Disorders of Children and Adolescents

Must know

• ADHD Subtype Clusters — Part 1: InattentionDiagnostic criteria require at least 6 inattention symptoms for children up to age 16, or at least 5 symptoms for individuals age 17 and older, persisting for at least 6 months.

  • Diagnostic criteria require at least 6 inattention symptoms for children up to age 16, or at least 5 symptoms for individuals age 17 and older, persisting for at least 6 months.
  • Several inattentive or hyperactive-impulsive symptoms must be present prior to 12 years of age.
  • Clear impairment from symptoms must be present across at least 2 distinct settings, such as at home and in the classroom.
  • Elementary school prevalence is 7% to 8% in children and 2.5% in adults, with a male-to-female ratio of 2 to 1 in children and 1.6 to 1 in adults.
  • Heritability for ADHD is approximately 75%, carrying a 2-to-8-fold increased risk among siblings of affected children.
  • First-line treatment for school-age children combines stimulant pharmacotherapy using methylphenidate or amphetamine preparations with behavioral interventions.
• Clinical Framework and Key SignpostsStimulants, including methylphenidate preparations and amphetamine salts, represent first-line pharmacotherapy for ADHD in school-age children, adolescents, and adults. They should be combined with behavioral strategies and parent support resources such as CHADD.

  • Stimulants, including methylphenidate preparations and amphetamine salts, represent first-line pharmacotherapy for ADHD in school-age children, adolescents, and adults. They should be combined with behavioral strategies and parent support resources such as CHADD.
  • Stimulants increase presynaptic dopamine and norepinephrine, requiring baseline and quarterly monitoring of height, weight, blood pressure, and pulse. Avoid or use with extreme caution in structural cardiac abnormalities, uncontrolled hypertension, active substance use disorders, severe agitation, or active motor tics.
  • Do not assume a child with a well-controlled seizure disorder cannot receive stimulants. Stimulants remain safe and effective when seizures are stabilized on an anticonvulsant. Avoid bupropion in patients with epilepsy because bupropion significantly lowers the seizure threshold.

  Board trap. Do not assume a child with a well-controlled seizure disorder cannot receive stimulants. Stimulants remain safe and effective when seizures are stabilized on an anticonvulsant. Avoid bupropion in patients with epilepsy because bupropion significantly lowers the seizure threshold.

  Safety. Stimulants increase presynaptic dopamine and norepinephrine, requiring baseline and quarterly monitoring of height, weight, blood pressure, and pulse. Avoid or use with extreme caution in structural cardiac abnormalities, uncontrolled hypertension, active substance use disorders, severe agitation, or active motor tics.

• ADHD Subtype Clusters: Inattention Domain and Diagnostic Architecture1. Failing to give close attention to details or making careless mistakes in schoolwork, work, or other activities.

  • 1. Failing to give close attention to details or making careless mistakes in schoolwork, work, or other activities.
  • 2. Difficulty sustaining attention in tasks, lengthy lectures, or play activities.
  • 3. Appearing not to listen when spoken to directly, as if the mind is elsewhere without any obvious distraction.
  • 4. Failing to follow through on instructions and failing to finish schoolwork, chores, or workplace duties due to starting tasks but quickly losing focus.
  • 5. Difficulty organizing tasks and activities, manifested by messy backpacks, disorganized lockers, poor time management, and failing to turn in completed homework assignments.
  • 6. Avoiding, disliking, or being reluctant to engage in tasks that require sustained mental effort, such as school projects or lengthy reports.
• ADHD Subtype Clusters — Part 2: Hyperactivity and ImpulsivityADHD hyperactive-impulsive subtype requires 6 or more out of 9 criteria for children under 17 years, and 5 or more out of 9 criteria for individuals 17 years or older.

  • ADHD hyperactive-impulsive subtype requires 6 or more out of 9 criteria for children under 17 years, and 5 or more out of 9 criteria for individuals 17 years or older.
  • Symptoms must persist for at least 6 months, have an onset prior to age 12, and cause demonstrable impairment across at least 2 distinct settings.
  • Elementary school prevalence is 7 to 8 percent in children and 2.5 percent in adults, with a 2 to 1 male-to-female ratio in youth and a high heritability rate of 75 percent.
  • First-line pharmacotherapy for school-aged youth is stimulant medication (methylphenidate or amphetamine salts), whereas behavioral therapy is first-line for children under 5 years.
  • Baseline cardiac risk evaluation, blood pressure, pulse, height, and weight must be monitored at initiation and quarterly during stimulant treatment.
  • Bupropion is strictly contraindicated in patients with seizure disorders due to lowering the seizure threshold, whereas methylphenidate can be safely restarted if seizures are well controlled on anticonvulsants.

