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Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2013. | This topic last updated: Apr 13, 2013.

INTRODUCTION — Attention deficit hyperactivity disorder (ADHD) is a disorder that manifests in childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning (table 1) [1].

This topic review focuses on the clinical features and evaluation of ADHD. The epidemiology, pathogenesis, management, and prognosis of ADHD in children and adolescents and ADHD in adults are discussed separately.

CLINICAL FEATURES

Core symptoms — ADHD is a syndrome with three categories of symptoms: hyperactivity, impulsivity, and inattention (table 1). Each of the core symptoms of ADHD has its own pattern and course of development. The complaint regarding symptoms of ADHD may originate from the parents, teachers, or other caregivers [2].

Hyperactivity — Hyperactive behavior is identified through excessive fidgetiness or talking, difficulty remaining seated when required to do so, difficulty playing quietly, and frequent restlessness or seeming to be always "on the go" (table 1).

The hyperactive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years [3,4]. They peak in severity when the child is seven to eight years of age, after which they begin to decline steadily. By the adolescent years, the hyperactive symptoms can be barely discernible to observers, but adolescents often report internal restlessness or inability to settle down.

Impulsivity — Impulsive behavior almost always occurs in conjunction with hyperactivity in young children. Impulsive behavior is manifested by difficulty waiting turns, blurting out answers too quickly, disruptive classroom behavior, intruding or interrupting other's activities, peer rejection, and unintentional injury (table 1).

Similar to the hyperactive symptoms, the impulsive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years to peak in severity when the child is seven to eight years of age [3,4]. In contrast to hyperactive symptoms, impulsive symptoms usually remain a problem throughout the life of the individual. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

The focus of impulsivity is related to the environment. As an example, adolescents with ADHD who are untreated and in an environment where alcohol and other commonly abused substances are readily available are at greater risk of engaging in drug use or experimentation than are adolescents without ADHD [5].

Inattention — Inattention may take many forms, including forgetfulness, being easily distracted, losing or misplacing things, disorganization, academic underachievement, poor follow-through with assignments or tasks, poor concentration, and poor attention to detail (table 1).

The symptoms of inattention typically are not apparent until the child is eight to nine years of age [3,4]. This delay may relate to reduced sensitivity of assessment of attention problems or increased variability in the normal development of the cognitive skills. Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

Subtypes of ADHD — Depending upon the predominant symptoms, ADHD can be categorized into one of three subtypes: predominantly inattentive; predominantly hyperactive-impulsive; and combined. The subtype of ADHD in a given patient can change from one to another over time [1,6-8].

The predominantly inattentive subtype of ADHD is characterized by reduced ability to focus attention and reduced speed of cognitive processing and responding [9,10]. Children with the inattentive subtype often are described as having a sluggish cognitive tempo and frequently appear to be daydreaming or "off task" [11]. The typical presenting complaints center on cognitive and/or academic problems. Symptoms may include [1]:

  • Failing to pay close attention to details or making careless mistakes in schoolwork or other activities
  • Difficulty sustaining attention in tasks or play activities
  • Not seeming to listen when spoken to directly
  • Not following through on instructions and failing to finish schoolwork, chores, or duties (not because of oppositional behavior or failure to understand instructions)
  • Difficulty organizing tasks and activities
  • Avoidance or reluctance to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • Losing things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools)
  • Being easily distracted by extraneous stimuli
  • Forgetfulness in daily activities

The predominantly hyperactive-impulsive subtype of ADHD is characterized by the inability to sit still or inhibit behavior. Symptoms may include [1]:

  • Fidgeting with hands or feet or squirming in seat
  • Leaving seat in classroom or in other situations where he or she is expected to remain seated
  • Running about or climbing excessively in situations in which it is inappropriate
  • Difficulty playing or engaging in leisure activities quietly
  • Often being "on the go" or acting as if "driven by a motor"
  • Excessive talking
  • Blurting out answers before questions have been completed
  • Difficulty awaiting his or her turn
  • Interrupting or intruding on others (eg, butting into conversations or games)

Children with the hyperactive-impulsive subtype of ADHD have relatively good attention skills. Cognitive performance may be unaffected [12]. Children with the hyperactive-impulsive subtype of ADHD usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak.

The combined subtype of ADHD is characterized by symptoms of hyperactivity, impulsivity, and inattention. The combined subtype is the classic subtype of ADHD and the subtype that is most easily identified. Presenting complaints may include disruptive or aggressive behavior, overactivity, disinhibition, and reduced attention span.

Children with the combined subtype of ADHD usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak.

Impaired functioning — In order to meet criteria for ADHD, core symptoms must impair function in academic, social, or occupational activities [1]. Social skills in children with ADHD often are significantly impaired. Problems with inattention may limit opportunities to acquire social skills or to attend to social cues necessary for effective social interaction, making it difficult to form friendships. Hyperactive and impulsive behaviors may result in peer rejection [13]. The negative consequences of impaired social function (eg, poor self-esteem, increased risk for depression and anxiety) may be long-standing.

