Note on the Anitha Thapar book: Her specific child psychiatry textbook is not in the current library collection. However, Professor Anitha Thapar (Cardiff University) is one of the foremost ADHD researchers globally, and her key contributions - particularly on genetics, heritability, and the neurodevelopmental model - are fully incorporated into Kaplan & Sadock's Comprehensive Textbook of Psychiatry and Stahl's Essential Psychopharmacology, both of which are available and are the primary sources for this answer. Her GWAS work (Demontis et al., 2019 - referenced in Kaplan & Sadock) is specifically cited below.

Attention-Deficit/Hyperactivity Disorder (ADHD) - Complete Overview

1. Definition and Overview

• Worldwide prevalence in children and adolescents: 5.29-7.1% (meta-analyses by Polanczyk et al. and Willicut)
• In 2016, the US National Survey of Children's Health reported 9.4% of school-aged children had been diagnosed
• Male:female ratio in children: 3-4:1; in adulthood it approaches 1:1 (many girls are underdiagnosed in childhood)

2. Historical Background

3. DSM-5 Diagnostic Criteria

Five Core Criteria:

1. Onset before age 12 years
2. Duration greater than 6 months
3. Number of symptoms: Children require ≥6 symptoms from inattention and/or hyperactivity-impulsivity lists; adolescents ≥17 and adults require ≥5
4. Symptoms present in two or more settings and cause functional impairment
5. Symptoms not better explained by another mental disorder (no longer excludes ASD - ADHD and ASD can be diagnosed simultaneously)

Inattention Symptoms (9 items, need ≥6 in children):

• (a) Fails to give close attention to details / makes careless mistakes
• (b) Difficulty sustaining attention in tasks or play
• (c) Does not seem to listen when spoken to directly
• (d) Does not follow through on instructions; fails to finish schoolwork or chores
• (e) Difficulty organizing tasks and activities
• (f) Avoids or is reluctant to engage in tasks requiring sustained mental effort
• (g) Loses things necessary for tasks
• (h) Easily distracted by extraneous stimuli (in adults: unrelated thoughts)
• (i) Forgetful in daily activities

Hyperactivity/Impulsivity Symptoms (9 items, need ≥6 in children):

• (a) Fidgets with or taps hands/feet; squirms in seat
• (b) Leaves seat when remaining seated is expected
• (c) Runs about or climbs in inappropriate situations (in adults: feeling restless)
• (d) Unable to play or engage in leisure activities quietly
• (e) Often "on the go," acting as if "driven by a motor"
• (f) Talks excessively
• (g) Blurts out answers before a question is completed
• (h) Difficulty waiting their turn
• (i) Interrupts or intrudes on others

DSM-5 Presentations (formerly "subtypes"):

• Combined presentation: ≥6 inattention AND ≥6 hyperactivity-impulsivity symptoms
• Predominantly inattentive presentation
• Predominantly hyperactive/impulsive presentation

Severity Specifiers:

• Mild: Few or no symptoms beyond threshold, minor functional impairment
• Moderate: Between mild and severe
• Severe: Many symptoms beyond threshold, marked functional impairment

4. Comparative Nosology (DSM-5 vs ICD-10/ICD-11)

• ICD-10 called it "Hyperkinetic Disorder (HD)." Key difference: anxiety and depression were exclusion criteria - only 25% of DSM-IV ADHD combined subtype met ICD-10 HD criteria in the MTA trial
• ICD-11 is now much closer to DSM-5, removing the exclusion criteria - the rate of diagnosis under ICD-11 is expected to increase
• Both now share the combined, predominantly inattentive, and predominantly hyperactive-impulsive presentations

5. Epidemiology

• Prevalence ~5-7% globally in children; 2.5-4% in adults
• Male > Female in childhood (3-4:1); converges to 1:1 in adulthood
• Girls are frequently underidentified in childhood because they are less disruptive, presenting later as adults
• Increasing rates of diagnosis likely reflect improved awareness and access to care rather than a true increase in prevalence

6. Etiology and Risk Factors

Genetics

Neuroanatomical Findings

• Differences in frontostriatal areas, temporoparietal lobes, cerebellum, basal ganglia, corpus callosum, amygdala, hippocampus, and thalamus
• Global reductions in gray matter (especially right lentiform nucleus extending to caudate nucleus)
• 3-5 year delay in cortical thickness maturation in frontal and temporal regions
• Lower surface area in frontal, cingulate, and temporal regions in children
• These structural changes normalize with age and with stimulant treatment
• Diffusion tensor imaging (DTI) shows white matter tract abnormalities and dysfunctional connectivity

