Clinical Practice Guideline: Diagnosis and Evaluation of the Child With

Attention-Deficit/Hyperactivity Disorder
Committee on Quality Improvement, Subcommittee on
Attention-Deficit/Hyperactivity Disorder
Pediatrics 2000;105;1158-1170

The online version of this article, along with updated information and services, is
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http://www.pediatrics.org/cgi/content/full/105/5/1158

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AMERICAN ACADEMY OF PEDIATRICS

Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder

Clinical Practice Guideline: Diagnosis and Evaluation of the Child With

Attention-Deficit/Hyperactivity Disorder
ABSTRACT. This clinical practice guideline provides
recommendations for the assessment and diagnosis of
school-aged children with attention-deficit/hyperactivity
disorder (ADHD). This guideline, the first of 2 sets of
guidelines to provide recommendations on this condition, is intended for use by primary care clinicians working in primary care settings. The second set of guidelines
will address the issue of treatment of children with
ADHD.
The Committee on Quality Improvement of the American Academy of Pediatrics selected a committee composed of pediatricians and other experts in the fields of
neurology, psychology, child psychiatry, development,
and education, as well as experts from epidemiology and
pediatric practice. In addition, this panel consists of experts in education and family practice. The panel worked
with Technical Resources International, Washington,
DC, under the auspices of the Agency for Healthcare
Research and Quality, to develop the evidence base of
literature on this topic. The resulting evidence report was
used to formulate recommendations for evaluation of the
child with ADHD. Major issues contained within the
guideline address child and family assessment; school
assessment, including the use of various rating scales;
and conditions seen frequently among children with
ADHD. Information is also included on the use of current diagnostic coding strategies. The deliberations of the
committee were informed by a systematic review of evidence about prevalence, coexisting conditions, and diagnostic tests. Committee decisions were made by consensus where definitive evidence was not available. The
committee report underwent review by sections of the
American Academy of Pediatrics and external organizations before approval by the Board of Directors.
The guideline contains the following recommendations for diagnosis of ADHD: 1) in a child 6 to 12 years
old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD; 2) the diagnosis of ADHD requires that
a child meet Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition criteria; 3) the assessment of
ADHD requires evidence directly obtained from parents
or caregivers regarding the core symptoms of ADHD in
various settings, the age of onset, duration of symptoms,
and degree of functional impairment; 4) the assessment
of ADHD requires evidence directly obtained from the
classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms,
degree of functional impairment, and associated conditions; 5) evaluation of the child with ADHD should inThe recommendations in this statement do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright 2000 by the American Academy of Pediatrics.

1158

clude assessment for associated (coexisting) conditions;

and 6) other diagnostic tests are not routinely indicated to
establish the diagnosis of ADHD but may be used for the
assessment of other coexisting conditions (eg, learning
disabilities and mental retardation).
This clinical practice guideline is not intended as a sole
source of guidance in the evaluation of children with
ADHD. Rather, it is designed to assist primary care clinicians by providing a framework for diagnostic decisionmaking. It is not intended to replace clinical judgment or to establish a protocol for all children with this
condition and may not provide the only appropriate approach to this problem.
ABBREVIATIONS. ADHD, attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition; AAP, American Academy of Pediatrics; DSM-PC,
Diagnostic and Statistical Manual for Primary Care.

ttention-deficit/hyperactivity disorder (ADHD)

is the most common neurobehavioral disorder of childhood. ADHD is also among the
most prevalent chronic health conditions affecting
school-aged children. The core symptoms of ADHD
include inattention, hyperactivity, and impulsivity.1,2
Children with ADHD may experience significant
functional problems, such as school difficulties, academic underachievement,3 troublesome interpersonal relationships with family members4,5 and
peers, and low self-esteem. Individuals with ADHD
present in childhood and may continue to show
symptoms as they enter adolescence6 and adult life.7
Pediatricians and other primary care clinicians frequently are asked by parents and teachers to evaluate a child for ADHD. Early recognition, assessment,
and management of this condition can redirect the
educational and psychosocial development of most
children with ADHD.8,9
Recorded prevalence rates for ADHD vary substantially, partly because of changing diagnostic criteria over time,10 13 and partly because of variations
in ascertainment in different settings and the frequent use of referred samples to estimate rates. Practitioners of all types (primary care, subspecialty, psychiatry, and nonphysician mental health providers)
vary greatly in the degree to which they use Diagnostic and Statistical Manual of Mental Health Disorders,
Fourth Edition (DSM-IV) criteria to diagnose ADHD.
Reported rates also vary substantially in different
geographic areas and across countries.14
With increasing epidemiologic and clinical research, diagnostic criteria have been revised on mul-

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tiple occasions over the past 20 years.10 13 A recent

