Attention deficit hyperactivity disorder in children and adolescents: Clinical features and

evaluation

Author

Kevin R Krull, PhD Section Editors

Marilyn Augustyn, MD

Steven Parker, MD Deputy Editor

Mary M Torchia, MD

Last literature review version 17.1: January 2009 | This topic last updated: February 13,
2009 (More)

INTRODUCTION — Attention-deficit/hyperactivity disorder (ADHD) is a disorder that manifests

in early childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The
symptoms affect cognitive, academic, behavioral, emotional, and social functioning (show
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. (See "Attention deficit hyperactivity disorder in children and
adolescents: Epidemiology and pathogenesis" and see "Overview of the treatment and
prognosis of attention deficit hyperactivity disorder in children and adolescents" and see
"Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents" and
see "Adult attention deficit hyperactivity disorder").

CORE SYMPTOMS — ADHD is a syndrome composed of three categories of symptoms:

hyperactivity, impulsivity, and inattention. The complaint regarding these symptoms may
originate from the parents, teachers, or other caregivers [2] . The symptoms may not be
apparent in the structured setting of the clinic visit, but the pediatric care provider can ask the
parents the following questions to elicit concerns regarding school performance and behavior
[3] : 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, home, or when playing with friends? Does your child have problems completing school
assignments at school or home?

Each of the core symptoms of ADHD has its own pattern and course of development.

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" (show 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 [4] . They peak in severity when the child
is seven to eight years of age, after which they begin to steadily decline. By the adolescent
years, the hyperactive symptoms are barely discernible.
Impulsivity — Impulsive behavior, which almost always occurs in conjunction with
hyperactivity in younger children, 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 (show table 1).

Similar to the hyperactive symptoms, the impulsive symptoms typically are observed by the
time the child is 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 [5] . In contrast to hyperactive symptoms,
impulsive symptoms usually remain a problem throughout the life of the individual. (See
"Overview of the treatment and prognosis of attention deficit hyperactivity disorder in
children and adolescents", section on Prognosis).

The focus of impulsivity is related to the environment. 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 [6] . Adults with ADHD may find themselves with higher rates of
financial mismanagement related to impulse buying.

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
(show table 1).

The symptoms of inattention typically are not apparent until the child is eight to nine years of
age [7] . 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 "Overview of the
treatment and prognosis of attention deficit hyperactivity disorder in children and
adolescents", section on Prognosis).

DIAGNOSTIC CRITERIA

Attention deficit hyperactivity disorder — Consensus criteria for the diagnosis of ADHD have
been defined by the American Psychiatric Association and published in the DSM-IV (show table
1) [1,2,8] . Several features of the DSM-IV criteria deserve emphasis: The symptoms must be
present in more than one setting (eg, school and home). The symptoms must persist for at
least six months. The symptoms must be present before the age of seven years. The symptoms
must impair function in academic, social, or occupational activities. The symptoms must be
excessive for the developmental level of the child. Other mental disorders that could account
for the symptoms must be excluded. (See "Differential diagnosis" below).

Adherence to the DSM-IV criteria can help to minimize over- and underdiagnosis of ADHD.
However, several limitations of the criteria must be noted [2] . The criteria were derived from
studies of children who were evaluated in psychiatric rather than primary care settings. Data
supporting the number of items required for diagnosis are lacking. Finally, the behavioral
characteristics specified in the definition are subject to different interpretations by different
observers [2] . Nonetheless, the diagnostic criteria, as used by appropriate examiners,
demonstrate high interrater reliability of individual items and of overall diagnosis [9,10] .

Depending upon the predominant symptoms, three subtypes of ADHD have been identified [1]
: Predominantly inattentive Predominantly hyperactive-impulsive Combined

The subtype of ADHD in a given patient can change from one to another over the course of
time [1,2,11] .