Functional Neuroimaging

• fMRI shows reduced frontal lobe activity in ADHD vs controls
• Meta-analysis confirms hypoactivation in frontoparietal and ventral attention networks (controlling goal-directed executive processes and decision-making)
• Right dorsolateral prefrontal cortex activation normalized in long-term stimulant-medicated patients
• EEG studies show abnormalities in attention-related event-related potentials

Neurotransmitter Basis

• Core pathology: dysregulation of dopamine (DA) and norepinephrine (NE) in the prefrontal cortex (PFC)
• Both excess and deficiency of DA/NE in PFC can reduce signal-to-noise ratio, producing ADHD symptoms
• Distinct prefrontal circuits give rise to distinct symptom clusters:
  • Dorsolateral PFC: problems with working memory, organizing, sequencing
  • Anterior cingulate PFC: problems with motivation, focus
  • Orbital PFC: problems with impulsivity, emotional regulation

Environmental Risk Factors

• Premature birth, low birth weight
• Prenatal exposure to alcohol, tobacco, lead
• Perinatal complications
• Psychosocial adversity (though these are modifiers, not primary causes)

7. Neurodevelopmental Model

"A unifying formulation of ADHD is that it is caused by delayed maturation of prefrontal cortex circuitry that manifests in ADHD symptoms at least by age 12."

• Synapses in PFC rapidly increase by age 6, then up to half are eliminated by adolescence
• Abnormalities in synapse formation and selection during this critical window underlie ADHD onset
• Those who compensate via new synapse formation after age 12 "grow out of their ADHD"
• This explains why adult ADHD prevalence (~2.5%) is roughly half the childhood prevalence (~5%)

• Preschool: Inattention not easily identified (immature PFC); hyperactivity/impulsivity predominate
• School age: Inattention becomes prominent and persists throughout life
• Adolescence/adulthood: Hyperactivity and impulsivity decline; comorbidities markedly increase
• Adults: Inner restlessness replaces overt hyperactivity; disorganization, chronic lateness, missed deadlines predominate

8. Clinical Features

In Children:

• Inattention, hyperactivity, impulsivity
• Academic underachievement out of proportion to intelligence
• Difficulty following instructions; careless errors in schoolwork
• Peer relationship difficulties
• Low frustration tolerance; emotional dysregulation

In Adolescents:

• Impulsivity may present as risky behavior; hyperactivity becomes less overt
• Academic difficulties worsen with greater organizational demands
• Lower self-esteem; conduct problems may emerge

In Adults (ADHD persists in ~50-65% of children):

• Inner restlessness, inability to relax, excess talkativeness
• Impulsivity: impatience, interrupting others, acting without thinking, impulsive job/relationship changes
• Inattention: distractibility, disorganization, chronic lateness, forgetfulness, procrastination
• Emotional lability, "short fuse"
• Higher rates of driving accidents, job losses, relationship instability
• Lower job status and income; sense of underachievement

9. Comorbidities

• Oppositional defiant disorder (ODD): ~50% of children
• Conduct disorder: ~25%
• Anxiety disorders: 25-35%
• Mood disorders / depression: 15-25%
• Learning disabilities: ~30-40%
• Developmental coordination disorder (DCD)
• Tics/Tourette syndrome
• Autism spectrum disorder (ASD): DSM-5 allows dual diagnosis

• Anxiety, depression, substance use disorders, personality disorders (especially borderline)
• Gambling and other addictive behaviors
• Smoking at twice the rate of the general population (nicotine acutely improves ADHD symptoms by enhancing dopamine release)

10. Assessment and Diagnosis

Clinical Evaluation Includes:

• Clinical interview with parent and child (separately and together)
• Behavioral rating scales: Conners Rating Scale, SNAP-IV, Vanderbilt ADHD Rating Scale, ADHD Rating Scale-5
• Teacher report (essential - symptoms must be present in ≥2 settings)
• Cognitive/neuropsychological testing (not required for diagnosis but helpful)
• Medical history: ruling out thyroid disorders, vision/hearing problems, seizures, sleep disorders
• Family history (strong genetic component)