review of prevalence rates in school-aged community samples (rather than referred samples) indicates
rates varying from 4% to 12%, with estimated prevalence based on combining these studies of 8% to
10%. In the general population,1523,24 9.2% (5.8%
13.6%) of males and 2.9% (1.9% 4.5%) of females are
found to have behaviors consistent with ADHD.
With the DSM-IV criteria (compared with earlier
versions), more females have been diagnosed with
the predominantly inattentive type.25,26 Prevalence
rates also vary significantly depending on whether
they reflect school samples 6.9% (5.5% 8.5%) versus
community samples 10.3% (8.2%12.7%).
Public interest in ADHD has increased along with
debate in the media concerning the diagnostic process and treatment strategies.27 Concern has been
expressed about the over-diagnosis of ADHD by
pointing to the several-fold increase in prescriptions
for stimulant medication among children during the
past decade.28 In addition, there are significant regional variations in the amount of stimulants prescribed by physicians.29 Practice surveys among primary care pediatricians and family physicians reveal
wide variations in practice patterns about diagnostic
criteria and methods.30
ADHD commonly occurs in association with oppositional defiant disorder, conduct disorder, depression, anxiety disorder,16 and with many developmental disorders, such as speech and language
delays and learning disabilities.
This diagnostic guideline is intended for use by
primary care clinicians to evaluate children between
6 and 12 years of age for ADHD, consistent with best
available empirical studies. Special attention is given
to assessing school performance and behavior, family functioning, and adaptation. In light of the high
prevalence of ADHD in pediatric practice, the guideline should assist primary care clinicians in these
assessments. The diagnosis usually requires several
steps. Clinicians will generally need to carry out the
evaluation in more than 1 visit, often indeed 2 to 3
visits. The guideline is not intended for children with
mental retardation, pervasive developmental disorder, moderate to severe sensory deficits such as visual and hearing impairment, chronic disorders associated with medications that may affect behavior,
and those who have experienced child abuse and
sexual abuse. These children too may have ADHD,
and this guideline may help clinicians in considering
this diagnosis; nonetheless, this guideline primarily
reviews evidence relating to the diagnosis of ADHD
in relatively uncomplicated cases in primary care
settings.
METHODOLOGY

To initiate the development of a practice guideline

for the diagnosis and evaluation of children with
ADHD directed toward primary care physicians, the
American Academy of Pediatrics (AAP) worked
with several colleague organizations to organize a
working panel representing a wide range of primary
care and subspecialty groups. The committee,
chaired by 2 general pediatricians (1 with substantial

additional experience and training in developmental

and behavioral pediatrics), included representatives
from the American Academy of Family Physicians,
the American Academy of Child and Adolescent
Psychiatry, the Child Neurology Society, and the
Society for Pediatric Psychology, as well as developmental and behavioral pediatricians and epidemiologists.
This group met over a period of 2 years, during
which it reviewed basic literature on current practices in the diagnosis of ADHD and developed a
series of questions to direct an evidence-based review of the prevalence of ADHD in community and
primary care practice settings, the rates of coexisting
conditions, and the utility of several diagnostic methods and devices. The AAP committee collaborated
with the Agency for Healthcare Research and Quality in its support of an evidence-based review of
several of these key items in the diagnosis of ADHD.
David Atkins, MD, provided liaison from the
Agency for Healthcare Research and Quality, and
Technical Resources International conducted the evidence review.
The Technical Resources International report focused on 4 specific areas for the literature review: the
prevalence of ADHD among children 6 to 12 years of
age in the general population and the coexisting
conditions that may occur with ADHD; the prevalence of ADHD among children in primary care settings and the coexisting conditions that may occur;
the accuracy of various screening methods for diagnosis; and the prevalence of abnormal findings on
commonly used medical screening tests. The literature search was conducted using Medline and PsycINFO databases, references from review articles, rating scale manuals, and articles identified by the
subcommittee. Only articles published in English between 1980 and 1997 were included. The study population was limited to children 6 to 12 years of age,
and only studies using general, unselected populations in communities, schools, or the primary clinical
setting were used. Data on screening tests were taken
from studies conducted in any setting. Articles accepted for analysis were abstracted twice by trained
personnel and a clinical specialist. Both abstracts for
each article were compared and differences between
them resolved. A multiple logistic regression model
with random effects was used to analyze simultaneously for age, gender, diagnostic tool, and setting
using EGRET software. Results were presented in
evidence tables and published in the final evidence
report.24
The draft practice guideline underwent extensive
peer review by committees and sections within the
AAP, by numerous outside organizations, and by
other individuals identified by the subcommittee.
Liaisons to the subcommittee also were invited to
distribute the draft to entities within their organizations. The resulting comments were compiled and
reviewed by the subcommittee co-chairpersons, and
relevant changes were incorporated into the draft
based on recommendations from peer reviewers.
The recommendations contained in the practice
guideline are based on the best available data (Fig 1).

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1159

Where data were lacking, a combination of evidence

and expert consensus was used. Strong recommendations were based on high-quality scientific evidence, or, in the absence of high-quality data, strong
expert consensus. Fair and weak recommendations
were based on lesser quality or limited data and
expert consensus. Clinical options were identified as
interventions because the subcommittee could not
find compelling evidence for or against. These clinical options are interventions that a reasonable health
care provider might or might not wish to implement
in his or her practice.
RECOMMENDATION 1: In a child 6 to 12 years old
who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior
problems, primary care clinicians should initiate an
evaluation for ADHD (strength of evidence: good;
strength of recommendation: strong).
The major justification for this recommendation is
the high prevalence of ADHD in school-aged populations. School-aged children with a variety of developmental and behavioral concerns present to primary care clinicians.31 Primary care pediatricians and
family physicians recognize behavior problems that
may impact academic achievement in 18% of schoolaged children seen in their offices and clinics. Hyperactivity or inattention is diagnosed in 9% of children.32
Presentations of ADHD in clinical practice vary. In
many cases, concerns derive from parents, teachers,
other professionals, or nonparental caregivers. Common presentations include referral from school for
academic underachievement and failure, disruptive
classroom behavior, inattentiveness, problems with
social relationships, parental concerns regarding
similar phenomena, poor self-esteem, or problems
with establishing or maintaining social relationships.
Children with core ADHD symptoms of hyperactivity and impulsivity are identified by teachers, because they often disrupt the classroom. Even mild
distractibility and motor symptoms, such as fidgetiness, will be apparent to most teachers. In contrast,
children with the inattentive subtype of ADHD,
where hyperactive and impulsive symptoms are absent or minimal, may not come to the attention of
teachers. These children may present with school
underachievement.
Symptoms may not be apparent in a structured
clinical setting that is free from the demands and
distraction of the home and school.33 Thus, if parents
do not bring concerns to the primary clinician, then
early detection of ADHD in primary care may not
occur. Clinical practices during routine health supervision may assist in early recognition of ADHD.34,35
Options include direct history from parents and children. The following general questions may be useful
at all visits for school-aged children to heighten attention about ADHD and as an initial screening for
school performance.
1. How is your child doing in school?
2. Are there any problems with learning that you or
the teacher has seen?
1160

