Diagnosing ADHD: Putting AAP guidelines to the test--and into practice

December 1, 2003

Step-by-step evaluation of an adolescent girl who may have ADHD highlights the strengths and limitations of the AAP diagnostic guidelines and offers insight into how to augment them.

 

Focus on ADHD

Diagnosing ADHD:
Putting AAP guidelines to the test—and into practice

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By Yi Hui Liu, MD, MPH, and Laurel K. Leslie, MD

Step-by-step evaluation of an adolescent girl who may have ADHD highlights the strengths and limitations of the AAP diagnostic guidelines and offers insight into how to augment them.

Pediatricians now have many resources for diagnosing attention deficit hyperactivity disorder (ADHD). In May 2000, the American Academy of Pediatrics (AAP) published evidence-based guidelines (Table 1) and a clinical algorithm (see: Diagnostic workup and evaluation of the child with possible ADHD, on page 55 of the print issue; used with permission from the American Academy of Pediatrics: Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000;105:1158) for primary care diagnosis and evaluation.1 The guidelines are based on criteria described in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (available in the print issue, reprinted with permission from The Diagnostic and Statistical Manual of Mental Disorders, text revision, copyright 2000 American Psychiatric Association).

 

TABLE 1
AAP clinical practice guidelines for the diagnostic workup and evaluation of the child with ADHD

1. In a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD.

2. The diagnosis of ADHD requires that a child meet criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.

3. The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, age of onset, duration of symptoms, and degree of functional impairment.

4. The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions.

5. Evaluation of the child with ADHD should include assessment for associated (coexisting) conditions.

6. Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (e.g., learning disabilities and mental retardation).

Source: American Academy of Pediatrics1

A. Either 1 or 2

1) Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

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

b) Often has difficulty sustaining attention in tasks or play activities

c) Often does not seem to listen when spoken to directly

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

e) Often has difficulty organizing tasks and activities

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

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

h) Is often easily distracted by extraneous stimuli

i) Is often forgetful in daily activities

2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

a) Often fidgets with hands or feet or squirms in seat

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

c) 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)

d) Often has difficulty playing or engaging in leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor"

f) Often talks excessively

Impulsivity

g) Often blurts out answers before questions have been completed

h) Often has difficulty awaiting turn

i) Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] or at 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 (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

Code based on type:

314.01 attention-deficit/hyperactivity disorder, combined type: if both criteria A1 and A2 are met for the past six months

314.00 attention-deficit/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past six months

314.01 attention-deficit/hyperactivity disorder, predominantly hyperactive, impulsive type: if criterion A2 is met but criterion A1 is not met for the past six months

314.9 attention-deficit/hyperactivity disorder not otherwise specified

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, text revision, copyright 2000, American Psychiatric Association

DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition

 

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The AAP recognized that issuing guidelines cannot by itself change physicians' patterns of practice, so the academy joined forces with the National Initiative for Children's Healthcare Quality (NICHQ) to develop tools for implementing guidelines in primary care. In the fall of 2002, the AAP and NICHQ issued a toolkit ("Caring for Children with ADHD: A Resource Toolkit for Clinicians"), an aid to incorporating the latest AAP guidelines into practice (available at www.nichq.org ). More recently, the two groups released the online module, "Managing Your Patients with ADHD" (available at www.eqipp.org ). The two organizations also have begun working with AAP chapters to implement the guidelines.

Despite all these resources, clinicians can encounter diagnostic ambiguities in evaluating children for possible ADHD when following the AAP guidelines. To illustrate potential problems, we follow a child being evaluated for possible ADHD, using the framework presented in the clinical algorithm and expanding on areas not specified in the guidelines.

Does Jenniferhave ADHD?

Jennifer, a 15-year-old African-American girl, arrives with her grandmother, Mary, for her first visit at your office. Mary is Jennifer's legal guardian and is concerned that Jennifer is "failing" school. A neighbor has suggested that Jennifer may have ADHD.

ADHD is characterized by hyperactivity/impulsivity and/or inattention outside of normal development. Three subtypes are recognized: hyperactive/impulsive (ADHD-HI), inattentive (ADHD-IA), and combined (ADHD-CT). The proposed etiology of ADHD in the literature include functional brain impairment, biochemical alterations, dietary habits, parenting style, and environmental stressors. Recent studies of brain imaging, molecular genetics, and neurochemical analyses strongly suggest that certain neurodevelopmental disorders may lead to ADHD.2,3

The overall prevalence of ADHD in youth is high; it has been estimated that 4% to 12% of school-age children meet strict criteria for ADHD (9.2% in males and 3.0% in females).3 Research increasingly documents that ADHD affects the individual, the family, and society because of associated personal, social, and economic burdens. The consequences of this disorder drive parents to pursue professional help in determining the source of their child's problems and finding a solution.