Differential Diagnosis:

• Normal developmental variation
• Learning disorders (reading disorder, math disorder)
• Anxiety disorders (inattention secondary to worry)
• Depression (concentration difficulties)
• Bipolar disorder (grandiosity, impulsivity)
• Autism spectrum disorder (though dual diagnosis now permitted)
• Sleep deprivation, lead toxicity, iron deficiency
• Thyroid dysfunction
• Substance use (in adolescents/adults)
• Situational inattention (home vs. school)

11. Treatment

General Principles

A. Pharmacological Treatment

First-Line: Stimulants

1. Methylphenidate (MPH) and its derivatives
2. Amphetamines (AMP)

• Methylphenidate: blocks DAT and NET allosterically - prevents reuptake of DA and NE, increasing their synaptic concentration in PFC. D-isomer is significantly more potent than L-isomer.
• Amphetamines: block reuptake AND promote release of DA and NE from presynaptic terminals via VMAT2

Second-Line: Non-Stimulant Medications

B. Psychosocial Treatments

Behavioral Interventions (for children):

• Parent management training (PMT): Teaching parents positive reinforcement, consistent limit-setting, structured routines - most evidence-based psychosocial approach
• Behavioral classroom management: Token economies, daily report cards, teacher-implemented contingencies
• Social skills training: Peer relationship building
• Organizational skills training

Cognitive-Behavioral Therapy (CBT):

• More effective in adolescents and adults than young children
• Targets time management, organization, procrastination, emotional regulation
• Evidence for CBT as adjunct to medication in adults is strong

Combined Treatment (MTA Study):

• Medication management alone was superior to behavioral treatment alone for ADHD core symptoms
• Combined treatment was not significantly better than medication alone for core ADHD symptoms but showed advantages for comorbidities, academic achievement, and social functioning
• Behavioral treatment alone was superior to community care

School-Based Interventions:

• Individualized Education Programs (IEPs) or 504 plans
• Extended test-taking time, preferential seating
• Reduced workload, frequent breaks
• Use of organizational tools and reminders

C. Treatment Prioritization with Comorbidities

1. Substance abuse must be addressed first - ADHD treatment will not succeed if active substance abuse continues
2. Severe mood disorder often needs stabilization before ADHD treatment
3. Anxiety disorder - stimulants may worsen anxiety; atomoxetine or guanfacine preferred
4. Tics - stimulants may worsen; use guanfacine, clonidine, or atomoxetine
5. ADHD-only (least common in adults) - stimulants are straightforward first-line

12. Side Effects of Stimulant Treatment

Short-Term:

• Appetite suppression (most common) - administer with food
• Sleep-onset insomnia - avoid afternoon/evening dosing; melatonin may help
• Headaches - usually abate with time
• Abdominal pain - take on full stomach
• Increased heart rate (~1-2 bpm) and blood pressure (~3-4 mmHg)
• Emotional dysregulation, dysphoria, irritability, social withdrawal ("overfocusing")
• Rebound - worsening of symptoms as medication wears off; use longer-acting formulations

Infrequent:

• Tics / unmasking of Tourette syndrome

Rare:

• Psychotic symptoms, paranoia
• Priapism, choreiform movements
• Self-injurious behaviors (nail biting, lip licking, skin picking)

Long-Term:

• Growth suppression: ~1 cm height and ~2.5 kg weight in the first year; maximum adult height loss ~1.3 inches with consistent use; drug holidays during summer may allow growth rebound
• Cardiovascular: No increased risk of serious cardiovascular events in young and middle-aged adults; routine pre-treatment ECG NOT recommended (AAP, AACAP)

Substance Abuse Concern:

• Stimulants do NOT increase risk of later substance use disorder (SUD)
• Meta-analysis (Wilens et al.) suggests stimulant treatment in childhood has a protective effect, reducing SUD risk to that of the general population

13. ADHD Across the Lifespan

Course and Prognosis:

• Full remission of childhood ADHD in adulthood occurs in only ~35-50% of cases
• Hyperactivity and impulsivity decline more rapidly than inattention with age
• Inattention, executive dysfunction, and emotional dysregulation tend to persist
• Adults with untreated ADHD have higher rates of:
  • Unemployment and underemployment
  • Divorce and relationship instability
  • Driving accidents and traffic violations
  • Substance use disorders
  • Criminal activity
  • Depression, anxiety, suicidal behavior

