The Child with ADHD: Using the AAP Clinical Practice Guideline

CARLA T. HERRERIAS, M.P.H.,
American Academy of Pediatrics, Elk Grove Village, Illinois
JAMES M. PERRIN, M.D.,
Harvard Medical School, Boston, Massachusetts
MARTIN T. STEIN, M.D.,
University of California, San Diego, School of Medicine, San Diego,
California
The American Academy of Pediatrics developed an evidence-based clinical
practice guideline that provides recommendations for the assessment and
diagnosis of school-aged children with attention-deficit/hyperactivity
disorder (ADHD). This guideline, the first of two guidelines to provide
recommendations on this condition, is intended for use by primary care
clinicians. The second set of guidelines will address the treatment of
children with ADHD. The guideline contains six recommendations for the
diagnosis of ADHD: (1) in a child six to 12 years of age 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 the criteria for
ADHD in the Diagnostic and Statistical Manual of Mental Disorders; (3) the
assessment of ADHD requires evidence directly obtained from parents or
caregivers regarding the core symptoms of ADHD in various settings, the age
of onset, duration of symptoms and degree of functional impairment; (4) the
assessment of ADHD also requires evidence directly obtained from a 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 coexisting
conditions; and (6) other diagnostic tests are not routinely indicated to
establish the diagnosis of ADHD but may be used for the assessment of
coexisting conditions. (Am Fam Physician 2001;63:1803-10,1811-2.)
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 A patient information handout on ADHD, written by the authors of this
article, is provided on page 1811.
<http://www.aafp.org/afp/20010501/1811ph.html>

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Attention-deficit/hyperactivity disorder (ADHD) is the most common
neurobehavioral disorder of childhood and among the most prevalent chronic
health conditions affecting school-aged children. This article provides a
summary of the American Academy of Pediatrics (AAP) Clinical Practice
Guideline on the Diagnosis and Evaluation of the Child with
Attention-Deficit/Hyperactivity Disorder.1 The guideline was developed by
the AAP Committee on Quality Improvement's Subcommittee on ADHD and included
participation of the American Academy of Family Physicians.
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See editorial
on page 1694. <http://www.aafp.org/afp/20010501/editorials.html>
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Prevalence rates for ADHD vary substantially, partly because of changing
diagnostic criteria over time2-5 and partly because of variations in
ascertainment in different settings and the frequent use of referred samples
to estimate rates. The core symptoms of ADHD include inattention,
hyperactivity and impulsivity.6,7 Children with ADHD may experience
significant functional problems, such as school difficulties, academic
underachievement, troublesome interpersonal relationships with family
members and peers, and low self-esteem.
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Children with ADHD may experience significant functional problems, such as
school difficulties, academic underachievement, troublesome interpersonal
relationships with family members and peers, and low self-esteem.
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Primary care clinicians frequently are asked by parents and teachers to
evaluate a child for ADHD; early recognition, assessment and management of
this condition can redirect the educational and psychosocial development of
most children with ADHD.8,9 The guideline primarily reviews evidence
relating to the diagnosis of ADHD in relatively uncomplicated cases in
primary care settings. Thus, the guideline is not intended for evaluation of
children with mental retardation, pervasive developmental disorder, moderate
to severe sensory deficits such as visual and hearing impairment and chronic
disorders associated with medications that may affect behavior, or children
who have experienced physical abuse or sexual abuse.
Development of the Guideline
The Subcommittee on ADHD was chaired by two general pediatricians and
included pediatricians and experts in the fields of neurology, psychology,
child psychiatry, development, epidemiology, education and practice.
Representatives from the American Academy of Family Physicians, the American
Academy of Child and Adolescent Psychiatry, the Child Neurology Society and
the Society for Pediatric Psychology served on the panel. The AAP committee
collaborated with the Agency for Healthcare Research and Quality. Results
from the literature were presented in evidence tables and published in the
final evidence report.10 The draft practice guideline underwent extensive
peer review by committees and sections within the AAP, numerous outside
organizations and persons identified by the subcommittee. The
recommendations contained in the practice guideline are based on the best
available data (Figure 1). Where data were lacking, a combination of
evidence and expert consensus was used.
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Evaluation for ADHD