DIFFERENTIAL DIAGNOSIS — The symptoms of ADHD overlap with a number of other conditions, including developmental variations, neurologic or developmental conditions, emotional and behavioral disorders, psychosocial or environmental factors, and certain medical problems (table 2) [1,2,14,15]. Some of these conditions can coexist with ADHD and may or may not be responsible for some of the symptoms (eg, children who have learning disabilities may develop inattention as a result of inability to understand new information) [16]. These conditions usually can be differentiated from ADHD with a thorough history and/or the use of a broadband behavior rating scale. If the diagnosis remains uncertain, psychometric testing or a mental health evaluation may be necessary. (See 'Coexisting disorders' below.)

  • Neurologic or developmental conditions – Neurodevelopmental conditions that can mimic or co-occur with ADHD include [14,18]:

  • Emotional and behavioral disorders – Emotional and behavioral disorders that can mimic or co-occur with ADHD include anxiety disorder, mood disorders, oppositional defiant disorder, conduct disorder, obsessive compulsive disorder, post-traumatic stress disorder, and adjustment disorder. The use of a broadband behavior scale may be helpful in the assessment of these disorders. However, evaluation by a mental health professional generally is necessary for diagnosis. (See 'Coexisting disorders' below and 'Behavior rating scales' below and 'Indications for referral' below.)
  • Psychosocial and environmental factors – Environmental factors that can contribute to inattention, impulsivity, or hyperactivity include a stressful home environment or an inappropriate educational setting. In contrast to ADHD, psychosocial and environmental factors generally affect behavior only in one setting (eg, at home but not at school, or at school, but not at home). Parent-child temperament or “personality” mismatch and parental mental health conditions (particularly maternal depression) can contribute to parent report of ADHD-type symptoms in the home setting. However, mothers of ADHD children with limited resources or support may also develop stress-related mental health conditions; in such circumstances, multiple respondent (eg, teacher, coach) reports help to confirm the diagnosis of ADHD.
  • Medical conditions – Medical conditions that may have clinical features that mimic ADHD include hearing or visual impairment, lead poisoning, thyroid abnormalities, sleep disorders (eg, obstructive sleep apnea, restless-leg/periodic limb movement disorder), medication effects (eg, albuterol), and substance abuse disorders [19,20]. (See appropriate topic reviews.) These conditions usually can be differentiated from ADHD because their symptoms fluctuate with the disease course or exposure to medication. In contrast, the symptoms in ADHD are persistent and pervasive.

EVALUATION

Overview — The evaluation for possible ADHD includes comprehensive medical, developmental, educational, and psychosocial evaluation [2,20-24]. Comprehensive evaluation is necessary to confirm the presence, persistence, pervasiveness, and functional complications of core symptoms (table 1), exclude other explanations for core symptoms (table 2), and identify coexisting emotional, behavioral, and medical disorders. (See 'Diagnostic criteria' below and 'Differential diagnosis' above and 'Coexisting disorders' below.)

The evaluation should include review of the medical, social, and family histories; clinical interviews with the parent and patient; review of information about functioning in school or day care; and evaluation for coexisting emotional or behavioral disorders [20-24]. The necessary information may be obtained in several ways, including in-person discussions, questionnaires, and Web-based tools, as described below.

The complete evaluation may require several office visits [21]. It is important to discuss safety and injury prevention at each visit because children with ADHD or symptoms of ADHD are at increased risk of intentional and unintentional injury compared with children without these symptoms. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

Reevaluation of children with ADHD is warranted whenever symptoms worsen or new symptoms emerge because the differential diagnosis of ADHD is extensive and comorbidity is common. (See 'Differential diagnosis' above and 'Coexisting disorders' below.)

Medical evaluation — Important aspects of the medical history include prenatal exposures (eg, tobacco, drugs, alcohol), perinatal complications or infections, central nervous system infection, head trauma, recurrent otitis media, and medications [21]. Family history of similar behaviors is important because ADHD has a strong genetic component. The review of systems should include information about sleep disturbances [20]. It is particularly important to obtain a dietary history (eg, appetite, picking eating) and history of sleep patterns before initiation of pharmacotherapy to avoid attributing preexisting problems to medications [25]. It is also important to obtain a thorough child and family cardiac history and cardiac review of systems before initiating medications. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on 'Genetic factors' and "Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder", section on 'Recommended approach'.)

The pediatric care provider can ask the parents the following questions to elicit concerns regarding school performance and behavior [26]:

  • How is your child doing at school?
  • Have you or the teacher noticed any problems with learning?
  • Is your child happy in school?
  • Does your child have any behavioral problems at school or home, or when playing with friends?
  • Does your child have problems completing school assignments at school or home?