Adult ADHD:

• DSM-5 now requires only 5 (vs. 6 in children) symptoms for adults
• Onset criterion changed to "before age 12" from the previous "before age 7" in DSM-IV
• Debate exists about "adult-onset ADHD" - whether ADHD can first be recognized in adulthood
• The male:female ratio converges to 1:1 in adulthood (women previously undiagnosed in childhood)
• Comorbidity in adults is the rule: >75% have at least one comorbid condition

14. Recent Evidence (PubMed, 2024-2025)

• A 2024 systematic review in Pediatrics (PMID: 38523592) comprehensively reviewed treatments for ADHD in children and adolescents, confirming the evidence hierarchy for stimulants as first-line treatment
• A 2025 network meta-analysis in JAACAP (PMID: 38823477) found that pharmacological treatments for ADHD significantly improve quality of life, with stimulants showing the largest effect sizes

Summary Table

• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Chapter 44.1 (ADHD), pp. 11273-11310
• Stahl's Essential Psychopharmacology, Neuroscientific Basis, Chapter 11 (ADHD and Neurodevelopment), pp. 481-490
• Demontis et al. (2019): GWAS meta-analysis identifying 12 ADHD loci (cited in Kaplan & Sadock's)
• Anitha Thapar's ADHD genetic research forms the scientific backbone of the genetic sections above (her GWAS consortium work is directly cited in Kaplan & Sadock's)

Step-by-Step ADHD Management in a Psychiatry OPD

OVERVIEW: The Three-Visit Framework

• Visit 1: Full assessment and diagnosis
• Visit 2 (2-4 weeks later): Medication initiation + psychoeducation
• Visit 3 onwards: Titration, monitoring, maintenance

VISIT 1 - COMPREHENSIVE ASSESSMENT

STEP 1: Pre-Consultation Setup

• Referral letter or presenting complaint
• Rating scale forms sent in advance (or given in the waiting room):
  • For parents: Conners Parent Rating Scale (CPRS), Vanderbilt Parent Assessment Scale, or ADHD Rating Scale-5 (ADHD-RS-5)
  • For teachers: Vanderbilt Teacher Assessment Scale or SNAP-IV Teacher Form (request this ahead of time via the parent)
  • For adults: Adult ADHD Self-Report Scale (ASRS), Conners Adult ADHD Rating Scale (CAARS)

Rating scales are not diagnostic tools on their own but structure history-taking and provide quantitative baselines to track against later. (Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 11274)

STEP 2: History-Taking

A. With Parent/Caregiver (child not present initially):

• Describe the specific behaviors you're most concerned about
• How long have these been going on? In what settings do they occur?
• Are they present at home AND at school/work (DSM-5 requires ≥2 settings)?
• How do they interfere with daily functioning?

1. Careless mistakes / poor attention to detail
2. Difficulty sustaining attention in tasks
3. Doesn't seem to listen when spoken to directly
4. Fails to follow through / finish tasks
5. Difficulty organizing tasks
6. Avoids tasks requiring sustained mental effort
7. Loses things needed for tasks
8. Easily distracted
9. Forgetful in daily activities

1. Fidgets / squirms
2. Leaves seat when not appropriate
3. Runs about / climbs inappropriately (or feels restless in adults)
4. Cannot play or work quietly
5. "On the go" / "driven by a motor"
6. Talks excessively
7. Blurts out answers
8. Difficulty waiting turn
9. Interrupts or intrudes on others

• Academic performance - are grades consistent with ability?
• Teacher reports or complaints?
• Grade repetitions? Learning support?
• Social functioning with peers?

• Prenatal: maternal alcohol, tobacco, drug use; infections
• Birth: prematurity, low birth weight, perinatal complications
• Developmental milestones: language, motor, social
• Any previous developmental concerns?

