UCSF BENIOFF CHILDREN’S HOSPITALs

Mental Health Clinical Guidelines

Attention Deficit/Hyperactivity Disorder (ADHD) in Children & Adolescents

Shelly Nakaishi, CPNP, and

Petra Steinbuchel, MD, Medical Director, Division of Mental Health & Child Development
 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

General Clinical Guidance Overview

 Pediatric primary care providers are on the front lines  ADHD is a neurocognitive executive function deficit
for preventing, screening, assessing, treating, and that results in failure to maintain an appropriate
monitoring pediatric mental health concerns. problem-solving set to attain a future goal likely
 The primary care clinician should initiate an evaluation involving fronto-striatal dopaminergic circuits.
for ADHD for any child 4 to 18 years of age who  ADHD has had multiple prior names, including
presents with academic or behavioral problems and “hyperkinetic syndrome of childhood” and “ADD.” Is
symptoms of inattention, hyperactivity, or impulsivity is now known as: 1) ADHD, inattentive type; 2) ADHD,
(quality of evidence B/strong recommendation). hyperactive/impulsive type; or 3) ADHD, combined type.
 The American Academy of Pediatrics has  Prevalence of ADHD is 3 to 12 percent; males are
recommended that the first step for addressing ADHD affected more than females by a ratio of 2–4 to 1.
and other common pediatric mental health concerns  ADHD continues in 60 to 85 percent of teens and
be to develop standard office procedures. in 40 percent or more of adults, with youth typically
 This booklet will give recommendations for children outgrowing hyperactivity first, followed by impulsivity.
and youth with suspected/diagnosed ADHD aged 4 to The most common residual symptom is inattention.
18 years:  ADHD is associated with higher rates of criminal and
„„ Screening tools antisocial behavior, greater marital and employment
„„ Treatment protocols difficulty, and higher rates of teen pregnancy, single
„„ Resource and referral guides parenthood, and MVAs.
„„ Criteria for consultation.  Untreated ADHD creates risks for low self-esteem and
depression due to a lack of progression along normal
academic and socio-emotional trajectories.
 Heritability is 76 percent (eight genes implicated; DAT,
D4).
For More Information  ADHD is associated with maternal smoking/substance
abuse, perinatal stress, low birth weight, traumatic
Oakland Campus brain injury, and severe early deprivation.
Phone: 510-428-8428
These guidelines will cover screening, assessment,
San Francisco Campus
treatment, and referral criteria. These guidelines will not
Phone: 415-476-7000
cover how to make specific referrals for specialty care or
therapy.

UCSF B enioff C hildren’s H osp itals 2

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Core Symptoms of ADHD Are Divided into two Symptom Clusters:

Inattention and Hyperactivity/Impulsivity
Inattention Hyperactivity/Impulsivity
Inattention manifests as six or more symptoms Hyperactivity/impulsivity manifests as six or more
for children up to age 16 years, or five or more for symptoms for children up to age 16 years, or five or more
adolescents 17 years and older and adults. Symptoms of for adolescents 17 years and older and adults. Symptoms
inattention will have been present for at least six months, of hyperactivity/impulsivity will have been present for
and they are inappropriate for the child or adolescent’s at least six months to an extent that is disruptive and
developmental level. Someone with ADHD: inappropriate for the child or adolescent’s developmental
 Often fails to give close attention to details, or makes level. Someone with ADHD:
careless mistakes in schoolwork, at work, or with other  Often fidgets with or taps their hands or feet, or
activities. squirms in their seat.
 Often has trouble holding attention on tasks or play  Often leaves their seat in situations when remaining
activities. seated is expected.
 Often does not seem to listen when spoken to directly.  Often runs about or climbs in situations where it is not
 Often does not follow through on instructions and appropriate (adolescents or adults may be limited to
fails to finish schoolwork, chores, or duties in the feeling restless).
workplace (e.g., loses focus, gets sidetracked).  Often is unable to play or take part in leisure activities
 Often has trouble organizing tasks and activities. quietly.
 Often avoids, dislikes, or is reluctant to do tasks that  Is often “on the go,” acting as if “driven by a motor.”
require mental effort over a long period of time—  Often talks excessively.
including schoolwork or homework.  Often blurts out an answer before a question has been
 Often loses things necessary for tasks and activities completed.
(e.g., school materials, pencils, books, tools, wallets,  Often has trouble waiting their turn.
keys, paperwork, eyeglasses, mobile telephones).  Often interrupts or intrudes on others (e.g., butts into
 Is often easily distracted. conversations or games).
 Is often forgetful in daily activities.

