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Diagnosis and treatment of

attention deficit hyperactivity disorder
Abstract: Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder
characterized by signs and symptoms of inattention, hyperactivity, and impulsivity that
typically begin in childhood. ADHD can persist into adulthood, causing impairments in
occupational performance and peer and family relationships. This article reviews the
epidemiology, diagnosis, and treatment of ADHD.

By Amy E. Vierhile, DNP; Donna Palumbo, PhD; and Heidi Belden, PharmD

ttention-deficit hyperactivity disorder (ADHD) ing impairments in social, educational, occupational, and

A is a chronic, neurobehavioral disorder associated

with significant signs and symptoms (includ-
ing inattention, hyperactivity, and impulsivity) that are
developmentally inappropriate and impair functioning
across settings.1 The onset of ADHD occurs in childhood,
and the disorder is most commonly diagnosed in children.
However, it can persist into adolescence and adulthood.1-3
Symptoms of ADHD can result in wide-ranging functional
impairments in academic, social, occupational, and home
environments, especially when untreated.4-6
ADHD that persists into adulthood can substantially
decrease an individual’s quality of life because of continu-
Keywords: ADHD, attention-deficit hyperactivity disorder, methylphenidate, neurobehavioral disorder
interpersonal functioning.7-11 This article reviews the epi-
demiology, diagnosis, and treatment of ADHD to help NPs
optimize patient management.
■ Prevalence of ADHD
The estimated worldwide prevalence of ADHD in children
and adolescents ranges from 3.4% to 7.1%, respectively;
however, a wide variability may exist in global prevalence
estimates resulting from cultural differences in popula-
tions studied and variable criteria used for diagnosis.12-15
The prevalence of ADHD in very young children is less
well studied.13

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 Diagnosis and treatment of attention deficit hyperactivity disorder

Overall, ADHD prevalence rates in children and ado- Societal factors (economic status, family dynamics, lan-
lescents residing in non-U.S. countries are generally similar guage of origin in home) that influence how, when, and
to those in the United States, indicating that ADHD is a where care is pursued, and whether providers appropri-
condition of worldwide concern.12,13 However, one excep- ately diagnose ADHD, may also explain the difference in
tion may be school-aged children who reside in Turkey, prevalence.23,24
as ADHD prevalence rates in this region are consider- An analysis by Fayyad and colleagues used the World
ably higher compared with global estimates, ranging from Health Organization’s (WHO’s) mental health surveys to
12.7% to 21.8%.16 assess ADHD prevalence in adults ages 18 to 44; estimates
The estimated prevalence of ADHD among children in ranged from 1.2% to 7.3% across the 10 countries surveyed.
the United States ranges from 8.7% to 11%; higher rates A greater prevalence was observed in France (7.3%), and
(15.5% to 16.1%) have been reported
in smaller population-based surveys
conducted in rural communities.17-20 ADHD that persists into adulthood can
A comparison of 2011 prevalence data cause impairments in social, educational,
from the National Survey of Children’s
Health with findings from similar occupational, and interpersonal functioning.
analyses conducted in 2003 and 2007
showed an overall upward trend in the
prevalence of ADHD in the United States (2003, 7.8%; substantially lower prevalence rates were observed in Co-
2007, 9.5%; 2011, 11%), with an increase of 41% from lombia (1.9%), Lebanon (1.8%), Mexico (1.9%), and Spain
2003 to 2011.18 (1.2%). Prevalence rates fell within the middle range in
Specifically, from 2003 to 2011, the number of children Belgium (4.1%), Germany (3.1%), Italy (2.8%), the Neth-
diagnosed with ADHD increased by 2 million, and the num- erlands (5.0%), and the United States (5.2%).25
ber receiving treatment for ADHD increased by 1 million. In the United States, previous survey-based analyses
Factors driving this increase in prevalence may include reported ADHD prevalence rates ranging from 4.4% to
greater awareness of the disorder, specific clinician char- 5.2% in adults, which are generally lower than that observed
acteristics (age, education, training, confidence regarding in children and adolescents.25,26 Prevalence estimates were
treatment effectiveness), and increased exposure to etiologic significantly higher in men, adults of non-Hispanic White
or environmental factors.18,21 ethnicity, those who had been previously married, and those
Results of a separate meta-regression analysis that evalu- who were unemployed or disabled (P < 0.05 for all). In
ated ADHD prevalence in children over the past 3 decades contrast, the prevalence of ADHD in employed adults was
(135 studies published from 1985 to 2012) observed no significantly lower than that of other survey participants
increase in ADHD prevalence when controlling for study (4.5% versus 7.2%, P = 0.021).27
methods. Specifically, criteria for ADHD diagnosis, impair- More recent analyses conducted in various adult
ment, and information sources were significantly associated patient populations in the United States have reported
with diversity of prevalence estimates.14 ADHD prevalence estimates of 0.31% to 11.3%.28-31 Preva-
In the analysis of 2011 data from the National Survey lence rates were gender-balanced in these studies with
of Children’s Health, the prevalence of ADHD was higher no substantial differences between men and women. An
among boys than girls (15.1% versus 6.7%, respectively), analysis of a large, managed care study in adults with
children age 11 years or older (11 to 14 years, 14.3%; 15 to ADHD found that prevalence rates were significantly
17 years, 14.0%) compared with those under age 11 years higher in younger adults ages 18 to 19; however, a separate
(4 to 10 years, 7.7%), and children with public healthcare study reported no significant differences in prevalence
coverage (14.4%).18 based on age.30,31
Similar findings—that cultural factors and access to Importantly, the prevalence of ADHD in older adults (age
healthcare influenced ADHD prevalence—were observed 50 or older) is thought to be lower than in younger adults.30
in an analysis of ADHD prevalence rates among children This remains to be established, as few epidemiologic studies
receiving services from the New York State public mental of ADHD have been conducted in older age groups.32,33
22
health system. ADHD prevalence rates reported in larger
national studies may reflect greater access to private health ■ Diagnosing ADHD
insurance and multiple types of healthcare providers, in- The Diagnostic and Statistical Manual of Mental Disorders,
cluding primary care physicians, NPs, and psychiatrists. fifth edition (DSM-5) has longer symptom narratives that