The physical examination of most children with ADHD is normal. However, the examination is necessary to evaluate other possibilities in the differential diagnosis. Important aspects of the examination include [21,26]:

  • Measurement of height, weight, head circumference, and vital signs
  • Assessment of dysmorphic features and neurocutaneous abnormalities
  • A complete neurologic examination, including assessment of vision and hearing
  • Observation of the child's behavior in the office setting; however, this isolated assessment of behavior should be interpreted cautiously; symptoms of ADHD may not be apparent in the structured setting of the clinic visit

Developmental and behavioral evaluation — Important aspects of the developmental and behavioral history include [21]:

  • Specific information about the onset, course, and functional impact of ADHD symptoms
  • Emotional, medical, and developmental events that may provide an alternative explanation for the symptoms (see 'Differential diagnosis' above)
  • Developmental milestones, particularly language milestones (table 3)
  • School absences
  • Psychosocial stressors
  • Observation of parent-child interactions

The behavioral assessment is focused on determining the age of onset of the core symptoms of ADHD, the duration of symptoms, the settings in which the symptoms occur, and the degree of functional impairment [2,21,22]. This information is necessary to establish the diagnosis of ADHD. (See 'Diagnostic criteria' below.)

Information about the core symptoms can be obtained through the use of open-ended questions or from ADHD-specific rating scales. If open-ended questions are used, the examiner must document the presence of the relevant behaviors from the DSM-IV (table 1).

Behavior rating scales — Various scales have been developed to collect structured observations of behavior (table 4). Completion of these scales by parents and teachers during the diagnostic evaluation helps to establish the presence of core symptoms of ADHD in more than one setting. (See 'Diagnostic criteria' below.)

  • ADHD-specific scales – ADHD-specific rating scales (also called narrow-band scales) focus directly on the symptoms of ADHD and can be used to establish the presence of the core symptoms of ADHD. The validity of ADHD rating scales in distinguishing children with ADHD from age-matched control children varies depending upon the age of the child, the scale that is used, and the informant (eg, parent, teacher, adolescent) [27].

    ADHD-specific rating scales have a sensitivity and specificity of greater than 90 percent when used in an appropriate population [27,28]. However, most of the studies validating the use of rating scales have taken place in referral rather than primary care settings. The National Initiative for Children's Healthcare Quality (NICHQ) ADHD toolkit includes the Vanderbilt Assessment Scales, which can be downloaded and printed from the Web site. The Vanderbilt Assessment Scales have been validated in both community and referral settings using longitudinal assessment and follow-up [29-31].

    Only the Conners Comprehensive Behavior Rating Scales and the ADHD Rating Scale IV have been validated in preschool-aged children [2,32]. The Vanderbilt rating scales were not designed for preschool children, but probably can be used in children ≥4 years [33,34].
  • Broadband scales – Broadband scales assess a variety of behavioral symptoms, including, but not limited to, the core symptoms of ADHD; they assess internalizing behaviors (eg, feeling depressed, anxious, withdrawn) and externalizing behaviors other than ADHD (eg, aggression). Broadband scales (with the exception of the Conners' Long form) are not recommended to establish the presence of the core symptoms of ADHD because they are less sensitive and specific (<86 percent) than ADHD-specific scales [28]. However, broadband scales can help to identify coexisting conditions and narrow the differential diagnosis [35]. (See "Developmental and behavioral screening tests in primary care", section on 'Behavioral screening tests'.)

Educational evaluation — The educational assessment centers on documentation of the core symptoms in the educational setting. Important aspects of the educational evaluation include [2,20]:

  • Completion of an ADHD-specific rating scale (see 'Behavior rating scales' above)
  • A narrative summary of classroom behavior and interventions, learning patterns, and functional impairment
  • Copies of report cards and samples of schoolwork
  • Review of school-based multidisciplinary evaluations (if such evaluations have been performed)

The teachers who provide the information should have regular contact with the child for a minimum of four to six months if they are to comment reliably on the persistence of symptoms. In the United States, schools are federally mandated to perform appropriate evaluations (eg, language, cognitive) at no cost to the family if a child is suspected of having a disability that impairs functioning (eg, ADHD or learning disability). (See "Support services for the care of chronically ill children", section on 'Education' and "Definitions of specific learning disability and laws pertaining to learning disabilities", section on 'Laws affecting the education of students with disabilities'.)

Obtaining information about the core symptoms of ADHD from professionals in after-school programs or other structured settings also may be helpful [2,20]. This information may be particularly useful in the evaluation of preschool children and adolescents, or if discrepancies exist between the parents’ and teachers’ reports of core symptoms. When such discrepancies occur, environmental factors (eg, different expectations, levels of structure, or behavior management strategies) may be contributing to the symptoms. (See 'Differential diagnosis' above.)

Coexisting disorders — The evaluation for ADHD should include assessment for coexisting behavior/emotional disorders including oppositional defiant disorder, conduct disorder, depression, anxiety disorder, and learning disabilities (table 5) [21,22,36]. Evaluation for these disorders may include history, broadband behavior scales (oppositional defiant disorder, conduct disorder, depression, anxiety) or psychometric testing (learning disability) (table 2).

Up to one-half of children with ADHD have one or more coexisting behavioral-emotional conditions [37-39]. The coexisting conditions can be primary or secondary (eg, disorders that are exacerbated by the ADHD). In either case, they require treatment in conjunction with treatment for ADHD [2]. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Treatment of coexisting conditions'.)

