Attention-deficit/hyperactivity disorder (ADHD) and its comorbid conditions represent a significant problem to the children in a pediatric practice. Pediatricians need to be not only cognizant of the diagnostic criteria, clinical mimics, comorbidities, and complications of ADHD, but also be comfortable with managing a whole host of complications and other issues, such as stimulant abuse and diversion, that can be very subtle. This article will review the diagnostic criteria for ADHD and discuss 6 pitfalls that may face the treating pediatrician.
Criteria of ADHD
As the pediatrician commonly experiences in practice, ADHD has 2 main types: inattentive and hyperactive.
The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)1 requires 6 or more symptoms of hyperactivity or inattention in children aged younger than 17 years and 5 or more in adolescents aged older than 17 years.
Whereas most pediatricians understand the diagnostic criteria, the DSM-5 expanded the age of symptom onset from prior to age 6 years to prior to age 12 years, in recognition of the later presentation of inattentive symptoms. Additionally, the DSM-5 also recognizes the presence of ADHD in adults, and requires 5 symptoms of the inattentive subtype or the hyperactive-impulsive subtype for diagnosis.
What many clinicians are not explicitly taught, however, is that the DSM-5 (and earlier editions) requires the critical diagnostic requirement that ADHD symptoms must be assessed at the “appropriate developmental age” and NOT the chronologic age.
Assessing a 7-year-old with a language age of a 4½-to-5-year-old (the lower end of the typical range) likely results in a diagnosis of ADHD because the child’s behaviors, attention, and activity level are inappropriate for a 7-year-old child. However, if these same symptoms are assessed at a 4½- to 5-year-old level, they may be much more appropriate.
Mistake #1 Starting medication too soon.
The American Academy of Pediatrics (AAP) guidelines for the diagnosis of ADHD were expanded to include children aged 4 to 5 years in 2011.2 However, 388,000 children aged 2 to 5 years have been diagnosed with ADHD despite there being no guidelines for a diagnosis before age 4 years.3
Although the pediatrician is well aware of the “terrible 2s,” not every child aged younger than 4 years with impulsivity, decreased attention span, tantrums, and high levels of activity goes on to develop ADHD. It is important for the pediatrician to remember the link between language age and behavior.
A 5-year-old child with a language delay who speaks at a 3-year-old level will generally have the attention span of a 3-year-old. It is the internal monologue that keeps our attention directed appropriately. This child may be challenged when trying to communicate his or her needs and resultantly acts out or has a tantrum in a similar fashion as a child with ADHD. However, this tantrum may be age appropriate for a 3-year-old. It is not chronological age but language age that is most important. Children are likely to function at the age of their language.
Diagnosing preschool-aged children with ADHD can be incredibly difficult. If the pediatrician decides a preschool-aged child has ADHD, behavior therapy is recommended as an initial therapy.2,4 However, the Centers for Disease Control and Prevention (CDC) estimates that fewer than half of children diagnosed with ADHD receive appropriate behavioral treatments.5
In children who do not meet diagnostic criteria for ADHD, it is reasonable to provide behavioral interventions.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association Publishing; 2013.
2. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management; Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.
3. Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD). Data and statistics about ADHD. Available at: https://www.cdc.gov/ncbddd/adhd/data.html, Accessed July 17, 2019.
4. Feldman ME, Charach A, Bélanger SA. ADHD in children and youth: part 2-treatment [article in English and French]. Paediatr Child Health. 2018;23(7):462-472.
5. Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among US children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199-212.
6. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086.
7. Centers for Disease Control and Prevention (CDC). Children’s mental health. Data and statistics on children’s mental health. Available at: https://www.cdc.gov/childrensmentalhealth/data.html. Accessed July 17, 2019.
8. Pliszka SR, Crismon ML, Hughes CW, et al; Texas Consensus Conference Panel on Pharmacotherapy of Childhood Attention-Deficit/Hyperactivity Disorder. The Texas Children’s Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(6):642-657.
9. Posner J, Kass E, Hulvershorn L. Using stimulants to treat ADHD-related emotional lability. Curr Psychiatry Rep. 2014;16(10):478.
10. DuPaul GJ, Gormley MJ, Laracy SD. Comorbidity of LD and ADHD: implica-tions of DSM-5 for assessment and treatment. J Learn Disabil. 2013;46(1):43-51.
11. Yoshimasu K, Barbaresi WJ, Colligan RC, et al. Written-language disorder among children with and without ADHD in a population-based birth cohort. Pediatrics. 2011;128(3):e605-e612.
12. Stein RE, Horwitz SM, Storfer-Isser A, Heneghan A, Olson L, Hoagwood KE. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr. 2008;8(1):11-17.
13. Stein RE, Storfer-Isser A, Kerker BD, et al. Beyond ADHD: how well are we doing? Acad Pediatr. 2016;16(2):115-121.
14. Lakhan SE, Kirchgessner A. Prescription stimulants in individuals with and without attention-deficit/hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2012;2(5):661-677.
15. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants pre-scribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47(1):21-31.
16. Pham T, Milanaik R, Kaplan A, Papaioannou H, Adesman A. Household diversion of prescription stimulants: medication misuse by parents of children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2017;27(8):741-746.
17. Edmundson M, Berry DTR, Combs HL, et al. The effects of symptom information coaching on the feigning of adult ADHD. Psychol Assess. 2017;29(12):1429-1436.