UCSF B enioff C hildren’s H osp itals 3

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Core Symptoms of ADHD Are Divided into two Symptom Clusters:

Inattention and Hyperactivity/Impulsivity (cont.)
In addition, to recognize ADHD, the following conditions Based on the types of symptoms, three kinds
must be met: (presentations) of ADHD can occur:
 Several inattentive or hyperactive-impulsive symptoms  Predominantly inattentive presentation: if enough
were present before age 12. symptoms of inattention, but not hyperactivity/
 Several symptoms are present in two or more settings, impulsivity, were present for the past six months.
including home, school, or work; with friends or  Predominantly hyperactive/impulsive presentation: if
relatives; or in other activities. enough symptoms of hyperactivity/impulsivity, but not
 There is clear evidence that the symptoms interfere inattention, were present for the past six months.
with or reduce the quality of social, school, or work  Combined presentation: if enough symptoms of both
functioning. criteria—inattention and hyperactivity/impulsivity—
 The symptoms are not better explained by another have been present for the past six months.
mental disorder, such as a mood disorder, anxiety
disorder, dissociative disorder, or personality disorder. Because symptoms can change over time, the
The symptoms do not happen only during the course presentation may change over time as well.
of schizophrenia or another psychotic disorder.
For adults and adolescents age 17 years or older, in
order to recognize ADHD, only five symptoms are needed
instead of the six needed for younger children.

History
Subjective  Obtain the patient’s history:
 Interview the child and caregivers using screening „„ Prior evaluations and treatments.
questions with an emphasis on developmental history „„ Current treatments, including alternative/
(especially language, diet, sleep, schedule, trauma, complementary treatments such as acupuncture,
and academic history). Many children with ADHD will herbs, and yoga.
not subjectively notice or endorse symptoms. Assess  Obtain a family history of mental illness, with special
for comorbid or mimicking psychiatric conditions, emphasis on ADHD, learning disorders, and erratic
e.g., depression, and anxiety, including PTSD. Often work and/or social history with frequent changes.
parents will give a history of lifelong difficulty with
 Obtain a sleep history.
sitting still, acting before thinking, losing things
 Obtain a record of adverse childhood experiences or
easily, pervasive disorganization, and failure to turn in
trauma history.
homework even when completed.
 Consider the child’s culture and culture-informed
 Determine the current psychosocial and environmental
perceptions of caregivers and teachers.
structures.