Inattentive subtype — Children with the predominantly inattentive subtype of ADHD (ADHD-I)
usually are diagnosed at 9 to 10 years of age, the age at which symptoms of inattention
become noticeable. Children with the ADHD-I have at least six of the symptoms of inattention
that have persisted for at least six months and are present to a degree that is maladaptive and
inconsistent with developmental level (show table 1) [1,2] : Often fails to give close attention
to details or makes careless mistakes in schoolwork or other activities Often has difficulty
sustaining attention in tasks or play activities Often does not seem to listen when spoken to
directly Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties (not because of oppositional behavior or failure to understand instructions) Often has
difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (such as schoolwork or homework) Often loses things
necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) Often is
easily distracted by extraneous stimuli Often is forgetful in daily activities

Children with ADHD-I may have mild symptoms of hyperactivity or impulsivity, but inattention
is their primary problem. Children ADHD-I are characterized by reduced ability to focus
attention and reduced speed of cognitive processing and responding [12,13] . They often are
described as having a sluggish cognitive tempo and frequently appear to be daydreaming or
"off task" [14] . The typical presenting complaints center around cognitive and/or academic
problems. ADHD-I is not as well studied as the other subtypes [15] .

Hyperactive-impulsive subtype — Children with the predominantly hyperactive-impulsive

subtype of ADHD (ADHD-HI) usually are diagnosed at six to seven years of age, when
symptoms of hyperactivity and impulsivity peak. Children with ADHD-HI have at least six of the
symptoms of hyperactivity-impulsivity that have persisted for at least six months and are
present to a degree that is maladaptive and inconsistent with developmental level (show table
1) [1,2] : Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or
in other situations in which remaining seated is expected Often runs about or climbs
excessively in situations in which it is inappropriate Often has difficulty playing or engaging in
leisure activities quietly Often is "on the go" or often acts as if "driven by a motor" Often talks
excessively Often blurts out answers before questions have been completed Often has
difficulty awaiting his or her turn Often interrupts or intrudes on others (eg, butts into
conversations or games)

Children with ADHD-HI have relatively good attention skills; they simply cannot sit still or
inhibit their behavior. Cognitive performance may be unaffected in children with ADHD-HI [16]
.
Combined subtype — Children with the combined subtype of ADHD (ADHD-C) usually are
diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak.
Children with ADHD-C have at least six of the symptoms of inattention and at least six of the
symptoms of hyperactivity-impulsivity (show table 1) [1,2] . ADHD-C is the subtype that is most
easily identified. Presenting complaints include disruptive or aggressive behavior, overactivity,
disinhibition, and reduced attention span. This is the classic subtype of ADHD and is seen most
commonly in clinical studies and treatment centers [17] .

Preschool children — Many of the symptoms of ADHD are common among preschool children
in various settings. For this reason, establishing the diagnosis of ADHD in children younger than
six years is difficult [1,2] . Nonetheless, data from longitudinal studies suggest that severe
hyperactivity, present in only a small subset of preschool children, persists into the school
years [18,19] . In one study evaluating the validity of Diagnostic and Statistical Manual of
Mental Disorders-IV (DSM-IV) criteria for ADHD (show table 1) in preschool children, 79
percent of children who met full DSM-IV diagnostic criteria at ages four to six years were more
likely to continue to meet criteria over the subsequent three years than children who only met
criteria in one setting (situational ADHD, 34 percent), or comparison children (3 percent) [20] .

Hyperkinetic disorder — In Europe, the diagnosis of hyperkinetic disorder (HKD) is defined by

the International Classification of Diseases (10th edition, ICD-10) criteria (show table 2) [4,21] .
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 met in more than one setting (ie, HKD is a subtype of ADHD-C)
[21] . HKD is subdivided into HKD with and without conduct disorder.

DIFFERENTIAL DIAGNOSIS — The symptoms of ADHD overlap with those of learning

disabilities and behavioral and emotional problems such as depression, bipolar disease,
anxiety, or post traumatic stress disorder [21-24] . These disorders frequently coexist with
ADHD and may or may not be responsible for the symptoms. As an example, children who
have learning disabilities may develop inattention as a result of inability to understand new
information [25] . The use of broadband behavior scales and psychometric testing may help to
differentiate these problems from ADHD. (See "Psychosocial evaluation" below and see
"Clinical features and evaluation of learning disabilities in children").

