Pediatric Attention Deficit Hyperactivity Disorder Workup

Author: Zainab P Contractor, MD; Chief Editor: Caroly Pataki, MD more...

Updated: Jan 25, 2012

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Laboratory Studies
Imaging Studies
Other Tests
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Laboratory Studies

Workup in attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), includes the following:

Liver function tests

Liver function tests (LFTs) may be indicated if the patient has a history of hepatic dysfunction.

Amphetamines, methylphenidate, atomoxetine, and tricyclic antidepressants are metabolized hepatically and excreted mainly in the urine.

A cause-and-effect relationship has been established between the use of atomoxetine and reversible hepatic failure. However, no evidence suggests that baseline LFT results assist care with atomoxetine in any way.

Consider checking LFTs if a patient who is taking atomoxetine presents with signs of hepatitis including early signs, such as nausea, vomiting, diarrhea, and muscle aches lasting longer than 5 days.

Determination of CBC counts

A coincident relationship has been reported, but no cause-and-effect relationship has been established between use of methylphenidate and blood dyscrasias.

A few clinical authorities recommend periodic determination of the CBC counts, but their necessity is not generally endorsed, even for patients receiving long-term treatment.

Drug screening

Consider periodic random drug screening by means of urine testing (witnessed) or serum testing (if witnessing of urine testing is not possible) in all patients with a history of chemical abuse or suspected chemical abuse.

Any suspected substances should be investigated.

Imaging Studies

Evidence suggests that MRI and positron emission tomography (PET) may be useful as future diagnostic methods. Current use is appropriate for research purposes only.

At present, no laboratory studies, imaging studies, or procedures help with the diagnosis of ADHD (ADD), unless the patient's history suggests that other pathology must be ruled out.

Other Tests

Psychometric and educational testing is often important for the diagnosis of ADHD (ADD). The patient's initial history may indicate a need for additional tests, as follows:

Examine children by using the Conners' Parent and Teacher Rating Scale and examine adolescents according to the Brown Attention Deficit Disorder Scale (BADDS) for Adolescents and Adults.^[4]
Assess impulsivity and inattention using timed computer tests such as the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both.
Assess girls using the Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls.
Assess the patient's executive function by using various neuropsychologic tests.
Perform a learning disability evaluation (intelligence quotient [IQ] vs achievement).
Several well-validated IQ tests are available. The Wechsler tests are the standards. Many believe that untimed tests are most appropriate for persons with ADHD (ADD). A large discrepancy between the patient's IQ and other measures, such as visual or auditory abilities or an ability to work with numbers, is not uncommon, particularly in older children and adolescents
Baseline ECG to access the QT interval may be indicated before a tricyclic antidepressant is prescribed.

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Zainab P Contractor, MD Medical Director, The Affinity Center; Cincinnati, Ohio

Disclosure: Nothing to disclose.

Coauthor(s)

Christine A Mayhall, PhD Clinical Psychologist, The Affinity Center

Christine A Mayhall, PhD is a member of the following medical societies: American Psychological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Chet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School of Medicine; LEND Director, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Susan Louisa Montauk, MD†,to the development and writing of this article.

References

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Ducharme S, Hudziak JJ, Botteron KN, Albaugh MD, Nguyen TV, Karama S, et al. Decreased regional cortical thickness and thinning rate are associated with inattention symptoms in healthy children. J Am Acad Child Adolesc Psychiatry. Jan 2012;51(1):18-27.e2. [Medline].
Brown TE. Brown ADD Scales. San Antonio, TX: Psychological Corp; 1996:5-6.
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Table 1. Pediatric Dosing of Stimulant Medications

