Attention-deficit/hyperactivity disorder is the most common childhood neurobehavioral disorder, with an estimated prevalence ranging from 3% to 12%.1–3 It is also among the three most prevalent chronic health conditions affecting school-age children, along with asthma and chronic otitis media.1,3
Attention-deficit/hyperactivity disorder (ADHD) begins in childhood and has residual symptoms that often persist into adulthood. Accumulating evidence suggests that genetic, neurobiological, and neurodevelopmental factors contribute to the onset of ADHD, while less evidence supports social and environmental causes.4 According to the American Medical Association (AMA) Council on Scientific Affairs, “attention-deficit/hyperactivity disorder is one of the best-researched disorders in medicine, and the overall data on its validity is far more compelling than for many medical conditions.”5
Significant disparities persist in rates of ADHD diagnosis and treatment among sex, racial, ethnic, socioeconomic, and geographic groups.1,2,6–10 White boys are diagnosed with ADHD more frequently than white girls, or black or Hispanic children.9 Sex differences in the identification of ADHD are complex — boys are likely affected by ADHD at three times the rate of girls, while girls with ADHD may be under-recognized and under-referred compared with boys.7 Experts have pointed out the likelihood of referral biases favoring boys, who are more likely to present with overtly disruptive symptoms (eg, hyperactivity and impulsivity) over girls, who are more likely to have ADHD symptoms of inattention and distractibility.6 Disruptive behavior often motivates parents and caregivers to seek treatment for their children and may prompt teachers to recommend that children be assessed for ADHD.
Black, Hispanic, rural, and poor children may be diagnosed with ADHD less frequently compared with white children because of various factors, including lack of access to mental health care services, negative parental beliefs about ADHD, or previous negative experiences with mental health treatment.8,10 Cultural factors likely affect how hyperactivity, impulsivity, and inattention are perceived within families and within communities. Perceived burden on the part of parents and caregivers in managing a child with ADHD affects the likelihood that a child will receive a diagnosis and treatment.11 As many as 50% of children with ADHD remain undiagnosed and untreated.2 Primary care pediatricians (PCPs) should be aware of these disparities so all children with ADHD symptoms can be evaluated and treated appropriately.8
Primary Symptoms of ADHD
The three cardinal symptoms of ADHD are hyperactivity, impulsivity, and inattention.12 Symptoms range from developmentally typical behavior to a substantial psychiatric disorder; ADHD is diagnosed when these symptoms present in a developmentally inappropriate manner and cause significant impairment to the child. Accumulating neurobiological evidence supports that these symptoms are associated with developmental and maturational differences in children with and without ADHD. For instance, children with limited symptoms of hyperactivity/impulsivity who don’t meet full criteria for ADHD have been shown to have similar brain development patterns to children with ADHD.13
Severity and type of ADHD symptoms tend to vary throughout the child’s life. The most common developmental progression of ADHD is for preschool-age children (3 to 5 years) to present with symptoms of hyperactivity-impulsivity; school-age children (6 to 12 years) to present with a combination of hyperactivity-impulsivity and inattentive symptoms; adolescents (13 to 18 years) to present with inattention and restlessness; and adults (older than 18 years) to present largely with inattention and periodic impulsivity. Inattention is the symptom most likely to persist into adulthood. At every age, diagnosing ADHD requires comparing presenting symptoms with behavioral expectations for typically developing children at the same age.
Unmanaged ADHD often causes significant psychosocial functional impairment, such as increased incidence of academic difficulties; academic underachievement; occupational difficulties; problematic relationships with family members and peers; sexual-reproductive risks, including early sexual activity and early pregnancy; motor vehicle risks; substance abuse/dependence; legal difficulties; physical injuries; and overall behavioral difficulties.14 The onset of other mental disorders, including depression, is also associated with untreated ADHD.
Challenges to Diagnosis and Management
Compelling reasons support the prominent role of PCPs in identifying and treating children with ADHD. The disorder is one of the most prevalent chronic health conditions presented in pediatric primary care settings. Left untreated, ADHD results in significant psychosocial functional impairment, whereas early identification, assessment, and management of ADHD positively affects educational and psychosocial development. Parents, caregivers, and teachers often request PCPs to assess children with school problems for ADHD; these children and their families often encounter social stigma related to ADHD and its treatment.3,10
There is a national shortage of child and adolescent psychiatrists, psychologists, and other mental health professionals trained to work with children, underscoring the importance of primary care providers in addressing mental disorders in children. These are only some of the multiple health disparities affecting children’s access to specialized mental health services.3,10
Youths with ADHD constitute an estimated 50% of the child population in need of psychiatric treatment; at least 50% of these youths are evaluated and managed in primary care settings.3
Unfortunately, PCPs encounter various challenges when attempting to address childhood psychiatric disorders such as ADHD. These challenges that may limit children’s access to appropriate assessment and treatment:
- Clinical time constraints, which are often cited as a primary reason PCPs struggle to identify and treat childhood psychiatric disorders effectively.4,15
- Inadequate training of pediatric PCPs in psychiatric disorders of childhood.
