Harlan R. Gephart, MD is guest editor of this issue and a member of the editorial board 
  of <i>Contemporary Pediatrics</i>, is clinical professor of pediatrics at the 
  University of Washington School of Medicine, Seattle.

Harlan R. Gephart, MD

The condition we now refer to as attention-deficit/hyperactivity disorder (ADHD) was first recognized in England in 1902 by eminent physician Dr George Still (eg, Still’s Disease = Juvenile Rheumatoid Arthritis). Dr Still identified and reported in the journal 

 several boys who seemed normal physically and intellectually but who struggled with symptoms of “restlessness, inattention, and hyper-arousal.” The cause was then unknown.

Following the pandemic of influenza in 1918, similar findings in children and adolescents were labeled “post-encephalitic syndrome” or “minimal brain damage,” later changed to “minimal brain dysfunction” when no obvious brain deficits were noted. Hyperactivity also led to the term “the hyperactive child.” Essentially, all the cases were male.

In the 1980s, emphasis was placed on the most universal trait, inattentiveness, and the term attention deficit disorder (ADD) was adopted. This gave rise to the diagnosis in females, who, though often “fidgety” are usually not grossly “hyperactive.” 

The Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition (DSM-IV)

 distinguished 3 subtypes: inattentive only, hyperactive/impulsive only, and combined type, (inattentive, hyperactive, and impulsive), and changed the terminology to ADHD.

The Diagnostic and Statistic Manual of Mental Disorders, Fifth Edition (DSM-5)

, published in 2013, made these changes in diagnostic criteria: (paraphrased). 1) ADHD was defined as a “neurodevelopmental disorder” rather than a “neurobehavioral disorder,” putting emphasis on the developmental rather than the behavioral, opening the door for educational interventions, as well as other advantages. 2) For adolescents aged 17 years and older, and adults, only 5 out of the 9 criteria for inattention, or hyperactivity/impulsivity are required for diagnosis, versus 6 in 

. 3) Several of the inattentive/hyperactive/impulsivity symptoms must present before age 12. (

 required symptoms prior to age 6: Females a year after 6, more likely to be the inattentive type, often did not meet diagnostic criteria. 4) 

 specified that ADHD may coexist with a diagnosis of autistic spectrum disorder (ASD) since some children have overlapping symptoms, allowing more clarity of diagnosis, and therapeutic options.

The American Academy of Pediatrics, who had initially published Guidelines for Diagnosis and Treatment of ADHD in 2011, published a guideline update in November 2019.

 Though the earlier guidelines were not significantly altered, the following rules were re-emphasized: (paraphrased)

1. ­Any child aged 4-18 years, who manifests academic or behavioral issues, symptoms of inattention, and/or hyperactivity/impulsivity, should be assessed for ADHD.

2. ­To make a diagnosis, the primary care clinician (PCC) should verify that 

 symptom criteria have been met, to a degree causing impairment, including documentation of symptoms in at least 2 environments (eg, school, home), as reported by caregivers, teachers or other school personnel, and/or mental health persons involved in the child’s care.

3. ­The evaluation for ADHD should include a screening process to rule out other comorbid conditions (see table) which can “mimic” the symptoms of ADHD, or be a coexistent condition. (Note: studies have shown that as many as 75% of children/adolescents diagnosed with ADHD fulfill criteria for another 

 condition, such as specific learning disorder (SLD), anxiety, and/or depression, oppositional defiant disorder, etc. The term “ADHD Complex” is now being used to describe those children/adolescents.)

4.­ Since ADHD is a chronic condition, the PCC should manage the child in the same manner used to manage any child with special care needs, using the principles of the chronic care model.

Miscellaneous “pearls” re: diagnosing

Pre-school child: can be challenging to diagnose accurately, eg, mistaken for delayed maturational skills versus inadequate parenting. Always withhold diagnosis until parents have attended a thorough parenting class or 1:1 parenting help and are practicing good parenting skills. If significant improvement, perhaps is not ADHD. Lack of adequate response to behavioral interventions can then lead to consideration of medication trial and presumptive diagnosis of ADHD.

Phone call to teacher. Invaluable. An experienced teacher can be extremely helpful to help decide whether child’s inattention is due to learning difficulty or more boredom/disinterest? (than ADHD).

Thorough medical history, as noted earlier: There are 30 or more conditions that can cause symptoms which mimic ADHD.

Medical: eg, obstructive sleep apnea, traumatic brain injury, lead, medications, hypoxemia, near-drowning, prematurity etc.

Developmental: eg, ASD, SLD, speech/language disorders, lower IQ

Environmental: eg, abuse, neglect, death in family, divorce/separation

Mental/behavioral: eg, anxiety, depression, trauma

About 2/3 of children/adolescents diagnosed with ADHD are combined typed (mostly males) and 1/3 are females, mostly inattentive type. Males are often diagnosed early, in kindergarten or first grade due to overactivity and impulsive behavior. Girls are frequently not diagnosed until later eg, start of middle school, when they fail to turn in assignments in a timely manner.

In July 2016 the US Department of Education classified ADHD as a “specific disability” under the Civil Rights Law, which helps obtain special services for children and adolescents with ADHD.

