Attention deficit hyperactivity disorder (ADHD) is a common childhood-onset disorder characterised by inattention, hyperactivity, and/or impulsivity demonstrated across 2 or more settings (such as home and school).
Some impairment must be present by 12 years of age, and 60% to 70% of patients have persistent functional impairment into adulthood.
Diagnosed by clinical history, which should include information from multiple sources, including parents, carers, and teachers.
Mainstay of treatment is stimulant medication, which can be effective in 85% of patients; non-stimulants are less often effective, but may have other advantages in terms of duration of action or in particular populations.
Stimulant medications have been associated with cardiovascular side effects. These should be monitored in children with heart conditions.
ADHD is a problem of inattention, hyperactivity, and impulsivity according to the American Psychiatric Association. This disorder is recognised globally and is referred to as hyperkinetic disorder in Europe and other countries that use the WHO classification system. ADHD is a chronic condition with symptoms that begin in early childhood but often persist into adult life. A key element of the definition is functional impairment across two or more domains, most often in school and at home. As a result, ADHD can limit academic, interpersonal, and occupational success and can also lead to greater risk-taking and accidents. In addition, patients with ADHD are more likely to have co-existing psychiatric disorders such as oppositional defiant disorder (ODD), conduct disorder, substance abuse, and possibly mood disorders, such as depression and mania.
History and exam
Key diagnostic factors
- presence of risk factors
- failure to give close attention to details or making careless mistakes in school work, work, or other activities
- difficulty sustaining attention in tasks or play activities
- does not seem to listen when spoken to directly
- does not follow through on instructions and fails to finish school work, chores, or duties in the workplace
- often has difficulty organising tasks and activities
- avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework)
- often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
- easily distracted by extraneous stimuli
- forgetful in daily activities
- fidgets with hands or feet or squirms in seat
- leaves seat in classroom or in other situations in which remaining seated is expected
- runs about or climbs excessively during inappropriate situations
- difficulty playing or engaging in leisure activities quietly
- often 'on the go' or often acts as if 'driven by a motor'
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others (e.g., butts into conversations or games)
Other diagnostic factors
- mild mood symptoms (dysphoria, mood lability, irritability, boredom)
- difficulty with peer interactions
- low self-esteem
- working memory (i.e., short-term memory) impairment
- processing speed impairment (i.e., the rate at which information is dealt with)
- family history of ADHD
- male sex
- low birth weight
- maternal nicotine use during pregnancy
- maternal alcohol use during pregnancy
- stress during pregnancy and labour
- psychosocial adversity
- lead exposure
- traumatic brain injury
- severe early deprivation
- iron deficiency
1st investigations to order
- no formal laboratory or imaging studies
Investigations to consider
- neuropsychological testing
pre-school-aged children: 4-6 years
school-aged children: 6-18 years
Mark Wolraich, MD
Professor Emeritus, Pediatrics
Section of Developmental and Behavioral Pediatrics
University Oklahoma Health Sciences
MW has chaired the American Academy of Pediatrics committee on revising the ADHD guidelines, and is on the steering committee and a faculty member in the REACH Institute.
Dr Mark Wolraich would like to gratefully acknowledge Dr Lawrence W. Brown, Dr Kristin S. Russell, Dr Howard Y. Liu, and Dr Michael S. Jellinek, previous contributors to this topic.
LWB was reimbursed by Sunovion for participation in a Medical Advisory Board. KSR, HYL, and MSJ declare that they have no competing interests.
Brian P. Daly, PhD
College of Health Professions
BPD declares that he has no competing interests.
Mohammed Munib Haroon, MBChB
Academic Specialist Registrar
Academic Department of Paediatrics and Obstetrics and Gynaecology
MMH declares that he has no competing interests.
- Learning/language disorder
- Oppositional defiant disorder
- Attention deficit hyperactivity disorder: diagnosis and management
- Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents
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