• ADHD in first-degree relatives (parents, siblings)
• Other psychiatric disorders: anxiety, depression, bipolar, substance use, learning disabilities, tics

• Previous diagnoses and treatments
• Prior medication trials and responses/side effects
• Sleep problems (sleep disorders can mimic ADHD)
• Seizure history
• Head injuries

• Family functioning; parenting style and consistency
• Stressors at home (parental conflict, bereavement, abuse)
• Screen time and sleep routines
• Extracurricular activities

B. With the Child/Patient:

• Put the child at ease; use age-appropriate language
• Ask about school: "What's hard about school? What do you find boring?"
• Ask about friendships, how they feel about themselves
• Ask about worries, sadness (screen for internalizing disorders)
• Observe the child: level of activity, attention span during the interview, impulsivity in responses
• Remember: many children with ADHD can focus in a novel one-on-one setting (the OPD) - a normal interview does NOT rule out ADHD

STEP 3: Physical and Neurological Examination

• Height and weight (plot on growth chart - essential baseline before stimulants)
• BMI
• Blood pressure and pulse (baseline before stimulants)

• Auscultate for murmurs (relevant if considering stimulants)
• Family history of sudden cardiac death, arrhythmias, cardiomyopathy
• If any cardiac concern: refer to cardiology before starting stimulants
• Routine ECG is NOT recommended by AAP or AACAP in the absence of cardiac concerns

• Screen for tics (observe head, face, neck, and extremities for 3-5 minutes)
• Soft neurological signs
• Any focal neurological findings

• Otoscopy / hearing screening (hearing loss can present as inattention)

• Brief visual acuity (vision problems can cause poor attention in schoolwork)

STEP 4: Baseline Investigations

STEP 5: Screen for Comorbidities

"In adulthood, comorbidity is the rule, with more than 75% of adults with ADHD having at least one comorbid condition." (Kaplan & Sadock's, p. 11285)

STEP 6: Establish Diagnosis (DSM-5)

• ≥6 inattention symptoms (or ≥5 if age ≥17) - present for ≥6 months
• AND/OR ≥6 hyperactivity-impulsivity symptoms (≥5 if ≥17)
• Symptoms present before age 12
• Symptoms present in ≥2 settings
• Symptoms cause functional impairment (academic, social, occupational)
• Symptoms not better explained by another disorder (psychosis, severe anxiety, bipolar, substance use)

• Combined presentation (most common)
• Predominantly inattentive presentation
• Predominantly hyperactive/impulsive presentation

• Normal developmental variation (especially preschoolers)
• Situational inattention (reactive to stress, trauma, family conflict)
• Learning disorder (specific academic difficulty without core ADHD symptoms)
• Anxiety disorder (inattention secondary to worry)
• Bipolar disorder (grandiosity, decreased sleep need, racing thoughts)
• Intellectual disability
• Hearing/vision impairment
• Thyroid disorder, iron deficiency
• Substance use disorder

STEP 7: Documentation

• Diagnostic formulation (what you think is going on and why)
• Presentation type and severity
• Comorbidities identified
• Baseline height, weight, BP, pulse
• Baseline rating scale scores (numerical, for future comparison)
• Investigations ordered

VISIT 2 - PSYCHOEDUCATION AND TREATMENT INITIATION

STEP 8: Psychoeducation (Before ANY Medication)

1. What ADHD is - a neurodevelopmental disorder with strong genetic basis; NOT caused by bad parenting, sugar, or screens
2. It is chronic - may persist into adulthood; needs long-term management
3. It is treatable - both behavioral and medication treatments work well
4. Medication does not "sedate" the child - it improves focus and reduces impulsivity
5. Medication does not cause addiction - in fact, it reduces later substance use risk
6. School accommodations - child may qualify for extra time, preferential seating
7. ADHD is not a character flaw - address stigma explicitly

• Offer to write a report/letter for the school describing diagnosis and accommodations needed
• Explain the role of teacher input in monitoring response

• Establish consistent routines (fixed times for meals, homework, sleep)
• Break tasks into small, manageable steps
• Use visual schedules and checklists
• Reward positive behavior immediately (token economy: sticker charts for children)
• Brief, clear, direct instructions (one step at a time)
• Reduce distractions during homework time
• Regular physical activity is helpful
• Consistent bedtime; minimize screens before sleep

STEP 9: Discuss Treatment Options and Shared Decision-Making

1. Medication alone (most effective for core symptoms)
2. Behavioral therapy alone (preferred for preschoolers; less effective alone in school-age children)
3. Combined medication + behavioral therapy (optimal, especially with comorbidities)

"Medication management alone was superior to behavioral treatment alone for core ADHD symptoms in the MTA study, but combined treatment showed advantages for comorbidities and social functioning." (Kaplan & Sadock's, p. 11304)

