Fall 2000

Printable Version (pdf)

Section Home

Articles

From the Editor
ADHD Guidelines
Life Expectancy
Boards Update
Strategic Plan
Book Review
SDBP

Awards

C. Anderson Aldrich
Dale Richmond

Commentary: AAP Clinical Practice Guidelines for the Diagnosis and Evaluation of Children with Attention-Deficit/Hyperactivity Disorder

by Daniel Kessler, M.D. FAAP, Phoenix AZ

With the publication of the long-awaited first installment of the American Academy of Pediatrics (AAP) Clinical Practice Guidelines on ADHD the Academy has officially come off the sidelines in the debate on the assessment and treatment of this common but still controversial clinical condition of childhood. The guidelines and the clinical algorithm provided are without question an improvement over the clinical practices reported by many parents whom I have seen and spoken too. If widely adopted the clinical care of children with behavioral and academic difficulties will experience a major step forward. Nevertheless, while the guidelines represent a good start and an excellent introduction for the practicing clinician there is still more to be done.

The guidelines represent the work of a select group of individuals chosen by the Committee on Quality Improvement of the American Academy of Pediatrics and consisting of representatives from the fields of neurology, psychology, child psychiatry, development, education, family practice and epidemiology, and included both academic and practicing pediatricians. The panel used an evidence report prepared by Technical Resources International, Washington, DC, under the auspices of the Agency for Healthcare Research and Quality.

Strength of the Guidelines

The panel included representatives from all the appropriate professional disciplines and included a most competent and expert group of individuals. AAP states that ADHD is “the most common neurobehavioral disorder of childhood” and “among the most prevalent chronic health conditions affecting school-age children.” This places the Academy right alongside the Council of Scientific Affairs of the American Medical Association (Goldman, 1998), the American Academy of Child and Adolescent Psychiatry (1997) and the National Institutes of Health (1998) in announcing to its many critics that ADHD is both very real and a significant public health concern.

Recommendations of the panel are a significant improvement over what too often in the past has been routine (if not standard) clinical practice. An evaluation for ADHD is appropriate in the presence of difficulties of behavior and academic underachievement as well as the more commonly described core symptoms of inattention, hyperactivity and impulsivity. Troublesome interpersonal relationships with family members or peers and/or low self-esteem, troubles that might indicate coexisting conditions should also raise the index of suspicion for the existence of ADHD.

Symptoms that may herald the presence of ADHD may not always be evident in the structured clinical setting where we see our patients. Pediatricians may sometimes need to look for ADHD and base their assessment on something more than their global clinical impression based on observation in the office setting. We will need to talk to and more importantly listen to children and parents and elicit through history information involving behavior at school and home. Information may be elicited through the use of a pre-visit questionnaire or through direct questions to parents or child.

When a concern about behavior at school or home is presented the pediatrician should document the presence of specific behavioral criteria (currently those described in DSM-IV) that are present in two or more settings that adversely affect functioning in school or social situations. Information must be collected directly from parents and/or other caregivers as well as from teachers or other personnel in out of home settings such as school (where children spend considerable amounts of time). Other appropriate information should be obtained directly from professionals who have contact with children in other structured environments (after school programs, parks and recreation programs, organized athletic programs).

An evaluation for ADHD should include a search for common coexisting conditions of behavior (oppositional defiant disorder, conduct disorder), mood and emotional functioning (anxiety and depression), and learning. ADHD remains a clinical disorder and additional specialized tests and assessments (including laboratory evaluation for lead poisoning, thyroid studies, EEGs, or continuous performance tests) are unnecessary.

Limitations of the Guidelines

The Subcommittee on ADHD undertook an evidenced-based review of the existing literature on the prevalence and assessment of ADHD as well as the accuracy of available screening methods used to diagnose it. Though data on screening tests were taken from studies conducted in any setting, the remaining data included only those studies involving children 6 to 12 years of age using general, unselected populations in communities, schools or the primary care setting. This rather narrow focus eliminated from the review a large number of well-designed research studies.

Though a larger number of studies were reviewed, based on unspecified inclusion and exclusion criteria only 87 published articles and 10 manuals were used in the final analysis (Agency for Health Care Policy and Research, 1999). The report indicates that recommendations contained in the practice guideline are based on the best available data, and where data were lacking, a combination of evidence and expert consensus was used. It is unclear, however, why the panel addressed themselves to this rather narrow focus.