Anxiety may develop in children with ADHD as a secondary disorder; however, in many cases anxiety appears to be independent of ADHD [37,40].

Children with the combined or hyperactive-impulsive subtype of ADHD are at increased risk for developing coexisting behavior problems, including oppositional defiant disorder [40-42]. Their excessive activity, impulsive response style, and disinhibited emotional expression frequently put them in conflict with parents and other adults. The increased conflict may lead to increased discipline and less positive reinforcement for the child. Under these circumstances, a potentially self-perpetuating pattern of oppositional defiant behavior can emerge (the oppositional acts bring parental attention, which is reinforcing for the child who rarely receives parental praise) [42-44].

Learning disabilities and depression are more common in children with the inattentive and combined subtypes of ADHD [45,46]. Children with ADHD and comorbid mood disorder may have family members with a history of major depressive disorder [47]. During adolescence, they are at increased risk for attempting suicide [48-50]. (See "Specific learning disabilities in children: Clinical features", section on 'Comorbidities' and "Depression in adolescents: Epidemiology, clinical manifestations, and diagnosis", section on 'Epidemiology' and "Suicidal behavior in children and adolescents: Epidemiology and risk factors", section on 'Psychiatric disorder'.)

Adolescents with newly diagnosed ADHD should be assessed for substance abuse [2]. Those with signs and symptoms of substance abuse should undergo evaluation and treatment for addiction before treatment for ADHD with medications (if possible) [51]. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Prerequisites'.)

Psychometric testing — Psychometric testing is not necessary in the routine evaluation for ADHD and does not distinguish children with ADHD from those without ADHD [22,52]. However, psychometric testing can be valuable in excluding other disorders. The public school system often is the best place to perform psychometric testing (ie, intellectual and academic testing), though more specialized neuropsychological testing requires consultation with a specialist. Testing for learning disabilities can be completed in whole or in part by the school system. (See 'Differential diagnosis' above.)

Children with learning, language, visual-motor, or auditory processing problems can be difficult to distinguish from those with ADHD. These problems tend to be pervasive and persistent and can impair academic function through decreased comprehension or excessive frustration. Children with these problems may attempt to avoid tasks through inattention, getting out of their seats, or impulsively guessing at answers. On the other hand, children with ADHD may perform poorly on language and visual-spatial tasks [53-55], particularly those that require sustained mental effort or are sensitive to impulsive responding (eg, multiple-choice formats).

Comprehensive neuropsychologic testing may help to clarify the diagnosis. Children with learning, language, visual-motor, or auditory processing problems usually perform poorly only in their particular problem area, whereas children with ADHD may perform poorly in several areas of evaluation. Assessment of verbal and nonverbal/performance skills with an intelligence measure such as the Wechsler Intelligence Scale for Children – Fourth Edition [56] or the Differential Abilities Scale [57] will help to identify language and/or visual-spatial processing deficits. Assessment of academic skills/achievement testing with a tool such as the Wechsler Individual Achievement Test – Second Edition [58], or the Wide Range Achievement Test – Fourth Edition [59] will help to identify potential learning disabilities. (See "Specific learning disabilities in children: Clinical features" and "Specific learning disabilities in children: Evaluation".)

Psychometric testing also can help to identify specific problem areas for children with ADHD, including abstract reasoning, mental flexibility, planning, and working memory, a collection of skills broadly categorized as “executive functions” [9,10,53,60]. Neuropsychological assessment of these skills, as well as direct assessment of attention and behavioral disinhibition, often is desirable to facilitate diagnosis, plan environmental and behavioral interventions, and track progress of treatment [61-64].

Ancillary evaluation — Other evaluations are not routinely indicated to establish the diagnosis of ADHD, but may be warranted to evaluate conditions remaining in the differential diagnosis after the initial assessment. (See 'Differential diagnosis' above.) These evaluations may include [20-22,65]:

Quantitative EEG (qEEG) is a method of analyzing the electrical activity of the brain to derive quantitative patterns that may correspond to diagnostic information and/or cognitive deficits [72]. We do not suggest qEEG for the evaluation of children with ADHD. Although several studies have demonstrated differences in qEEG between children with ADHD and normal children [73-78], the studies were limited by non-random assignment, lack of blinding, failure to consider comorbidities, and/or failure to control for pharmacologic therapy [72,76,79]. Furthermore, the studies did not demonstrate the specificity of the findings for ADHD [79]. Thus, current evidence is insufficient to support the use of qEEG in clinical populations [76,79].

DIAGNOSIS

Diagnostic criteria

ADHD — The American Psychiatric Association has defined consensus criteria for the diagnosis of ADHD, which are published in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) (table 1) [1]. Several features of the DSM-IV-TR criteria deserve emphasis; the symptoms must:

  • Be present in more than one setting (eg, school and home)
  • Persist for at least six months
  • Be present before the age of seven years
  • Impair function in academic, social, or occupational activities
  • Be excessive for the developmental level of the child

In addition, other physical, situational, or mental health conditions that could account for the symptoms must be excluded. (See 'Differential diagnosis' above.)