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 Diagnosis and treatment of attention deficit hyperactivity disorder

explain how symptoms may present in adolescents and ■ ADHD rating scales
adults as compared with the previous edition.34 Further- Examples of rating scales commonly used by parents and
more, the DSM-5 lessens the importance of distinctions teachers include the Conners Parent Rating Scale-Revised,
between ADHD presentations, an approach similar to the the Conners’ Teacher Rating Scale-Revised, the Vanderbilt
WHO’s International Classification of Diseases, 10th edition ADHD Diagnostic Teacher Rating Scale (vadtrs), and
(ICD-10).34 the Vanderbilt ADHD Diagnostic Parent Rating Scale
Diagnosis of ADHD requires an early onset of symp- (vadprs). 39-43 The Conners Parent and Teacher Rating
toms; however, the DSM-5 revised the required age for onset Scales consist of questions categorized across up to seven
of symptoms prior to age 12 years rather than age 7 years.3,34 subscales of symptoms, including cognitive problems,
oppositional behaviors, hyperactiv-
ity/impulsivity, anxiety, perfectionism,
Symptoms of ADHD include inattention and/ social functioning, and psychosomatic
symptoms.40,41
or hyperactivity-impulsivity that interfere with
Questions are scored on a 4-point
social, academic, or occupational functioning. scale from 0 (not at all true) to 3 (very
much true), with higher scores indi-
cating greater symptom severity. The
Expanding the age requirement addresses challenges with 43-item vadtrs is a relatively easy-to-use scale that evalu-
retrospectively determining the specific timing of symptom ates teachers’ perceptions of ADHD symptoms as well
onset during childhood and may be helpful when diagnosing as academic and behavioral performance; similarly, the
older individuals who have difficulty recalling symptoms 45-item vadprs assesses parent or caregiver perceptions
from earlier years. of these behaviors.42,43
According to the DSM-5, core symptoms of ADHD Both of the Vanderbilt scales score ADHD symptoms on
include inattention and/or hyperactivity-impulsivity that a 4-point scale from 0 (never) to 3 (very often), with higher
occur in two or more settings (home, sports/activities, and/ scores indicating greater symptom severity. Academic and
or school) and interfere with the quality of social, academic, behavioral performances are rated on a 5-point scale, with
or occupational functioning (see DSM-5 ADHD diagnostic higher scores indicating above-average performance. These
criteria).3 scales were not developed to evaluate or diagnose ADHD
Clinical practice guidelines for the diagnosis of ADHD independently from other checklists and interviews but are
published by the American Academy of Child and Ado- often used to supplement patient history, monitor treatment
lescent Psychiatry (AACAP) and the American Academy response, and evaluate whether an individual requires more
of Pediatrics (AAP) recommend that healthcare providers detailed, specialized assessments.43,44
perform a DSM-5 evaluation for any child who experi- Although scales rated by parents, teachers, and caregiv-
ences academic or behavioral problems with accompany- ers provide important information regarding the individual
ing signs and symptoms of developmentally inappropriate with ADHD, additional rating scales and assessments em-
inattention, hyperactivity, or impulsivity.35,36 AAP recom- ployed in clinical trials of patients with ADHD are also
mendations apply specifically to individuals ages 4 to 18 important to evaluate the efficacy and safety of pharma-
years.36 cologic treatment.
Guidelines recommend that when making an ADHD
diagnosis, healthcare providers closely evaluate the detailed ■ ADHD treatment
developmental, social, and medical history regarding the Guidelines put forth by the AACAP and AAP recommend
patient, as ADHD is often a diagnosis of exclusion. Such that a treatment plan for an individual with ADHD should
information should be obtained from multiple sources, include both psychopharmacologic and behavioral inter-
including the patient, parents and caregivers, teachers, psy- ventions.35,36
chologists, and other physicians when possible.34,37,38
In addition to key behaviors characteristic of ADHD, Pharmacotherapy
comorbid emotional disorders (anxiety, depression), de- Approved pharmacotherapies recommended by AAP
velopmental disorders (learning and language deficits), and AACAP clinical practice guidelines include psycho-
or physical conditions (tics, obstructive sleep apnea) may stimulants (mixed salts of amphetamine-based products,
also be present and should be considered because they may dextroamphetamine sulfate, and methylphenidate hydro-
influence the ADHD diagnosis.36-38 chloride) and nonstimulants (including atomoxetine, a

