← Diagnosis and Management Guides
ADHD Evaluation
Key considerations: Learning disability, Anxiety disorder, Hearing/vision impairment
Cannot miss
- Learning disability
- Anxiety disorder
- Hearing/vision impairment
- Sleep disorder
- Thyroid dysfunction
- Lead toxicity
Likely diagnoses
- ADHD combined type
- ADHD predominantly inattentive
- ADHD predominantly hyperactive-impulsive
- Normal developmental variation
Red flags
- Regression in skills (not ADHD)
- Focal neurologic findings
- Significant mood symptoms
Workup
- history: Vanderbilt Assessment Scales (parent + teacher); Symptoms in 2+ settings for ≥6 months, onset before age 12; Developmental history, academic performance, social functioning; exam: Physical exam, vision and hearing screen, neurologic exam; labs: Lead level, thyroid function if clinically indicated; imaging: Not indicated for routine ADHD evaluation; bedside: Behavioral observation (office behavior does NOT rule out ADHD)
Management
- immediate: Not applicable — this is a longitudinal diagnosis; general: Age 4-5: behavioral therapy first-line; Age ≥6: methylphenidate or amphetamine-based stimulant + behavioral therapy; Second-line: atomoxetine, guanfacine, clonidine; Monitor height, weight, BP, HR at every visit; Medication holidays if appropriate; 504 plan or IEP for school accommodations
Disposition
- admit: Not applicable; discharge: Outpatient management with regular follow-up; consults: Developmental pediatrics or child psychiatry for complex cases, educational psychology for learning assessment
Clinical pearls
- ADHD is a clinical diagnosis — there is no definitive lab test or imaging study
- Vanderbilt scales must be completed by BOTH parent and teacher — multi-setting impairment required
- Stimulants are safe and effective — growth effects are minimal and mostly in first 1-2 years
Source and review
- AAP ADHD Clinical Practice Guideline 2019. Last reviewed: 2024-11-01