Adherence to the DSM-IV-TR criteria can help to minimize over- and underdiagnosis of ADHD. The diagnostic criteria have high interrater reliability for individual items and for overall diagnosis even though the behavioral characteristics specified in the definition are subject to different interpretation by different observers [20,80,81].

Limitations of the DSM-IV-TR criteria include their derivation from studies of children who were evaluated in psychiatric rather than primary care settings and lack of data supporting the number of items required for diagnosis.

The response to stimulant medication cannot be used to confirm or refute the diagnosis of ADHD [80]. Stimulant medications improve behavior in children with ADHD, children with conditions other than ADHD (eg, learning disabilities, depression), and normal control children [82,83].

ADHD subtype — Depending upon the predominant symptoms, ADHD can be categorized into one of three subtypes [1]:

  • Predominantly inattentive – ≥6 symptoms of inattention (table 1)
  • Predominantly hyperactive-impulsive – ≥6 symptoms of hyperactivity-impulsivity (table 1)
  • Combined – ≥6 symptoms of inattention and ≥6 symptoms of hyperactivity-impulsivity (table 1)

Hyperkinetic disorder — In Europe, the diagnosis of hyperkinetic disorder (HKD) is defined by the International Classification of Diseases (10th edition, ICD-10) criteria (table 6) [21,24]. The ICD-10 criteria for HKD are more restrictive than the DSM-IV criteria for ADHD, requiring that at least six symptoms of inattention, at least three symptoms of hyperactivity, and at least one symptom of impulsivity are present in more than one setting [24]. HKD is subdivided into HKD with and without conduct disorder.

Diagnosis in preschool children — The diagnostic criteria for ADHD (without subtyping) can be applied to children as young as four years of age [2,84]. Longitudinal studies suggest that severe hyperactivity, which is present in only a small subset of preschool children, persists into the school years [85-87].

The criterion that impairment is present in at least two settings may be difficult to meet if the child does not attend preschool or a child care program [2]. In such circumstances, clinicians who suspect ADHD can recommend that the parents attend a parent-training program or that the child be enrolled in a qualified preschool program (eg, Head Start, public prekindergarten programs, Early Childhood Special Education services) [2]. The clinician can then obtain information about core symptoms of ADHD and functional impairment from the instructors of the preschool program or the parenting program (if the child is directly observed).

Diagnosis in adolescents — Establishing a new diagnosis of ADHD in adolescents can be challenging. Adolescents may underreport core symptoms or functional impairment and may spend too little time at home for parents to be accurate informants [2,88]. In such cases, it is important for clinicians to obtain information from at least two teachers and/or other adults with whom the adolescent interacts (eg, guidance counselor, coaches, etc) [2].

INDICATIONS FOR REFERRAL — Evaluation by a pediatric specialist (eg, a psychologist, psychiatrist, neurologist, educational specialist, or developmental-behavioral pediatrician) is indicated for children in whom the following diagnoses are of concern [2]:

RESOURCES — The National Initiative for Children's Healthcare Quality (NICHQ), in conjunction with North Carolina’s Center for Child Health Improvement, and the American Academy of Pediatrics (AAP), has developed a toolkit to assist primary care practitioners in the evaluation and management of children with ADHD. The toolkit includes information for parents, copies of ADHD-specific questionnaires for parents and teachers, and an initial primary care evaluation form. It can be downloaded without charge through the NICHQ but requires registration. A revised edition of the toolkit, which also includes tools and resources for preschool children and adolescents, is available for purchase through the American Academy of Pediatrics.

Resources for families of children with ADHD are provided in the table (table 7).

Information for teachers of children with ADHD is available through the National Resource Center on ADHD.

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SUMMARY AND RECOMMENDATIONS

  • Attention deficit hyperactivity disorder (ADHD) is a behavioral condition with core symptoms of inattention, hyperactivity, and impulsivity (table 1). The symptoms affect cognitive, academic, behavioral, emotional, and social functioning. (See 'Core symptoms' above.)
  • The differential diagnosis for ADHD includes developmental variations, neurologic or developmental conditions, emotional and behavioral disorders, psychosocial or environmental factors, and certain medical problems (table 2). Most of these conditions may coexist with ADHD and require simultaneous treatment. (See 'Differential diagnosis' above and 'Coexisting disorders' above.)
  • The diagnosis of ADHD requires that the child meet the criteria defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) (table 1). The response to stimulant medication cannot be used to confirm or refute the diagnosis. (See 'Diagnostic criteria' above.)
  • Evaluation for ADHD requires comprehensive medical, developmental, educational, and psychosocial evaluation to confirm the presence, persistence, pervasiveness, and functional complications of core symptoms (table 1), exclude other causes of core symptoms (table 2), and identify coexisting learning and psychiatric disorders (table 5). (See 'Overview' above and 'Coexisting disorders' above.)
  • The evaluation for ADHD requires information about the child's behavior in more than one setting (eg, home and school or after-school program). ADHD-specific behavior scales (table 4) can be used to gather this information from the parents and teacher(s). (See 'Educational evaluation' above and 'Behavior rating scales' above.)
  • Psychometric testing is not necessary in the routine evaluation for ADHD. However, it is valuable in narrowing the differential diagnosis and planning the approach to management. (See 'Psychometric testing' above.)
  • The evaluation for ADHD does not require blood lead levels, thyroid hormone levels, neuroimaging, or electroencephalography unless these tests are indicated by findings in the clinical evaluation. (See 'Ancillary evaluation' above.)
  • Reevaluation of children with ADHD is warranted whenever symptoms worsen or new symptoms emerge because the differential diagnosis of ADHD is extensive and comorbidity is common. (See 'Differential diagnosis' above and 'Coexisting disorders' above.)

