Attention-Deficit/Hyperactivity Disorder (ADHD) Clinical Pathway — Primary Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Related Pathways

Child 3-18 yrs with New Evaluation for ADHD Behaviors

History and Physical Exam

Review Differential Diagnoses, Comorbidities

Primary Care (PC) Screening

Vanderbilt Assessment Scales preferred, others as indicated
- Parent rating in office plus copy for teacher(s) to complete
Use and Interpretation of Vanderbilt Score
Diagnostic considerations for preschool-age, adolescents, females
Neuropsychological or psychoeducational testing not required

PC Visit to Review Diagnosis

Review differential diagnoses, comorbidities
Shared decision making with family to outline care plan
Involve child in discussion as developmentally appropriate
ADHD and Comorbid Neurologic Conditions

Unclear ADHD Diagnosis

Review differential diagnoses, comorbidities
Consider ADHD Center Referral
for diagnostic clarity
- Place PC to BH ADHD order
- Family calls ADHD center for eval

Determine ADHD Severity

Medication Ordering Support

Southeastern PA: Telephonic Psychiatric Consultation Service Program, Pennsylvania (TiPS-PA)
CHOP network only: E-consult to psychiatry via EHR
All other areas:
- National Network of Child Psychiatry Access Program (NNCPAP)
- NJ: Pediatric Mental Health Care Access Program (PMHCA)

Begin Treatment
Age (yrs)	Psychosocial Intervention	Medications	Additional Considerations
3-5	Behavioral parent training recommended	Severe Recommend medications ≥ 4 yrs	Consult to psychiatry or developmental-behavioral pediatrics (DBP) if severe or for diagnostic clarity Medication Side Effect Management
6-18	Psychosocial interventions recommended	Mild Consider medications Moderate-severe Recommend medications	Adolescents Review comorbidities Consider psychiatry consult for comorbid depression, substance use Medication Side Effect Management
Existing evidence does not support alternative and complentary therapies Providers should consider the individual child/adolescent and family preferences

Initial Follow-Up Visits

Every 2-4 wks, telehealth as appropriate
- Until effective stable dose without significant side effects
In person visit at 3 mos from stable dosing

Ongoing Evaluation and Management

In-person visits every 3-6 mos
- Monitor effect, weight, growth, BP
Consider scheduled visit at start of school year
Continue Vanderbilt Follow-up Scale
Promote multimodal intervention plan per developmental stage
- Transition to Adulthood Resources

Inadequate Response

Consider
- Second-line medications
- ADHD Center referral after trial of 2 medications
- Local psychiatry resources
- Psychoeducational or neuropsychological testing to assess for learning difficulties

Posted: December 2024
Revised: January 2025

Authors:
- T. Power, PhD;
- W. Wallace, DO;
- M. Volkert, MD;
- K. Garcia PsyD;
- C. Maehler, PharmD;
- E. Edelson, PsyD;
- J. Chua, DO;
- N. Blum, MD;
- R. Usher, MD;
- J. Michel, MD;
- S. Alperin, MD;
- A. Rosen, MD

Evidence

CHOP Program

Center for Management of ADHD

Media

Primary Care Perspectives: Podcast for Pediatricians
Episode 150: ADHD Medication Management

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Primary Care Clinical Pathway for Evaluation and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

Evidence

CHOP Program

Media

Primary Care Clinical Pathway for Evaluation and Treatment
of Attention-Deficit/Hyperactivity Disorder (ADHD)