3. Is your child happy in school?

4. Are you concerned with any behavioral problems
in school, at home, or when your child is playing
with friends?
5. Is your child having problems completing classwork or homework?
Alternatively, a previsit questionnaire may be sent
to parents or given while the family is waiting in the
reception area.36 When making an appointment for a
health supervision visit for a school-aged child, 1 or
2 of these questions may be asked routinely to sensitize parents to the concerns of their childs clinician.
For example, Your childs clinician is interested in
how your child is doing in school. You might check
with her teacher and discuss any concerns with your
childs physician. Wall posters, pamphlets, and
books in the waiting area that focus on educational
achievements and school-aged behaviors send a
message that this is an office or clinic that considers
these issues important to a childs development.37
RECOMMENDATION 2: The diagnosis of ADHD
requires that a child meet DSM-IV criteria (strength
of evidence: good; strength of recommendation:
strong).
Establishing a diagnosis of ADHD requires a strategy that minimizes over-identification and underidentification. Pediatricians and other primary care
health professionals should apply DSM-IV criteria in
the context of their clinical assessment of a child. The
use of specific criteria will help to ensure a more
accurate diagnosis and decrease variation in how the
diagnosis is made. The DSM-IV criteria, developed
through several iterations by the American Psychiatric Association, are based on clinical experience and
an expanding research foundation.13 These criteria
have more support in the literature than other available diagnostic criteria. The DSM-IV specification of
behavior items, required numbers of items, and levels of impairment reflect the current consensus
among clinicians, particularly psychiatry. The consensus includes increasing research evidence, particularly in the distinctions that the DSM-IV makes for
the dimensions of attention and hyperactivity-impulsivity.38
The DSM-IV criteria define 3 subtypes of ADHD
(see Table 1 for specific inattention and hyperactiveimpulsive items).
ADHD primarily of the inattentive type (ADHD/I,
meeting at least 6 of 9 inattention behaviors)
ADHD primarily of the hyperactive-impulsive
type (ADHD/HI, meeting at least 6 of 9 hyperactive-impulsive behaviors)
ADHD combined type (ADHD/C, meeting at
least 6 of 9 behaviors in both the inattention and
hyperactive-impulsive lists)
Children who meet diagnostic criteria for the behavioral symptoms of ADHD but who demonstrate
no functional impairment do not meet the diagnostic
criteria for ADHD.13 The symptoms of ADHD should
be present in 2 or more settings (eg, at home and in
school), and the behaviors must adversely affect

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Fig 1. Clinical algorithm.

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TABLE 1.

Diagnostic Criteria for ADHD

A. Either 1 or 2
1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:
Inattention
a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) Often has difficulty sustaining attention in tasks or play activities
c) Often does not seem to listen when spoken to directly
d) 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)
e) Often has difficulty organizing tasks and activities
f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools)
h) Is often easily distracted by extraneous stimuli
i) Is often forgetful in daily activities
2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Hyperactivity
a) Often fidgets with hands or feet or squirms in seat
b) Often leaves seat in classroom or in other situations in which remaining seated is expected
c) 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)
d) Often has difficulty playing or engaging in leisure activities quietly
e) Is often on the go or often acts as if driven by a motor
f) Often talks excessively
Impulsivity
g) Often blurts out answers before questions have been completed
h) Often has difficulty awaiting turn
i) Often interrupts or intrudes on others (eg, butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.
C. Some impairment from the symptoms is present in 2 or more settings (eg, at school [or work] or at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other
psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative
disorder, or personality disorder).
Code based on type:
314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both criteria A1 and A2 are met for the past 6 months
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if criterion A1 is met but criterion A2 is not met
for the past 6 months
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive, Impulsive Type: if criterion A2 is met but criterion
A1 is not met for the past 6 months
314.9 Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). Copyright 1994. American
Psychiatric Association.

functioning in school or in a social situation. Reliable

and clinically valid measures of dysfunction applicable to the primary care setting have been difficult to
develop. The diagnosis comes from a synthesis of
information obtained from parents; school reports;
mental health care professionals, if they have been
involved; and an interview/examination of the child.
Current DSM-IV criteria require evidence of symptoms before 7 years of age. In some cases, the symptoms of ADHD may not be recognized by parents or
teachers until the child is older than 7 years of age,
when school tasks become more challenging. Age of
onset and duration of symptoms may be obtained
from parents in the course of a comprehensive history.
Teachers, parents, and child health professionals
typically encounter children with behaviors relating
to activity, impulsivity, and attention who may not
fully meet DSM-IV criteria. The Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and
Adolescent Version,39 provides a guide to the more
common behaviors seen in pediatrics. The manual
describes common variations in behavior, as well as
more problematic behaviors, at levels less than those
1162

specified in the DSM-IV (and with less impairment).