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 Diagnosis and treatment of attention deficit hyperactivity disorder
DSM-5 ADHD diagnostic criteria3
A. A persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or development,
as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have
persisted for at least 6 months to a degree that is inconsis-
tent with developmental level and negatively impact social
and academic/occupational activities.
Note: The symptoms are not solely a manifestation of
oppositional behavior, defiance, hostility, or failure to
understand tasks or instructions. For older adolescents
and adults (age 17 years and older), at least five symptoms
are required.
• Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or during
other activities (overlooks or misses details, work is
inaccurate).
• Often has difficulty sustaining attention in tasks or play
activities (has difficulty remaining focused during lectures,
conversations, or lengthy reading).
• Often does not seem to listen when spoken to directly
(mind seems elsewhere, even in the absence of any obvious
distraction).
• Often does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace (starts
tasks but quickly loses focus and is easily sidetracked).
• Often has difficulty organizing tasks and activities
(difficulty managing sequential tasks; difficulty keeping
materials and belongings in order; messy, disorganized
work; has poor time management; fails to meet dead-
lines).
• Often avoids, dislikes, or is reluctant to engage in
tasks that require sustained mental effort (school-
work or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy
papers).
• Often loses things necessary for tasks or activities (school
materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
• Is often easily distracted by extraneous stimuli (for
older adolescents and adults, may include unrelated
thoughts).
• Is often forgetful in daily activities (doing chores, running
errands; for older adolescents and adults, returning calls,
paying bills, keeping appointments).
2. Hyperactivity and impulsivity: Six (or more) of the fol-
lowing symptoms have persisted for at least 6 months to
a degree that is inconsistent with developmental level and
that negatively impacts directly on social and academic/
occupational activities.
Note: The symptoms are not solely a manifestation of oppo-
sitional behavior, defiance, hostility, or failure to understand
tasks or instructions. For older adolescents and adults (age
17 years and older), at least five symptoms are required.
• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated
is expected (leaves his or her place in the classroom, in
the office or other workplace, or in other situations that
require remaining in place).
• Often runs about or climbs in situations where it is inap-
propriate (in adolescents or adults, may be limited to
feeling restless).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (©2013). American Psychiatric Association. All Rights
Reserved.
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• Often unable to play or engage in leisure activities
quietly.
• Is often “on the go,” acting as if “driven by a mo-
tor” (is unable to be or uncomfortable being still for
extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep
up with).
• Often talks excessively.
• Often blurts out an answer before a question has been
completed (completes people’s sentences; cannot wait for
turn in conversation).
• Often has difficulty waiting his or her turn (waiting in
line).
• Often interrupts or intrudes on others (butts into conversa-
tions, games, or activities; may start using other’s things
without asking or receiving permission; for adolescents
and adults, may intrude into or take over what others are
doing).
B. Several inattentive or hyperactive-impulsive symptoms
were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms
are present in two or more settings (at home, school, or
work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with,
or reduce the quality of, social, academic, or occupational
functioning.
E. The symptoms do not occur exclusively during the course
of schizophrenia or another psychotic disorder and are
not better explained by another mental disorder (mood
disorder, anxiety disorder, dissociative disorder, personal-
ity disorder, substance intoxication, or withdrawal).
Specify whether:
314.01 (F90.2) Combined presentation: If both criterion A1
(inattention) and criterion A2 (hyperactivity-impulsivity) are
met for the past 6 months.
314.00 (F90.0) Predominantly inattentive presenta-
tion: If criterion A1 (inattention) is met but criterion
A2 (hyperactivity-impulsivity) is not met for the past
6 months.
314.01 (F90.1) Predominantly hyperactive/impulsive
presentation: If criterion A2 (hyperactivity-impulsivity) is
met and criterion A1 (inattention) is not met for the past
6 months.
Specify if:
In partial remission: When full criteria were previously
met, fewer than the full criteria have been met for the past
6 months, and the symptoms still result in impairment in
social, academic, or occupational functioning.
Specify current severity:
Mild: Few, if any, symptoms in excess of those required to
make the diagnosis are present, and symptoms result in
no more than minor impairments in social or occupational
functioning.
Moderate: Symptoms or functional impairment between
“mild” and “severe” are present.
Severe: Many symptoms in excess of those required to
make the diagnosis, or several symptoms that are particu-
larly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning.
The Nurse Practitioner • October 2017 51
 Diagnosis and treatment of attention deficit hyperactivity disorder

