Evaluate for Key Features of ADHD Using DSM-IV/DSM-PC Criteria
Key Points:
- Evaluation of primary symptoms should include information from multiple sources such as parents/caregivers, the child, and school personnel.
- Three subtypes of ADHD are described based on the predominance of presenting symptoms: Predominantly Inattentive Type, Predominantly Hyperactive Impulsive Type, Combined Type.
- Criteria related to age of onset, duration, pervasiveness of symptoms, and impairment should be considered in establishing the diagnosis of ADHD.
The evaluation of primary symptoms should include information from multiple sources such as parents, the child, and school personnel. A comprehensive interview with parents or caregivers including current symptoms and their previous history, past medical and developmental history, school and educational history, family and psychosocial history is most important. There is no single evaluation tool available to make a definitive diagnosis of ADHD. The diagnosis is based on a clinical picture of early onset, significant duration and pervasiveness, and causing functional impairment within the life of the child or adolescent. This can be facilitated through the use of a semistructured interview or questionnaire with behavior rating scales completed by the parents, other caregivers, and school personnel.
The American Academy of Pediatrics (AAP) has developed a tool kit to assist clinicians in providing quality care for children with ADHD. This resource provides a basis for a coordinated multidisciplinary system of care including primary care professionals, school personnel, parents, and children. Ordering information may be obtained by accessing their web site: www.aap.org/bookstore or calling 1-888-227-1770. In addition, the NICHQ/Vanderbilt Assessment Scale is available as a non-normative referenced screening questionnaire.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), is recognized as the most widely used resource for diagnosis of mental disorders, including ADHD. Alternatively, a manual designed for use in primary care practice, the Diagnostic and Statistical Manual for Primary Care (DSM-PC): Child and Adolescent Version, is now available. The DSM-PC is designed to bridge the gap between pediatric primary care and mental health services. It contains the DSM-IV criteria for childhood mental health disorders including ADHD and related conditions, but also contains useful information on the developmental continuum of behavior, from normal variations to mental disorders.
Note: The DSM-IV TR (2000) is an updated version with no changes to ADHD criteria.
Other components of the evaluation are described at subsequent points within the original guideline document.
Symptoms
ADHD is categorized by the following core symptoms:
- Inattention
- Hyperactivity
- Impulsivity
Refer to DSM-IV/DSM-PC criteria in the original guideline document for specific behavioral symptoms.
There are 3 subtypes of the disorder based upon the "often" occurrence of at least six of nine behaviors within the inattention dimension, and six of nine behaviors within the combined hyperactivity/impulsivity dimension:
- Predominantly inattentive type (meeting criteria for the inattention dimension)
- Predominantly hyperactive/impulsive type (meeting criteria for the hyperactive/impulsive dimension)
- Combined type (meeting criteria for both dimensions)
Onset
Some behavioral symptoms typically have begun prior to the age of seven years in most children (see DSM-IV/DSM-PC criteria in the original guideline document). These symptoms may not be obvious in children who are predominantly inattentive without significant hyperactivity or impulsivity. Previous history must be reviewed carefully, especially in older children and adolescents, for the presence of symptoms not previously recognized or identified.
Duration
The presence of behavioral symptoms is typically of long duration (at least six months - see DSM-IV/DSM-PC criteria in the original guideline document) and previously recognized by parents, teachers, or the patient. Careful review of previous symptoms is critical for evaluation of the presence or absence of symptoms not otherwise identified by parents, school personnel, or other caregivers. It is also helpful to assess the characteristics of previous observers with respect to the validity of information (e.g., specific teacher qualities, home and class room environment).
Pervasiveness
Due to the relationship of ADHD symptoms to the external environment, specific interest and motivation, individual demands on attention and focus, and day-to-day influences, there can be significant variability within a given child. Nevertheless, ADHD behaviors are typically present in more than one setting (e.g., home, school, play, or work – see the DSM-IV/DSM-PC criteria).
Impairment
ADHD symptoms present in varying degrees of severity and impairment, depending upon individual characteristics and demands. It is important to assess the degree of impairment as the ADHD symptoms relate to the child's or adolescent's social, academic, or family functioning (see DSM-IV/DSM-PC criteria in the original guideline document).
A word about behavior rating scales:
At least one standardized rating scale (see the original guideline document) is recommended for reviewing observations from those persons in direct contact with the child/adolescent (parents, day care providers, teachers, etc.) These observations/ratings should be used as part of the overall historical data base and should not be the sole criteria used to include or exclude the diagnosis of ADHD. Caution should be used in interpreting these due to observer bias, threshold of problem identification, and lack of observer knowledge (especially true of older children/adolescents in middle or upper grades). The ADHD Rating Scale IV is normed based on DSM-IV/DSM-PC criteria and available for current use. (Refer to the list of knowledge products in the Support for Implementation section of the original guideline document).
A word about continuous performance tasks:
Various continuous performance tasks (CPTs) have been developed to attempt to objectively measure sustained and selective attention: for example, Test of Variables of Attention (TOVA), Gordon Diagnostic System, Conners CPT, etc. These tasks involve the rapid presentation of stimuli where subjects are asked to respond to specific targets. The results measure certain variables of attention related to errors of omission and commission. Although these instruments appear to discriminate between children with ADHD and their normal counterparts at a group level, the usefulness of these measures in assessing individual children is limited. Due to significant false negative rates (estimated at 15-30%), these instruments are not considered pathognomonic of ADHD and are of limited utility in screening and evaluation. They are most useful in research settings and the complex individual patient where more extensive data may be useful.
Evidence supporting this recommendation is of classes: C, R