As shown in step 1 of the algorithm, children 6 to 12 years old with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems deserve to be evaluated for ADHD. Children who exhibit low self-esteem or poor family and peer relationships may also warrant evaluation. These red flags may be uncovered through questions targeting progress in school, level of satisfaction with school, and learning problems. Behavioral concerns of parents or teachers also offer clues.

Making the assessment

Although Jennifer does not fall within the age range specified in the diagnostic algorithm, pediatricians often care for children over 12 years of age, and Jennifer's academic underachievement necessitates an evaluation for ADHD. How do you go about this process?

Unlike many pediatric complaints, ADHD is a chronic disorder with treatment implications that affect both home and school. You must conduct a thorough evaluation to determine if a child indeed has ADHD or another condition with symptoms that closely mimic ADHD. To complicate matters, at least one third of children with ADHD have one or more coexisting conditions that may affect treatment decisions. Prevalence rates for the most common comorbid psychiatric diagnoses are 35.2% for oppositional defiant disorder, 25.7% for conduct disorder, 25.8% for an anxiety disorder, and 18.2% for depression.3 Learning disabilities are estimated at 12%.3

Because other medical, developmental, behavioral, and socioenvironmental problems may also coexist with ADHD, the full differential diagnosis must be considered from the start of the evaluation: Do not wait until you have concluded that the child does not meet ADHD criteria, as depicted (rather artificially) in step 4 of the algorithm! In other words, a major part of the evaluative process is to delineate—early—all conditions that may be affecting the child.

This process should begin at step 2 in the clinical algorithm, which calls for a history and physical examination, including a neurologic examination, family assessment, and school assessment. Not only do many medical, neurologic, psychosocial, or psychiatric conditions present in the same manner as ADHD (Table 3), but some of these conditions are common ADHD comorbidities. These disorders may be the primary cause of the child's behavioral and attention difficulties or may increase a child's level of impairment if they coexist with ADHD. The history and physical need to target signs and symptoms related to these conditions.

 

TABLE 3
The differential diagnosis of ADHD

Medical conditions

Fetal alcohol syndrome

Fragile X syndrome

Hearing impairment

Medication side effects

Obstructive sleep apnea

Other chronic disease

Substances of abuse

Thyroid disease

Toxins

Vision impairment

Neurologic and developmental problems

Cerebral palsy

Communication disorders

Developmental delays

Learning disabilities

Mental retardation

Neurodevelopmental syndromes

Seizure disorder

Tic disorders (e.g., Tourette syndrome)

Psychiatric illness

Anxiety

Bipolar disorder

Conduct disorder

Depression

Obsessive-compulsive disorder

Oppositional-defiant disorder

Pervasive developmental disorder

Posttraumatic stress disorder

Schizophrenia

Psychosocial factors

Abuse

Family dysfunction

Neglect

Parenting dysfunction

Stress in environment (new home, new school)

Stress in family situation (marriage, separation or divorce, birth of sibling, death)

 

The history, therefore, should cover a broad range of areas, including parental concerns, behavioral history, medical history, developmental milestones, school history, family history, and social history (Table 4). To understand the child in the context of his environment, the social history should cover living arrangements, family dysfunction, social skills, work performance, substance abuse, and problems with authority.4 Although environmental stressors can induce symptoms comparable to those of ADHD, the presence of these stressors, which can exacerbate ADHD symptoms, does not rule out ADHD itself.

