Practice Guidelines

Attention-Deficit/Hyperactivity Disorder: AAP Updates Guideline for Diagnosis and Management

 

Am Fam Physician. 2020 Jul 1;102(1):58-60.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Most children diagnosed with ADHD also meet criteria for another behavioral health disorder.

• Parent training in behavior management is strongly recommended for children up to middle school age with ADHD or behavior concerning for ADHD.

• School evaluation of children with ADHD can lead to accommodations and additional learning services to optimize academic performance.

From the AFP Editors

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in 7% to 8% of children. It affects academic achievement and socioemotional well-being. The American Academy of Pediatrics (AAP) updated guidelines to emphasize evaluation for comorbid conditions and overcoming systemic barriers to increase treatment equity.

Diagnosis

The average age at ADHD diagnosis is seven years. ADHD is twice as common in boys than it is in girls, which is partially explained by increased hyperactivity and impulsiveness in boys. Children who are at the younger end of their academic grade are more likely to be diagnosed with ADHD.

ADHD should be considered in children four years or older with academic or behavioral concerns and symptoms of inattentiveness, hyperactivity, or impulsivity. The AAP supports the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria requiring six or more symptoms (Table 11) for at least six months. Symptoms must occur in more than one social setting, including home, school, or day care, and be unexplained by age or another condition. For adolescents, symptoms must have been present before 12 years of age. Neuropsychological testing does not increase diagnostic accuracy.

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TABLE 1.

Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Inattention*

Appearing not to listen

Avoiding tasks requiring sustained attention

Careless mistakes

Difficulty organizing

Difficulty sustaining attention

Easily distracted

Failing to finish tasks

Forgetfulness

Losing things

Hyperactivity and impulsivity*

Always “on the go”

Blurting out answers before questions are completed

Difficulty waiting for turn

Excessively talkative

Fidgeting

Inability to play quietly

Inability to stay seated

Interrupting or intruding on others

Restlessness


Note: Patients can meet criteria for inattention, hyperactivity and impulsivity, or both.

*—Six or more symptoms must persist for at least six months, and have been present before 12 years of age.

Information from reference 1.

TABLE 1.

Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Inattention*

Appearing not to listen

Avoiding tasks requiring sustained attention

Careless mistakes

Difficulty organizing

Difficulty sustaining attention

Easily distracted

Failing to finish tasks

Forgetfulness

Losing things

Hyperactivity and impulsivity*

Always “on the go”

Blurting out answers before questions are completed

Difficulty waiting for turn

Excessively talkative

Fidgeting

Inability to play quietly

Inability to stay seated

Interrupting or intruding on others

Restlessness


Note: Patients can meet criteria for inattention, hyperactivity and impulsivity, or both.

*—Six or more symptoms must persist for at least six months, and have been present before 12 years of age.

Information from reference 1.

PRESCHOOL-AGED CHILDREN

Diagnosing children four to six years of age is challenging because ADHD criteria overlap with age-appropriate behavior. Combining direct clinical observation and parent interviews with parent and teacher rating scales increases diagnostic accuracy. Parent training in behavior management (PTBM) is the primary treatment in this age group and should be recommended before making the diagnosis of ADHD.

ADOLESCENTS

ADHD can be difficult to identify in adolescents who show less hyperactivity and often minimize symptoms. Obtaining detailed teacher reports can be cumbersome because most adolescents have multiple teachers and behavior can vary across settings.

COMORBID CONDITIONS

Most children with ADHD also meet criteria for another behavioral disorder. ADHD symptoms can mask language and learning disorders as well as overlap with mood disorders. The AAP strongly recommends children with ADHD be evaluated for mood disorders and past trauma. Screening for substance abuse is especially important in older children and adolescents because effects of marijuana use can

Author disclosure: No relevant financial affiliations.

Reference

1. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013:59–60.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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