creation date: 2026-08-13 17:51
tags: Pathologies
Attention Deficit Hyperactivity Disorder
Background
Definitions
Attention deficit hyperactivity disorder (ADHD) is one of the most common disorders in young people.
ADHD is more common in males (2-4x) which may have to do with underdiagnosis.
Etiology & Risk Factors
Genetic risk is 30-40% for first degree relative
Pathogenesis
Clinical Presentation
Signs & Symptoms
There are three types of ADHD. Each have symptoms specific to them which are crucial for diagnosis.
It should be noted that ADHD can change over time, especially from childhood to adulthood.
Inattentive ADHD
- Carelessness / poor attention to detail
- Difficulty sustaining attention
- Absent minded in conversation
- Sidetracking/derailable
- Disorganized
- Avoiding tasks requiring attention
- Misplacing/losing items
- Easily distractible
- Forgetful in daily activity
Hyperactive-impulsive ADHD
- Fidgety
- Inappropriate seat leaving
- Restlessness
- Loud (unable to engage in activities quietly)
- Excess energy
- Excess speech
- Pre-emptive conversation
- Difficulty waiting for their turn
- Intrusive (interrupting/intruding on others)
Combined / Mixed ADHD
Combined ADHD consist of a combination of the two above types.
History & Physical Exam
History should include:
- Chief concerns / symptoms
- Challenges with school, work, home life
- ROS involving mental health and other conditions
- Safety and risk assessment
- Legal history (eg. suspension/expulsions, tickets, involvement with criminal justice system)
- Past psychiatric history (including previous antidepressant/stimulant medication trials)
- Past medical history (including cardiac as many medications can have cardiac side effects)
- Developmental history
- Family history
- Current medications, allergies
- Social history
Physical exam consist of:
- Hearing/vision assessment
- Neurological and genetic conditions
- Annual cardiovascular exam
Questionnaires
A number of questionnaires are available for assessment of symptoms and screening.
- CADDRA ADHD Assessment
- SNAP-IV-26
- Weiss Functional Impairment Rating Scale – Parent
- Adult ADHD Self Report Scale (ASRS) and Weiss Functional Impairment Rating Scale – Self
Diagnosis
Criteria
Diagnostic criteria is as follows:
- ≥6 symptoms (if patient is ≤16 years old)
- ≥5 symptoms (if patient is ≥17 years old)
- ≥2 settings affected (eg. home, school. work)
- There is no better psychiatric condition/substance use that can explain the symptoms
- Symptoms causes distress or impairment
- Many symptoms present before age 12
Work-up
Bloodwork
Routine blood work includes:
- CBC (rule out anemia)
- TSH
- Ferritin
- Vitamin B12
- Calcium
- Albumin
Prior to use of antipsychotics:
- ALT, ALP
- Creatinine/eGFR
- Lipids
- A1C/glucose
For mood stabilizers:
- WBC
- ALT, ALP
- Creatinine/eGFR
- Electrolytes
Additional workup
For patients with suspected cardiac conditions, previous or ordered ECG/ECHO may be needed.
Differential
Other school and learning difficulty conditions include:
- Developmental disorders
- Specific learning disorder
- Autism spectrum disorder
- Intellectual disability / developmental delay
- Sensory impairment (eg. hearing, vision)
- Neurological disorders
- Seizure disorder
- Fetal alcohol spectrum disorder
- Mental health disorders
- Depression
- Anxiety
- Attachment disorder
- Psychosocial stressors
- Hunger/nutritional deficiencies
- Adverse childhood experience
- Chronic medical disease
- Substance abuse-related/addictive disorder
Red Flags / Complications
Treatment of ADHD reduces risks:
- Dropping out of school or poorer academic success
- Developing anxiety disorder, substance use disorder, other psychiatric disorders
- Struggles with peers, caregivers, and other individuals
Management
Pharmacological
While medications do not cure ADHD, they are generally effective at controlling impairing symptoms during active periods.
A number of options are available ranging from stimulants (amphetamine-type and methylphenidate-type) and non-stimulants (alpha-2 agonist and SNRI).
Generally, a long-acting stimulant is recommended as first-line. Brand names are preferred as they often have superior delivery mechanisms.
For many brand name options, co-pay cards are available to reduce costs. (eg. Concerta and Vyvanse/Adderall XR)
Monitoring and Follow-up
Doses are titrated upwards as tolerated every 1-4 weeks. Frequently follow up may be necessary when starting treatment due to side effect profiles and dosing.
For follow up appointments:
- For children assess school, home, and extracurriculars
- For adults assess home, school, work, social life
- Effectiveness of medication
- Side effects of medication
- Vitals (height, weight, blood pressure, heart rate)
- Mood and substance use (including caffeinated drinks)
Patients taking stimulants should have side effects monitored:
- Appetite suppression
- Blood pressure increase
- Heart rate and cardiac symptoms
- Insomnia concerns
- Intolerable xerostomia
- Worsening tic disorders, anxiety, mania, psychosis, epilepsy
Considering using ASRS and WEISS questionnaires prior to each appointment.
Non-pharmacological
Non-pharmacological strategies should be employed to address any remaining symptoms not addressed by medications or during periods without medication coverage.
- Social workers to aid with financial assistance
- Academic supports (eg. IEP)
- Accommodations in classroom, structured recreational activites
- Behavioural management strategies/programs in community
- Psychological counselling
- Nutrition and sleep support
- Management of vision/hearing impairment
Other lifestyle changes include:
- Sleep hygiene
- Avoiding cannabis use
- Reducing alcohol/tobacco use
- Timing and amount of caffeine intake