- ADHD is a clinical diagnosis requiring evaluation of behavior across multiple settings (eg, family, academic, social). There is no laboratory “test” for ADHD.
- ADHD is a chronic condition that may persist into adulthood, extends across developmental phases, and presents different challenges during each phase.
- Clinician interviews and rating scales of parents/caregiver/teachers are the core of ADHD assessment process.
- Therapeutic alliance with patient/parents/caregiver/teachers is crucial to treatment planning/implementation.
- Important role of educational system in patient treatment/monitoring distinguishes ADHD from many other chronic conditions.
- Key to effective long-term management of patient with ADHD is continuity of care with a clinician experienced in treatment of ADHD.
- Treatment plans should:
- Be individualized
- Consider patient strengths and target symptoms identified in assessment process
- Include psychoeducation of parents and patient about ADHD
- Provide periodic, systematized follow-up focused on targeted outcomes and adverse effects based on input from parents, teachers, and patient
- Anticipate long-term therapeutic planning and monitoring
- Treatment goals should be realistic, attainable, and measurable:
- Improved relationships with parents, siblings, teachers, peers
- Decreased disruptive/setting-inappropriate behaviors
- Improved academic performance
- Increased independence by self-monitoring and completion of assigned activities
- Improved self-esteem
- Decision to treat with medication should be based on persistent target symptoms sufficiently severe to cause functional impairment in home, school, work, or peer-related activities, on continuing efficacy of medication, and on family/parent preference.
- Patients treated pharmacologically should have their height and weight monitored throughout treatment.
- Limitations in pharmacologic and behavioral treatments arise from lack of maintenance if treatment discontinued and/or failure in settings where treatment has not been well applied.
- Medication should be reinstituted when target symptoms re-emerge if medication is discontinued and when ratio of therapeutic benefit to side effects is acceptable.
- Psychosocial treatments may be useful for ADHD with comorbid disorders or other problems responsive to such nonmedication treatments.
Diagnosis and Assessment of Disease
Table 1. Five Criteria for ADHD
|2. Some inattention or hyperactivity-impulsivity to be consistent symptoms causing impairment present before age 7|
|3. Some impairment from symptoms present in 2 or more settings (eg, home, school/work, sociala)|
|4. Clear evidence of clinically significant impairment in social, academic, or occupational functioning|
|5. Symptoms do not occur exclusively during course of a pervasive developmental disorder, schizophrenia, or psychotic disorder and are not better accounted for by another mental disorder|
(eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder)
|Types of ADHD|
|ADHD, Combined Type: Criteria for inattention AND hyperactivity-impulsivity met for past 6 mo (DSM-IV code 314.01; ICD-10 code F90.0)|
|ADHD, Predominantly Inattentive Type: Criteria for inattention met but criteria for hyperactivity-impulsivity NOT met for past 6 mo (DSM-IV code 314.00; ICD-10 code F98.8)|
|ADHD, Predominantly Hyperactive-Impulsive Type: Criteria for hyperactivity-impulsivity met but criteria for inattention NOT met for past 6 mo (DSM-IV code 314.01; ICD-10 code F90.0)|
|a Clinical consensus is that severe impairment in one setting can warrant treatment for ADHD (eg, inordinate amount of time after school completing schoolwork not done in class).|
Table 2. Behavior Rating Scales Commonly Used in Assessment of ADHD and Monitoring of Treatment
|Academic Performance Rating Scale (APRS)|
|19-item scale for determining child’s academic productivity and accuracy in grades 1-6 with|
6 scale points, construct, concurrent, and discriminant validity data, as well as norms (n = 247)
|ADHD Rating Scale-IV|
|18-item scale using DSM-IV criteria|
|Brown ADD Rating Scales for Children, Adolescents, and Adults (BADDS)|
|Assess wide range of symptoms of ADHD executive function impairments in children, adolescents, and adults|
|Child Behavior Checklist (CBCL)|
|Parent-completed CBCL and teacher-completed Teacher Report Form (TRF)|
|Conners Parent Rating Scale-Revised (CPRS-R)|
Conners Teacher Rating Scale-Revised (CTRS-R)
Conners Wells Adolescent Self-Report Scale
|Longer form should be used for initial assessment|
Shorter form often used for assessing response to treatment, particularly when repeated administration required
Parent and adolescent self-report versions available
|Home Situations Questionnaire-Revised (HSQ-R)|
School Situations Questionnaire-Revised (SSQ-R)
|14-item scale designed to assess specific problems with attention and concentration across a variety of home and public situations, using a 0-9 scale; has test-retest, internal consistency, construct validity, discriminant validity, concurrent validity, and norms (n = 581)|
|Inattention/Overactivity With Aggression (IOWA)|
Conners Teacher Rating Scale
|10-item scale developed to separate inattention and overactivity ratings from oppositional defiance|
|Swanson, Nolan, and Pelham (SNAP-IV) Scale DSM diagnoses|
|10-item scale (6 deportment and 4 attention items) measuring impairment of functioning at home and at school|
|Swanson, Kotkin, Agler, M/Flynn, and Pelham (SKAMP) Scale|
|26-item scale containing DSM-IV criteria for ADHD and screens for other disorders|
|Vanderbilt ADHD Diagnostic Rating Scale|
|55-item parent form, 43-item teacher form; initial assessment tool for use with children 6-12 yrs old; contains rating scales for symptoms and impairment in academic and behavioral performance|