FIGURE 1. Algorithm to aid in the diagnosis and evaluation of the child with
attention-deficit/hyperactivity disorder. (ADHD =
attention-deficit/hyperactivity disorder; DSM-IV = Diagnostic and
Statistical Manual of Mental Disorders, 4th ed.; DSM-PC = Diagnostic and
Statistical Manual of Mental Disorders, 4th ed., primary care version)
Reprinted with permission from American Academy of Pediatrics. Clinical
practice guideline: diagnosis and evaluation of the child with
attention-deficit/hyperactivity disorder. Pediatrics 2000;105:1158-70.
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Guideline Recommendations
Recommendation 1
In a child six to 12 years of age who presents with inattention,
hyperactivity, impulsivity, academic underachievement or behavior problems,
primary care clinicians should initiate an evaluation for ADHD (strength of
evidence: good; strength of recommendation: strong).
Primary care pediatricians and family physicians recognize behavior problems
that may affect academic achievement in 18 percent of the school-aged
children seen in their offices and clinics. Hyperactivity or inattention is
diagnosed in 9 percent of children.11 However, presentations of ADHD in
clinical practice vary, and symptoms may not be apparent in a structured
clinical setting that is free from the demands and distractions of the home
and school.12 Clinical practices during routine health supervision, such as
asking questions about the child's behavior, may assist in early recognition
of ADHD.13,14 Sample questions include: (1) How is your child doing in
school? (2) Are there any problems with learning that you or the teacher
have seen? (3) Are you concerned with behavior problems in school, at home
or when your child is playing with friends?
Recommendation 2
The diagnosis of ADHD requires that a child meet the criteria for ADHD in
the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)
(strength of evidence: good; strength of recommendation: strong).
Primary care professionals should apply DSM-IV criteria in the context of
their clinical assessment of a child; the use of specific criteria will help
to ensure an accurate diagnosis and decrease variation in the way the
diagnosis is made. The DSM-IV criteria, developed through several iterations
by the American Psychiatric Association, are based on clinical experience
and an expanding research foundation (Table 1).5 These criteria have more
support in the literature than other diagnostic criteria.
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TABLE 1
Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
  _____

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
                e.      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 age seven.
C.     Some impairment from the symptoms is present in two or more settings
(e.g., at school [or work] and 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 a personality
disorder).
  _____

Reprinted with permission from American Psychiatric Association. Diagnostic
and statistical manual of mental disorders. 4th ed. Washington, D.C.:
American Psychiatric Association, 1994:83-4. Copyright 1994.
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It is important to recognize the limitations of the DSM-IV definition. Most
of the development and testing of the DSM-IV criteria occurred through
studies of children seen in psychiatric settings, and much less is known
about their use in other populations, such as those seen in general
pediatric or family practice settings. The DSM-IV criteria remain a
consensus without clear empiric data supporting the number of items required
for the diagnosis. The criteria do not take into account gender differences
or developmental variations in behavior and may be interpreted differently
by different observers. These complexities in the diagnosis mean that
clinicians using DSM-IV criteria must apply them in the context of their
clinical judgment.
Recommendation 3
The assessment of ADHD requires evidence directly obtained from parents or
caregivers regarding the core symptoms of ADHD in various settings, the age
of onset, duration of symptoms and degree of functional impairment (strength
of evidence: good; strength of recommendation: strong).
Behavior symptoms may be obtained from parents or guardians using one or
more methods, including general questions about behavior, focused questions
about specific behaviors, semi-structured interview schedules,
questionnaires and rating scales. Clinicians who obtain information from
general or focused questions about behavior must obtain and record the
relevant behaviors of inattention, hyperactivity and impulsivity from the
DSM-IV. Gathering data about the child's behavior provides an opportunity to
evaluate the family environment and parenting style so that behavior
symptoms may be evaluated in the context of the child's environment.
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Clinicians should use criteria from the Diagnostic and Statistical Manual of
Mental Disorders, 4th ed., when evaluating children for ADHD.
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Specific questionnaires and rating scales have been developed to review and
quantify the behavioral characteristics of ADHD. Scales that are specific to
ADHD accurately distinguish between children with ADHD and those without
ADHD. Most studies of these scales and checklists have taken place under
ideal conditions (i.e., comparing children in referral sites with apparently
healthy children). These instruments may not function as well in the primary
care clinician's office. In addition, questions on which these rating scales
are based are subjective; their results may convey a false sense of validity
and must be interpreted in the context of the overall evaluation of the
child.
Recommendation 3a
Use of ADHD­specific scales is a clinical option when evaluating children
for ADHD (strength of evidence: strong; strength of recommendation: strong).
In contrast, global, nonspecific questionnaires and rating scales that
assess a variety of behavioral symptoms do not distinguish well between
children with ADHD and those without ADHD.
Recommendation 3b
Use of broadband scales is not recommended in the diagnosis of children for
ADHD, although they may be useful for other purposes (strength of evidence:
strong; strength of recommendation: strong).
Recommendation 4
The assessment of ADHD also 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
coexisting conditions. A physician should review any reports from a
school-based multidisciplinary evaluation where they exist, which will
include assessments from the teacher or other school-based professional
(strength of evidence: good; strength of recommendation: strong).
Children six to 12 years of age generally are students and spend a
substantial portion of their waking hours in school. Therefore, a
description of their behavior in the school setting is important to the
evaluation. With permission from the legal guardian, the clinician should
review a report from the child's school. The classroom teacher typically has
more information about the child's behavior than do other professionals at
the school and, when possible, should provide the report. ADHD-specific
questionnaires and rating scales also are available for teachers (Table 2)10
and can accurately distinguish children with ADHD from those without ADHD.
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TABLE 2
Summary of Prevalence of Selected Coexisting Conditions in Children with
ADHD
  _____