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REFERENCES

  1. Attention-deficit and disruptive behavior disorders. In: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, 4th, American Psychiatric Association, Washington, DC 2000. p.85.
  2. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011; 128:1007.
  3. Applegate B, Lahey BB, Hart EL, et al. Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 1997; 36:1211.
  4. Lahey BB, Applegate B, McBurnett K, et al. DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry 1994; 151:1673.
  5. Levin FR, Kleber HD. Attention-deficit hyperactivity disorder and substance abuse: relationships and implications for treatment. Harv Rev Psychiatry 1995; 2:246.
  6. Lahey BB, Pelham WE, Loney J, et al. Instability of the DSM-IV Subtypes of ADHD from preschool through elementary school. Arch Gen Psychiatry 2005; 62:896.
  7. Larsson H, Dilshad R, Lichtenstein P, Barker ED. Developmental trajectories of DSM-IV symptoms of attention-deficit/hyperactivity disorder: genetic effects, family risk and associated psychopathology. J Child Psychol Psychiatry 2011; 52:954.
  8. Hinshaw SP, Owens EB, Zalecki C, et al. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. J Consult Clin Psychol 2012; 80:1041.
  9. Nigg JT, Blaskey LG, Huang-Pollock CL, Rappley MD. Neuropsychological executive functions and DSM-IV ADHD subtypes. J Am Acad Child Adolesc Psychiatry 2002; 41:59.
  10. Weiler MD, Bernstein JH, Bellinger DC, Waber DP. Processing speed in children with attention deficit/hyperactivity disorder, inattentive type. Child Neuropsychol 2000; 6:218.
  11. Carlson CL, Mann M. Sluggish cognitive tempo predicts a different pattern of impairment in the attention deficit hyperactivity disorder, predominantly inattentive type. J Clin Child Adolesc Psychol 2002; 31:123.
  12. Faraone SV, Biederman J, Weber W, Russell RL. Psychiatric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention-deficit/hyperactivity disorder: results from a clinically referred sample. J Am Acad Child Adolesc Psychiatry 1998; 37:185.
  13. Hoza B. Peer functioning in children with ADHD. Ambul Pediatr 2007; 7:101.
  14. Leslie LK, Guevara JP. Attention-deficit/hyperactivity disorder. In: American Academy of Pediatrics Textbook of Pediatric Care, McInerny TK. (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.1201.
  15. Morrow RL, Garland EJ, Wright JM, et al. Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. CMAJ 2012; 184:755.
  16. Gilger JW, Pennington BF, DeFries JC. A twin study of the etiology of comorbidity: attention-deficit hyperactivity disorder and dyslexia. J Am Acad Child Adolesc Psychiatry 1992; 31:343.
  17. Hyperactive/impulsive behaviors. In: The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version, 1st, Wolraich ML. (Ed), American Academy of Pediatrics, Elk Grove Village, IL 1996. p.93.
  18. Wijburg FA, Węgrzyn G, Burton BK, Tylki-Szymańska A. Mucopolysaccharidosis type III (Sanfilippo syndrome) and misdiagnosis of idiopathic developmental delay, attention deficit/hyperactivity disorder or autism spectrum disorder. Acta Paediatr 2013; 102:462.
  19. Pearl PL, Weiss RE, Stein MA. Medical mimics. Medical and neurological conditions simulating ADHD. Ann N Y Acad Sci 2001; 931:97.
  20. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Process of Care Supplemental Appendix. Available at: http://pediatrics.aappublications.org/content/128/5/1007/suppl/DC1 (Accessed on January 06, 2012).
  21. Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder -- first upgrade. Eur Child Adolesc Psychiatry 2004; 13 Suppl 1:I7.
  22. Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:894.
  23. National Institutes of Health Consensus Development Conference Statement: diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). J Am Acad Child Adolesc Psychiatry 2000; 39:182.
  24. National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. 2008. http://www.nice.org.uk/CG72 (Accessed on October 25, 2011).
  25. Wender EH. Managing stimulant medication for attention-deficit/hyperactivity disorder. Pediatr Rev 2001; 22:183.
  26. Sleator EK, Ullmann RK. Can the physician diagnose hyperactivity in the office? Pediatrics 1981; 67:13.
  27. Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales. V: scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2003; 42:1015.
  28. Agency for Healthcare Research and Quality. Diagnosis of Attention-Deficit/Hyperactivity Disorder. Clinical Focus. Rockville, MD, October 1999. http://www.ahrq.gov/clinic/tp/adhddtp.htm (Accessed on October 25, 2011).
  29. Wolraich ML, Lambert W, Doffing MA, et al. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. J Pediatr Psychol 2003; 28:559.
