..
    4. Castellanos, F.X., Giedd, J.N., Marsh, W.L., Hamburger, S.D., Vaituzis, A.C., Dickstein, D.P., et al. (1996). Quantitative Brain Magnetic Resonance Imaging in Attention-Deficit Hyperactivity Disorder. .
    5. Culbert, T.P., Banez, G.A., Reiff, M.I. (1994). Children who have Attentional Disorders: Interventions. .
    6. Cook Jr., E.H., Stein, M.A., Krasowski, M.D., Cox, N.J., Olkon, D.M., Kieffer, J.E., et al. (1995). Association of Attention-Deficit Disorder and the Dopamine Transporter Gene. .
    7. Diller, L.H. (1998). Running on Ritalin.
    8. Gill, M., Daly, G., Heron, S., Hawi, Z., Fitzgerald, M. (1997). Confirmation of Association Between Attention Deficit Hyperactivity Disorder and a Dopamine Transporter Polymorphism. .
    9. Giros, Bruno, Jaber, Mohamed, Jones, Sara R, Wightman, Mark R, Caron, Marc G (). Hyperlocomotion and Indifference to Cocaine and Amphetamine in Mice Lacking the Dopamine Transporter. .
    10. Greenhill, L.L. (). Attention-deficit hyperactivity disorder. The stimulants.. .
    11. Hynd, G.W., Hern, K.L., Novey, E.S., Eliopulos, D., Marshall, R., Gonzalez, J.J., et al. (1993). Attention deficit-hyperactivity disorder and asymmetry of the caudate nucleus. .
    12. Lou, H.C., Henriksen, L., Bruhn, P. (1990). Focal cerebral dysfunction in developmental learning disabilities. .
    13. The MTA Cooperative Group (1999). NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit Disorder. .
    14. Rapoport, J.L., Buchbaum, M.S., Zahn, T.P., Weingartner, H., Ludlow, C., Mikkelsen, E.J. (1978). Dextroamphetamine: cognative and behavioral effects on normal prepubertal boys. .
    15. Reiff, M.I., Banez, G.A., Culbert, T.P. (1993). Children Who Have Attentional Disorders: Diagnosis and Evaluation. .
    16. Szatmari, P, Offord, DR, Boyle, MH (1989). Correlates, associated impairments and patterns of service utilization of children with attention deficit disorder: findings from the Ontario Child Health Study. .
    17. Swanson, J.M., Sunohara, G.A., Kennedy, J.L., Regino, R., Fineberg, E., Wigal, T., et al. (1998). Association of the dopamine receptor D4 (DRD4) gene with a refined phenotype of attention deficit hyperactivity disorder (ADHD): a family-based approach.. .
    18. Vaidya, C.J., Austin, G., Kirkorian, G., Ridlehuber, H.W., Desmond, J.E., Glover,G.H., et al. (1998). Selective effects of methylphenidate in Attention Deficit Hyperactivity Disorder: A functional magnetic resonance study. .
    19. Wasserman, RC, Kelleher, KJ, Bocian, A, et al (1999). Identification of attentional and hyperactivity problems in primary care: a report from pediatric research in office settings and the ambulatory sentinel practice network. .
    20. Wolraich, M. (Ed.) (1996). Diagnostic and Statistical Manual for Primary Care (DSM-PC): Child and Adolescent Version.
    21. Wolraich, ML, Hannah, JN, Pinnock, TY, et al (1996). Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. .
    22. Zametkin, A.J., Ernst, M. (1999). Problems in the Management of Attention-Deficit-Hyperactivity Disorder. .


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