Comorbid disorder
  _____

Estimated prevalence (%)
  _____

Confidence limits for estimated prevalence (%)
  _____

Oppositional defiant disorder
35
27, 44
Conduct disorder
26
13, 41
Anxiety disorder
26
18, 35
Depressive disorder
18
11, 27
  _____

ADHD = attention-deficit/hyperactivity disorder.
Reprinted with permission from U.S. Dept of Health and Human Services,
Agency for Health Care Policy and Research. Diagnosis of
attention-deficit/hyperactivity disorder. Rockville, Md.: Government
Printing Office, 1999; AHCPR publication no. 99-0050.
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Recommendation 4a
Use of ADHD-specific scales is a clinical option when diagnosing children
for ADHD (strength of evidence: strong; strength of recommendation: strong).
In contrast, teacher global questionnaires and rating scales that assess a
variety of behavior conditions do not accurately distinguish between
children with ADHD and those without ADHD.
Recommendation 4b
Use of teacher global questionnaires and rating scales is not recommended in
diagnosing children for ADHD, although they may be useful for other purposes
(strength of evidence: strong; strength of recommendation: strong).
If a child six to 12 years of age spends considerable time in other
structured environments such as after-school care centers, additional
information about core symptoms can be sought from professionals in those
settings, contingent on parental permission. For children who are educated
in their homes by parents, evidence of the presence of core behavior
symptoms in settings other than the home should be obtained.
Frequently, significant discrepancies exist between parent and teacher
ratings,15 but the finding of such a discrepancy does not preclude the
diagnosis of ADHD. A helpful clinical approach for understanding the sources
of the discrepancies and determining whether the child meets DSM-IV criteria
is to obtain additional information from other informants, such as former
teachers, religious leaders or athletic coaches.
Recommendation 5
Evaluation of the child with ADHD should include assessment for coexisting
conditions (strength of evidence: strong; strength of recommendation:
strong).
Other psychologic and developmental disorders frequently coexist in children
who are being evaluated for ADHD. As many as one third of children with ADHD
have one or more coexisting conditions (Table 2). Although the primary care
clinician may not always be in a position to make a precise diagnosis of
coexisting conditions, consideration of and examination for coexisting
conditions such as conduct and oppositional defiant disorder (co-occurring
in about 35 percent of children), mood disorders (in about 18 percent),
anxiety disorders (in about 25 percent) and learning disabilities (in an
estimated 12 to 60 percent) should be an integral part of the evaluation.
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Children evaluated for attention-deficit/hyperactivity disorder should also
be assessed for coexisting conditions.
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Evidence for most coexisting disorders may be readily detected by the
primary care clinician. For example, frequent sadness and a preference for
isolated activities may alert the physician to the presence of depressive
symptoms, whereas a family history of anxiety disorders and a patient
history characterized by frequent fears and difficulties with separation
from caregivers may be suggestive of an anxiety disorder. Similarly, poor
school performance may indicate a learning disability. Testing may be
required to determine whether a discrepancy exists between the child's
learning potential and the actual academic progress, indicating the presence
of a learning disability.
Recommendation 6
Other diagnostic tests are not routinely indicated to establish the
diagnosis of ADHD but may be used for the assessment of coexisting
conditions (strength of evidence: strong; strength of recommendation:
strong).
Other diagnostic tests contribute little to establishing the diagnosis of
ADHD. There are few data to support the regular screening of children for
high lead levels, routine screening of thyroid function or routine use of
electroencephalography as part of the effort to diagnose ADHD. Continuous
performance tests have been designed to obtain samples of a child's
behavior--generally by measurement of diligence or distractibility--which
may correlate with behaviors associated with ADHD. However, current data do
not support the use of any continuous performance tests in the diagnosis of
ADHD, since they have limited ability to differentiate children with ADHD
from normal comparison control subjects.
Future Research
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Children six to 12 years of age generally spend a substantial portion of
their waking hours in school. Therefore, a description of their behavior in
school is an important part of their evaluation for ADHD.
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There are three major areas for future research in the diagnosis of ADHD.
Further research is required to validate ADHD subtypes and determine whether
the findings of previous research can be generalized to the type of children
currently diagnosed and treated by primary care clinicians. In addition,
there is inadequate information about the applicability of DSM-IV criteria
to persons younger or older than the age range for this guideline.
Specific examples for research related to the diagnostic process include the
need for additional information about the reliability and validity of
teacher and parent rating scales and the reliability and validity of
different interviewing methods. It is essential to develop and assess better
measurements of impairment that can be applied practically in the primary
care setting. Research into diagnostic methods also should include those
methods helpful in identifying clinically relevant coexisting conditions.
Finally, research is required to identify the current practices of primary
care physicians. Such research is critical in determining the practicality
of guideline recommendations as a method of determining changes in practice
and whether changes have an actual impact on the treatment and outcome of
children with the diagnosis of ADHD.
Final Comment
The clinical practice guideline offers recommendations for the diagnosis and
evaluation of school-aged children with ADHD in primary care practice and
should aid primary care professionals in their assessment of a common child
health problem. The guideline emphasizes (1) the use of explicit criteria
for the diagnosis using DSM-IV criteria; (2) the importance of obtaining
information about the child's symptoms in more than one setting and
especially from schools; and (3) the search for coexisting conditions that
may make the diagnosis more difficult or complicate treatment planning.
Interested readers are urged to consult the full practice guideline for
detailed information.
The authors acknowledge the hard work and dedication of the following
members, liaisons and consultants of the Subcommittee on ADHD: Robert W.
Amler, M.D.; Thomas A. Blondis, M.D.; Ronald T. Brown, M.D. (Society for
Pediatric Psychology); Anthony DeSpirito, M.D. (consultant); Heidi M.
Feldman, M.D.; Ted G. Ganiats, M.D. (American Academy of Family Physicians);
Brian Grabert, M.D. (Child Neurology Society); Charles J. Homer, M.D.,
M.P.H. (consultant); Bruce P. Meyer, M.D.; Karen Pierce, M.D. (American
Academy of Child and Adolescent Psychiatry); Bennett A. Shaywitz, M.D.; and
Mark L. Wolraich, M.D. We also acknowledge efforts of the Agency for
Healthcare Research and Quality, and Technical Resources International,
Inc., in developing the evidence report.
  _____