  30. Wolraich ML, Bard DE, Neas B, et al. The psychometric properties of the vanderbilt attention-deficit hyperactivity disorder diagnostic teacher rating scale in a community population. J Dev Behav Pediatr 2013; 34:83.
  31. Bard DE, Wolraich ML, Neas B, et al. The psychometric properties of the vanderbilt attention-deficit hyperactivity disorder diagnostic parent rating scale in a community population. J Dev Behav Pediatr 2013; 34:72.
  32. McGoey KE, DuPaul GJ, Haley E, Shelton TL. Parent and teacher ratings of attention-deficit/hyperactivity disorder in preschool: the ADHD Rating Scale-IV Preschool Version. J Psychopathol Behav Assess 2007; 29:269.
  33. Dreyer BP. The diagnosis and management of attention-deficit/hyperactivity disorder in preschool children: the state of our knowledge and practice. Curr Probl Pediatr Adolesc Health Care 2006; 36:6.
  34. Kaplan A, Adesman A. Clinical diagnosis and management of attention deficit hyperactivity disorder in preschool children. Curr Opin Pediatr 2011; 23:684.
  35. Biederman J, Monuteaux MC, Kendrick E, et al. The CBCL as a screen for psychiatric comorbidity in paediatric patients with ADHD. Arch Dis Child 2005; 90:1010.
  36. Pastor PN, Reuben CA. Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004-2006. Vital Health Stat 10 2008; :1.
  37. Jensen PS, Hinshaw SP, Kraemer HC, et al. ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry 2001; 40:147.
  38. 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; 56:1073.
  39. Levy F, Hay DA, Bennett KS, McStephen M. Gender differences in ADHD subtype comorbidity. J Am Acad Child Adolesc Psychiatry 2005; 44:368.
  40. Pliszka SR. Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview. J Clin Psychiatry 1998; 59 Suppl 7:50.
  41. Neuman RJ, Heath A, Reich W, et al. Latent class analysis of ADHD and comorbid symptoms in a population sample of adolescent female twins. J Child Psychol Psychiatry 2001; 42:933.
  42. Lalonde J, Turgay A, Hudson JI. Attention-deficit hyperactivity disorder subtypes and comorbid disruptive behaviour disorders in a child and adolescent mental health clinic. Can J Psychiatry 1998; 43:623.
  43. Barkley RA, Fischer M, Edelbrock C, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology. J Child Psychol Psychiatry 1991; 32:233.
  44. Pliszka SR. Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 2000; 9:525.
  45. Wolraich ML, Hannah JN, Pinnock TY, et al. Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry 1996; 35:319.
  46. Wolraich ML, Hannah JN, Baumgaertel A, Feurer ID. Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample. J Dev Behav Pediatr 1998; 19:162.
  47. Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry 1991; 148:564.
  48. Lam LT. Attention deficit disorder and hospitalization owing to intra- and interpersonal violence among children and young adolescents. J Adolesc Health 2005; 36:19.
  49. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988; 45:581.
  50. Nasser EH, Overholser JC. Assessing varying degrees of lethality in depressed adolescent suicide attempters. Acta Psychiatr Scand 1999; 99:423.
  51. Riggs PD. Clinical approach to treatment of ADHD in adolescents with substance use disorders and conduct disorder. J Am Acad Child Adolesc Psychiatry 1998; 37:331.
  52. Doyle AE, Biederman J, Seidman LJ, et al. Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit-hyperactivity disorder. J Consult Clin Psychol 2000; 68:477.
  53. Aman CJ, Roberts RJ Jr, Pennington BF. A neuropsychological examination of the underlying deficit in attention deficit hyperactivity disorder: frontal lobe versus right parietal lobe theories. Dev Psychol 1998; 34:956.
  54. Nigg JT, Swanson JM, Hinshaw SP. Covert visual spatial attention in boys with attention deficit hyperactivity disorder: lateral effects, methylphenidate response and results for parents. Neuropsychologia 1997; 35:165.
  55. Purvis KL, Tannock R. Language abilities in children with attention deficit hyperactivity disorder, reading disabilities, and normal controls. J Abnorm Child Psychol 1997; 25:133.
  56. Wechsler D. Wechsler Intelligence Scale for Children: 4th Edition. Harcourt Assessment, Inc., San Antonio, TX 2003.
  57. Elliott C. Differential Ability Scales. The Psychological Corporation, San Antonio, TX 1990.
  58. Wechsler Individual Achievement Test-Second Edition. The Psychological Corporation, San Antonio, TX 2001.
  59. Glutting JJ, Wilkinson GS. Wide Range Achievement Test – 3. Wide Range, Inc., Wilmington, DE, 2006.
  60. Rubia K, Taylor E, Smith AB, et al. Neuropsychological analyses of impulsiveness in childhood hyperactivity. Br J Psychiatry 2001; 179:138.