selective norepinephrine reuptake inhibitor [NRI]; guan-
facine hydrochloride extended-release, a selective alpha2a-
adrenergic receptor agonist; and clonidine hydrochloride
extended-release, a centrally acting alpha2-adrenergic
receptor agonist).35-37
Psychostimulants. Amphetamine- and methylphenidate-
based psychostimulants are considered first-line treatment
for ADHD, with efficacy rates of 70% to 90% and rapid onset
Nonstimulant drugs for the treatment of
ADHD include atomoxetine and extended-
release guanfacine and clonidine.
of action within several hours of dosing.34,45-47 Although
clinical evidence has established that methylphenidate and
amphetamine demonstrate similar efficacy in the treat-
ment of ADHD, methylphenidate has been the primary
psychostimulant prescribed by healthcare providers for
over 30 years.35,47
Methylphenidate was initially formulated as an immediate-
release oral tablet requiring multiple daily doses for effective may be effective in patients whose ADHD symptoms do not
treatment; subsequent extended-release formulations were
developed to provide all-day coverage (eliminating the need
for in-school administration), increased efficacy, and reduc-
tion in adverse reactions.47 However, many children with
ADHD have difficulty swallowing methylphenidate in the
extended-release tablet or capsule form or cannot tolerate
a methylphenidate extended-release patch. To address
this, liquid and chewable formulations of extended-release
methylphenidate have been developed.47,48
Psychostimulants are associated with an increased risk
of cardiovascular events, reduced growth, and suppressed
appetite.49 Guidelines from the American Heart Associa-
tion recommend that children with a personal history of
a cardiac dysrhythmia, structural heart defect, or a close
relative with similar cardiac conditions
undergo ECG screening before initiat-
ing treatment with a psychostimulant.50
Similarly, AAP guidelines rec-
ommend that healthcare providers
conduct an interview to rule out the
presence of specific cardiac symptoms,
Wolff-Parkinson-White syndrome,
sudden death in the family, hypertrophic cardiomyopathy,
and long QT syndrome before initiating treatment with a
psychostimulant in children with ADHD.36
Nonstimulants. Nonstimulant pharmacotherapies rec-
ommended for the treatment of ADHD include the selective
NRI atomoxetine and extended-release formulations of
guanfacine and clonidine.35,36 These pharmacologic agents
improve adequately with psychostimulants, who experience
intolerable adverse reactions when taking psychostimulants,
or have medical comorbidities that preclude them from
taking psychostimulants.49,51
Extended-release formulations of guanfacine and cloni-
dine are approved for use as monotherapy or as adjunctive