UCSF B enioff C hildren’s H osp itals 4

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

History (cont.)
Objective  Screen for substances with those who are age 12 or
 Perform physical/mental status examination: older.
„„ Note that not all children/adolescents will „„ The CRAFFT screening tool is recommended.
demonstrate ADHD symptoms in a one-on-one The questionnaire takes less than five minutes to
office setting evaluation. complete and score, and it can be scored by the
doctor, nurse, medical technician, or other office
„„ Assess for other possible comorbid physical
staff member prior to the patient’s exam with the
conditions, espcially when indicated by history
PCP. See the appendix for the CRAFFT on page 11.
(may include sleep apnea, anemia, allergies, thyroid
disease, celiac disease/gluten sensitivity, and/or „„ It is recommended that parents are informed that
tics). Persons with zinc and iron deficiencies can a behavioral health screening questionnaire will
present with ADHD symptoms and, when treated, be administered as part of the exam. In order
the ADHD symptoms may resolve. to obtain honest answers, patients should be
left alone to complete the CRAFFT in a private
„„ Note that ADHD symptoms are usually present
environment and should be informed of their rights
throughout life, though sometimes symptoms
regarding confidentiality before the questionnaire is
may not cause impairment until school demands
administered.
become more complex—especially if a child has
other compensatory mechanisms (e.g., giftedness, „„ Perform a toxicology screen if appropriate, as the
parents who scaffold, or symptom of inattention rate of substance abuse, especially tobacco use, is
only). However, if inattention, hyperactivity, or higher in youth with ADHD.
impulsivity suddenly develop in an older child, „„ Clinicians should assess adolescent patients with
evaluate for other causes. newly diagnosed ADHD for symptoms and signs of
 Commonly used screens include the Vanderbilt, the substance abuse. When these signs and symptoms
Connors, and the ADHD Symptom Checklist. See the are found, evaluation and treatment for addiction
appendix on page 11 for Vanderbilt tools. should precede treatment for ADHD, if possible, or
careful treatment for ADHD can begin if appropirate
and necessary.
Screen for comorbid conditions: oppositional defiant
disorder (ODD) 54 to 84 percent, conduct disorder (CD)
25 to 45 percent, substance abuse 15 to 19 percent,
learning disorders 25 to 35 percent, anxiety disorders 33
percent, depression 0 to 33 percent, bipolar disorder
0 to 16 percent.
 Vanderbilt offers a screen for learning disorders,
depression, anxiety, ODD, and CD.
 For anxiety, you can use the SCARED anxiety
rating scale or RCADS anxiety rating scale. See the
appendix.
 If there are bipolar diagnosis concerns, consult with a
psychiatrist.
 For co-occurring mental and complicated medical
conditions, or for multiple comorbid psychiatric
conditions, consider a referral to psychiatry.

UCSF B enioff C hildren’s H osp itals 5

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Plan and Treatment for ADHD

Recommendations for treatment of children and youth The PCP should help the family advocate for a 504 or
with ADHD vary depending on the patient’s age. individualized educational plan (IEP) when appropriate,
as educational interventions may be a key component of
For preschool-aged children (4 to 5 years of age): treatment for ADHD. Most students with only ADHD will
The primary care physician (PCP) should prescribe qualify for a 504 but may not qualify for an IEP unless
evidence-based, parent- and/or teacher-administered there are comorbid disorders. Regardless, the Individuals
behavior therapy as the firstline of treatment (quality with Disabilities Education Act (IDEA) requires schools to
of evidence A/strong recommendation). PCPs may meet the educational needs of eligible students who have
also prescribe short-acting methylphenidate if the disabilities. Schools must evaluate students suspected
behavior interventions do not provide significant of having disabilities—including learning disabilities—but
improvement and there is a moderate to severe level not every child with learning and attention issues qualifies
of continuing disturbance in the child’s functioning. In for special education services under IDEA. Interventions
areas where evidence-based behavioral treatments are may include preferred seating, extended time on tests,
not available, the clinician needs to weigh the risks of limitations on homework, and improved communication
starting medication at an early age against the harm of between parents and teachers to help students with
delaying diagnosis and treatment (quality of evidence B/ ADHD develop improved organizational habits that are
recommendation). consistent with those of their peers.

For elementary school-aged children (6 to 11 years

of age): The primary care clinician should prescribe
U.S. Food and Drug Administration (FDA)-approved
medications for ADHD (quality of evidence A/strong
recommendation) and/or evidence-based, parent- and/
or teacher-administered behavior therapy as treatment
for ADHD—preferably both (quality of evidence B/strong
recommendation). The evidence is particularly strong
for stimulant medications (75- 90-percent effective) and
sufficient but less strong for atomoxetine, extended-
release guanfacine, and extended-release clonidine (in
that order, 50- 60-percent effective) (quality of evidence
A/strong recommendation). The school environment,
program, or placement is a part of any treatment plan.