 

TABLE 4
ADHD evaluation: The relevant history

Parental concerns

Child's strengths and weaknesses

Duration and onset of symptoms

Goals for evaluation process

Level of impairment

Past approaches to concerns

Specific perceived problems

Behavioral history

Ability to separate from caregivers

ADHD symptoms

Psychiatric symptoms

Psychological counseling

Sleep issues (poor quality or quantity, nightmares, snoring)

Suicidal or homicidal thoughts and attempts

Temperament (colic, temper tantrums, irregular or picky eating, difficulty keeping a babysitter)

Medical history

Birth history (prematurity, substance abuse during pregnancy, problems during pregnancy, labor, or delivery)

Depression

Growth difficulties

Learning problems

Loss of consciousness

Medications (including vitamins, herbal supplements, and over-the-counter remedies)

Meningitis or encephalitis

Recurrent headache or abdominal pain

Seasonal allergies

Seizures

Serious head injury

Staring spells

Tics

Developmental history

Milestones

Speech, physical, or occupational therapy

Educational history

Conflict with teachers or school staff, or with peers at school

Current performance in each school subject

Disciplinary actions (suspensions), consistency of education (school, teacher)

Discussions about repeating grades or classes

Early intervention programs

Individualized educational program

Problems in each grade completed

Special education

Strongest and weakest areas in school

Student study team meetings

Family history

ADHD

Mental illness

Drug and alcohol abuse

Neurologic disorders

Learning or reading difficulties

Birth defects

Trouble with the criminal justice system

Physical or sexual abuse

Thyroid disease

Toxic exposures

Personal and social history

Family dysfunction

Living arrangements

Problems with authorities

Social skills

Substance abuse

Work performance

 

Try to interview all primary caregivers and the child. Sensitive issues can be discussed most freely when the family is interviewed in different combinations: the entire family together; the child with parents or caregivers, and the child alone (if the child is willing and able). In interviewing the child, focus on general likes and dislikes; perception of performance at school and home; relationships with family, teachers, and peers; and what the child likes and dislikes about himself or herself. Asking a child what he would change about his life can be enlightening. Ascertain if the child has any history of being abused or suicidal ideation—either of which should prompt immediate referral.

The physical must include vital signs, height, weight, and head circumference. A vision and hearing screening should be part of the exam, with referral for further evaluation of any abnormal findings that could lead to behavioral, emotional, and academic difficulties. Dysmorphic features or birthmarks may raise questions about syndromes or neurocutaneous disorders, and tattoos and pierced body parts may suggest risk-taking behavior or gang involvement. Pay attention to the child's general appearance: Does she fidget? Does she have an impulse-control problem? What about her state of arousal? At the same time, be aware that the one-on-one attention and unnatural environment of an office visit may inhibit the child's usual fidgeting. A mental status exam also is necessary; study the child's affect while determining his thought patterns and mood. Unusual behaviors or speech patterns and poor communication skills may signify processing problems or autistic features.

Diagnostic tests, such as a lead level, thyroid function, and brain imaging, are generally unnecessary. They are warranted only when the history or physical elicits specific areas of concern.

Zeroing in

According to Jennifer's grandmother, who has raised her from birth, Jennifer was born "two months early" to a mother who abused drugs and alcohol during pregnancy. Although Jennifer was a "colicky" infant who was difficult to feed, she had no major problems after birth and has been healthy except for a "few" early ear infections. She has since developed into a social child with "endless" energy and is active as a member of the school's cheerleader squad. Jennifer became talkative in first grade and every teacher she has had since that time has made this observation. At 6 years old, she could not read simple words, but her progress in reading through elementary school was "adequate." Although the school has never provided Jennifer with an evaluation or services, Mary has been helping significantly by structuring Jennifer's approach to her schoolwork and by paying for private tutoring.

Jennifer recently has been asking Mary why her mother does not want her. Mary comments that Jennifer's mother is a high-school dropout who is often in trouble with the law and has been unable to keep a job. No one knows where she is right now. Lately, Jennifer has been having difficulty falling asleep and is hard to arouse in the morning. Her appetite has been poor although she insists that she is just "not hungry." She denies any suicidal thoughts. Her grades had been average until last year, when she started "failing."

On the physical exam, Jennifer is at the 75th percentile for height, weight, and head circumference. Vital signs, vision screening, and hearing screening are normal. She has no dysmorphic features. The only dermatologic findings are pierced ears and one café-au-lait macule. Her neurologic exam is normal. Jennifer is articulate and answers your questions willingly.

Jennifer's history suggests ADHD; her academic history raises the question of a reading disorder. Her difficulty sleeping and eating may indicate anxiety or depression.

