Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation Author Kevin R Krull, PhD

Section Editors Marilyn Augustyn, MD Steven Parker, MD Deputy Editor Mary M Torchia, MD Last literature review version 17.1: January 2009 | This topic last updated: February 13, 2009 (More) INTRODUCTION — Attention-deficit/hyperactivity disorder (ADHD) is a disorder that manifests in early childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning (show table 1) [1] . This topic review focuses on the clinical features and evaluation of ADHD. The epidemiology, pathogenesis, management, and prognosis of ADHD in children and adolescents and ADHD in adults are discussed separately. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis" and see "Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents" and see "Pharmacotherapy for attention deficit hyperactivity disorder in children and adolescents" and see "Adult attention deficit hyperactivity disorder"). CORE SYMPTOMS — ADHD is a syndrome composed of three categories of symptoms: hyperactivity, impulsivity, and inattention. The complaint regarding these symptoms may originate from the parents, teachers, or other caregivers [2] . The symptoms may not be apparent in the structured setting of the clinic visit, but the pediatric care provider can ask the parents the following questions to elicit concerns regarding school performance and behavior [3] : How is your child doing at school? Have you or the teacher noticed any problems with learning? Is your child happy in school? Does your child have any behavioral problems at school, home, or when playing with friends? Does your child have problems completing school assignments at school or home? Each of the core symptoms of ADHD has its own pattern and course of development. Hyperactivity — Hyperactive behavior is identified through excessive fidgetiness or talking, difficulty remaining seated when required to do so, difficulty playing quietly, and frequent restlessness or seeming to be always "on the go" (show table 1). The hyperactive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years [4] . They peak in severity when the child is seven to eight years of age, after which they begin to steadily decline. By the adolescent years, the hyperactive symptoms are barely discernible.

Impulsivity — Impulsive behavior, which almost always occurs in conjunction with hyperactivity in younger children, is manifested by difficulty waiting turns, blurting out answers too quickly, disruptive classroom behavior, intruding or interrupting other's activities, peer rejection, and unintentional injury (show table 1). Similar to the hyperactive symptoms, the impulsive symptoms typically are observed by the time the child is four years of age and increase during the next three to four years to peak in severity when the child is seven to eight years of age [5] . In contrast to hyperactive symptoms, impulsive symptoms usually remain a problem throughout the life of the individual. (See "Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents", section on Prognosis). The focus of impulsivity is related to the environment. Adolescents with ADHD who are untreated and in an environment where alcohol and other commonly abused substances are readily available are at greater risk of engaging in drug use or experimentation than are adolescents without ADHD [6] . Adults with ADHD may find themselves with higher rates of financial mismanagement related to impulse buying. Inattention — Inattention may take many forms, including forgetfulness, being easily distracted, losing or misplacing things, disorganization, academic underachievement, poor follow-through with assignments or tasks, poor concentration, and poor attention to detail (show table 1). The symptoms of inattention typically are not apparent until the child is eight to nine years of age [7] . This delay may relate to reduced sensitivity of assessment of attention problems or increased variability in the normal development of the cognitive skills. Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem. (See "Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents", section on Prognosis). DIAGNOSTIC CRITERIA Attention deficit hyperactivity disorder — Consensus criteria for the diagnosis of ADHD have been defined by the American Psychiatric Association and published in the DSM-IV (show table 1) [1,2,8] . Several features of the DSM-IV criteria deserve emphasis: The symptoms must be present in more than one setting (eg, school and home). The symptoms must persist for at least six months. The symptoms must be present before the age of seven years. The symptoms must impair function in academic, social, or occupational activities. The symptoms must be excessive for the developmental level of the child. Other mental disorders that could account for the symptoms must be excluded. (See "Differential diagnosis" below). Adherence to the DSM-IV criteria can help to minimize over- and underdiagnosis of ADHD. However, several limitations of the criteria must be noted [2] . The criteria were derived from studies of children who were evaluated in psychiatric rather than primary care settings. Data supporting the number of items required for diagnosis are lacking. Finally, the behavioral characteristics specified in the definition are subject to different interpretations by different