  Board trap. Bupropion is strictly contraindicated in patients with seizure disorders due to lowering the seizure threshold, whereas methylphenidate can be safely restarted if seizures are well controlled on anticonvulsants.

  Safety. Baseline cardiac risk evaluation, blood pressure, pulse, height, and weight must be monitored at initiation and quarterly during stimulant treatment.

• Diagnostic ArchitectureCore threshold: 6 or more symptoms of hyperactivity-impulsivity for individuals up to 16 years of age. 5 or more symptoms required for individuals 17 years of age and older.

  • Core threshold: 6 or more symptoms of hyperactivity-impulsivity for individuals up to 16 years of age. 5 or more symptoms required for individuals 17 years of age and older.
  • Duration requirement: Symptoms must persist for at least 6 consecutive months to a degree that is maladaptive and inconsistent with developmental level.
  • Age of onset gate: Several hyperactive-impulsive or inattentive symptoms must be present prior to age 12 years.
  • Setting gate: Symptoms or impairment must be present in 2 or more settings, such as home, school, sports, or work.
  • Functional interference: Clear evidence of significant interference with social, academic, or occupational functioning.
• FIDGETY MnemonicF: Fidgets with hands or feet, or squirms in seat.

  • F: Fidgets with hands or feet, or squirms in seat.
  • I: In seat fails to remain when remaining seated is expected in classroom or work settings.
  • D: Driven by a motor, acting as if on the go, or running/climbing excessively in inappropriate situations.
  • G: Gabs excessively, demonstrating continuous over-talkativeness.
  • E: Early answer blurted out before a question has been fully completed.
  • T: Turns waiting difficulty, struggling to wait turn in lines or group games.
• Developmental EvolutionYoung children manifest hyperactivity as overt gross motor behaviors like climbing on furniture, running constantly, and failing to engage in quiet play.

  • Young children manifest hyperactivity as overt gross motor behaviors like climbing on furniture, running constantly, and failing to engage in quiet play.
  • Adolescents and adults display less gross motor running but experience a subjective internal feeling of restlessness, excessive talking, and impulsive decision-making.
• First-lineFirst-line treatment for children aged 6 and older with ADHD is stimulant pharmacotherapy (methylphenidate or dextroamphetamine).

  • First-line treatment for children aged 6 and older with ADHD is stimulant pharmacotherapy (methylphenidate or dextroamphetamine).
  • First-line intervention for preschool children under age 5 is evidence-based parent training in behavior management before initiating medications.
  • First-line strategy when motor tics develop during stimulant therapy is switching to a non-stimulant like atomoxetine.
• Board trapDo not confuse ADHD hyperactivity with bipolar mania. Mania is episodic and cyclic, whereas ADHD is a chronic baseline state. Both share distractibility and excessive talking, but grandiosity and decreased need for sleep point to mania.

  • Do not confuse ADHD hyperactivity with bipolar mania. Mania is episodic and cyclic, whereas ADHD is a chronic baseline state. Both share distractibility and excessive talking, but grandiosity and decreased need for sleep point to mania.
  • Do not withhold stimulants in patients with well-controlled seizure disorders. Methylphenidate does not lower seizure threshold when seizures are stabilized on anticonvulsants, whereas bupropion is strictly contraindicated.
  • Expected stimulant side effects include insomnia, reduced appetite, weight loss, and transient headache. Hypersomnia is not a stimulant side effect.
• Safety alertMonitor blood pressure, heart rate, height, and weight at baseline and quarterly during stimulant therapy to evaluate for cardiovascular changes and growth suppression.

  • Monitor blood pressure, heart rate, height, and weight at baseline and quarterly during stimulant therapy to evaluate for cardiovascular changes and growth suppression.
  • Exercise caution when prescribing stimulants in patients with hypertension, structural cardiac abnormalities, active motor tics, severe anxiety/agitation, or a prior history of substance use disorder.
• Hyperactivity in ADHD vs Bipolar I ManiaThink: ADHD is chronic and continuous from childhood; mania is episodic with distinct mood changes.

  • Think: ADHD is chronic and continuous from childhood; mania is episodic with distinct mood changes.
  • Priority: Distinguish baseline restlessness from acute manic grandiosity and decreased need for sleep.
  • Boards are testing: ADHD symptoms do not wax and wane in discrete manic cycles.
• ADHD Hyperactive Subtype vs Anxiety DisordersThink: Anxiety-driven motor restlessness is linked to internal worry; ADHD motor restlessness is driven by executive dysfunction.