Other conditions to consider in children with symptoms of inattention, hyperactivity, and

impulsivity include cognitive problems (mental retardation, fragile X syndrome), environmental
factors (eg, stressful home environment, inappropriate educational setting), and various
medical conditions such as hearing or visual impairment, diabetes mellitus, lead poisoning,
asthma, fetal alcohol syndrome, thyroid abnormalities, sleep disorder, and seizure disorder
(show table 3) [26-31] . These conditions usually can be differentiated from ADHD because
their symptoms fluctuate with the course of disease. In contrast, the symptoms in ADHD are
persistent and pervasive.
EVALUATION

Overview — Children who are being evaluated for possible ADHD should undergo
comprehensive medical, developmental, educational, and psychosocial evaluation
[2,4,8,15,21] . Comprehensive evaluation is necessary to confirm the presence, persistence,
pervasiveness, and functional complications of core symptoms (show table 1), exclude other
explanations for core symptoms (show table 3), and identify comorbid psychiatric disorders.
(See "Diagnostic criteria" above and see "Differential diagnosis" above and see "Comorbid
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
daycare; and evaluation for comorbid psychiatric disorders [2,4,8,15,21] . 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 [4] . Safety and injury prevention
should be discussed 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 "Overview of the treatment and prognosis of attention deficit hyperactivity
disorder in children and adolescents", section on Injuries).

Because the differential diagnosis of ADHD is extensive and because comorbidity is a common
finding, children should be reevaluated whenever the symptoms worsen or new symptoms
emerge. (See "Differential diagnosis" above and see "Comorbid disorders" below).

ADHD Toolkit — The National Initiative for Children's Healthcare Quality (NICHQ), in
conjunction with the American Academy of Pediatrics (AAP), has developed a toolkit for
primary care practitioners to assist 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
through NICHQ (www.nichq.org/adhd.html, requires registration).

Medical evaluation — The medical history should include prenatal exposures (eg, tobacco,
drugs, alcohol), perinatal complications or infections, central nervous system infection, head
trauma, recurrent otitis media, and medications [4] . Family history of similar behaviors is
important because ADHD has a strong genetic component. (See "Attention deficit hyperactivity
disorder in children and adolescents: Epidemiology and pathogenesis", section on Genetic
factors).

The examination should include measurement of height, weight, head circumference, and vital
signs [4] . Dysmorphic and neurocutaneous findings should be noted. A complete neurologic
examination, including assessment of vision and hearing, should be performed. The child's
behavior in the office setting should be observed. 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 [32] .
Developmental and behavioral evaluation — The developmental and behavioral history should
include specific information about the onset and course of ADHD symptoms, as well as
information regarding psychological, medical, and developmental events that may provide an
alternative explanation for the symptoms [4] . Information regarding developmental
milestones, particularly language milestones, school absences, and psychosocial stressors,
should be obtained. Parent-child interactions should be observed.

The behavioral assessment should focus 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 [2,4,8] . The information regarding core symptoms can be
obtained through the use of open-ended questions or from ADHD-specific rating scales,
described below [2] . If open-ended questions are used, the examiner must document the
presence of the relative behaviors from the DSM-IV (show table 1). (See "Rating scales"
below).

Educational evaluation — The educational assessment should focus on documentation of the

core symptoms in the educational setting. Information from the school should include
completion of an ADHD-specific rating scale and a narrative summary of classroom behavior
and interventions, learning patterns, and functional impairment [2] . In addition, copies of
report cards and samples of school work should be obtained. (See "Rating scales" below).

The pediatric care provider should review the results of school-based multidisciplinary
evaluations if such evaluations have been performed [2] . 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.)

Obtaining information about the core symptoms of ADHD from professionals in after-school
programs or other structured settings also may be helpful [2] . This information may be
particularly useful if discrepancies exist between the parent's and teacher's 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
[2] . (See "Differential diagnosis" above).

Psychosocial evaluation

Rating scales — Various scales have been developed to collect structured observations of
behavior (show table 2). These scales should be completed by parents and teachers for
diagnosis, during medication titration, and at regular medication follow-up visits. (See
"Overview of the treatment and prognosis of attention deficit hyperactivity disorder in
children and adolescents"). 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
diagnosis 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) [33] .

ADHD-specific rating scales have a sensitivity and specificity of greater than 90 percent when
used in an appropriate population [33,34] . However, most of the studies validating the use of
rating scales have taken place in referral rather than primary care settings [2] . The NICHQ
ADHD toolkit includes the Vanderbilt Assessment Scales, which can be downloaded and
printed from the Web site (www.nichq.org/adhd.html, requires registration). The Vanderbilt
has been validated in a community setting using longitudinal assessment and follow-up [35] .
Broadband scales — Broadband scales assess a variety of behavioral symptoms, including, but
not limited to, the core symptoms of ADHD; they assess internalizing and externalizing
behaviors other than ADHD. Broadbased scales are not recommended to establish the
diagnosis of ADHD because they are less sensitive and specific (<86 percent) than ADHD-
specific scales [34] . However, broadband scales can help to identify comorbid conditions or
narrow the differential diagnosis [36] . (See "Developmental and behavioral screening tests in
primary care" section on Behavioral screening tests).