Table 1. Pediatric Dosing of Stimulant Medications

Medication	Initial Pediatric Dose	Pediatric Dosage Range and Maximum Dose*	Common Pediatric Dose*	Preparations
Methylphenidate immediate release (IR) (Ritalin, Methylin, generic)	2.5-5 mg	0.1-0.8 mg/kg/dose PO qd to 5 times/d; not to exceed 60 mg/d	0.3-0.5 mg/kg/dose PO tid/qid	All preparations available as 5-mg, 10-mg, or 20-mg scored tabs; Methylin also available as 2.5-mg, 5-mg, or 10-mg chewable tab and PO solution (5 mg/5 mL and 10 mg/mL)
Methylphenidate sustained-release (SR) (Ritalin LA, Metadate CD)	Convert from IR or use 10 mg.	0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d	0.6-1 mg/kg/dose PO qd/bid	10-mg, 20-mg, 30-mg, or 40-mg tabs (Metadate also has 50-mg and 60-mg tabs.); can be sprinkled into soft food (Do not cut, crush, or chew.)
Methylphenidate extended release (ER)‡ (Ritalin SR, Methylin ER, Metadate ER, generic SR)	Convert from IR.	0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d	0.6-1 mg/kg/dose PO qd/bid	20-mg Spansules (Do not cut, crush, or chew.)
Methylphenidate OROS tablets (Concerta)	Convert from IR or use 18 mg.	0.3-2 mg/kg PO qd; not to exceed 54 mg/d	0.8-1.6 mg/kg PO qd	18-mg, 27-mg, 36-mg, and 54-mg tabs (Do not cut, crush, or chew.)
Methylphenidate transdermal patch (Daytrana)^†	Convert from IR or use 10 mg (12.5 cm² patch) released over 9 h and titrate up prn.	0.3-2 mg/kg released over 9 h; not to exceed one 30-mg patch	10-30 mg released over 9 h	10-mg, 15-mg, 20-mg, 30-mg patches, applied to the hip
Dexmethylphenidate IR (Focalin)	2.5-5-mg	0.1-0.5 mg/kg/dose PO qd to qid; not to exceed 20 mg/d	0.2-0.3 mg/kg/dose PO bid/tid	2.5-mg, 5-mg, or 10-mg scored tabs (Do not cut, crush, or chew.)
Dexmethylphenidate extended release (Focalin-XR)	5-10-mg	0.2-1 mg/kg/dose PO qd to bid; not to exceed 20 mg/d	0.4-0.6 mg/kg/dose PO qd/bid	5-mg, 10-mg, or 20-mg scored tabs; can be sprinkled into soft food (Do not cut, crush, or chew.)
Dextroamphetamine (Dexedrine, Dextrostat)	2.5-5 mg	0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 60 mg/d	0.3-0.5 mg/kg/dose PO qd/tid	Dexedrine: 5-mg scored tabs; Dextrostat: 5-mg and 10-mg scored tabs
Dextroamphetamine Spansules (Dexedrine CR)	5 mg	0.1-0.75 mg/kg/dose PO qd/bid; not to exceed 60 mg/d	0.3-0.6 mg/kg/dose PO qd/bid	5-mg, 10-mg, or 15-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.)
Mixed amphetamine salts IR (Adderall, generic)	2.5-5 mg	0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 40 mg/d	0.3-0.5 mg/kg/dose PO tid/qid	5-mg, 7.5-mg, 10-mg, 12.5-mg, 15-mg, 20-mg, or 30-mg scored tabs
Mixed amphetamine salt XR (Adderall-XR)	Convert from IR or use 5-10 mg	0.2-1.4 mg/kg/dose PO qd/tid Not to exceed 30 mg/d	0.6-1 mg/kg/dose PO qd/bid	5-mg, 10-mg, 15-mg, 20-mg, 25-mg, or 30-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.)
Lisdexamfetamine (Vyvanse)	30 mg PO qam	30-70 mg PO qam	Data limited (too early to tell)	20-mg, 30-mg, 40-mg, 50-mg, 60-mg, or 70-mg caps (Swallow cap whole, sprinkle into soft food, or dissolve contents in glass of water and drink immediately.)
Note. In general, when the terms methylphenidate, Dexedrine, and Ritalin are used without abbreviations for extended-release preparations (eg, continuous release [CR], SR, osmotic-release oral system [OROS]), a short-acting, IR preparation is implied. ^* Maximum pediatric dose suggested by the US Food and Drug Administration (FDA). Although some children benefit greatly from doses greater than these, benefit from use of either the lowest and highest ends of the dose range is uncommon. †The methylphenidate patch contains a different total methylphenidate dose than the name implies because it is designed to last 12 hours (eg, 10-mg patch [patch size 12.5 cm²] delivers about 10 mg over 9 h [estimated delivery rate is 1.1 mg/h for this particular patch]). Delivery rate varies depending on patch size. ‡Many patients describe their experience with methylphenidate SR preparations as erratic and uncomfortable.

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