Evidence-based behavioral treatments for ADHD36

Type of intervention Description of intervention Typical outcomes

Behavioral parent Behavior-modification principles • Improved compliance with parental commands
training provided to parents for use in home • Increased parental understanding of behavioral
settings principles
• High levels of parental satisfaction with treatment
Behavioral classroom Behavior-modification principles • Improved attention to instruction
management provided to teachers for use in class- • Increased compliance with classroom rules
room settings • Decreased disruptive behavior
• Improved work productivity
Behavioral peer • Interventions focused on peer • Office-based interventions produced minimal
interventions interactions/relationships effects
• Often group-based interventions • Interventions considered to have questionable
provided weekly social validity
• Include clinic-based social skills • Some studies of behavioral peer interventions
training used either alone or con- combined with clinic-based behavioral parent
currently with behavioral parent training found positive effects on parent ratings
training and/or medication of ADHD symptoms
• No differences on social functioning or parent
ratings of social behavior demonstrated
Reproduced with permission from Pediatrics. 2011;128(5):1007-1022. ©2011 by the American Academy of Pediatrics.

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 Diagnosis and treatment of attention deficit hyperactivity disorder
therapy to psychostimulant medications.36 Adverse reac-
tions associated with atomoxetine include somnolence,
gastrointestinal symptoms, decreased appetite, increased
suicidal thoughts, and, in rare instances, hepatitis. Adverse
reactions associated with extended-release formulations of
guanfacine and clonidine include hypotension, somnolence,
and dry mouth.35,36
Behavioral therapy
Practice guidelines recommend evidence-based behav-
ioral interventions in combination with pharmacologic
treatment for children and adolescents with ADHD.35,36
For some individuals (specifically those with mild ADHD
symptoms; minimal functional impairments; or strong
disagreement among parents, teachers, or healthcare pro-
viders regarding the diagnosis), behavioral interventions
may be recommended first before initiating pharmaco-
logic therapy.36
Several behavioral approaches and interventions have
been shown to be effective in individuals with ADHD, in-
cluding behavioral parent training, behavioral classroom
management, behavioral peer interventions, combined be-
havior management interventions, and organization train-
ing (see Evidence-based behavioral treatments for ADHD).36,52
More recently, Pelham and colleagues provided evidence of
clinical benefit with initiating behavioral interventions prior
to implementing pharmacologic treatment over 1 school
year in children with ADHD (n = 146).53
Generally, children who received behavioral therapy
prior to treatment with extended-release methylphenidate
had greater improvements in behavioral outcomes com-
pared with children who initiated pharmacotherapy first.53
Of importance, behavioral interventions are diverse with
numerous outcome measures, which makes analyses of their
efficacy, either alone or in combination with pharmacologic
therapies, reasonably challenging. As such, the benefits of
behavioral interventions over long durations of time have
not yet been established; however, continued adherence to
behavior modification programs is likely critical to achieve
optimal outcomes for individuals with ADHD.36
■ Understanding ADHD
ADHD is a common, widespread neurobehavioral disorder
that appears to be increasing in prevalence in both children
and adults, both in the United States and globally. Despite
the growing prevalence, a number of individuals remain
undiagnosed and untreated, which may result from parental
fears and societal stigma associated with the disorder. Clini-
cal practice guidelines recommend that healthcare providers
initiate a clinical evaluation for any child who experiences
academic or behavioral problems with accompanying symp-
