Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed bio-behavioral disorder of childhood. It occurs in 6% to 9% of children--about the same prevalence as childhood asthma. It is also one of the most controversial diagnoses in children; parents are often perplexed about whether ADHD is underdiagnosed or overdiagnosed, or undertreated or overtreated. A good deal of this confusion stems from the fact that there are no laboratory tests, imaging studies, or psychological testing profiles that can be used to make the diagnosis.
Theories abound about the cause of ADHD. These include the impact of genetic factors, variations in temperament and emotional reactivity, neurologic factors, and a host of environmental influences on the developing brain. ADHD is a heterogeneous condition, and many diverse biologic and environmental factors--alone or in combination--can result in the behaviors that lead to the diagnosis of ADHD.
The core symptoms of ADHD are inattention, hyperactivity, and impulsivity; the case vignette in the Box illustrates typical ways in which these manifest. The disorder can be thought of as a spectrum of "attention disorders" rather than a single entity.
Because of the high prevalence of ADHD, and because pediatricians have many opportunities to screen for ADHD before parents might be alerted to seek care, evaluation and management of ADHD are important and doable tasks for primary care pediatricians.
The American Academy of Pediatricians' Guidelines for Evaluation and Diagnosis of ADHD describe a format for evaluating a child with ADHD from an evidence-based or best practice perspective.1 This article is organized around those recommendations.
GUIDELINES FOR DIAGNOSING ADHD
Recommendation 1: In a child aged 6 to 12 years who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD.
Questions about ADHD can come from parents or teachers. When attention problems or hyperactivity or impulsivity are the concerns, an evaluation is indicated. If you want to screen or conduct some surveillance, you might consider using a questionnaire that can be given to parents of school-aged children at well-child or other non-acute visits. The kinds of questions that could be asked include:
- How is your child doing in school?
- Are there any learning problems?
- Is your child happy in school?
- Are there any behavior problems in school, at home, or with friends?
- Is your child having problems completing classwork or homework?
During adolescent health supervision visits, questions can be modified. Ask about difficulties with organization, forgetfulness, careless work, procrastination, and/or difficulty in completing or turning in homework. Inquire, too, about high-risk behaviors, including truancy, substance abuse, oppositional behavior, fighting, and sexual activity. Any positive responses provide reasonable grounds for considering an evaluation for ADHD.