  • Think: Anxiety-driven motor restlessness is linked to internal worry; ADHD motor restlessness is driven by executive dysfunction.
  • Priority: Assess whether restlessness occurs only during anxious triggers or across all daily settings continuously.
  • Boards are testing: Anxiety and ADHD co-occur in up to 70 percent of cases, but primary anxiety features excessive apprehension.
• ADHD Impulsivity vs Oppositional Defiant DisorderThink: ADHD impulsivity is unintended impatience or blurted responses; Oppositional Defiant Disorder is deliberate defiance, spitefulness, and arguing with authority.

  • Think: ADHD impulsivity is unintended impatience or blurted responses; Oppositional Defiant Disorder is deliberate defiance, spitefulness, and arguing with authority.
  • Priority: Oppositional Defiant Disorder is treated with family behavioral therapy; ADHD is treated with stimulants.
  • Boards are testing: Academic failure is not a diagnostic criterion for Oppositional Defiant Disorder or conduct disorder.
• Pharmacological Management of ASD SymptomsAutism Spectrum Disorder requires persistent deficits across two core domains: social communication/interaction and restricted, repetitive patterns of behavior or interests.

  • Autism Spectrum Disorder requires persistent deficits across two core domains: social communication/interaction and restricted, repetitive patterns of behavior or interests.
  • Pharmacotherapy does not cure or treat core social communication deficits in Autism Spectrum Disorder.
  • Risperidone and aripiprazole are the only two atypical antipsychotics with FDA approval for treating irritability, aggression, and explosive tantrums associated with Autism Spectrum Disorder in pediatric patients.
  • Applied Behavioral Analysis (ABA) therapy is the gold-standard, first-line non-pharmacological behavioral intervention, recommended for up to 20 hours per week starting early in development.
  • The M-CHAT-R (Modified Checklist for Autism in Toddlers, Revised) is the standard screening tool used between 16 and 30 months; a score of 8 or higher indicates high risk for Autism Spectrum Disorder.
  • Initial clinical presentations often involve parents suspecting a hearing impairment due to the child's lack of response to their name or poor social responsiveness.
• Must-Know Concepts for BoardsApplied Behavioral Analysis (ABA) therapy is the primary first-line non-pharmacological treatment of choice for managing behavior in Autism Spectrum Disorder.

  • Applied Behavioral Analysis (ABA) therapy is the primary first-line non-pharmacological treatment of choice for managing behavior in Autism Spectrum Disorder.
  • Risperidone and aripiprazole are first-line FDA-approved psychotropic choices when severe irritability, physical aggression, temper tantrums, or self-injurious behaviors impair functioning or safety.
  • Baseline metabolic screening is mandatory before starting risperidone or aripiprazole. Measure weight, height, body mass index, blood pressure, fasting blood glucose, and fasting lipid panel at baseline and monitor quarterly due to high risks of rapid weight gain, metabolic syndrome, hyperprolactinemia, and extrapyramidal symptoms.
  • Do not prescribe psychotropic medications with the expectation of correcting core social deficits, speech delays, or lack of eye contact. Medications target secondary behavioral symptoms like severe irritability, severe hyperactivity, or aggression.
  • When parents report a toddler fails to respond to spoken commands or verbal cues, do not assume a primary hearing deficit without first screening for Autism Spectrum Disorder using the M-CHAT-R tool.

  Board trap. Do not prescribe psychotropic medications with the expectation of correcting core social deficits, speech delays, or lack of eye contact. Medications target secondary behavioral symptoms like severe irritability, severe hyperactivity, or aggression.

  Safety. Baseline metabolic screening is mandatory before starting risperidone or aripiprazole. Measure weight, height, body mass index, blood pressure, fasting blood glucose, and fasting lipid panel at baseline and monitor quarterly due to high risks of rapid weight gain, metabolic syndrome, hyperprolactinemia, and extrapyramidal symptoms.

• Core Diagnostic DomainsAutism Spectrum Disorder is characterized by persistent impairment in social communication and social interaction across multiple contexts, alongside restricted and repetitive patterns of behavior, interests, or activities. Symptoms must be present in the early developmental period and cause clinically significant functional impairment.

  • Autism Spectrum Disorder is characterized by persistent impairment in social communication and social interaction across multiple contexts, alongside restricted and repetitive patterns of behavior, interests, or activities. Symptoms must be present in the early developmental period and cause clinically significant functional impairment.