- Diagnostic complexity in children with ADHD, including comorbid conditions.
- Health insurance-based restrictions on reimbursement for mental health treatment.
- Concerns regarding misuse and diversion of stimulant medications.
- Tendency of PCPs to under-identify mild-to-moderate ADHD symptoms.16
- Paucity of child and adolescent psychiatrists and other mental health professionals to whom patients can be referred, or with whom PCPs can collaborate, when a mental health problem is identified.
ADHD is a clinical diagnosis, meaning there is no specific test or biomarker available to confirm its presence. The DSM-IV-TR-based diagnostic criteria define four subtypes of ADHD based on behavioral domains — nine symptoms related to hyperactivity-impulsivity and nine related to inattention: ADHD, predominantly inattentive subtype (ADHD-I) must display at least six of the nine symptoms of inattention; ADHD, predominantly hyperactive-impulsive subtype (ADHD-HI) must display at least six of the nine symptoms of hyperactivity-impulsivity; ADHD, combined subtype (ADHD-C) must display at least six of the behavioral symptoms described in each of the two domains; ADHD, not otherwise specified (ADHD-NOS), applied to disorders with prominent symptoms of attention deficit or hyperactivity-impulsivity that meet criteria for either of the above.12
Table 1 (see page 494) outlines the ADHD behavioral domains. A child meets the diagnostic criteria for ADHD through documentation of these symptoms together with the functional impairment criteria outlined in the Sidebar.17
Table 1. DSM-IV-TR ADHD Behavioral Domains17
- Behaviors should occur often and to a degree that is maladaptive and inconsistent with the child’s developmental level.
- Presence of behaviors in two or more settings (eg, at home and at school) for at least the past 6 months.
- Presence of some symptoms of ADHD before 7 years of age (history from parents).
- Clear evidence of clinically significant impairment in academic or social functioning, or in both.
- These symptoms should not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder, and should not be accounted for by another mental disorder (eg, mood disorder or anxiety disorder).
Assessment and Treatment of ADHD
In 2000, the American Academy of Pediatrics (AAP) published evidence-based guidelines for assessing, diagnosing, and treating school-age children (6 to 12 years) with ADHD. Their consensus statement was developed by the AAP Committee on Quality Improvement’s Subcommittee on ADHD along with the American Academy of Family Physicians (AAFP).18
In 2007, the American Academy of Child and Adolescent Psychiatry (AACAP) published its own evidence-based guidelines for the assessment and treatment of children and adolescents with ADHD. Following is a distillation of these guidelines regarding the diagnosis of ADHD as they apply to primary care settings.
Psychological Screening for ADHD
PCPs should evaluate for ADHD when a child presents with symptoms, including inattention, hyperactivity, impulsivity, academic underachievement and/or failure, disruptive classroom behavior, aggression, involvement in physically dangerous activities, mood lability, poor self-esteem, or problems establishing or maintaining social relationships.17,19
A child’s parent/caregiver interview is crucial in the assessment of ADHD because of the limited validity and reliability of a child’s self-report of his/her symptoms and impairment. Children usually have difficulty (at least until adolescence) describing their ADHD symptoms. The parent interview should include assessment of the DSM-IV-TR-described symptoms of inattention, hyperactivity, and impulsivity, and each symptom’s frequency. It should also include information about the age of symptom onset, duration, presence and degree of functional impairment resulting from the symptoms, and the effect of ADHD symptoms on the child’s functioning in family and social relationships, self-esteem, leisure activities, self-care, and school achievement. Additional vital data include medical and developmental history, school and educational history, and family and psychosocial history.17,19
ADHD diagnosis is based on clinical assessment and careful history. ADHD-specific behavioral rating scales are also a critical tool in obtaining relevant information from parents, teachers, and other sources.