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toms of developmentally inappropriate inattention, hyper-
activity, or impulsivity.
Once a diagnosis is confirmed, a comprehensive treat-
ment plan should be developed, including both behav-
ioral and pharmacologic interventions. As ADHD remains
a diagnosis of exclusion, other causes of inattention and/
or hyperactivity, including anxiety disorders, depression,
and learning disabilities, must be excluded. Numerous be-
havioral interventions have been shown to be effective for
individuals with ADHD, although the long-term benefits
have yet to be established.
Amphetamine- and methylphenidate-based psycho-
stimulants are considered first-line treatments for ADHD;
methylphenidate has been considered the gold standard in
ADHD pharmacotherapy for over 30 years. To achieve suc-
cessful outcomes, clinicians and parents must consider the
long-term chronic nature of this neurobehavioral disorder
and work to develop the most effective treatment plan tai-
lored specifically for the individual with ADHD.
REFERENCES
1. Childress AC, Berry SA. Pharmacotherapy of attention-deficit hyperactivity
disorder in adolescents. Drugs. 2012;72(3):309-325.
2. Centers for Disease Control and Prevention. Key findings: trends in the
parent-report of health care provider-diagnosis and medication treatment
for ADHD: United States, 2003-2011. 2014. www.cdc.gov/ncbddd/adhd/
features/key-findings-ADHD72013.html.
3. Attention-deficit/hyperactivity disorder. Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Washington DC: American Psychiatric Association;
2013.
4. Bjerrum MB, Pedersen PU, Larsen P. Living with symptoms of attention
deficit hyperactivity disorder in adulthood: a systematic review of qualitative
evidence. JBI Database System Rev Implement Rep. 2017;15(4):1080-1153.
5. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of
hyperactive children diagnosed by research criteria: I. An 8-year prospective
follow-up study. J Am Acad Child Adolesc Psychiatry. 1990;29(4):546-557.
6. Gardner DM, Gerdes AC, Weinberger K. Examination of a parent-assisted,
friendship-building program for adolescents with ADHD. J Atten Disord.
[e-pub June 9, 2015]
7. Ginsberg Y, Quintero J, Anand E, Casillas M, Upadhyaya HP. Underdiagnosis
of attention-deficit/hyperactivity disorder in adult patients: a review of the
literature. Prim Care Companion CNS Disord. 2014;16(3).
8. Ramsay JR. Assessment and monitoring of treatment response in adult ADHD
patients: current perspectives. Neuropsychiatr Dis Treat. 2017;13:221-232.
9. Adamou M, Arif M, Asherson P, et al. Occupational issues of adults with
ADHD. BMC Psychiatry. 2013;13:59.
10. Doshi JA, Hodgkins P, Kahle J, et al. Economic impact of childhood and
adult attention-deficit/hyperactivity disorder in the United States. J Am Acad
Child Adolesc Psychiatry. 2012;51(10):990-1002.e2.
11. Barkley RA. Global issues related to the impact of untreated attention-deficit/
hyperactivity disorder from childhood to young adulthood. Postgrad Med.
2008;120(3):48-59.
12. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The world-
wide prevalence of ADHD: a systematic review and metaregression analysis.
Am J Psychiatry. 2007;164(6):942-948.
13. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity
disorder: a meta-analytic review. Neurotherapeutics. 2012;9(3):490-499.
14. Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD
prevalence estimates across three decades: an updated systematic review and
meta-regression analysis. Int J Epidemiol. 2014;43(2):434-442.
15. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research
review: a meta-analysis of the worldwide prevalence of mental disorders in
children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345-365.
The Nurse Practitioner • October 2017 53
 Diagnosis and treatment of attention deficit hyperactivity disorder
16. Ercan ES, Bilaç Ö, Uysal Özaslan T, Rohde LA. Is the prevalence of ADHD
in Turkish elementary school children really high? Soc Psychiatry Psychiatr
Epidemiol. 2015;50(7):1145-1152.
17. Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK, Kahn