Step 2 in the clinical algorithm calls for gathering information from many sources about core ADHD symptoms, symptom duration, and degree of functional impairment to determine if the DSM-IV criteria for ADHD are being met. The guidelines specify that this information can be gathered through narratives (verbal or written), questionnaires, or rating scales. Broadband checklists, such as the Child Behavior Checklist, are not recommended for determining if a child has ADHD because these instruments have low sensitivity and specificity for this diagnosis.1 At this point in the algorithm, the clinician is expected to assess for any alternative diagnoses (steps 4 through 6) or coexisting conditions (steps 7 through 12). As discussed, however, this is an ongoing process that must be begun much earlier.

On the surface, the algorithm appears straightforward, but following the guidelines it represents in a busy office setting can be challenging. In fact, a recent study of more than 400 clinicians found that fewer than 40% used the DSM-IV criteria to diagnose attentional and hyperactivity problems, as called for in step 3 of the algorithm.5 Clinicians cite many barriers to implementing the AAP recommendations, including not knowing which tools to use to make the diagnosis, difficulty obtaining information from schools, and limited time to complete a comprehensive evaluation.

Using rating scales. The guidelines present the option of using ADHD-specific rating scales but do not emphasize the necessity of understanding the basis and limitations of specific tools. Each tool has strengths and weaknesses with respect to cost, differentiated symptom endorsement by age and gender, inclusion of screening questions regarding common coexisting conditions, and measurement of impairment (Table 5). It is particularly important to recognize that, although the guidelines call for evidence of impairment (when symptoms interfere with functioning), no consensus exists about what constitutes impairment and how it should be measured. Certain ADHD-specific rating scales, such as the Vanderbilt scale, do address this issue. So does the Columbia Impairment Scale, which is not an ADHD-specific rating scale.

 

TABLE 5
How do ADHD rating scales compare?

Rating scaleDescriptionStrengthsWeaknesses
Vanderbilt Parent and Teacher Scales [Used in AAP toolkit] (Wolraich ML et al:Classifies 18 DSM-IV behavior descriptions according to subtypes Scoring based on numbers of behaviors endorsed on a four-point rating scale that provides both a categorical diagnosis and dimensional score Norms based on more than 10,000 children between 5 and 11 years old in a suburban Tennessee countyIncludes screening questions for conduct disorder, oppositional defiant disorder, and anxiety/depression Includes impairment measures for home setting, academic performance, and classroom behavior; freeDoes not screen for learning disabilities
Conners' Parent and Teacher Rating Scales– Revised–Long Form (Conners CK et al:Classifies 18 DSM-IV ADHD behavior descriptions according to subtypes Scoring is based on numbers of behaviors endorsed and uses conversion of raw scores T-scores for comparison with normative data Norms based on more than 8,000 children, with separate norms available for boys and girls in 3-year intervalsIncludes screening questions for oppositionality, anxiety/shyness, perfectionism, social problems, psychosomatic problems Measures impairment indirectly through T-scores for items described aboveDoes not screen for learning disabilities Must be paid for (other rating scales are in the public domain) Short form does not screen sufficiently for inattentive subtype
Swanson, Nolan and Pelham Questionnaire IV Teacher and Parent Rating Scale (SNAP-IV) (Swanson JM:Classifies 18 DSM-IV ADHD behavior descriptions according to subtypes Scoring based on numbers of behaviors endorsed on a four-point rating scale providing both a categorical diagnosis and dimensional score Norms based on school samples in Irvine, Calif. (>600), Austin, Texas (>3,000), and the MTA clinical sample (n=579 children with ADHDcombined type) and their classmates (n=288)Includes screening questions for oppositional defiant disorder and mood disorders Includes questions on classroom impairment; also measures impairment indirectly through standard scores to identify severity of symptoms; freeDoes not screen for learning disabilities
Disruptive Behavior Disorder Scale (Pelham WE et al:Classifies 18 DSM-IV ADHD behavior descriptions according to subtypes Scoring is based on numbers of behaviors endorsed on a four-point rating scale providing both a categorical diagnosis and dimensional score Norms based on 2,000 children rated by teachersIncludes all DSM-IV symptoms for oppositional defiant disorder and conduct disorder Used in conjunction with the impairment rating scale, a brief scale for parents and teachers assessing impairment in key domains (peer relations, adult relations, academic functioning, self-esteem, and overall functioning); freeDoes not screen for learning disabilities Does not include screening questions for mood disorders
ADHD Rating Scale (DuPaul GJ et al:Classifies 18 DSM-IV ADHD behavior descriptions according to subtypes Scoring uses means, standard deviations, and percentiles and compares individual child's score to normative sample. Means, standard deviations, and percentiles are provided for four age groupings (5–7, 8–10, 11–13, 14–18 years), by gender, and by respondent (parent or teacher) Norms based on 2,000 boys and girls, ages 5–17, matched to 1990 US Census data for distribution across regions and ethnic groupsDifferentiates symptom endorsement by age and gender; freeDoes not screen for learning disabilities Does not include subtests for coexisting conditions Does not include specific impairment measure but does provide percentiles that can be used to describe severity of a child's score

