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- Fig. 1.
Clinical algorithm.
Tables
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 home- work) 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.
Developmental Variation Common Developmental Presentations V65.49 Hyperactive/impulsive variation Early childhood 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. The child runs in circles, doesn't stop to rest, may bang into objects or people, and asks questions constantly. During school years and adolescence, activity may be high in play situations and impulsive behaviors may normally occur, especially in peer pressure situations. Middle childhood High levels of hyperactive/impulsive behavior do not indicate a problem or disorder if the behavior does not impair function. 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 caregiver's 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 child's 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
Developmental Variation Common Developmental Presentations V65.49 Inattention variation Early childhood A young child will have a short attention span that will increase as the child matures. The inattention should be appropriate for the child's level of development and not cause any impairment. 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 child's or adolescent's interest and skill in the activity, so much so that a short attention span for a particular task may reflect the child's 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
Study Behavior Rating Scale Age Gender Effect Size 95% Confidence Limits Conners (1997) CPRS-R:L-ADHD Index
(Conners Parent Rating Scale—1997
Revised Version: Long Form, ADHD Index Scale)6 –17 MF 3.1 2.5, 3.7 Conners (1997) CTRS-R:L-ADHD Index
(Conners Teacher Rating Scale—
1997 Revised Version: Long Form, ADHD Index Scale)6 –17 MF 3.3 2.8, 3.8 Conners (1997) CPRS-R:L-DSM-IV Symptoms
(Conners Parent Rating Scale—1997
Revised Version: Long Form, DSM-IV Symptoms Scale)6 –17 MF 3.4 2.8, 4.0 Conners (1997) CTRS-R:L-DSM-IV Symptoms
(Conners Teacher Rating Scale—1997
Revised Version: Long Form, DSM-IVSymptoms Scale)6 –17 MF 3.7 3.2, 4.2 Breen (1989) SSQ-O-I
Barkley's School Situations Questionnaire-Original Version, Number of Problem Settings Scale6 –11 F 1.3 0.5, 2.2 Breen (1989) SSQ-O-II
Barkley's School Situations Questionnaire-Original Version, Mean Severity Scale6 –11 F 2.0 1.0, 2.9 Combined 2.9 2.2, 3.5 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
Study Behavior Rating Scale Age Gender Effect Size 95% Confidence Limits Achenbach (1991b) CBCL/4-18-R, Total Problem Scale
(Child Behavior Checklist for Ages 4–18, Parent Form)4–11 M 1.4 1.3, 1.5 Achenbach (1991b) Same as above 4–11 F 1.3 1.2, 1.4 Achenbach (1991c) CBCL/TRF-R, Total Problem Scale
(Child Behavior Checklist, Teacher Form)5–11 M 1.2 1.0, 1.4 Achenbach (1991c) Same as above 5–11 F 1.1 1.0, 1.3 Naglieri, LeBuffe, Pfeiffer (1994) DSMD-Total Scale
(Devereaux Scales of Mental Disorders)5–12 MF 1.0 0.8, 1.3 Conners (1997) CPRS-R:L-Global Problem Index
(1997 Revision of Conners Parent Rating Scale, Long Version)— MF 2.3 1.9, 2.6 Conners (1997) CTRS-R:L-Global Problem Index
(1997 Revision of Conners Teacher Rating Scale, Long Version)— MF 2.0 1.7, 2.3 Combined 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.
Comorbid Disorder Estimated
Prevalence (%)Confidence
Limits for
Estimated
Prevalence (%)Oppositional defiant disorder 35.2 27.2, 43.8 Conduct disorder 25.7 12.8, 41.3 Anxiety disorder 25.8 17.6, 35.3 Depressive disorder 18.2 11.1, 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 99-0050
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Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder
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