Comorbid disorders — The evaluation should include assessment for comorbid disorders [4,8] .
As many as one-half of children with ADHD have one or more comorbid conditions, including
oppositional defiant disorder, conduct disorder, depression, anxiety disorder, and learning
disabilities [37-39] . The comorbid conditions can be primary or secondary (eg, disorders that
are exacerbated by the ADHD). In either case, they require treatment independent of the
treatment for ADHD [40] . Oppositional defiant disorder — DSM-IV criteria for oppositional
defiant disorder (ODD) include recurrent patterns of negativistic, defiant, disobedient, and
hostile behavior toward authority figures [1] , and at least four of the following:

- Often loses temper

- Often argues with adults

- Often actively defies or refuses to comply with adults' requests or rules

- Often deliberately annoys people

- Often blames others for his or her mistakes or misbehavior

- Often is touchy or easily annoyed by others

- Often is angry and resentful

- Often is spiteful or vindictive

In addition, the behavior must cause significant impairment in social or academic functioning,
should not occur exclusively in conjunction with a psychotic or mood disorder, and must not
meet criteria for a conduct disorder [1] .

Children with ADHD-C or ADHD-HI subtypes of ADHD are at increased risk for developing
behavior problems, including ODD [41-43] . 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. That is, the oppositional acts bring parental
attention, which can be reinforcing for the child who rarely receives parental praise [42,44,45]
. Conduct disorder — DSM-IV criteria for conduct disorder include a repetitive and persistent
pattern of behavior in which the basic rights of others or major age-appropriate societal norms
or rules are violated [1] . Additional symptoms include:

- Aggression to people and animals

- Destruction of property

- Deceitfulness or theft

- Serious violations of rules

Anxiety disorder — Anxiety may develop in children with ADHD as a secondary disorder;
however, in many cases anxiety appears to be independent of ADHD [37,43] . DSM IV criteria
for anxiety disorder include: excessive anxiety and worry (apprehensive expectation),
occurring on a majority of days for at least six months, about a number of events or activities
(such as school performance) that the child finds difficult to control and is associated with at
least one of the following [46] :

- Restlessness

- Easy fatigability

- Difficulty concentrating

- Irritability

- Muscle tension

- Sleep disturbance

Depression — Depression is more common in ADHD-I and ADHD-C [47,48] . Children with
ADHD and comorbid mood disorder may have family members with a history of major
depressive disorder [49] . During adolescence, they are at increased risk for attempting suicide
[50-52] . (See "Depression in adolescents: Epidemiology, clinical manifestations, and diagnosis"
and see "Epidemiology and risk factors for suicidal behavior in children and adolescents").
Learning disability — Learning disabilities are more common in children with ADHD-I and
ADHD-C [47,48] . (See "Clinical features and evaluation of learning disabilities in children").

Psychometric testing — Psychometric testing is not necessary for the routine diagnosis of
ADHD and does not distinguish children with ADHD from those without ADHD [8,53] .
Nonetheless, psychometric testing is valuable in narrowing the differential diagnosis because
the core symptoms of ADHD can be related to delayed processing skills, language disorders,
and learning disabilities.
Children with learning, language, visual-motor, or auditory processing problems can be difficult
to distinguish from those with ADHD. The 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 [54-56] , 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 [57]
or the Differential Abilities Scale [58] 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 [59] , or the Wide Range Achievement
Test - Fourth Edition [60] will help to identify potential learning disabilities. (See "Clinical
features and evaluation of learning disabilities in children").

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 function [12,13,54,61] . 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 [62-65] .

Ancillary evaluation — Language, occupational therapy, or mental health evaluation may be

necessary, if indicated by the history and physical examination, to evaluate other conditions
that are being considered in the differential diagnosis. Similarly, other diagnostic tests (eg,
blood lead levels, thyroid hormone levels, genetic testing, neuroimaging, and
electroencephalography) are not indicated routinely to establish the diagnosis of ADHD, but
may be warranted based upon the history and physical examination findings [2,4,8,66-73] .
(See "Differential diagnosis" above).