The guidelines state that they address the assessment of ADHD in school-age children, though as already stated they actually limit themselves somewhat more narrowly to primary school children between the ages of 6 and 12 years. Children are entering school settings as young as 3 years of age and adolescents are one of the most important school-age populations for pediatricians. ADHD is best defined as a lifespan disorder. How should the practicing pediatrician approach children outside this narrow age range?

Preschool Children

While the assessment of preschool children may be seen as more controversial than the assessment of primary school-age children, there is clear evidence that significant problems may appear at ages younger than 6 years. The field trials for DSM-IV (Lahey et al. 1994) demonstrated that the group of children with the ADHD-Predominantly Hyperactive-Impulsive subtype consisted primarily of preschool age children while the ADHD-combined type consisted primarily of school-age children, leading them to speculate that the former might be a developmental precursor of the latter. Barkley (1998) has argued that 3 years of age should be seen as the lower bound for diagnostic applications of the ADHD label.

While the guidelines indicate, “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” (p. 1162), the practitioner is provided little guidance as to how to address this situation. Since the report is focused rather narrowly on the 6 to 12 year age range this is an important assessment issue and an important oversight.

Tools for Assessment

In addition to issues of prevalence of ADHD and coexisting conditions, the guidelines seek to address the question of assessment using standardized and non-standardized tools. In collecting data regarding behavioral symptoms from parents or school personnel, the guidelines provide the practitioner with a choice between the use of open ended questions, focused questions about specific behaviors, semi-structured interview schedules (for parents), verbal narratives, written narratives (for teachers or school personnel), or questionnaires and rating scales.

As indicated in the technical review, the use of ADHD-specific questionnaires and rating scales for both parents and teachers have been shown to have an odds-ratio greater than 3 (equivalent to sensitivity and specificity greater than 94%) in studies differentiating children with ADHD from normal peers in the community. However, rather than recommending these ADHD-specific scales and questionnaires, their use is suggested as a clinical option. No evidence is presented on the validity or reliability of the other methods recommended. How can they be considered comparable?

Coexisting Conditions

The final recommendation of the report has to do with the importance of assessing coexisting conditions. Despite the strength of the evidence for this recommendation, no specific guidelines are provided to the clinician (outside of family history) for obtaining this information. In addition while the report indicated that the use of the global questionnaires and rating scales (such as the Child Behavior Checklist or CBCL) “may be useful for other purposes” little guidance is provided on what these other purposes may be. These scales are directly useful (along with other methods) for the assessment of these exact coexisting conditions that are so important to assess.

The Total Problem Scale of the CBCL (Table 5) fails to differentiate between children with and without ADHD. However, the CBCL includes several subscales (anxiety/depression, social problems, inattention, delinquent and aggressive behavior problems) that appear to cover the major dimensions of child psychopathology that should be of interest to the clinician given the high prevalence of coexisting conditions and their effects on children.

Conclusions:

The report also highlights the important limitations of existing diagnostic criteria (their subjective nature, lack of reliable methods to assess functional impairment in children, paucity of studies involving non-psychiatric populations) as well as important areas for future research. As such this is a document that should be seen as a beginning rather than an end.

Hopefully it is the beginning of important further work that the Academy could take a leadership role. Perhaps through its Pediatric Research in Office Settings (PROS) network, and with the assistance of important collaborators in other disciplines as well as consumers of care such as CHADD, the Academy should take the lead in filling the important gaps in the available evidence base for children.

References

Agency for Health Care Policy and Research. Diagnosis of Attention-Deficit/Hyperactivity Disorder. Summary, Technical Review: Number 3, August 1999. Rockville, MD. http://www.ahrq.gov/clinic/adhdsutr.htm

American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry, 36(suppl 10):085s-121s, 1997.

Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics 2000 105: 1158-1170.

Goldman LS, Genel M, Bezman RJ, et al. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA, 279:1100-1107, 1998

Lahey, Applegate, McBurnett, Biederman, et al. DSM-IV field trials for attention deficit/hyperactivity disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1994;151:1673-1685

NIH Consensus Development Conference on ADHD, Bethesda, MD. November 1998

Dr. Kessler is a member of the Section Executive Committee. He is a member of CHADD’s Professional Advisory Board.ª

AAP Home | Section Home