 

The ADHD-specific rating scales also vary in how well they screen for coexisting conditions. Some clinicians have instead used a broadband scale, such as the Child Behavior Checklist or the Behavioral Assessment Scale for Children, or a DSM-IV-based tool—for example, the Childhood Symptom Inventory—to address coexisting mental health conditions. Also, no available tool screens for learning disabilities, making it incumbent on the clinician to do so, using the history and a brief evaluation in the office or by referring for psychoeducational evaluation by the school district or private services.

Ultimately, each clinician needs to identify one or more tools for use in documenting whether a child meets DSM-IV criteria for ADHD and if coexisting conditions and impairments are present. The clinician also needs to consider the practicality of using these tools in the office. Parents with a language barrier or limited reading skill, for example, may need assistance in completing forms and interacting with school professionals.

Obtaining information from school professionals. Another major challenge in diagnosing (and then managing) ADHD is to secure information from school professionals. Under new Health Insurance Portability and Accountability Act (HIPAA) regulations, an office must have a system for procuring family permission for the school staff and provider to exchange information. Questionnaires can be helpful in both the initial assessment and subsequent feedback. If a child has more than one teacher, gathering input from several teachers may be essential in determining how a child responds to different subject matters or teaching styles. School personnel, families, and clinicians need to work collaboratively to document specific symptoms and their effect on a child's functioning.

Completing a comprehensive evaluation is a complex task, but the guidelines do not propose how to accomplish it in the typically limited time of clinical visits. Estimated times for making an evaluation, according to published protocols, range from 1.5 to 8 hours.6–9 To implement the guidelines, each clinician needs to address several time-related and logistical issues: Should the evaluation be performed in one extended visit or several consecutive visits? How should the pre-visit parent and teacher questionnaires be used? What are the responsibilities of office staff and affiliated mental health professionals? The literature contains helpful suggestions about the practical implementation of the guidelines, which is critical to the success of caring for children with ADHD in today's medical environment.10

What if diagnostic information is inconsistent?

For Jennifer's next visit, you ask the family to bring in the completed rating scales and any available school records (report cards, academic evaluations), schoolwork, and psychological evaluations. Jennifer and Mary return to your office with completed parent and teacher Vanderbilt scales. Jennifer meets the criteria for ADHD-IA and screens positive for anxiety/depression on Mary's version of the scale. On the teacher's version, Jennifer does not meet the criteria for ADHD but screens positive for anxiety and depression. How do you deal with this discrepancy?

Regrettably, parents and teachers often disagree about children's impairments. In the Multimodal Treatment Study of Children with ADHD (MTA study) and in the San Diego ADHD Project, discrepancies in results were present in more than one third of the evaluated children.11,12 Discrepancies among respondents arise from diverse expectations, varied levels of imposed structure, use or nonuse of behavioral management techniques, consequences for rule-breaking, and environment. Motivation also has an influence; one respondent, for example, may want the child to be on medication to control behavior whereas another might not want the child to be labeled with ADHD.

Although a discrepancy does not preclude the diagnosis of ADHD, clinicians need clear guidelines on how to address it. Reviewing the conflicting results with the parents may help to determine the reason for a difference in reports. Phoning the teacher, meeting with the school's multidisciplinary team, referring to a mental health professional, or observing the child in the classroom may also clarify matters. A family history of ADHD and the degree of impairment that symptoms cause can also help resolve the issue. Knowing the impact of age, gender, and ethnicity on the diagnosis of ADHD is useful, too.