“Broadband” rating scales, such as the Behavior Assessment System for Children (BASC) and the Achenbach Child Behavior Checklist (CBCL), are used for screening general psychopathology in children, including depression, anxiety, oppositional/conduct problems, and aggression. These scales are not recommended for diagnosing children with ADHD.14,17
“Narrowband” rating scales focus on screening for specific DSM-IV-TR ADHD symptoms. These scales are specifically helpful in distinguishing between children with ADHD and those without ADHD, and are more useful than broadband scales, which focus on a range of psychiatric problems and do not thoroughly investigate ADHD symptoms.9 Rating scales provide subjective data, so results must be interpreted according to the rater’s perspective and within the context of the child’s clinical evaluation. Narrowband rating scales are also useful in monitoring the course of treatment. Table 2 lists common examples of narrowband behavioral rating scales.
Table 2. Common Behavioral Rating Scales/Evaluation Narrowband Instruments Used in the Assessment of ADHD and Monitoring of Treatment
Standardized behavioral rating scales should be obtained from adults, such as parents, other caregivers, teachers, and coaches, who observe the child in his/her natural environments of home and school and can provide information regarding symptoms of ADHD, duration, degree of functional impairment, and coexisting conditions.
Obtaining Information from Teachers and Other Professionals
Teachers often play a crucial role in recognition and referral of children with ADHD. With permission from the legal guardian, the PCP should review reports from the child’s school and after-school settings.
Sometimes, significant discrepancies occur between ratings from parents/caregivers and teachers. 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 scales are available for teachers and other professionals involved with the child and can help distinguish children with ADHD from those without. Discrepancies do not preclude a diagnosis of ADHD, and additional clinical assessment may be helpful in clarifying them. For example, information from a second teacher or coach may provide important auxiliary data, and investigation of parents’ expectations for their child’s behavior may help to explain responses to rating scale queries.
Psychological and Neuropsychological Tests
Learning disabilities (LD), such as dyslexia and intellectual impairment, are more common in children with ADHD. Children with symptoms of ADHD should also be screened for learning disabilities or intellectual impairment. Psychological testing, including standardized assessment of intellectual ability (IQ) and academic achievement, can be useful in identifying LD or low general cognitive ability in the setting of academic impairment or under-achievement.14 However, psychological testing is not indicated routinely and should be prompted only by concerns about LD or general cognitive ability that emerge in the context of an assessment for ADHD.14 If there is clinical suspicion that a child may have an LD, PCPs should refer him or her for psychoeducational evaluation.
Neuropsychological batteries exist to examine inattention and other symptoms of ADHD. Continuous performance tests/tasks (CPTs) are the most common neuropsychological measure used to quantify attention. CPTs have been designed to measure a child’s diligence or distractibility, which might correlate with behaviors associated with ADHD; these tests may be useful in monitoring symptom severity and changes that occur over time with treatment. Current evidence does not support routine use of CPTs in the diagnosis of ADHD because of their limited ability to differentiate children with ADHD from normal comparison control subjects.
Medical Screening Tests
Other diagnostic tests typically contribute little information learned from interviews, and reviews of the child’s medical, psychiatric, social, and family history. There are few data to support the regular screening of children with routine laboratory tests (eg, thyroid, lead, or iron testing) or routine use of electroencephalography or neuroimaging studies in diagnosing ADHD14,17
Hearing or visual impairment may co-occur with ADHD. Unrecognized hearing and visual impairments may lead to impaired school performance or the appearance of symptoms of inattention or defiant behavior, thereby leading to a misdiagnosis of ADHD. With clinical suspicion of a hearing or visual impairment, audiometric and ophthalmic examinations respectively should be performed to rule out associated or isolated impairments.
Assessing Psychiatric Comorbidities
Almost one-third of children with ADHD have multiple comorbid conditions, including depression and other mood disorders; anxiety disorders; tic disorders; learning disorders; conduct disorder; oppositional defiant disorder; substance abuse/dependence; and pervasive developmental disorders.17,19,20
Psychiatric comorbidity must be evaluated in all patients diagnosed with ADHD.19,20,21 Psychiatric comorbidities complicate diagnosis and treatment of ADHD and comorbid disorders. Children with multiple diagnoses likely have higher morbidity with a more challenging prognosis. One way to evaluate for comorbidities is to use standardized broadband screening instruments, such as the Achenbach CBCL. If comorbid conditions are suspected, the patient should be evaluated further and treated or referred as appropriate. If ADHD is the likely primary diagnosis, but psychiatric comorbidity is suspected, PCPs may choose to begin treatment for ADHD while concurrently evaluating for the suspected comorbidity or referring when appropriate.