The behavioral descriptions of the DSM-PC have not
yet been tested in community studies to determine
the prevalence or severity of developmental variations and moderate problems in the areas of inattention and hyperactivity or impulsivity. They do, however, provide guidance to clinicians in the evaluation
of children with these symptoms and help to direct
clinicians to many elements of treatment for children
with problems with attention, hyperactivity, or impulsivity (Tables 2 and 3). The DSM-PC also considers environmental influences on a childs behavior
and provides information on differential diagnosis
with a developmental perspective.
Given the lack of methods to confirm the diagnosis
of ADHD through other means, it is important to
recognize the limitations of the DSM-IV definition.
Most of the development and testing of the DSM-IV
has occurred through studies of children seen in
psychiatric settings. Much less is known about its use
in other populations, such as those seen in general
pediatric or family practice settings. Despite the
agreement of many professionals working in this
field, the DSM-IV criteria remain a consensus with-

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TABLE 2.

DSM-PC: Developmental Variation: Impulsive/Hyperactive Behaviors

Developmental Variation

Common Developmental Presentations

V65.49 Hyperactive/impulsive variation

Young children in infancy and in the preschool years are normally
very active and impulsive and may need constant supervision to
avoid injury. Their constant activity may be stressful to adults
who do not have the energy or patience to tolerate the behavior.
During school years and adolescence, activity may be high in play
situations and impulsive behaviors may normally occur,
especially in peer pressure situations.
High levels of hyperactive/impulsive behavior do not indicate a
problem or disorder if the behavior does not impair function.

Early childhood
The child runs in circles, doesnt stop to rest, may
bang into objects or people, and asks questions
constantly.
Middle childhood
The child plays active games for long periods.
The child may occasionally do things impulsively,
particularly when excited.
Adolescence
The adolescent engages in active social activities (eg,
dancing) for long periods, may engage in risky
behaviors with peers.
Special Information
Activity should be thought of not only in terms
of actual movement, but also in terms of
variations in responding to touch, pressure,
sound, light, and other sensations. Also, for
the infant and young child, activity and
attention are related to the interactions
between the child and caregiver, eg, when
sharing attention and playing together.
Activity and impulsivity often normally
increase when the child is tired or hungry
and decrease when sources of fatigue or
hunger are addressed.
Activity normally may increase in new
situations or when the child may be anxious.
Familiarity then reduces activity.
Both activity and impulsivity must be judged
in the context of the caregivers expectations
and the level of stress experienced by the
caregiver. When expectations are
unreasonable, the stress level is high, and/or
the parent has an emotional disorder
(especially depression), the adult may
exaggerate the childs level of
activity/impulsivity.
Activity level is a variable of temperature. The
activity level of some children is on the high
end of normal from birth and continues to be
high throughout their development.

Taken from: American Academy of Pediatrics. The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and
Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics; 1996

out clear empirical data supporting the number of

items required for the diagnosis. Current criteria do
not take into account gender differences or developmental variations in behavior. Furthermore, the behavioral characteristics specified in the DSM-IV, despite efforts to standardize them, remain subjective
and may be interpreted differently by different observers. Continuing research will likely clarify the
validity of the DSM-IV criteria (and subsequent
modifications) in the diagnosis. These complexities
in the diagnosis mean that clinicians using DSM-IV
criteria must apply them in the context of their clinical judgment.
No instruments used in primary care practice reliably assess the nature or degree of functional impairment of children with ADHD. With information
obtained from the parent and school, the clinician
can make a clinical judgment about the effect of the
core and associated symptoms of ADHD on aca-

demic achievement, classroom performance, family

and social relationships, independent functioning,
self-esteem, leisure activities, and self-care (such as
bathing, toileting, dressing, and eating).
The following 2 recommendations establish the presence of core behavior symptoms in multiple settings.
RECOMMENDATION 3: The assessment of ADHD
requires evidence directly obtained from parents or
caregivers regarding the core symptoms of ADHD in
various settings, the age of onset, duration of symptoms, and degree of functional impairment (strength
of evidence: good; strength of recommendation:
strong).
Behavior symptoms may be obtained from parents
or guardians using 1 or more methods, including
open-ended questions (eg, What are your concerns
about your childs behavior in school?), focused

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TABLE 3.

DSM-PC: Developmental Variation: Inattentive Behaviors

Developmental Variation

V65.49 Inattention variation

A young child will have a short attention span that will
increase as the child matures. The inattention should be
appropriate for the childs level of development and not
cause any impairment.

Common Developmental Presentations

Early childhood
The preschooler has difficulty attending, except
briefly, to a storybook or a quiet task such as
coloring or drawing.
Middle childhood
The child may not persist very long with a task the
child does not want to do such as read an
assigned book, homework, or a task that requires
concentration such as cleaning something.
Adolescence
The adolescent is easily distracted from tasks he or
she does not desire to perform.
Special Information
Infants and preschoolers usually have very short
attention spans and normally do not persist
with activities for long, so that diagnosing this
problem in younger children may be difficult.
Some parents may have a low tolerance for
developmentally appropriate inattention.
Although watching television cartoons for long
periods of time appears to reflect a long
attention span, it does not reflect longer
attention spans because most television
segments require short (2- to 3-minute)
attention spans and they are very stimulating.
Normally, attention span varies greatly
depending upon the childs or adolescents
interest and skill in the activity, so much so
that a short attention span for a particular task
may reflect the childs skill or interest in that
task.

