Synopsis
Recognise developmentally inappropriate inattention, hyperactivity and impulsivity, establish impairment across settings through specialist assessment, distinguish common mimics and coexisting needs, and use environmental, behavioural and medicine interventions safely in children and young people.
- ADHD is a neurodevelopmental disorder: symptoms are developmentally inappropriate, began before age 12, persist, occur in at least 2 important settings and cause clear functional impairment.
- Diagnosis is specialist and clinical. Rating scales support multi-informant assessment but neither a positive nor a negative score can independently diagnose or exclude ADHD.
- Always assess sleep, hearing, vision, language, learning, autism, tics, anxiety, depression, trauma, epilepsy and the classroom environment; coexistence is common.
- Under age 5, first-line treatment is an ADHD-focused group parent-training programme; medicine requires a second specialist opinion and persistent severe impairment.
- From age 5, provide information, parent support and school environmental modifications before medicine; offer medication when significant impairment persists after these measures have been implemented and reviewed.
- First-line medicine for children aged 5 years and over is methylphenidate. Age 5 use is off-label and remains specialist initiated.
- After an adequate 6-week methylphenidate trial at an effective tolerated dose, switch to lisdexamfetamine when benefit remains insufficient.
- Use dexamfetamine when lisdexamfetamine works but its longer effect is not tolerated; use atomoxetine or guanfacine when stimulants are not tolerated or separate adequate trials are ineffective.
- Before medication record height, weight, pulse, blood pressure, cardiovascular history and current medicines; routine ECG is unnecessary without a clinical cardiac indication or interacting cardiac-risk medicine.
- Monitor growth, pulse, blood pressure, sleep, appetite, mood, tics, seizures, adherence and diversion; review the continuing need for medicine at least annually.
Key red flags
Syncope on exertion, exertional chest pain, sudden-onset rapid regular palpitations, a murmur or a first-degree relative who died suddenly before age 40 requires cardiovascular opinion before ADHD medication.
Blood pressure persistently above the 95th centile for age and height requires paediatric hypertension assessment before or during treatment.
New hallucinations, delusions, marked mood elevation, severe agitation or suicidal thinking demands urgent mental-health review and medicine reassessment.
Developmental regression, seizures, focal neurological signs, episodic altered awareness or a major change from baseline is not explained by uncomplicated ADHD.
Severe sleepiness, loud snoring with witnessed apnoeas or profound insomnia can mimic or worsen inattention and needs a sleep-focused assessment.
Rapid weight loss, marked slowing of linear growth, persistent tachycardia or hypertension during medication requires dose review and specialist action.
Requests for early replacement prescriptions, sharing, selling or coercion around stimulants raise diversion and safeguarding risk.
Investigation priorities
Integrate developmental and psychiatric history, symptom criteria, onset, persistence, multi-setting impairment, observation, collateral and differential diagnosis.
Obtain concrete examples from child, caregivers and education, including strengths, impairment, age of onset, masking and environmental support.
Management branches
Inattention, hyperactivity or impulsivity is causing concern.
- Screen immediately for acute risk, regression, seizures, sleep disorder, sensory loss, trauma and safeguarding concerns.
- Gather developmental history and concrete child, caregiver and education examples, then refer for specialist assessment when symptoms persist and impair function.
- Specialist confirms onset before age 12, presence in at least 2 settings, impairment and exclusion or recognition of alternative and coexisting conditions.