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
[74] . Several studies have demonstrated differences in qEEG between groups of children with
ADHD and normal children [75-80] . However, these studies are limited by non-random
assignment, lack of blinding, failure to consider comorbidities, and/or failure to control for
pharmacologic therapy [74,78,81] . In addition, the specificity of the findings for ADHD has not
been demonstrated [81] . Although qEEG may prove to be helpful in the diagnosis and/or
classification of ADHD in the future, at present, there is insufficient evidence to support its use
in clinical populations [78,81] .
INDICATIONS FOR REFERRAL — Evaluation by a pediatric specialist (eg, a psychologist,
psychiatrist, neurologist, educational specialist, or developmental-behavioral pediatrician) is
indicated for children who are younger than six years of age or in whom the following
diagnoses are of concern [2,40] : Mental retardation Developmental disorder (eg, speech or
motor delay) Learning disability Visual or hearing impairment History of abuse Severe
aggression Seizure disorder Comorbid learning and/or emotional problems Chronic illness that
requires treatment with a medication that interferes with learning Children who continue to
have problems in functioning despite treatment

INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients.
(See "Patient information: Symptoms and diagnosis of attention deficit hyperactivity disorder
in children"). We encourage you to print or e-mail this topic, or to refer patients to our public
Web site, www.uptodate.com/patients, which includes this and other topics.

SUMMARY AND RECOMMENDATIONS Attention deficit hyperactivity disorder (ADHD) is a

behavioral condition with core symptoms of inattention, hyperactivity, and impulsivity. The
symptoms affect cognitive, academic, behavioral, emotional, and social functioning. (See "Core
symptoms" above). The diagnosis of ADHD requires that the child meet the criteria defined by
the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (show table 1). (See
"Diagnostic criteria" above). The differential diagnosis for ADHD includes other behavioral and
emotional conditions, medical, developmental, and environmental problems (show table 3).
Most of these conditions may coexist with ADHD and require simultaneous treatment. (See
"Differential diagnosis" above and see "Comorbid disorders" above). Evaluation for ADHD
requires comprehensive medical, developmental, educational, and psychosocial evaluation to
confirm the presence, persistence, pervasiveness, and functional complications of core
symptoms (show table 1), exclude other causes of core symptoms (show table 3), and identify
comorbid psychiatric disorders. (See "Overview" 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 (show table 2) can be used to gather this
information from the parents and teacher(s). (See "Educational evaluation" above and see
"Rating scales" above). The evaluation for ADHD should include an assessment for comorbid
conditions. (See "Comorbid disorders" above). Psychometric testing is not necessary for the
routine diagnosis of 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). Children who have been diagnosed with ADHD should be
reevaluated whenever the symptoms worsen or new symptoms emerge. (See "Differential
diagnosis" above and see "Comorbid disorders" above).

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GRAPHICS

DSM-IV criteria for attention deficit hyperactivity disorder

Presence of 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:

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

Often has difficulty sustaining attention in tasks or play activities

Often does not seem to listen when spoken to directly

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)

Often has difficulty organizing tasks and activities

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

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

Is often easily distracted by extraneous stimuli

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

Often fidgets with hands or feet or squirms in seat

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

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)

Often has difficulty playing or engaging in leisure activities quietly

Is often "on the go" or often acts as if "driven by a motor"

Often talks excessively

Impulsivity

Often blurts out answers before questions have been completed

Often has difficulty awaiting turn

Often interrupts or intrudes on others (eg, butts into conversations or games)

Additional criteria

Some hyperactive-impulsive or inattentive symptoms that caused impairment were present

before age seven years.

Some impairment from the symptoms is present in two or more settings (eg, at school [or
work] and at home).

There must be clear evidence of clinically significant impairment in social, academic or

occupational functioning.

Adapted with permission from American Psychiatric Association, Diagnostic and statistical
manual of mental disorders, 4th ed. Washington, D.C., 1994. Copyright © 1994 American
Psychiatric Association.

