What is the approach to diagnosing and treating Attention Deficit Hyperactivity Disorder (ADHD) in children?

Diagnosing ADHD in Children

Primary care clinicians should initiate an ADHD evaluation for any child age 4 through 18 years presenting with academic or behavioral problems plus symptoms of inattention, hyperactivity, or impulsivity, then confirm diagnosis by meeting DSM-5 criteria with documented impairment in more than one setting using multi-informant reports. 1

When to Initiate Evaluation

• Begin evaluation when children present with academic or behavioral problems accompanied by symptoms of inattention, hyperactivity, or impulsivity 1
• Age range for diagnosis: 4 years through 18th birthday 1
• For children younger than 4 years, there is insufficient evidence to recommend diagnosis; consider referral for parent training in behavior management if ADHD-like symptoms cause substantial impairment 1
• ADHD affects approximately 7-8% of children, making it the most common neurobehavioral disorder of childhood 1

Diagnostic Criteria: DSM-5 Requirements

The diagnosis requires meeting ALL of the following DSM-5 criteria: 1

Symptom Criteria

• For Inattentive Type: At least 6 symptoms must persist for at least 6 months, including lack of attention to details/careless mistakes, lack of sustained attention, poor listening, failure to follow through on tasks, poor organization, avoids tasks requiring sustained mental effort, loses things, easily distracted, and forgetfulness 2
• For Hyperactive-Impulsive Type: At least 6 symptoms must persist for at least 6 months, including fidgeting/squirming, leaving seat inappropriately, inappropriate running/climbing, difficulty with quiet activities, being "on the go," excessive talking, blurting answers, inability to wait turn, and intrusiveness 2
• For Combined Type: Both inattentive and hyperactive-impulsive criteria must be met 2

Functional Impairment

• Document impairment in MORE than one major setting (home, school/work, social) 1, 3
• This is a critical requirement—symptoms alone without functional impairment do not warrant diagnosis 1, 3

Multi-Informant Reports

• Obtain information primarily from parents/guardians, teachers, other school personnel, and mental health clinicians involved in the child's care 1, 3
• Use standardized behavior rating scales from multiple informants, but recognize that questionnaires alone cannot diagnose ADHD—they must be combined with clinical interviews 3
• Be aware that parent and teacher ratings are frequently discrepant, which is why multiple sources are essential 4

Rule Out Alternative Causes

• Exclude other conditions that could explain symptoms through clinical assessment 1, 3
• Do not diagnose ADHD when symptoms are secondary to environmental factors or other primary psychiatric disorders, including psychosis 2

Diagnostic Process: Step-by-Step Algorithm

Step 1: Clinical Interview

• Conduct thorough clinical interview to verify DSM-5 criteria, establish symptom onset, and document functional impairment in multiple settings 3
• Assess chronicity and severity of symptoms 2

Step 2: Behavior Rating Scales

• Use standardized rating scales from parents, teachers, and other involved clinicians 1, 5, 3
• Rating scales remain the standard of care for assessing diagnostic criteria 5
• Important caveat: While the Conners' Rating Scales are commonly used, research shows they have poor specificity (35.7%) when used alone, meaning they generate many false positives 4
• Therefore, rating scales must be combined with comprehensive clinical assessment—never use them as the sole diagnostic tool 3, 4

Step 3: Screen for Comorbid Conditions

This is mandatory, not optional. Screen systematically for: 1, 5, 6

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 5, 6
• Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 1, 5, 6
• Physical conditions: tics, sleep apnea, seizures 1, 5, 6

Why this matters: Comorbidity rates range from 12-60%, with significant symptom overlap that can lead to misdiagnosis 7. Sleep disorders can both mimic and exacerbate ADHD symptoms 6. Learning disabilities frequently co-occur and require specific educational interventions 6.

Step 4: Document Everything

• Document all aspects of diagnostic procedures in the patient's record 1
• Include rating scale results, multi-informant reports, functional impairment documentation, and management plans 1

Common Pitfalls to Avoid

• Never diagnose based on rating scales alone—they have poor specificity and must be combined with clinical interviews and multi-informant data 3, 4
• Never skip comorbidity screening—failing to identify comorbid conditions leads to inappropriate treatment 6
• Never diagnose when symptoms are only of recent origin—DSM criteria require persistence for at least 6 months 2, 8
• Never assume a positive response to stimulant medication confirms ADHD—empiric trials do not distinguish between children with and without ADHD 7

When to Refer to Subspecialist

• Refer when you feel inadequately trained or uncertain about diagnosis or treatment 1
• Refer for complex cases involving significant comorbidities 1
• Refer preschool children (age 4-5 years) when behavioral interventions are unavailable or ineffective and medication is being considered 1
• If subspecialist makes diagnosis, develop a management strategy ensuring continued care within a medical home model 1

Recognize ADHD as a Chronic Condition

• Manage ADHD following chronic care model principles and medical home approach 1, 5, 3
• Establish continuous, coordinated care with systematic follow-up 5
• Develop communication systems with schools and other personnel 5
• Untreated ADHD is associated with increased risk for early death, suicide, psychiatric comorbidity, lower educational achievement, and increased incarceration rates 6