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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Symptoms begin before age 12 and occur in >=2 settings
- Children <=16 need >=6 symptoms; age >=17 need >=5 symptoms
- School-age first-line medication: FDA-approved stimulants plus behavioral/school interventions
- Preschool: parent training/behavioral therapy first
- Assess anxiety, depression, learning disorder, sleep disorder, SUD, trauma, bipolar disorder
Overview
ADHD involves developmentally inappropriate inattention and/or hyperactivity-impulsivity that impairs functioning, begins before age 12, occurs in at least two settings, and is not better explained by another disorder. Adult hyperactivity may feel like internal restlessness.
Epidemiology
ADHD often persists into adulthood and is associated with academic/occupational impairment, accidents, emotional dysregulation, sleep problems, SUD risk, and comorbid learning disorders, ODD, anxiety, depression, ASD, and tics.
Clinical Features
Symptoms
Inattention: careless mistakes, disorganization, forgetfulness, loses things
Hyperactivity: fidgeting, leaving seat, restlessness
Impulsivity: blurting, interrupting, difficulty waiting, risky decisions
Emotional dysregulation, procrastination, time blindness
Mania, psychosis, intoxication, suicidality, or severe aggression
Signs
Restlessness, fidgeting, distractibility
Normal neurological exam in uncomplicated ADHD
Hypertension/tachycardia/weight loss/insomnia/tics affect medication choice
Sleep apnea, seizures, thyroid disease, intoxication, trauma can mimic
Investigations
First-line
DSM-5-TR assessment with collateralOnset before 12, >=2 settings, impairment, alternative explanations
Rating scalesVanderbilt, Conners, ADHD-RS, adult scales; support not replace diagnosis
Comorbidity/mimic screenSleep, anxiety, depression, bipolar, trauma, SUD, learning disorder, ASD, seizures, hearing/vision
Second-line
Vitals/growthHeight, weight, BP, HR, appetite, sleep, cardiac history before stimulants
Educational evaluationLearning disorders, IEP/504 supports
ECG/cardiologyNot routine; consider cardiac disease, syncope, arrhythmia, family sudden death
Specialist
Child psychiatry/developmental pediatricsComplex diagnosis, preschool severe ADHD, ASD/ID, severe comorbidity
School psychologyLearning assessment/accommodations
1
Behavioral/educational
- Parent training and classroom behavioral interventions
- IEP/504 supports: seating, chunking, reminders, movement breaks, extended time
- Sleep, exercise, organization coaching
2
Medication
- Methylphenidate or amphetamine preparations first-line for most school-age children/adolescents/adults
- Monitor appetite/weight, sleep, BP/HR, mood, misuse/diversion, tics
- Long-acting formulations reduce school dosing and diversion risk
3
Non-stimulants/safety
- Atomoxetine for anxiety, tics, or misuse risk; slower onset
- Guanfacine/clonidine ER help hyperactivity/impulsivity, sleep, tics; monitor sedation/hypotension
- Treat mania/psychosis before stimulants
Complications
- Academic/occupational impairment:
- Accidents/injuries:
- Substance use risk:
- Anxiety/depression/ODD/learning disorder/ASD/sleep disorders:
- Medication appetite, insomnia, BP/HR, diversion:
USMLE Step 2 CK Exam Tips
- 1Before age 12 and >=2 settings
- 2Preschool: behavioral parent training first
- 3School-age: stimulants first-line medication
- 4Bipolar clue is episodic decreased need for sleep/grandiosity
- 5Atomoxetine has no abuse potential and slower onset
- 6Routine ECG not required unless cardiac history
practicetest your knowledge on adhdApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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