Age. Although DSM-IV criteria are specific for school-age children, they are less helpful in making a diagnosis in a preschooler, adolescent, or adult. The Diagnostic and Statistical Manual for Primary Care (DSM-PC), child and adolescent version, can provide a developmental perspective on variations of normal behavior, helping the clinician determine what is and is not appropriate behavior for a child's age (see step 5 of the algorithm). For example, although a high activity level, impulsiveness, and a short attention span can be normal in preschoolers, these behaviors still warrant consideration of ADHD when they are excessive. In contrast, in adolescents and adults with ADHD, inattention and impulsivity are generally prominent behaviors.13 Adolescents with ADHD, therefore, may have less trouble staying in their seats than younger children, but they might have driving problems (crashes, suspended license, tickets) and sexual issues (early intercourse, multiple partners, sexually-transmitted disease, pregnancy).14,15

Furthermore, DSM-IV criteria lack a developmental perspective about children who have different subtypes of ADHD. Behavior problems of children with ADHD-HI and ADHD-CT commonly manifest in kindergarten or first grade. On the other hand, children with ADHD-IA who struggle with metacognitive tasks, organization, and short term memory sequencing often do not attract attention until the fourth, sixth, or ninth grade, when they need higher-level academic and organizational skills and schoolwork becomes more challenging. This makes problematic the DSM-IV diagnostic criterion that some symptoms causing impairment must be present before 7 years of age.

Gender. Although AAP guidelines note a higher overall prevalence of ADHD in males and a greater likelihood of ADHD-IA in affected females, they do not address other gender differences. Recent work stresses that the research upon which the guidelines were based was conducted primarily in boys, and that girls may manifest symptoms in a different manner.16,17 Girls who display symptoms of hyperactivity, for example, tend to exhibit their hyperactivity verbally, emotionally, and socially; they struggle with daily demands and blame others for their difficulties. Primary symptoms of inattention in girls include unusual messiness or forgetfulness; these characteristics can lead to social isolation, rejection by peers, and poor self-esteem. Working hard to please their teachers, these girls survive elementary school but cannot manage the demands of secondary school. Consequently, girls with ADHD may never be identified, or may be identified only upon reaching middle or high school. These gender differences point up the need for different diagnostic criteria and a higher level of suspicion for ADHD in girls.

Ethnicity. Differences in ADHD among ethnic minorities remain understudied and are not mentioned in AAP guidelines. A review of studies on ADHD among diverse ethnic groups within the United States found that, compared with Caucasians, African-Americans were rated higher on more hyperactivity whereas Mexican-American children were rated lower.18 Investigators have also suggested that crosscultural differences in rates of diagnosed ADHD likely reflect diagnostic inconsistency, not true differences in behavior.19 Diverse cultures may differ in their tolerance or perception of the same behaviors and in their willingness to discuss unacceptable behaviors with a primary care provider. These differences have important implications for diagnosing ADHD across cultures and have not yet been fully elucidated.

Management of children who don't meet ADHD criteria. Last, although the clinical algorithm recognizes that some children who are being evaluated may not meet criteria for ADHD (steps 4 through 6), the guidelines do not comment on their management. Symptoms consistent with ADHD present along a continuum—from the occasional minor manifestation in an unaffected child to the behavioral extremes of a child with ADHD. Keep in mind that conservative criteria can result in failure to diagnose ADHD. And even if a child does not have ADHD, she may have one or more of the other conditions in the differential diagnosis. Behavioral modification strategies commonly used for ADHD can help in many of these disorders. Appropriate follow-up is critical and often clarifies the diagnosis. If difficulties persist and you are uncomfortable with sorting out the diagnosis, consider referral to a mental health professional, as discussed below.

Completing the diagnostic process: Should you refer?

After talking with Jennifer's teachers, and considering her age, gender, and ethnicity, you determine that Jennifer has ADHD-IA. Because of the Vanderbilt results, you also are concerned about depression. You talk again with Jennifer and are reassured that she is not actively suicidal. You know that some depressive symptoms in children with ADHD decrease in response to medication and improved performance in school. You, Mary, and Jennifer decide to begin medication for ADHD and to track Jennifer's depression.

Because you also are concerned about Jennifer's reading problems, you initiate assessment for an individualized educational program (IEP) through the school district. Additional evaluation from the school psychologist as part of the IEP process identifies a reading disorder, for which Jennifer has been compensating with her high intelligence and her grandmother's help. The psychologist also notes increasing depression despite medication for ADHD and improvement in Jennifer's classroom performance and wonders if treatment for depression is indicated. Because Jennifer's scholastic performance has improved after starting medication without a corresponding improvement in her depressive symptoms, you decide that you should treat her depression or refer her to a mental health professional. Jennifer's grandmother is upset that these problems were not identified until Jennifer was 15 years old.