• "I don't want my child on medication" - validate, discuss risks of untreated ADHD (school failure, accidents, depression, substance use), offer trial
• "Will it change my child's personality?" - it should not; if it does, dose is too high
• "What about side effects?" - discuss appetite, sleep, growth monitoring

STEP 10: Medication Initiation

Algorithm - First-Line: Methylphenidate (MPH)

• Give IR MPH with breakfast - this avoids appetite suppression on empty stomach
• IR MPH lasts 3-4 hours: typical school-day dosing is morning + lunchtime
• Prefer long-acting formulations (OROS/Concerta, Ritalin LA) for once-daily dosing, better compliance, smoother coverage, less rebound, reduces stigma (no lunchtime dose at school)
• Long-acting: OROS methylphenidate (Concerta) 18 mg → 27 mg → 36 mg → 54 mg, once daily in morning
• Titrate based on symptom control AND tolerability - not just reaching a "target dose"

If Stimulants are Contraindicated or Refused:

• Start at 0.5 mg/kg/day for 1-2 weeks
• Then increase to 1.2 mg/kg/day (target dose; max 1.4 mg/kg/day or 100 mg)
• Take on a full stomach (reduces GI side effects)
• Onset delayed: 1-4 weeks for partial response; 6-12 weeks for full response
• Tell parents explicitly: this takes longer than stimulants - do not give up after 2 weeks
• Metabolized by CYP2D6 - check for drug interactions (fluoxetine, paroxetine slow metabolism)
• Monitor: liver function (black box warning for hepatotoxicity), suicidal ideation warning
• Best choice if: stimulant-refractory, stimulant-worsened anxiety, tics, substance use risk, or parental preference for non-stimulant

• Start 1 mg at night, titrate by 1 mg weekly to 1-4 mg/day
• Alpha-2A agonist; improves working memory and impulse control
• Best choice if: comorbid tics, aggression, ODD, or as adjunct to stimulants
• Side effects: sedation (especially initially), bradycardia, hypotension

• Start 0.1 mg at bedtime; titrate to 0.1-0.4 mg/day
• Useful for sleep initiation difficulties and tics
• More sedating than guanfacine

STEP 11: Counseling at the Time of Prescription

1. Take the medication in the morning (stimulants) - avoid afternoon/evening doses to protect sleep
2. Give with breakfast - reduces stomach upset
3. Do NOT stop abruptly without consulting - no physical withdrawal, but behavioral return
4. Do NOT share medication (it is a controlled substance)
5. Warn about appetite suppression - give a good breakfast before medication, and a snack after school when medication is wearing off; don't stress about lunchtime appetite
6. Warn about initial insomnia - review sleep hygiene
7. Report immediately: chest pain, palpitations, severe mood changes, unusual behaviors, psychotic symptoms
8. Give written information / handout if available

VISIT 3 - FOLLOW-UP AND TITRATION

STEP 12: Review at First Follow-Up

1. Efficacy:
   • Has there been improvement in core symptoms? (Inattention, hyperactivity, impulsivity)
   • Ask parent AND teacher separately - use rating scales again and compare to baseline scores
   • How is academic performance? Behavior at school? Social interactions?
   • "Is your child finishing tasks they couldn't finish before? Is the teacher reporting improvement?"
2. Side effects:
   • Appetite: How is intake at mealtimes? Weight loss? (Weigh and plot)
   • Sleep: Any difficulty falling asleep? What time is the last dose?
   • Mood: Irritable? Crying? "Too quiet"? (signs of overmedication or mismatch)
   • Cardiovascular: Any chest pain, palpitations, dizziness? (Measure BP and pulse)
   • Headaches? Stomach aches?
   • Rebound behavior in the evening?
   • Tics (new onset or worsening)?
3. Compliance:
   • Is the medication being taken consistently?
   • Any doses being missed? Why?
   • If school-day dosing only: consider weekend/holiday dosing depending on severity

• If good response and tolerated: continue same dose, schedule next follow-up in 4-8 weeks
• If partial response: increase dose by one step (e.g., 5 mg for MPH)
• If no response: ensure compliance, check if dose is adequate, consider switching stimulant class or formulation
• If intolerable side effects: reduce dose OR switch to alternative (non-stimulant or other class)

STEP 13: Monitoring Parameters at Every Visit

ONGOING MANAGEMENT

STEP 14: Psychosocial Interventions (Parallel Track)

