However, comprehensive evaluation for possible ADHD includes obtaining information to confirm the presence, persistence, and pervasiveness of inattentive and hyperactive/impulsive symptoms in 2 or more settings (eg, school and home). Symptoms must be present for at least 6 months and cause significant functional impairment. Although the mother describes the child as "very active" in general and the teachers note disruptive behavior, a more detailed assessment of specific ADHD symptoms is necessary. ADHD-specific behavior scales completed by the parent and teacher are most commonly used to obtain a systematic evaluation of the child's behaviors. These scales enable the physician to identify the presence of ADHD symptoms in both settings, and to assess symptom severity and the degree of related impairment, which are necessary for accurate diagnosis.
Parent-child behavioral therapy improves problem behaviors and parent-child relationships. It involves teaching parents to consistently implement effective behavioral techniques (eg, rewards and nonpunitive consequences to shape behavior, calm limit setting, structured daily schedules, minimizing of distractions). Behavioral interventions can also be used in patients who do not meet full ADHD criteria or in combination with medication for school-age children and adolescents with ADHD.
Children with persistent symptoms despite adequate treatment with the initial medication (methylphenidate) and/or intolerable side effects can be treated with an alternate ADHD medication, including other stimulants (eg, mixed amphetamine salts). No tapering or washout is needed, and the patient can be switched immediately from one stimulant to another. More than half of children who are inadequate responders or have side effects with one type of stimulant will have improved efficacy and tolerability with another. The norepinephrine reuptake inhibitor atomoxetine and an alpha-2 adrenergic agonist are nonstimulant options.