One of the most challenging decisions for a primary care clinician is when to refer a child for assistance in the diagnostic process. Clearly, immediate referral to a mental health professional is needed for a child who may have bipolar disorder or suicidal or homicidal ideation. Indications for referral to other professionals might include possible mental retardation, seizure disorders, Tourette syndrome, speech problems, motor problems, learning disabilities, abuse or neglect, or family or social issues. Dysmorphic features may warrant referral to a medical geneticist to rule out syndromes such as fetal alcohol, fragile X, Williams, and Turner—all of which are usually associated with ADHD symptoms or learning problems.6 Children whose symptoms do not meet criteria for ADHD and who remain a diagnostic puzzle may benefit from careful assessment by a professional with expertise in ADHD and related disorders.

Final appraisalof Jennifer

Jennifer's history is typical of many cases of ADHD. She has some signs of depression but is not severely impaired by her depressive symptoms; your decision to follow those symptoms while treating her ADHD is appropriate, as is your subsequent decision to treat or refer her for depression when the depressive symptoms fail to improve. She also has a history that suggests a learning problem—a delay in reading simple words and specific challenges in this area, compared with other subjects. At issue is whether Jennifer has a learning disability that requires intervention through school-based services. In general, a history of developmental delay (including speech and language problems as a toddler, delayed phonetic awareness, and late acquisition of reading skills) requires comprehensive psychoeducational testing. Keep in mind that variable daily school performance in all subjects is more typical of ADHD, whereas poor academics or spotty performance across subjects may indicate a learning disability.20 A learning assessment that includes evaluation of reading, writing, mathematics, spelling, auditory and visual processing, and short-term memory should be performed by special education assessment personnel in the public school system, a clinician specializing in psychoeducational evaluation, a psychologist, or a local developmental service agency. Note, however, that a learning disability need not be present for a child to qualify for special education services.

Report card onthe AAP guidelines

Faced with a child who may have ADHD, the primary care clinician's initial role is to objectively synthesize and interpret information about her behavior, to identify medical or psychosocial problems that might cause or exacerbate these symptoms, and to refer for further evaluation when needed. Although AAP guidelines for diagnosing ADHD may not be comprehensive, they do provide a framework upon which to base the evaluation. As we have said, the guidelines should be supplemented in several ways:

  • Early consideration of a full differential diagnosis to identify ADHD and conditions that present similarly or comorbidly

  • Collaboration with families and school personnel when gathering information

  • Development of an understanding of the tools used for diagnosis

  • Knowledge of the impact of age, gender, and ethnicity to help resolve disputes over diagnosis

Once a diagnosis of ADHD is made, you must not only provide appropriate medical treatment but should also be available to counsel and support the family. The family often needs time to accept and deal with the diagnosis, and questions often arise during this process. This requires your utmost attention.

REFERENCES

1. American Academy of Pediatrics: Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105:1158

2. Brown RT, Freeman WS, Perrin WS, et al: Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings. Pediatrics 2001;107:e43

3. Agency for Health Care Policy and Research: Diagnosis of attention-deficit/hyperactivity disorder (Technical Review No. 3). Rockville, Md., US Department of Health and Human Services,1999

4. Montauk SL, Mayhall C: Attention-deficit hyperactivity disorder. Available at: http://www.emedicine.com/ped/topic177.htm

5. Wasserman RC, Kelleher KJ, Bocian A, et al: Identification of attentional and hyperactivity problems in primary care: A report from pediatric research in office settings and the ambulatory sentinel practice network. Pediatrics 1999;103(3):e38

6. Gephart HR: A managed care approach to ADHD. Contemporary Pediatrics 1997;14(5):123

7. Barkley RA: Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, ed 2. New York, Guilford, 1998

8. Block SL: Attention-deficit disorder: A paradigm for psychotropic medication intervention in pediatrics. Pediatr Clin North Am 1998;45:1053

9. Robin AL: ADHD in Adolescents: Diagnosis and Treatment. New York, Guilford, 1998

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DR. LIU is a fellow in behavioral and developmental pediatrics at the University of California, San Diego.
DR. LESLIE is a research scientist at the Child and Adolescent Services Research Center at Children's Hospital and Health Center, San Diego, and assistant professor of pediatrics at the University of California, San Diego.
The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

 



Diagnosing ADHD: Putting AAP guidelines to the test--and into practice.

Contemporary Pediatrics

December 2003;20:51.