Taken from: American Academy of Pediatrics. The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and
Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics; 1996

questions about specific behaviors, semi-structured

interview schedules, questionnaires, and rating
scales. Clinicians who obtain information from openended or focused questions must obtain and record
the relevant behaviors of inattention, hyperactivity,
and impulsivity from the DSM-IV. The use of global
clinical impressions or general descriptions within
the domains of attention and activity is insufficient to
diagnose ADHD. As data are gathered about the
childs behavior, an opportunity becomes available
to evaluate the family environment and parenting
style. In this way, behavioral symptoms may be evaluated in the context of the environment that may
have important characteristics for a particular child.
Specific questionnaires and rating scales have been
developed to review and quantify the behavioral
characteristics of ADHD (Table 4). The ADHDspecific questionnaires and rating scales have been
shown to have an odds ratio greater than 3.0 (equivalent to sensitivity and specificity greater than 94%)
in studies differentiating children with ADHD from
normal, age-matched, community controls.24 Thus,
ADHD-specific rating scales accurately distinguish
between children with and without the diagnosis of
ADHD. Almost all studies of these scales and checklists have taken place under ideal conditions, ie, comparing children in referral sites with apparently
1164

healthy children. These instruments may function

less well in primary care clinicians offices than indicated in the tables. In addition, questions on which
these rating scales are based are subjective and subject to bias. Thus, their results may convey a false
sense of validity and must be interpreted in the
context of the overall evaluation of the child.
Whether these scales provide additional benefit beyond careful clinical assessment informed by
DSM-IV criteria is not known. RECOMMENDATION 3A: Use of these scales is a clinical option
when evaluating children for ADHD (strength of evidence: strong; strength of recommendation: strong).
Global, nonspecific questionnaires and rating
scales that assess a variety of behavioral conditions,
in contrast with the ADHD-specific measures, generally have an odds ratio 2.0 (equivalent to sensitivity and specificity 86%) in studies differentiating
children referred to psychiatric practices from children who were not referred to psychiatric practices
(Table 5). Thus, these broadband scales do not distinguish well between children with and without
ADHD. RECOMMENDATION 3B: Use of broadband scales is not recommended in the diagnosis of
children for ADHD, although they may be useful for
other purposes (strength of evidence: strong; strength
of recommendation: strong).

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Total ADHD-Specific Checklists: Ability to Detect ADHD vs Normal Controls

TABLE 4.
Study

Behavior Rating Scale

Age

Gender

Effect
Size

95%
Confidence
Limits

Conners (1997)

CPRS-R:L-ADHD Index
(Conners Parent Rating Scale1997
Revised Version: Long Form, ADHD Index Scale)
CTRS-R:L-ADHD Index
(Conners Teacher Rating Scale
1997 Revised Version: Long Form, ADHD Index Scale)
CPRS-R:L-DSM-IV Symptoms
(Conners Parent Rating Scale1997
Revised Version: Long Form, DSM-IV Symptoms Scale)
CTRS-R:L-DSM-IV Symptoms
(Conners Teacher Rating Scale1997
Revised Version: Long Form, DSM-IV Symptoms Scale)
SSQ-O-I
Barkleys School Situations Questionnaire-Original Version,
Number of Problem Settings Scale
SSQ-O-II
Barkleys School Situations Questionnaire-Original Version,
Mean Severity Scale

617

MF

3.1

2.5, 3.7

617

MF

3.3

2.8, 3.8

617

MF

3.4

2.8, 4.0

617

MF

3.7

3.2, 4.2

611

1.3

0.5, 2.2

611

2.0

1.0, 2.9

2.9

2.2, 3.5

Conners (1997)
Conners (1997)
Conners (1997)
Breen (1989)
Breen (1989)
Combined

Taken from: Green M, Wong M, Atkins D, et al. Diagnosis of Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: US
Department of Health and Human Services, Agency for Health Care Policy and Research; 1999. AHCPR publication 99-0050
Total Scales of Broadband Checklists: Ability to Detect Referred vs Nonreferred

TABLE 5.

Study

Behavior Rating Scale

Achenbach (1991b)
Achenbach (1991b)
Achenbach (1991c)
Achenbach (1991c)
Naglieri, LeBuffe, Pfeiffer
(1994)
Conners (1997)
Conners (1997)

CBCL/4-18-R, Total Problem Scale

(Child Behavior Checklist for Ages 418,
Parent Form)
Same as above
CBCL/TRF-R, Total Problem Scale
(Child Behavior Checklist, Teacher Form)
Same as above
DSMD-Total Scale
(Devereaux Scales of Mental Disorders)
CPRS-R:L-Global Problem Index
(1997 Revision of Conners Parent Rating
Scale, Long Version)
CTRS-R:L-Global Problem Index
(1997 Revision of Conners Teacher Rating
Scale, Long Version)

Combined

Age

Gender

Effect
Size

95%
Confidence
Limits

411

1.4

1.3, 1.5

411
511

F
M

1.3
1.2

1.2, 1.4
1.0, 1.4

511
512

F
MF

1.1
1.0

1.0, 1.3
0.8, 1.3

MF

2.3

1.9, 2.6

MF

2.0

1.7, 2.3

1.5

1.2, 1.8

Taken from: Green M, Wong M, Atkins D, et al. Diagnosis of Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: US
Department of Health and Human Services, Agency for Health Care Policy and Research; 1999. AHCPR publication 99-0050.

