• Affects 6%–9% of school-aged children.

Evaluation and Diagnosis

• Multiple components are involved in appropriate evaluation and diagnosis (Pediatrics 2000;105(5):1158).
  
• The PCP should consider ADHD in any child age 6–12 yr with:
  
  
  
  • Inability to sit still or hyperactivity
    
  • Lack of attention, poor concentration, or frequent daydreaming
    
  • Impulsiveness
    
  • Behavior problems
    
  • Poor academic achievement
  
  
• Assessment for ADHD by the pediatrician should include a complete history, complete physical examination (including thorough neurologic examination), family assessment, and school assessment.

• Additional testing generally is not necessary for the diagnosis of ADHD/ADD (lead screening, thyroid screening, EEG, brain imaging), particularly when the medical history is unremarkable.
  
• Psychological and neuropsychological testing is not required but should be performed if the history is suggestive of low cognitive ability or low achievement in language or studies relative to intellectual ability.
  
• Use of formal parent and teacher rating scales (eg, Conners scale, Vanderbilt scale; available at http://www.nichq.org/toolkits_publications/complete_adhd/index.html) is an option to assist in the evaluation or diagnosis of ADHD; if used, the short forms are recommended. Repeated serial administration of these scales at follow-up may provide additional helpful data on response to interventions.
  
• The diagnosis of ADHD/ADD requires that DSM-IV criteria are met (see below).
  
• Comorbid conditions must be considered and addressed. Up to one in three children has a significant comorbid condition, and many children have multiple comorbidities:
  
  
  
  • Learning disorders (one in eight children with ADHD/ADD meet criteria) or language disorders
    
  • Oppositional defiant disorder (one in three)
    
  • Conduct disorder (one in four)
    
  • Anxiety disorder (one in four)
    
  • Depression disorder (one in five)

Diagnostic Criteria for ADHD: DSM-IV Criteria

(Pediatrics 2000;105(5):1158)

Must meet each of the following criteria (A through E):

A. Must meet 6+ criteria under either of the following two subtypes:

Inattentive Criteria

6+ of the following symptoms of inattention persisting for 6 mo and are maladaptive and inconsistent with developmental level:

1. 
   

   Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

   
   
2. 
   

   Often has difficulty sustaining attention in tasks or play activities

   
   
3. 
   

   Often does not seem to listen when spoken to directly

   
   
4. 
   

   Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not because of oppositional behavior or failure to understand instructions)

   
   
5. 
   

   Often has difficulty organizing tasks and activities

   
   
6. 
   

   Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg, schoolwork or homework)

   
   
7. 
   

   Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools)

   
   
8. 
   

   Is often easily distracted by extraneous stimuli

   
   
9. 
   

   Is often forgetful in daily activities

Hyperactive-Impulsive Criteria

6+ of the following symptoms of hyperactivity-impulsivity persisting for 6 mo and are maladaptive and inconsistent with developmental level:

Hyperactivity

1. 
   

   Often fidgets with hands or feet or squirms in seat

   
   
2. 
   

   Often leaves seat in classroom or in other situations in which remaining seated is expected

   
   
3. 
   

   Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

   
   
4. 
   

   Often has difficulty playing or engaging in leisure activities quietly

   
   
5. 
   

   Is often “on the go” or often acts as if “driven by a motor”

   
   
6. 
   

   Often talks excessively

Impulsivity

7. 
   

   Often blurts out answers before questions have been completed

   
   
8. 
   

   Often has difficulty awaiting turn

   
   
9. 
   

   Often interrupts or intrudes on others (eg, butts into conversations or games)

B. Some symptoms that caused impairment were present before 7 years of age.

C. Some impairment from the symptoms is present in two or more settings (eg, at school, work, or home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (eg, mood, anxiety, dissociative, or personality disorder).

Diagnosis Based on Criteria

• Attention-deficit/hyperactivity disorder, combined type: Meets both sets of criteria
  
• Attention-deficit/hyperactivity disorder, predominantly inattentive type: Meets inattentive criteria only
  
• Attention-deficit/hyperactivity disorder, predominantly hyperactive, impulsive type: Meets hyperactive-impulsive criteria only

Treatment

• ADHD should be treated as a chronic condition (see table below); the resultant treatment plan should reflect this.

• The clinician must collaborate with the parents, teachers, and school personnel to specify and monitor proposed treatment outcomes (see table below). Target outcomes measures should include the key symptoms and impairments encountered by the child.

• The physician is integral in developing both a behavioral and pharmacologic treatment plan. Behavioral therapy alone may be effective in milder cases.