For adolescents (12 to 18 years of age): The primary

care clinician should prescribe FDA-approved medications
for ADHD with the assent of the adolescent (quality of
evidence A/strong recommendation) and may prescribe
behavior therapy as treatment for ADHD (quality of
evidence C/recommendation)—preferably both.

The primary care clinician should titrate doses of

medication for ADHD to achieve maximum benefit with
minimum adverse effects (quality of evidence B/strong
recommendation).

UCSF B enioff C hildren’s H osp itals 6

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Behavioral Therapy
Behavioral Therapy Engaging and Informing Parents
10 to 20 sessions with parents to: For the purpose of this booklet, “parents” are defined as
 Inform and educate the patient and family regarding a the legal guardian for the patient.
diagnosis, prognosis, and treatment.  Inform parents of confidentiality rules for the patient.
 Pay attention to the patient’s positive and negative  Obtain written permission from parents to allow
behaviors. collaboration between the primary care physician and
 Establish a token economy. the behavioral health specialist.
 Use time-outs.
 Manage behaviors in public.
Educational Materials for Families
 AACAP ADHD guide for families on aacap.org.
 Use a daily report card/planner and communicate with
staff at the school.  Taking Charge of ADHD by Russell Barkley.
 Anticipate future behaviors.  Educational materials for patients.
 ADHD and Me: What I Learned from Lighting Fires at
Ineffective treatments: the Dinner Table by Blake Taylor.
 EEG feedback: There is mild evidence for
neurofeedback, but the benefits are modest, and it is
costly.
 Eye Movement Desensitization & Reintegration
(EMDR).
 Social skills groups.
 Routine play therapy.

UCSF B enioff C hildren’s H osp itals 7

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Starting Medication Treatment

Stimulants „„ Medications that treat ADHD have not been shown
Stimulants are the firstline treatment for ADHD and are to cause heart conditions, nor have they been
generally the most effective. See the appendix (page 11) demonstrated to cause sudden cardiac death.
for a list of commonly prescribed stimulants. Dosage is However, some of these medications can increase
based on weight and should be titrated to effect, and as or decrease heart rate and blood pressure. While
the child grows. Not included in the appendix are newer, these side effects are not usually considered
long-acting stimulants, including Quillivant,which is long- dangerous, they should be monitored in children
acting liquid methylphenidate, and Quillichew, which is with heart conditions, as the physician feels it is
long-acting chewable methylphenidate. necessary.
„„ This clarification has been endorsed by the
 The most common side effect of stimulant use is American Academy of Pediatrics (AAP), the
appetite suppression, as well as possibly increased American Heart Association (AHA), the American
irritability, especially around the time that a stimulant is Academy of Child and Adolescent Psychiatry
wearing off (this effect may be related, at least in part, (AACAP), the American College of Cardiology
to hunger). Work with the family to ensure the patient (ACC), Children and Adults with Attention-Deficit/
has a good breakfast; recommend healthy snacks— Hyperactivity Disorder (CHADD), the National
e.g., nuts, cheese, smoothies—for afternoon as meds Institute for Children’s Healthcare Quality (NICHQ),
start to wear off. Educate the family that the child may and the Society for Developmental and Behavioral
not feel hungry until later in the evening. If there is Pediatrics (SDBP).
severe appetite suppression, this may affect final adult
height (on average, 1 cm). Non-stimulants
 When using stimulants, patients may experience  Atomoxetine is a norepinephrine reuptake inhibitor that
insomnia. is 60- to 70-percent effective. It needs to be at 1.0 to
 Minor elevations in blood pressure can occur. 1.5 mg/kg to be effective, and it tends to work best
 Rarely patient’s may experience perceptual when dosed twice daily.
disturbances, including tactile, auditory, and/or visual „„ It may be helpful in cases with comorbid anxiety
hallucinations. when the anxiety is exacerbated by stimulants;
 Patient’s may have a “Zombie” feeling or affective it may be better tolerated by some patients with
flattening; usually this occurs when the dose is too autism spectrum disorder.
high. Some youth feel they are “not as funny” when „„ Side effects: It is commonly associated with
taking a stimulant, since their thoughts tend to be more nausea, which can be prevented by taking it with
linear and less disinhibited. Try to use motivational food. Liver toxicity is less than 1 percent, and risk
interviewing to look at goals (e.g., doing well in school), of suicidal ideation is 4/1000.
and exploring the benefits versus side effects.  Extended-release guanfacine is an alpha-2 adrenergic
 Cardiac monitoring: agonist that increases synaptic norepinephrine.
„„ Acquiring an ECG is a Class IIa recommendation. 65-percent effective. Dosage is 0.08 to .12mg/kg,
This means that it is reasonable for a physician to dosed once daily. It tends to last 18 to 2 hours and
consider obtaining an ECG as part of the evaluation is usually best administered in the morning, but if it
of children being considered for stimulant drug causes sedation may change to qhs dosing; regular-
therapy; but this should be at the physician’s release guanfacine may also be used and should be
judgment, and it is not mandatory to obtain one. doses BID-TID.
„„ Treatment of a patient with ADHD should not be „„ It tends to be more helpful with impulsive/
withheld because an ECG is not done. The child’s hyperactive symptoms as well as possible
physician is the best person to make the assessment comorbid poor frustration tolerance. It may also
about whether there is a need for an ECG. be helpful with comorbid autonomic hyperarousal
related to PTSD.