More research is needed on the use of the ADHDspecific and global rating scales in pediatric practices
for the purposes of differentiating children with
ADHD from other children with different behavior
or school problems.
RECOMMENDATION 4: The assessment of ADHD
requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, the duration of
symptoms, the degree of functional impairment, and
coexisting conditions. A physician should review
any reports from a school-based multidisciplinary
evaluation where they exist, which will include assessments from the teacher or other school-based
professional (strength of evidence: good; strength of
recommendation: strong).
The evaluation of ADHD must establish whether
core behavior symptoms of inattention, hyperactiv-

ity, and impulsivity are present in 1 setting to meet

DSM-IV criteria for the condition. Children 6 to 12
years of age generally are students in an elementary
school setting, where they spend a substantial proportion of waking hours. Therefore, a description of
their behavioral characteristics in the school setting is
highly important to the evaluation. With permission
from the legal guardian, the clinician should review
a report from the childs school. The classroom
teacher typically has more information about the
childs behavior than do other professionals at the
school and, when possible, should provide the report. Alternatively, a school counselor or principal
often is helpful in coordinating the teachers reporting and may be able to provide the required information.
Behavior symptoms may be obtained using 1 or
more methods such as verbal narratives, written narratives, questionnaires, or rating scales. Clinicians

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1165

who obtain information from narratives or interviews must obtain and record the relevant behaviors
of inattention, hyperactivity, and impulsivity from
the DSM-IV. The use of global clinical impressions or
general descriptions within the domains of attention
and activity is insufficient to diagnose ADHD.
The ADHD-specific questionnaires and rating
scales also are available for teachers (Table 4).
Teacher ADHD-specific questionnaires and rating
scales have been shown to have an odds ratio 3.0
(equivalent to sensitivity and specificity greater than
94%) in studies differentiating children with ADHD
from normal peers in the community.24 Thus, teacher
ADHD-specific rating scales accurately distinguish
between children with and without the diagnosis of
ADHD. Whether these scales provide additional
benefit beyond narratives or descriptive interviews
informed by DSM-IV criteria is not known. RECOMMENDATION 4A: Use of these scales is a clinical
option when diagnosing children for ADHD (strength
of evidence: strong; strength of recommendation:
strong).
Teacher global questionnaires and rating scales
that assess a variety of behavioral conditions, in contrast with the ADHD-specific measures, generally
have an odds ratio 2.0 (equivalent to sensitivity
and specificity 86%) in studies differentiating children referred to psychiatric practices from children
who were not referred to psychiatric practices (Table
5). Thus, these broadband scales do not distinguish
between children with and without ADHD. RECOMMENDATION 4B: Use of teacher global questionnaires and rating scales is not recommended in
the diagnosing of children for ADHD, although they
may be useful for other purposes (strength of evidence: strong; strength of recommendation: strong).
If a child 6 to 12 years of age routinely spends
considerable time in other structured environments
such as after-school care centers, additional information about core symptoms can be sought from professionals in those settings, contingent on parental
permission. The ADHD-specific questionnaires may
be used to evaluate the childs behavior in these
settings. For children who are educated in their
homes by parents, evidence of the presence of core
behavior symptoms in settings other than the home
should be obtained as an essential part of the evaluation.
Frequently there are significant discrepancies between parent and teacher ratings.40 These discrepancies may be in either direction; symptoms may be
reported by teachers and not parents or vice versa.
These discrepancies may be attributable to differences between the home and school in terms of
expectations, levels of structure, behavioral management strategies, and/or environmental circumstances. The finding of a discrepancy between the
parents and teachers does not preclude the diagnosis
of ADHD. A helpful clinical approach for understanding the sources of the discrepancies and
whether the child meets DSM-IV criteria is to obtain
additional information from other informants, such
as former teachers, religious leaders, or coaches.
1166

RECOMMENDATION 5: Evaluation of the child

with ADHD should include assessment for coexisting conditions (strength of evidence: strong; strength
of recommendation: strong).
A variety of other psychological and developmental disorders frequently coexist in children who are
being evaluated for ADHD. As many as one third of
children with ADHD have 1 or more coexisting conditions (Table 6). Although the primary care clinician
may not always be in a position to make a precise
diagnosis of coexisting conditions, consideration and
examination for such a coexisting condition should
be an integral part of the evaluation. A review of all
coexisting conditions (such as motor disabilities,
problems with parent-child interaction, or family violence) is not possible within the scope of this review. More common psychological disorders include
conduct and oppositional defiant disorder, mood
disorders, anxiety disorders, and learning disabilities. The pediatrician should also consider ADHD as
a coexisting condition when considering these other
conditions. Evidence for most of these coexisting
disorders may be readily detected by the primary
care clinician. For example, frequent sadness and
preference for isolated activities may alert the physician to the presence of depressive symptoms,
whereas a family history of anxiety disorders coupled with a patient history characterized by frequent
fears and difficulties with separation from caregivers
may be suggestive of symptoms associated with an
anxiety disorder. Several screening tests are available
that can detect areas of concern for many of the
mental health disorders that coexist with ADHD.
Although these scales have not been tested for use in
primary care settings and are not diagnostic tests for
either ADHD or associated mental health conditions,
some clinicians may find them useful to establish
high risk for coexisting psychological conditions.
Similarly, poor school performance may indicate a
learning disability. Testing may be required to determine whether a discrepancy exists between the
childs learning potential (intelligence quotient) and
his actual academic progress (achievement test
scores), indicating the presence of a learning disability. Most studies of rates of coexisting conditions
have come from referral populations. The following
data generally reflect the relatively small number of
studies from community or primary care settings.
TABLE 6.
Summary of Prevalence of Selected Coexisting
Conditions in Children With ADHD
Comorbid Disorder

Estimated
Prevalence (%)