  61. Hale JB, Hoeppner JA, DeWitt MB, et al. Evaluating medication response in ADHD: cognitive, behavioral, and single-subject methodology. J Learn Disabil 1998; 31:595.
  62. Kempton S, Vance A, Maruff P, et al. Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children. Psychol Med 1999; 29:527.
  63. Risser MG, Bowers TG. Cognitive and neuropsychological characteristics of attention deficit hyperactivity disorder children receiving stimulant medications. Percept Mot Skills 1993; 77:1023.
  64. Tannock R, Ickowicz A, Schachar R. Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. J Am Acad Child Adolesc Psychiatry 1995; 34:886.
  65. Zametkin AJ, Ernst M. Problems in the management of attention-deficit-hyperactivity disorder. N Engl J Med 1999; 340:40.
  66. Kahn CA, Kelly PC, Walker WO Jr. Lead screening in children with attention deficit hyperactivity disorder and developmental delay. Clin Pediatr (Phila) 1995; 34:498.
  67. Gittelman R, Eskenazi B. Lead and hyperactivity revisited. An investigation of nondisadvantaged children. Arch Gen Psychiatry 1983; 40:827.
  68. Elia J, Gulotta C, Rose SR, et al. Thyroid function and attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1994; 33:169.
  69. Weiss RE, Stein MA, Trommer B, Refetoff S. Attention-deficit hyperactivity disorder and thyroid function. J Pediatr 1993; 123:539.
  70. Stephen E, Kindley AD. Should children with ADHD and normal intelligence be routinely screened for underlying cytogenetic abnormalities? Arch Dis Child 2006; 91:860.
  71. Bastain TM, Lewczyk CM, Sharp WS, et al. Cytogenetic abnormalities in attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2002; 41:806.
  72. Krull KR, George MR, Strother D. Quantitative electroencephalography and neurofeedback. In: Pediatric Neuropsychological Intervention: A Critical Review of Science & Practice, Hunter SJ, Donders J (Eds), Cambridge University Press, Cambridge 2007. p.392.
  73. Lazzaro I, Gordon E, Li W, et al. Simultaneous EEG and EDA measures in adolescent attention deficit hyperactivity disorder. Int J Psychophysiol 1999; 34:123.
  74. Lazzaro I, Gordon E, Whitmont S, et al. Quantified EEG activity in adolescent attention deficit hyperactivity disorder. Clin Electroencephalogr 1998; 29:37.
  75. Chabot RJ, Merkin H, Wood LM, et al. Sensitivity and specificity of QEEG in children with attention deficit or specific developmental learning disorders. Clin Electroencephalogr 1996; 27:26.
  76. Snyder SM, Hall JR. A meta-analysis of quantitative EEG power associated with attention-deficit hyperactivity disorder. J Clin Neurophysiol 2006; 23:440.
  77. Swartwood JN, Swartwood MO, Lubar JF, Timmermann DL. EEG differences in ADHD-combined type during baseline and cognitive tasks. Pediatr Neurol 2003; 28:199.
  78. Kuperman S, Johnson B, Arndt S, et al. Quantitative EEG differences in a nonclinical sample of children with ADHD and undifferentiated ADD. J Am Acad Child Adolesc Psychiatry 1996; 35:1009.
  79. Barry RJ, Clarke AR, Johnstone SJ. A review of electrophysiology in attention-deficit/hyperactivity disorder: I. Qualitative and quantitative electroencephalography. Clin Neurophysiol 2003; 114:171.
  80. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA 1998; 279:1100.
  81. Power TJ, Costigan TE, Leff SS, et al. Assessing ADHD across settings: contributions of behavioral assessment to categorical decision making. J Clin Child Psychol 2001; 30:399.
  82. Rapoport JL, Buchsbaum MS, Zahn TP, et al. Dextroamphetamine: cognitive and behavioral effects in normal prepubertal boys. Science 1978; 199:560.
  83. Peloquin LJ, Klorman R. Effects of methylphenidate on normal children's mood, event-related potentials, and performance in memory scanning and vigilance. J Abnorm Psychol 1986; 95:88.
  84. Lahey BB, Pelham WE, Loney J, et al. Three-year predictive validity of DSM-IV attention deficit hyperactivity disorder in children diagnosed at 4-6 years of age. Am J Psychiatry 2004; 161:2014.
  85. Campbell SB, Ewing LJ, Breaux AM, Szumowski EK. Parent-referred problem three-year-olds: follow-up at school entry. J Child Psychol Psychiatry 1986; 27:473.
  86. McGee R, Partridge F, Williams S, Silva PA. A twelve-year follow-up of preschool hyperactive children. J Am Acad Child Adolesc Psychiatry 1991; 30:224.
  87. Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry 2013; 52:264.
  88. Adler LA, Newcorn JH. Administering and evaluating the results of the adult ADHD Self-Report Scale (ASRS) in adolescents. J Clin Psychiatry 2011; 72:e20.
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