UCSF B enioff C hildren’s H osp itals 8

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Starting Medication Treatment (cont.)

„„ Side effects include sedation, especially in the first
one to two weeks of treatment, with a secondary
effect of irritability. Orthostatic hypotension,
if present, needs monitoring, and encourage
adequate hydration.

Maintenance
Once an optimal dose is determined, maintenance
treatment begins. Frequency of monitoring can be
reduced to follow-up every one to three months,
depending on the patient’s needs.

Trials off stimulants or other ADHD medications may be

done during periods of less academic demand, including
summer, to see how much the child has outgrown ADHD
symptoms. It is best to include a fallback agreement that,
should the child’s academic and/or social functioning
decline, as evidenced by external measures, including
Vanderbilt and/or a precipitous drop in grades, the child
will agree to restart ADHD medication.

When to Refer the Patient to Child Psychiatry

 Complexity or lack of clarity regarding a diagnosis.
 Moderate to severe substance abuse.
 Primary caregiver has serious mental health problems
(including substance abuse).
 Psychosis or mania.
 History of psychiatric hospitalization.
 Lack of response after three medical trials.
 Patient is 6 years old or younger.
 A chronic medical condition and/or the patient’s
behavior seriously interferes with medical treatment.

http://www.aacap.org/aacap/Member_Resources/
Practice_Information/When_to_Seek_Referral_or_
Consultation_with_a_CAP.aspx

UCSF B enioff C hildren’s H osp itals 9

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

Appendix

CRAFFT – Adolescent Substance Use Screening

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?

4. Do you ever FORGET things you did while using alcohol or drugs?

5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

CRAFFT Scoring: Each “yes” response scores 1 point.

A total score of 2 or higher is a positive screen, indicating a need for additional assessment.