Oppositional defiant disorder

Conduct disorder
Anxiety disorder
Depressive disorder

35.2
25.7
25.8
18.2

Confidence
Limits for
Estimated
Prevalence (%)
27.2,
12.8,
17.6,
11.1,

43.8
41.3
35.3
26.6

Taken from: Green M, Wong M, Atkins D, et al. Diagnosis of

Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: US Dept of Health and Human Services. Agency for
Health Care Policy and Research; 1999. AHCPR publication 990050

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Conduct Disorder and Oppositional Defiant Disorder

Oppositional defiant or conduct disorders coexist

with ADHD in 35% of children.24 The diagnostic
features of conduct disorder include a repetitive
and persistent pattern of behavior in which the basic
rights of others or major age-appropriate social
norms or rules are violated.13 Oppositional defiant
disorder (a less severe condition) includes persistent
symptoms of negativistic, defiant, disobedient, and
hostile behaviors toward authority figures.13 Frequently, children and adolescents with persisting oppositional defiant disorder later develop symptoms
of sufficient severity to qualify for a diagnosis of
conduct disorder. Longitudinal follow-up for children with conduct disorders that coexist with ADHD
indicates that these children fare more poorly in
adulthood relative to their peers diagnosed with
ADHD alone.41 For example, 1 study has reported
the highest rates of police contacts and self-reported
delinquency in children with ADHD and coexisting
conduct disorder (30.8%) relative to their peers diagnosed with ADHD alone (3.4%) or conduct disorder
alone (20.7%). Preliminary studies suggest that these
coexisting conditions are more frequent in children
with the predominantly hyperactive-impulsive and
combined subtypes.25,26
Mood Disorders/Depression

The coexistence of ADHD and mood disorders (eg,

major depressive disorder and dysthymia) is 18%.39
Frequently, the family history of children with
ADHD includes other family members with a history
of major depressive disorder.42 In addition, children
who have coexisting ADHD and mood disorders
also may have a poorer outcome during adolescence
relative to their peers who do not have this pattern of
co-occurrence.43 For example, adolescents with coexisting mood disorders and ADHD are at increased
risk for suicide attempts.44 Preliminary studies suggest that these coexisting conditions are more frequent in children with the predominantly inattentive
and combined subtypes.25,26
Anxiety

The coexisting association between ADHD and

anxiety disorders has been estimated to be 25%.24
In addition, the risk for anxiety disorders among
relatives of children and adolescents diagnosed with
ADHD is higher than for typically developing children, although some research suggests that ADHD
and anxiety disorders transmit independently from
families.45 In either case, it is important to obtain a
careful family history. Preliminary studies suggest
that these coexisting conditions are more frequent in
children with the predominantly inattentive and
combined subtypes.25,26
Learning Disabilities

Only 1 published study examined the coexistence

of ADHD and learning disabilities in children evaluated in general pediatric settings using DSM-IV
criteria for the diagnosis of ADHD.46 The prevalence
of learning disabilities as a coexisting condition can-

not be determined in the same manner as other psychological disorders because studies have employed
dimensional (looking at the condition on a spectrum)
rather than categorical diagnoses. Rates of learning
disabilities that coexist with ADHD in settings other
than primary care have been reported to range from
12% to 60%.24
To date, no definitive data describe the differences
among groups of children with different learning
disabilities coexisting with ADHD in the areas of
sociodemographic characteristics, behavioral and
emotional functioning, and response to various interventions. Nonetheless, the subgroup of children
with learning disabilities, compared with their
ADHD peers who do not have a learning disability,
is most in need of special education services. Preliminary studies suggest that these coexisting conditions
are more frequent in children with the predominantly inattentive and combined subtypes.25,26
RECOMMENDATION 6: Other diagnostic tests are
not routinely indicated to establish the diagnosis of
ADHD (strength of evidence: strong; strength of recommendation: strong).
Other diagnostic tests contribute little to establishing the diagnosis of ADHD. A few older studies have
indicated associations between blood lead levels and
child behavior symptoms, although most studies
have not.47 49 Although lead encephalopathy in
younger children may predispose to later behavior
and developmental problems, very few of these children will have elevated lead levels at school age.
Thus, regular screening of children for high lead
levels does not aid in the diagnosis of ADHD.
Studies have shown no significant associations between abnormal thyroid hormone levels and the
presence of ADHD.50 52 Children with the rare disorder of generalized resistance to thyroid hormone
have higher rates of ADHD than other populations,
but these children demonstrate other characteristics
of that condition. This association does not argue for
routine screening of thyroid function as part of the
effort to diagnose ADHD.
Brain imaging studies and electroencephalography
do not show reliable differences between children
with ADHD and controls. Although some studies
have demonstrated variation in brain morphology
comparing children with and without ADHD, these
findings do not discriminate reliably between children with and without this condition. In other
words, although group means may differ significantly, the overlap in findings among children with
and without ADHD creates high rates of false-positives and false-negatives.5355 Similarly, some studies
have indicated higher rates of certain electroencephalogram abnormalities among children with
ADHD,56 58 but again the overlap between children
with and without ADHD and the lack of consistent
findings among multiple reports indicate that current literature do not support the routine use of
electroencephalograms in the diagnosis of ADHD.
Continuous performance tests have been designed
to obtain samples of a childs behavior (generally

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1167

measuring vigilance or distractibility), which may

correlate with behaviors associated with ADHD.
Several such tests have been developed and tested,
but all of these have low odds ratios (all 1.2, equivalent to a sensitivity and specificity 70%) in studies
differentiating children with ADHD from normal
comparison controls.24,45,59,60 Therefore, current data
do not support the use of any available continuous
performance tests in the diagnosis of ADHD.