The proper testings/screenings, of course, are only half the battle. However, once a conclusive diagnosis of ADHD has been made, there are a number of medications and tools to help your child navigate the healthiest and happiest childhood and adolescence possible (see 

1) Wolraich ML, Hagan, JF, Allan C, et al. Clinical practice guidelines for the diagnosis, evaluation, and treatment of attention deficit/hyperactivity disorder in children and adolescents. 

. October 2019;144(4). doi:10.1542/peds.2019-2528

ADHD Complex: Practicing Mental Health in Primary Care.

3) Langberg JM et al. Clinical utility of the Vanderbilt ADHD Rating Scale for ruling out comorbid learning disorders. 

 October 2010;126(5).
doi:10.1542/peds.2010-1267

Articles

Attention-deficit/hyperactivity disorder (ADHD) was first recognized over 100 years ago, but the diagnostic criteria has changed over the years. Here's a look at the latest guidance for diagnosing ADHD.

The Dx of ADHD

 25 years ago by the husband-and-wife team of Sally and Bennett Shaywitz instructed pediatricians on medications to treat attention deficit disorders (ADD),

  but it went much farther than that, including information on diagnosis and etiology of ADD, as well as challenges for the patient and family. Their observations were so perceptive that, with a few tweaks here and there, they could be republished as a 2009 update on attention deficit/hyperactivity disorder (ADHD). 

For example, the authors describe their own observations of familial tendency to ADD. Even though the cause of ADHD is unclear, we now recognize that for the great majority of ADHD patients, there are genetic factors, as demonstrated by data from twin studies conducted in the United States and medical databases in Scandinavia and Great Britain. We even have identified 7 or 8 genes that have been linked to this diagnosis, most of these genes being regulators of dopamine and/or norepinephrine release, transport, or uptake. The diagnostic technique propounded by the Shaywitz team in 1984 involved gathering historical and descriptive behavioral information about the child from a variety of sources-the child, the parents, and the teacher. That is still the gold standard method of diagnosis, as recommended by the American Academy of Pediatrics guidelines for diagnosis of ADHD, published in 2000.

  The authors also pioneered the use of rating scales to narrow down the diagnosis, using items from the Yale Children's Inventory. One can readily see that many of the 18 items from the DSM-IV criteria for ADHD (1994) appear on that earlier inventory. Though these behavioral criteria are not specific for ADHD and may be seen in a variety of other developmental and behavioral situations, using the DSM-IV criteria has made a significant advancement in diagnostic clarity and accuracy. 

The authors very correctly identified the learning issues associated with ADD/ADHD. Children with ADHD struggle greatly in school, not only with inattention and lack of organizational skills, but also with associated learning disabilities that compound the behavioral problems. Furthermore, learning disabilities themselves cause inattention and distractibility, complicating a diagnosis of ADHD. All this must be sorted out in the diagnostic process. 

We also know the medicines augment the function of dopamine and norepinephrine at the neuronal synapse, particularly in certain frontal and prefrontal regions such as those associated with executive function. We know, as did the Shaywitz team, that the medication adverse effects are numerous, but we now have multiple forms of medications (immediate, intermediate, and long acting) and in various vehicles (liquid, pills, transdermal) to modify or circumvent adverse effects. 

What, then, are some of the current issues in ADHD care not known about or dealt with 25 years ago? For one, behavioral therapy was not talked about much. Most of the work in this area, by people like Satterfield, Pelham, and others, was just beginning to get published. Now behavioral therapy for ADHD is recommended by the AAP as 1 of the only 2 evidenced-based treatments.

In addition, there wasn't any mention of coexisting conditions such as anxiety, depression, oppositional defiant disorder, conduct disorder, or substance abuse in the 1984 article. Now we recognize that not only are these conditions extremely common in ADHD patients but that they must be diagnosed and treated appropriately or else they will impair or prevent success in ADHD treatment outcomes.

Last, the recognition that ADHD is a chronic disorder is crucial. We know that 50% or more of ADHD children will continue to manifest difficulties into adult life, with impairment in employment, marriage, and social behavior, creating a burden for the medical, social, and judicial systems. 

At present, we lack the specific knowledge to either predict or prevent these consequences. Most of our monitoring efforts have been directed toward symptom control, which medication can do very effectively. Unfortunately the answer isn't that simple, and more research is needed to delineate type, severity of ADHD, and all the related coexistent behavioral, educational, and socioeconomic issues that greatly influence outcomes.

 is a clinical professor at the University of Washington, School of Medicine, Seattle and an ADHD consultant with Pediatrics Associates, Bellevue, Washington. The author has nothing to disclose in regard to affliliations with or financial interest in any organization that may have any part of this article. 

 Shaywitz S, Shaywitz B. Devising the proper drug therapy for attention deficit disorders. 

 American Academy of Pediatrics. Diagnosis and evaluation of the child with attention deficit/hyperactivity disorder. 

 Gephart H, Leslie L. ADHD Pharmacotherapy. 

 American Academy of Pediatrics. Treatment of the school-aged child with attention deficit/hyperactivity disorder. 

 Molina BS, et al. The MTA at 8 years: Prospective follow-up of children with combined-type ADHD in a multisite study. 

An article published in Contemporary Pediatrics 25 years ago instructed pediatricians on medications to treat attention deficit disorders (ADD). Their observations were so perceptive that, with a few tweaks, they could be republished as a 2009 update on attention deficit/hyperactivity disorder (ADHD).

Harlan R. Gephart, MD

Articles

The Dx of ADHD

ADHD: Evaluating advances in treatment