UCSF B e nioff C hildren’s H osp itals 10

 Attenti o n D e f ic it / H y pe ract iv i t y D is o rder (A D H D ) in C hildren & A do les cents

References
 AACAP Practice Parameters ADHD. (2007). www.jaacap.com/article/S0890-8567(09)62182-1/pdf
 AACAP Practice Parameters ODD. (2007). www.jaacap.com/article/S0890-8567(09)61969-9/pdf
 Manuzza, S., et al. (2008). Age of Methylphenidate Treatment Initiation in Children with ADHD and Later Substance
Abuse: Prospective Follow-Up into Adulthood. Am J Psychiatry. 165:604-609.
 Faraone, S., Biederman, J., Morley, C., Spencer, T. (2008). Effect of Stimulants on Height and Weight: A Review of the
Literature. J Am Acad Child Adolesc Psychiatry. 47(9):994-1009.
 Towbin, K. (2008). Paying Attention to Stimulants: Height, Weight, and Cardiovascular Monitoring in Clinical Practice.
J Am Acad Child Adolesc Psychiatry. 47(9):977-980.
 Vetter, V., Elia, J., Erickson, C., Berger, S., Blum, N., Uzark, K., Webb, C. (2008). Cardiovascular Monitoring of
Children and Adolescents with Heart Disease Receiving Medications for Attention Deficit/Hyperactivity Disorder.
Circulation. 117:2407-2423.
 Weber, W., Newmark, S. (2007). Complementary and Alternative Medical Therapies for ADHD and Autism. Ped Clin of
North Am. 54:983-1006.
 Faraone, S., Mick, E. (2010). Molecular Genetics of Attention Deficit Hyperactivity Disorder. Psychiatr Clin North Am.
33(1):159-180.
 Bauermeister, J.J., Bird, H.R., Shrout, P.E., Chavez, L., Ramírez, R., Canino, G., et al. Short-Term Persistence
of DSM-IV ADHD Diagnoses: Influence of Context, Age, and Gender. J Am Acad Child Adolesc Psychiatry.
50(6):554-562.
 van der Meer, J.M.J., Oerlemans, A.M., van Steijn, D.J., Lappenschaar, M.G.A., de Sonneville, L.M.J., Buitelaar,
J.K., Rommelse, N.N.J., et al. Are Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder Different
Manifestations of One Overarching Disorder? Cognitive and Symptom Evidence from a Clinical and Population-
Based Sample. J Am Acad Child Adolesc Psychiatry. 51(11):1160-1172.e3.
 Ramtekkar, U.P., Reiersen, A.M., Todorov, A.A., Todd, R.D. Sex and Age Differences in Attention-Deficit/Hyperactivity
Disorder Symptoms and Diagnoses: Implications for DSM-V and ICD-11. J Am Acad Child Adolesc Psychiatry.
49(3):217-228.e3.
 Antshel, K.M., Faraone, S., Maglione, K., Doyle, A., Fried, R., Seidman, L., Biederman, J., et al. Temporal Stability
of ADHD in the High-IQ Population: Results from the MGH Longitudinal Family Studies of ADHD. J Am Acad Child
Adolesc Psychiatry. 47(7):817-825.
 Biederman, J., Ball, S., Monuteaux, M., Mick, E., Spencer. T.J., McCreary, M., Cote, M., Faraone, S., et al. New
Insights into the Comorbidity Between ADHD and Major Depression in Adolescent and Young Adult Females. J Am
Acad Child Adolesc Psychiatry. 47(4):426-434.
 Wilens, T.E., Martelon, M., Joshi, G., Bateman, C., Fried, R., Petty, C., Biederman, J., et al. Does ADHD Predict
Substance-Use Disorders? A 10-Year Follow-up Study of Young Adults With ADHD. J Am Acad Child Adolesc
Psychiatry. 50(6):543-553.
 Scassellati, C., Bonvicini, C., Faraone, S., Gennarelli, M. Biomarkers and Attention-Deficit/Hyperactivity Disorder:
A Systematic Review and Meta-Analyses. J Am Acad Child Adolesc Psychiatry. 51(10):1003-1019.e20.

UCSF B e nioff C hildren’s H osp itals 11

747 52nd Street, Oakland, CA 94609