RS. Prevalence, recognition, and treatment of attention-deficit/hyperactiv-
ity disorder in a national sample of US children. Arch Pediatr Adolesc Med.
2007;161(9):857-864.
18. Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of
health care provider-diagnosed and medicated attention-deficit/hyperactivity
disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry.
2014;53(1):34-46.e2.
19. Rowland AS, Skipper BJ, Umbach DM, et al. The prevalence of ADHD in a
population-based sample. J Atten Disord. 2015;19(9):741-754.
20. Nyarko KA, Grosse SD, Danielson ML, Holbrook JR, Visser SN, Shapira SK.
Treated prevalence of attention-deficit/hyperactivity disorder increased from
2009 to 2015 among school-aged children and adolescents in the United
States. J Child Adolesc Psychopharmacol. [e-pub Mar. 22, 2017]
21. Patel A, Medhekar R, Ochoa-Perez M, et al. Care provision and prescrib-
ing practices of physicians treating children and adolescents with ADHD.
Psychiatr Serv. 2017;68(7):681-688.
22. Siegel CE, Laska EM, Wanderling JA, Hernandez JC, Levenson RB. Preva-
lence and diagnosis rates of childhood ADHD among racial-ethnic groups
in a public mental health system. Psychiatr Serv. 2016;67(2):199-205.
23. Collins KP, Cleary SD. Racial and ethnic disparities in parent-reported
diagnosis of ADHD: National Survey of Children’s Health (2003, 2007, and
2011). J Clin Psychiatry. 2016;77(1):52-59.
24. Fulton BD, Scheffler RM, Hinshaw SP. State variation in increased ADHD
prevalence: links to NCLB school accountability and state medication laws.
Psychiatr Serv. 2015;66(10):1074-1082.
25. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and cor-
relates of adult attention-deficit hyperactivity disorder. Br J Psychiatry.
2007;190:402-409.
26. Young JL, Goodman DW. Adult attention-deficit/hyperactivity disorder
diagnosis, management, and treatment in the DSM-5 era. Prim Care
Companion CNS Disord. 2016;18(6).
27. De Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult
attention-deficit/hyperactivity disorder (ADHD) on the performance of
workers: results from the WHO World Mental Health Survey Initiative.
Occup Environ Med. 2008;65(12):835-842.
28. Nylander L, Holmqvist M, Gustafson L, Gillberg C. Attention-deficit/
hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in adult
psychiatry. A 20-year register study. Nord J Psychiatry. 2013;67(5):344-350.
29. Moffitt TE, Houts R, Asherson P, et al. Is adult ADHD a childhood-onset
neurodevelopmental disorder? Evidence from a four-decade longitudinal
cohort study. Am J Psychiatry. 2015;172(10):967-977.
30. Knight TK, Kawatkar A, Hodgkins P, et al. Prevalence and incidence of adult
attention deficit/hyperactivity disorder in a large managed care population.
Curr Med Res Opin. 2014;30(7):1291-1299.
31. Caci HM, Morin AJ, Tran A. Prevalence and correlates of attention deficit
hyperactivity disorder in adults from a French community sample. J Nerv
Ment Dis. 2014;202(4):324-332.
32. Torgersen T, Gjervan B, Lensing MB, Rasmussen K. Optimal management of
ADHD in older adults. Neuropsychiatr Dis Treat. 2016;12:79-87.
33. Goodman DW, Mitchell S, Rhodewalt L, Surman CB. Clinical presentation,
diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD)
in older adults: a review of the evidence and its implications for clinical care.
Drugs Aging. 2016;33(1):27-36.
34. Thapar A, Cooper M. Attention deficit hyperactivity disorder. Lancet.
2016;387(10024):1240-1250.
35. Wagner DJ, Vallerand IA, McLennan JD. Treatment receipt and outcomes
from a clinic employing the attention-deficit/hyperactivity disorder treat-
ment guideline of the children’s medication algorithm project. J Child
Adolesc Psychopharmacol. 2014;24(9):472-480.
36. American Academy of Pediatrics. ADHD: clinical practice guideline for the
diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disor-
der in children and adolescents. Pediatrics. 2011;128(5):1007-1022.
37. Sharma A, Couture J. A review of the pathophysiology, etiology, and treat-
ment of attention-deficit hyperactivity disorder (ADHD). Ann Pharmacother.
2014;48(2):209-225.
38. Efron D, Bryson H, Lycett K, Sciberras E. Children referred for evaluation