Ratings scales in the assessment and monitoring of AD/HD

Scales Behaviors Assessed

Broad Band Assessment

Conners' Rating Scale (revised): Long form Combined measure of oppositional, cognitive
problems, hyperactivity, anxiousness/shyness, perfectionism, social problems, psychosomatic
illnesses, restlessness/impulsiveness, emotional lability, DSM-IV symptoms scale, DSM-IV
inattentive, DSM-IV hyperactive-impulsive

Behavior Assessment System for Children* Hyperactivity, aggression, conduct problems,

anxiety, depression, somatization, atypicality, withdrawal, attention problems, learning
problems, lack of adaptability/social/leadership/study skills
Child Behavior Checklist/Teacher Report Form Somatic complaints, social/thought/attention
problems, anxiety/ depression, aggressive/delinquent behavior, withdrawal

Narrow Band Assessment

ACTeRS: Boys' and girls' form Attention problems, hyperactivity, lack of social skills,
oppositional

AD/HD Rating Scale Symptoms of AD/HD according to DSM-IV criteria

Childhood Attention Problems Scale§ Combined measure of attention problems, impulsivity,

hyperactivity

Conners' Rating Scale (revised): Short form Combined measure of oppositional, cognitive
problems, hyperactivity, AD/HD index

BASC Monitor Rating Scale Attention/adaptive problems, hyperactivity, problems with

internalizing

Disruptive Behavior Rating Scale¥ DSM-IV symptoms of ODD, AD/HD, and CD (parent-form
only)

Vanderbilt Assessment Scales Symptoms of AD/HD according to DSM-IV criteria; screen for
comorbid conditions (oppositional-defiance, conduct, anxiety, depression)

Assessment of Medication Side Effects

Side Effects Rating Scale¥ Sleeping/appetite problems, staring/daydreaming, withdrawal,

anxiety, irritability, somatic complaints, emotional lability, dizziness, tics

Data from Conners, CK. Conners' Rating Scales - Revised User's Manual. Multi Health Systems
Inc, New York, 1997.

* Data from Reynolds, CR, Kamphaus, RW. Behavior Assessment System for Children - Manual.
American Guidance Service, Inc, Circle Pine, MN, 1992.

Data from Achenbach, TM. Manual for the Child Behavior Checklist. University of Vermont,
Department of Psychiatry, Burlington, 1991; and Achenbach, TM. Manual for the Teachers
Report Form. University of Vermont, Department of Psychiatry, Burlington, 1991.

Data from Ullmann, RK, Sleator, EK, Sprague, RL. Psychopharmacol Bull 1984; 20:160.

Data from DuPaul, GJ. J Clin Child Psychol 1991; 20:242.

§ Data from Edelbrock, C. Child Attention Problems Scale (unpublished manuscript). Penn State
University, University Park, 1978.

Data from Kamphaus, RW, Reynolds, CR. BASC Monitor for ADHD: Manual and Software
Guide. American Guidance Service, Circle Pine, MN 1998.
¥ Data from Barkley, RA, Murphy, KR. Attention Deficit Hyperactivity Disorder: A Clinical
Workbook. Guilford Press, New York 1998.

Differential diagnosis for attention deficit hyperactivity disorder

Developmental

Normal variation

Mental retardation

Giftedness

Learning disability

Perceptual processing disorder

Language disorder

Pervasive developmental disorder

Emotional/Behavioral

Depression or mood disorder

Anxiety disorder

Oppositional defiant disorder

Conduct disorder

Obsessive compulsive disorder

Post traumatic stress disorder

Adjustment disorder

Environmental

Child abuse or neglect

Stressful home environment

Inadequate or punitive parenting

Parental psychopathology

Sociocultural differences

Inappropriate educational setting

Frequent school absence

Medical
Sensory impairments

Seizure disorder

Sequelae of CNS infection/trauma

Fetal alcohol syndrome

Fragile X syndrome

Lead poisoning

Iron deficiency anemia

Neurodegenerative disorder

Tourette syndrome

Thyroid disorder

Diabetes mellitus

Substance abuse

Medication side effects (eg, bronchodilators, corticosteroids, isoniazid, neuroleptics)

Undernutrition

Sleep disorder

Enuresis/encopresis

Motor coordination disorder

Stereotypic movement disorder

Data from:

Miller, KJ, Wender, EH. Attention deficit/hyperactivity disorder. In: Primary Pediatric Care, 4th
ed, Hoekelman, RA (Ed), Mosby, St. Louis 2001. p.756.

Attention-deficit and disruptive behavior disorders. In: Diagnostic and Statistical Manual of
Mental Disorders, 4th ed, Text Revision, American Psychiatric Association 2000.