Attention-deficit/hyperactivity disorder (ADHD) is a common condition marked by inattention, hyperactivity, and impulsivity. Diagnosis can be straightforward or complex; however, many patients who present with learning or behavioral problems and in whom ADHD is suspected can be evaluated and treated in the primary care setting.

Diagnosis and Evaluation

The National Health and Nutrition Examination Survey found that approximately 8.7 percent of children eight to 15 years of age meet criteria for ADHD. The condition is classified into three subtypes, depending on the prevalence of specific behaviors: predominantly inattentive, predominantly hyperactive/impulsive, and combined types.

A comprehensive interview with parents and caregivers is key to the diagnosis of ADHD. It should include questions about current symptoms and the patient's medical, developmental, educational, family, and psychosocial histories. The diagnosis is based on a clinical picture of early onset and significant duration and pervasiveness of symptoms, and functional impairment. These symptoms can be elicited by use of a semistructured interview or questionnaire, with behavior rating scales completed by the parents, other caregivers, and school personnel.

As with many conditions, ADHD is rarely a singular diagnosis. In addition to evaluating for primary symptoms of ADHD as described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed. or primary care manual), physicians should screen for other primary conditions and comorbidities (e.g., vision, hearing, or speech problems; learning disabilities; other psychiatric conditions; Table 1). Subspecialty consultation should be obtained if necessary.

If comorbid issues are not identified and addressed, they may complicate the patient's level of functional impairment and lead to higher morbidity with a poor prognosis. One way to evaluate for comorbidities is to use standardized screening instruments, such as the Child Behavior Checklist. However, it should be noted that this instrument is for screening purposes only, and should not be used to diagnose any specific condition.

Once ADHD has been diagnosed, the physician must determine whether it is the primary or secondary diagnosis. If an alternative primary diagnosis (e.g., anxiety disorder, oppositional defiant disorder, depression) is identified, the patient should be treated or referred as appropriate. If ADHD is the likely primary diagnosis but a comorbid condition is suspected, physicians may choose to begin treatment for ADHD while concurrently evaluating for the suspected comorbidity.

Management

Once ADHD is confirmed, physicians should counsel the child and the parents about the diagnosis. For the child, a developmentally appropriate explanation of ADHD may be helpful. Parents should be given information about neurologic mechanisms, common features of ADHD and how they relate to the child's previous and current problems, and expectations of the clinical course and intervention strategies. The importance of individual teacher selection each year should be emphasized. It is also important to provide specific teacher-focused information for the parents to share with school personnel.

The decision to treat ADHD with medication should be made with the parents after a discussion of the expected benefits and potential risks. Factors such as the child's age, severity of symptoms, and comorbidities should also be considered and may influence the choice of medication. Stimulant and nonstimulant medications are approved by the U.S. Food and Drug Administration for use in children with ADHD (Table 2). The use of stimulants should be avoided in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems that could put them at increased risk of sympathomimetic effects. A family and personal cardiovascular history should be obtained for all patients before initiating stimulant therapy. Findings from the history or physical examination that suggest cardiac disease may require evaluation by a cardiologist. The American Academy of Pediatrics recommends against performing routine electrocardiography or routine subspecialty cardiology evaluations before initiating stimulant therapy in children with ADHD.

When adequate trials of stimulants and nonstimulants are unsuccessful because of poor response or adverse effects, or if a comorbidity is present, alternative medications can be considered (Table 3, p. 768 ). Adverse effects of these medications may be more common and more serious than those associated with stimulants. In addition, there are fewer studies documenting their benefit and safety in children and adolescents. Occasionally a comorbid condition may warrant the use of alternative medications. In these cases, the primary symptoms should influence the medication decision.

Although medication is the cornerstone of ADHD treatment, multimodal intervention may be needed for concomitant conditions and comorbidities. Primary care physicians are in a unique position to coordinate care.

Family-focused management strategies include ADHD support groups, advocacy groups, and parenting skills training. Parents should learn to provide a structured home environment, clear expectations, consistent responses, positive attention for appropriate behaviors, and appropriate consequences for maladaptive behaviors. These methods serve to give the child direction, goals, and limits in the hopes of improving compliance, increasing self-esteem, enhancing the parent-child relationship, and reducing tension within the home.

Children with ADHD may benefit from social skills training to improve peer relationships that are often negatively affected by ADHD symptoms (e.g., impulsivity). Cognitive behavior therapy also may be warranted. Study and organizational skills training should be offered in conjunction with curriculum intervention.

Neurofeedback, a form of biofeedback, has been promoted as an alternative therapy for ADHD. Neurofeedback uses electroencephalography biofeedback to teach children with ADHD how to self-regulate certain brain activity patterns and then to generalize these skills to daily life. Although early studies provided some evidence that neurofeedback may have some positive effects, these studies had significant methodologic problems that limit their usefulness. A recent randomized controlled trial showed that neurofeedback is superior to computerized attention skills training. Based on this evidence, neurofeedback may be a reasonable alternative to medication use, or may be used as part of a multimodal treatment program.