Lastly, research is required to identify more clearly

the current practices of primary care physicians beyond using self-report. Such research is critical in
determining the practicality of guideline recommendations as a method to determine changes in practice
and to determine whether changes have an actual
impact on the treatment and outcome of children
with the diagnosis of ADHD.

AREAS FOR FUTURE RESEARCH

This guideline offers recommendations for the diagnosis and evaluation of school-aged children with
ADHD in primary care practice. The guideline emphasizes: 1) the use of explicit criteria for the diagnosis using DSM-IV criteria; 2) the importance of
obtaining information regarding the childs symptoms in more than 1 setting and especially from
schools; and 3) the search for coexisting conditions
that may make the diagnosis more difficult or complicate treatment planning. The guideline further
provides current evidence regarding various diagnostic tests for ADHD. It should help primary care
providers in their assessment of a common child
health problem.

CONCLUSION

The research issues pertaining to the diagnosis of

ADHD relate to the diagnostic criteria themselves as
well as the methods used to establish the diagnosis.
The DSM-IV has helped to define behavioral criteria
for ADHD more specifically. Although research has
established the dimensional concepts of inattention
and hyperactivity-impulsivity, further research is required to validate these subtypes. Because most of
the existing research has been conducted with referred convenience samples, primarily in psychiatric
settings, further research is required to determine
whether the findings of previous research are generalizable to the type of children currently diagnosed
and treated by primary care clinicians. Although the
current DSM-IV criteria are appropriate for the age
range included in this guideline, there is, as yet,
inadequate information about its applicability to individuals younger or older than the age range for
this guideline. Further research should clarify the
developmental course of ADHD symptomatology.
An additional difficulty for primary care is that existing evidence indicates that the behaviors used in
making a DSM-IV diagnosis of ADHD fall on a spectrum. Currently, decisions about the inappropriateness of the behaviors in children depend on subjective judgments of observers/reporters. There are no
data to offer precise estimates of when diagnostic
behaviors become inappropriate. This is particularly
problematic to primary care clinicians, who care for a
number of patients who fit into borderline or gray
areas. The inadequacy of research on this aspect is
central to the issue of which children should be diagnosed with ADHD and treated with stimulant
medication. Further research using normative or
community-based samples to develop more valid
and precise diagnostic criteria is essential.
The diagnostic process is also an area requiring
further research. Because no pathognomonic findings currently establish the diagnosis, further research should examine the utility of existing methods, with the goal of developing a more definitive
process. Specific examples include the need for additional information about the reliability and validity
of teacher and parent rating scales and the reliability
and validity of different interviewing methods. Further, given the prominence of impairment in the
current diagnostic requirements, it is imperative to
develop and assess better measurements of impairment that can be applied practically in the primary
care setting. The research into diagnostic methods
also should include those methods helpful in identifying clinically relevant coexisting conditions.
1168

Committee on Quality Improvement, 1999 2000

Charles J. Homer, MD, MPH, Chairperson
Richard D. Baltz, MD
Gerald B. Hickson, MD
Paul V. Miles, MD
Thomas B. Newman, MD, MPH
Joan E. Shook, MD
William M. Zurhellen, MD
Liaison Representatives
Betty A. Lowe, MD, National Association of
Childrens Hospitals and Related Institutions
Ellen Schwalenstocker, MBA, National Association of
Childrens Hospitals and Related Institutions
Michael J. Goldberg, MD, Council on Sections
Richard Shiffman, MD, Section on Computers and
Other Technologies
Jan Ellen Berger, MD, Committee on Medical Liability
F. Lane France, MD, Committee on Practice and
Ambulatory Medicine
Subcommittee on Attention-Deficit/
Hyperactivity Disorder
James M. Perrin, MD, Co-chairperson
Martin T. Stein, MD, Co-chairperson
Robert W. Amler, MD
Thomas A. Blondis, MD
Heidi M. Feldman, MD, PhD
Bruce P. Meyer, MD
Bennett A. Shaywitz, MD
Mark L. Wolraich, MD
Consultants
Anthony DeSpirito, MD
Charles J. Homer, MD, MPH
Liaison Respresentatives
Karen Pierce, MD, American Academy of Child and
Adolescent Psychiatry
Theodore G. Ganiats, MD, American Academy of
Family Physicians
Brian Grabert, MD, Child Neurology Society
Ronald T. Brown, PhD, Society for Pediatric
Psychology

DIAGNOSIS AND EVALUATION OF THE CHILD WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

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ACKNOWLEDGMENTS
The Practice Guideline, Diagnosis and Evaluation of the Child
With Attention-Deficit/Hyperactivity Disorder, was reviewed by
appropriate committees and sections of the AAP, including the
Chapter Review Group, a focus group of office-based pediatricians representing each AAP District: Gene R. Adams, MD; Robert
M. Corwin, MD; Diane Fuquay, MD; Barbara M. Harley, MD;
Thomas J. Herr, MD, Chair Person; Kenneth E. Mathews, MD;
Robert D. Mines, MD; Lawrence C. Pakula, MD; Howard B. Weinblatt, MD; and Delosa A. Young, MD. The Practice Guideline was
also reviewed by relevant outside medical organizations as part of
the peer review process as well as by several patient advocacy
organizations.

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DIAGNOSIS AND EVALUATION OF THE CHILD WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

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Clinical Practice Guideline: Diagnosis and Evaluation of the Child With

Attention-Deficit/Hyperactivity Disorder
Committee on Quality Improvement, Subcommittee on
Attention-Deficit/Hyperactivity Disorder
Pediatrics 2000;105;1158-1170
Updated Information
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