Causes of ADHD
Chronic or acute psychosocial stressors (eg, physical/sexual abuse, birth of a sibling, illness or death of a loved one, or parental divorce) may precipitate changes in a child’s academic or behavioral functioning, such as mimicking ADHD symptoms or exacerbating existing symptoms.19 Clinicians must rule out these potential reasons for the child’s behavior before diagnosing ADHD, particularly in children who are presenting with symptoms of ADHD for the first time, at a relatively late age.
ADHD is a highly heritable condition.22 Family history of ADHD in siblings and parents can provide further support for suspected ADHD in a child undergoing assessment. Evidence suggests that family members of children with predominantly hyperactive and impulsive symptoms of ADHD may have elevated rates of ADHD, aggression, and substance abuse, whereas family members of children with predominantly inattentive symptoms of ADHD may be at greater risk for ADHD, anxiety disorders, and learning problems.23,24
Reasons for Psychiatric Referrals
In cases in which ADHD is more severe or complex, consultation with or referral to a child and adolescent psychiatrist is appropriate and can contribute significantly to optimal outcomes. Reasons for consultation or referral may include: suspicion that another primary psychiatric condition is most responsible for functional impairment in the child; suspicion that ADHD has a problematic psychiatric comorbidity; significant family psychopathology; treatment refractory ADHD (ie, lack of response to first- and second-line medication trials); and barriers to treatment in a given practice setting.4
Given the high prevalence rates of ADHD, well-established risks of untreated ADHD, and shortage of child and adolescent psychiatrists in the United States, PCPs are critical in identifying and treating children with ADHD, and are particularly well positioned to work to reduce disparities in the rates of ADHD diagnosis and treatment among different sex, racial, ethnic, socioeconomic, and geographic groups.
An ADHD diagnosis should be based on guidelines set forth by the AAP and AACAP, which emphasize that clinicians need to perform a careful clinical assessment and history. There is no single test to establish the diagnosis of ADHD. PCPs should use ADHD-specific behavioral rating scales completed by parents/caregivers and teacher(s) to identify children with suspected ADHD. Ratings from multiple informants should be employed to ascertain the DSM-IVTR-based diagnostic criteria. Besides ADHD-specific rating scales, a thorough history of symptoms and the effect of these symptoms on the child’s current functioning should be evaluated.
Broadband rating scales may be useful in identifying problems or symptoms that may co-occur with ADHD, but their use in diagnosing ADHD is not supported. Routine medical and laboratory testing to diagnose ADHD are not indicated. Psychiatric comorbidity must be assessed for all patients diagnosed with ADHD. With appropriate vigilance, knowledge about ADHD, and effective collaboration with colleagues, PCPs can successfully detect, diagnose, and manage children with ADHD.
- Chan E., Hopkins MR., Perrin JM., Herrerias C., Homer CJ.Diagnostic practices for attention deficit hyperactivity disorder: a national survey of primary care physicians. Ambulatory Pediatrics. 2005;5(4):201–208. doi:10.1367/A04-054R1.1 [CrossRef]
- Foy JM, Earls MF. A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics. 2005;115(1):97–104.
- Leslie LK. The role of primary care physicians in attention deficit hyperactivity disorder (ADHD). Pediatr Ann. 2002;31(8):475–484.
- Shaw K, Wagner I, Eastwood H, Mitchell G. A qualitative study of Australian GPs’ attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). Family Practice. 2003;20(2):129–134. doi:10.1093/fampra/20.2.129 [CrossRef]
- Goldman LS, Genel M, Bezman RJ, Slanetz RJ. Diagnosis and treatment of attention deficit/hyperactivity disorder in children and adolescents. JAMA. 1998;279(14):1100–1107. doi:10.1001/jama.279.14.1100 [CrossRef]
- Biederman J, Mick E, Faraone SV, et al. Influence of Gender on Attention Deficit Hyperactivity Disorder in Children Referred to a Psychiatric Clinic. Am J Psychiatry. 2002;159(1):36–42. doi:10.1176/appi.ajp.159.1.36 [CrossRef]
- Groenewald C, Emond A, Sayal K. Recognition and referral of girls with Attention Deficit Hyperactivity Disorder: case vignette study. Child Care Health Dev. 2009;35(6):767–772. doi:10.1111/j.1365-2214.2009.00984.x [CrossRef]
- Miller TW, Nigg JT, Miller RL. Attention deficit hyperactivity disorder in African American children: what can be concluded from the past ten years?Clinical Psychology Review. 2009;29(1):77–86. doi:10.1016/j.cpr.2008.10.001 [CrossRef]
- Schneider H, Eisenberg D. Who receives a diagnosis of attention-deficit/hyperactivity disorder in the United States elementary school population?Pediatrics. 2006;117(4):601–609. doi:10.1542/peds.2005-1308 [CrossRef]
- Sturm R, Ringel JS, Andreyeva T. Geographic Disparities in Children’s Mental Health Care. Pediatrics. 2003; 112(4):308–315. doi:10.1542/peds.112.4.e308 [CrossRef]
- Angold A, Messer SC, Stangl D, Farmer EMZ, Costello EJ, Burns BJ. Perceived Parental Burden and Service Use for Child Psychiatric Disorders. Am J Public Health. 1998; 88(1):75–80. doi:10.2105/AJPH.88.1.75 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.