The Authors
CARLA T. HERRERIAS, M.P.H.,
is a senior health policy analyst in the Department of Practice and Research
at the American Academy of Pediatrics (AAP), Elk Grove Village, Ill., and
coordinates the AAP's evidence-based clinical practice guideline development
efforts and practice guideline implementation initiatives.
JAMES M. PERRIN, M.D.,
is associate professor of pediatrics at Harvard Medical School, Boston, and
director of the Division of General Pediatrics and the Center for Child and
Adolescent Health Policy at Massachusetts General Hospital for Children,
also in Boston. He chaired the American Academy of Pediatrics Committee on
Children with Disabilities and is past president of the Ambulatory Pediatric
Association at the University of Rochester, Rochester, New York.
MARTIN T. STEIN, M.D.,
is professor of pediatrics at the University of California, San Diego,
School of Medicine, where he teaches and practices pediatrics as a
generalist and a developmental and behavioral pediatrician. Dr. Stein is the
immediate past president of the Society for Developmental and Behavioral
Pediatrics and co-author of Encounters with Children: Pediatric Behavior and
Development.
Address correspondence to Carla T. Herrerias, M.P.H., American Academy of
Pediatrics, Department of Practice and Research, 141 Northwest Point Blvd.,
Elk Grove Village, IL 60007 (e-mail: [log in to unmask]
<mailto:[log in to unmask]> ). Reprints are not available from the authors.
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  _____




Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.