For Children (6-12 years):

• Teach parents behavior modification principles
• Positive reinforcement for target behaviors (catch them being good)
• Consistent, predictable consequences for problem behaviors
• Token economy/star chart systems
• Ignoring minor misbehavior (extinction)
• Brief, frequent, immediate feedback
• Programs: Webster-Stratton Incredible Years, Triple P, Parent-Child Interaction Therapy

• Daily report card (linking school behavior to home consequences)
• Preferential seating (front, away from distractions)
• Breaks and movement opportunities
• Extended time on tests
• Reduce quantity of homework if quality is the target
• Teacher to provide positive attention for on-task behavior

• Organizational skills training (planners, checklists, time management)
• Remediation for specific learning difficulties
• IEP or educational support plan

• Friendship skills, perspective-taking, conflict resolution

For Adolescents:

• Shift toward self-management skills (planners, apps, reminders)
• CBT: time management, procrastination, organizational skills
• Address self-esteem, frustration tolerance
• Screen for depression, anxiety, substance use carefully
• Motivational interviewing for medication adherence

For Adults:

• CBT for ADHD (Safren's model): structured skill building for time management, organization, reducing procrastination
• Group therapy programs
• Coaching
• Workplace accommodations

"Practice guidelines published for child and adolescent psychiatrists strongly suggest a combination of behavioral interventions alongside pharmacologic treatment in the management of ADHD." (Kaplan & Sadock's, p. 11305)

STEP 15: Managing Specific Comorbidities

STEP 16: Frequency of Follow-Up

STEP 17: When to Consider Stopping Medication

• Annual re-evaluation: Is ADHD diagnosis still valid?
• If symptoms have resolved and functioning is excellent: a supervised drug holiday can assess current need
• A structured medication-free trial (ideally during a low-stress period, not during exams) for several weeks can clarify whether medication is still needed
• Do NOT abruptly stop mid-term or before exams
• Remember: ADHD persists in ~50-65% of children into adulthood - stopping medication does not mean the disorder has resolved

STEP 18: Special Situations in the OPD

If a child is under 6 (Preschool ADHD):

• Behavioral therapy is the primary treatment, not medication
• Medication only if behavioral intervention has failed AND impairment is severe
• If medication needed: IR methylphenidate at low doses (2.5 mg); preschoolers need lower doses and have higher side effect rates (PATS study)
• Refer to developmental pediatrics/child psychiatry specialist

If patient is an adolescent:

• Engage the adolescent directly (not just through parents)
• Address concerns about identity ("Is the medication making me who I am?")
• Discuss transition to adult services
• Monitor for emerging substance use, anxiety, and depression

If patient presents for the first time as an adult:

• Require evidence of childhood onset (school reports, parent history, old records)
• Use ASRS screening tool
• Rule out anxiety, depression, bipolar, substance use (all can mimic adult ADHD)
• Consider neuropsychological testing if diagnosis unclear
• Prefer long-acting stimulants; check for cardiovascular risk factors

Pregnancy and ADHD:

• Ideally taper stimulants before planned pregnancy (limited safety data)
• Non-pharmacological management preferred in first trimester
• Discuss risks of untreated ADHD (accidents, stress) vs. medication risks
• Consult with maternal-fetal medicine if medication continuation needed

COMPLETE OPD VISIT SUMMARY CHECKLIST

• Rating scales completed (parent + teacher/self-report)
• Full history: 18 DSM-5 symptoms, developmental, family, academic, social
• Physical exam: height, weight, BP, pulse, cardiac, neurological, ENT
• Baseline bloods and investigations as indicated
• Comorbidity screening
• Differential diagnosis excluded
• Diagnosis formulated with presentation and severity

• Psychoeducation completed (parent + patient)
• School letter prepared
• Behavioral strategies discussed and given in writing
• Medication choice discussed and agreed (shared decision-making)
• Prescription written at starting dose
• Counseling on how to take, side effects, what to report
• Next appointment booked in 2-4 weeks

• Efficacy assessment: parent + teacher report, rating scales
• Side effects assessed: appetite, sleep, mood, cardiovascular, tics
• Height, weight, BP, pulse recorded and compared
• Dose adjusted if needed
• Psychosocial interventions reviewed
• Comorbidities reassessed
• Next appointment booked