- Shaw P, Gilliam M, Liverpool M, et al. Cortical development in typically developing children with symptoms of hyperactivity and impulsivity: support for a dimensional view of attention deficit hyperactivity disorder. Am J Psychiatry. 2011;168(2):143–151. doi:10.1176/appi.ajp.2010.10030385 [CrossRef]
- AACAP Official Action. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894–921.
- Cooper S, Valleley RJ, Polaha J, Begeny J, Evans JH. Running out of time: physician management of behavioral health concerns in rural pediatric primary care. Pediatrics. 2006;118(1):e132–e138. doi:10.1542/peds.2005-2612 [CrossRef]
- Steele MM, Lochrie AS, Roberts MC. Physician identification and management of psychosocial problems in primary care. J Clin Psychol Med Settings. 2010;17(2):103–115. doi:10.1007/s10880-010-9188-1 [CrossRef]
- American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158–1170.
- American Academy of Pediatrics: Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2000: 105(5):1158–1170.
- Institute for Clinical Systems Improvement (ICSI). Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care for School Age Children and Adolescents. Bloomington (MN): ICSI; Apr.2010.
- Rader R, McCauley L. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician. 2009;79(8):657–665.
- Furman L. What is attention-deficit hyperactivity disorder (ADHD)?J Child Neurol. 2005;20(12):994–1002. doi:10.1177/08830738050200121301 [CrossRef]
- Larsson H, Lichtenstein P, Larsson J. Genetic Contributions to the Development of ADHD Subtypes From Childhood to Adolescence. J Am Acad Child Adol Psychiatry. 2006;45(8): 973–981. doi:10.1097/01.chi.0000222787.57100.d8 [CrossRef]
- Biederman J, Petty CR, Wilens TE, et al. Familial risk analyses of attention deficit hyperactivity disorder and substance use disorders. Am J Psychiatry. 2008;165(1):107–115. doi:10.1176/appi.ajp.2007.07030419 [CrossRef]
- Geller D, Petty C, Vivas F, et al. Examining the relationship between obsessive-compulsive disorder and attention-deficit/hyperactivity disorder in children and adolescents: a familial risk analysis. Biol Psychiatry. 2007;61(3):316–321. doi:10.1016/j.biopsych.2006.03.083 [CrossRef]
DSM-IV-TR ADHD Behavioral Domains17
|Symptoms of Inattention||Symptoms of Hyperactivity-Impulsivity|
Often fails to pay 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 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, tools).
Is often easily distracted by extraneous stimuli.
Is often forgetful in daily activities.
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 where it is inappropriate (may be limited to subjective feelings of restlessness).
Often has difficulty playing or engaging in leisure activities quietly.
Is often “on the go” or acts as if “driven by a motor.”
Often talks excessively.
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).
Common Behavioral Rating Scales/Evaluation Narrowband Instruments Used in the Assessment of ADHD and Monitoring of Treatment
|Narrowband Assessments||For Ages (years)||Informant(s)|
|Attention-Deficit/Hyperactivity Disorder Rating Scale, Version-IV (ADHD-IV)||6 to 12|
|ADHD Symptoms Rating Scale (ADHD-SRS)||3 to 23|
|Brown Attention Deficit Disorder Scale (BADDS)||6 to 11|
|Conners Parent and Teacher Rating Scales (short form)||3 to 17|
|Vanderbilt Assessment Scales||6 to 12|
|Swanson, Nolan, and Pelham–IV Questionnaire-Revised (SNAP-IV-R)||6 to 12|