for ADHD: comorbidity profiles and characteristics associated with a posi-
tive diagnosis. Child Care Health Dev. 2016;42(5):718-724.
54 The Nurse Practitioner • Vol. 42, No. 10
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
39. Conners CK. A teacher rating scale for use in drug studies with children. Am
J Psychiatry. 1969;126(6):884-888.
40. Conners CK, Sitarenios G, Parker JD, Epstein JN. Revision and restandard-
ization of the Conners Teacher Rating Scale (CTRS-R): factor structure, reli-
ability, and criterion validity. J Abnorm Child Psychol. 1998;26(4):279-291.
41. Conners CK, Sitarenios G, Parker JD, Epstein JN. The revised Conners’ Par-
ent Rating Scale (CPRS-R): factor structure, reliability, and criterion validity.
J Abnorm Child Psychol. 1998;26(4):257-268.
42. Wolraich ML, Feurer ID, Hannah JN, Baumgaertel A, Pinnock TY. Obtaining
systematic teacher reports of disruptive behavior disorders utilizing DSM-
IV. J Abnorm Child Psychol. 1998;26(2):141-152.
43. Wolraich ML, Bard DE, Neas B, Doffing M, Beck L. The psychometric
properties of the Vanderbilt attention-deficit/hyperactivity disorder diag-
nostic teacher rating scale in a community population. J Dev Behav Pediatr.
2013;34(2):83-93.
44. Conners CK. Rating scales in attention-deficit/hyperactivity disorder: use in as-
sessment and treatment monitoring. J Clin Psychiatry. 1998;59(suppl 7):24-30.
45. Bonvicini C, Faraone SV, Scassellati C. Attention-deficit hyperactivity disor-
der in adults: a systematic review and meta-analysis of genetic, pharmacoge-
netic and biochemical studies. Mol Psychiatry. 2016;21(7):872-884.
46. Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of
stimulant medications in the treatment of children, adolescents, and adults.
J Am Acad Child Adolesc Psychiatry. 2002;41(2 suppl):26S-49S.
47. Sugrue D, Bogner R, Ehret MJ. Methylphenidate and dexmethylphenidate
formulations for children with attention-deficit/hyperactivity disorder. Am
J Health Syst Pharm. 2014;71(14):1163-1170.
48. Wigal SB, Childress AC, Belden HW, Berry SA. NWP06, an extended-release
oral suspension of methylphenidate, improved attention-deficit/hyperactivity
disorder symptoms compared with placebo in a laboratory classroom study.
J Child Adolesc Psychopharmacol. 2013;23(1):3-10.
49. Childress A. The safety of extended-release drug formulations for the treat-
ment of ADHD. Expert Opin Drug Saf. 2017;16(5):603-615.
50. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and
adolescents with heart disease receiving medications for attention deficit/
hyperactivity disorder [corrected]: a scientific statement from the American
Heart Association Council on Cardiovascular Disease in the Young Congenital
Cardiac Defects Committee and the Council on Cardiovascular Nursing.
Circulation. 2008;117(18):2407-2423.
51. Hirota T, Schwartz S, Correll CU. Alpha-2 agonists for attention-deficit/
hyperactivity disorder in youth: a systematic review and meta-analysis
of monotherapy and add-on trials to stimulant therapy. J Am Acad Child
Adolesc Psychiatry. 2014;53(2):153-173.
52. Pelham WE Jr, Fabiano GA. Evidence-based psychosocial treatments
for attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol.
2008;37(1):184-214.
53. Pelham WE Jr, Fabiano GA, Waxmonsky JG, et al. Treatment sequencing for
childhood ADHD: a multiple-randomization study of adaptive medication
and behavioral interventions. J Clin Child Adolesc.Psychol. 2016;45(4):396-415.
Amy E. Vierhile is a senior NP at the University of Rochester Medical Center
and assistant professor at the University of Rochester, School of Nursing,
Rochester, N.Y.
Donna Palumbo is a medical director, ADHD franchise at Pfizer, Inc., New York,
N.Y.
Heidi Belden is a medical director at Tris Pharma, Inc., Monmouth Junction, N.J.
Medical writing support was provided by Kathy Covino, PhD, and Callie
Grimes, PhD, of Peloton Advantage.
The authors and planners have disclosed the following financial relationships
related to this article: Pfizer, Inc., Lundbeck Pharmaceuticals, and Tris Pharma-
ceuticals.
DOI-10.1097/01.NPR.0000521995.38311.e7
www.tnpj.com