observers [2] . Nonetheless, the diagnostic criteria, as used by appropriate examiners, demonstrate high interrater reliability of individual items and of overall diagnosis [9,10] . Depending upon the predominant symptoms, three subtypes of ADHD have been identified [1] : Predominantly inattentive Predominantly hyperactive-impulsive Combined The subtype of ADHD in a given patient can change from one to another over the course of time [1,2,11] . Inattentive subtype — Children with the predominantly inattentive subtype of ADHD (ADHD-I) usually are diagnosed at 9 to 10 years of age, the age at which symptoms of inattention become noticeable. Children with the ADHD-I have at least six of the symptoms of inattention that have persisted for at least six months and are present to a degree that is maladaptive and inconsistent with developmental level (show table 1) [1,2] : Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties (not because of oppositional behavior or failure to understand instructions) Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) Often is easily distracted by extraneous stimuli Often is forgetful in daily activities Children with ADHD-I may have mild symptoms of hyperactivity or impulsivity, but inattention is their primary problem. Children ADHD-I are characterized by reduced ability to focus attention and reduced speed of cognitive processing and responding [12,13] . They often are described as having a sluggish cognitive tempo and frequently appear to be daydreaming or "off task" [14] . The typical presenting complaints center around cognitive and/or academic problems. ADHD-I is not as well studied as the other subtypes [15] . Hyperactive-impulsive subtype — Children with the predominantly hyperactive-impulsive subtype of ADHD (ADHD-HI) usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak. Children with ADHD-HI have at least six of the symptoms of hyperactivity-impulsivity that have persisted for at least six months and are present to a degree that is maladaptive and inconsistent with developmental level (show table 1) [1,2] : Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty playing or engaging in leisure activities quietly Often is "on the go" or often acts as if "driven by a motor" Often talks excessively Often blurts out answers before questions have been completed Often has difficulty awaiting his or her turn Often interrupts or intrudes on others (eg, butts into conversations or games) Children with ADHD-HI have relatively good attention skills; they simply cannot sit still or inhibit their behavior. Cognitive performance may be unaffected in children with ADHD-HI [16] .

Combined subtype — Children with the combined subtype of ADHD (ADHD-C) usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak. Children with ADHD-C have at least six of the symptoms of inattention and at least six of the symptoms of hyperactivity-impulsivity (show table 1) [1,2] . ADHD-C is the subtype that is most easily identified. Presenting complaints include disruptive or aggressive behavior, overactivity, disinhibition, and reduced attention span. This is the classic subtype of ADHD and is seen most commonly in clinical studies and treatment centers [17] . Preschool children — Many of the symptoms of ADHD are common among preschool children in various settings. For this reason, establishing the diagnosis of ADHD in children younger than six years is difficult [1,2] . Nonetheless, data from longitudinal studies suggest that severe hyperactivity, present in only a small subset of preschool children, persists into the school years [18,19] . In one study evaluating the validity of Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for ADHD (show table 1) in preschool children, 79 percent of children who met full DSM-IV diagnostic criteria at ages four to six years were more likely to continue to meet criteria over the subsequent three years than children who only met criteria in one setting (situational ADHD, 34 percent), or comparison children (3 percent) [20] . Hyperkinetic disorder — In Europe, the diagnosis of hyperkinetic disorder (HKD) is defined by the International Classification of Diseases (10th edition, ICD-10) criteria (show table 2) [4,21] . The ICD-10 criteria for HKD are more restrictive than the DSM-IV criteria for ADHD, requiring that at least six symptoms of inattention, at least three symptoms of hyperactivity, and at least one symptom of impulsivity are met in more than one setting (ie, HKD is a subtype of ADHD-C) [21] . HKD is subdivided into HKD with and without conduct disorder. DIFFERENTIAL DIAGNOSIS — The symptoms of ADHD overlap with those of learning disabilities and behavioral and emotional problems such as depression, bipolar disease, anxiety, or post traumatic stress disorder [21-24] . These disorders frequently coexist with ADHD and may or may not be responsible for the symptoms. As an example, children who have learning disabilities may develop inattention as a result of inability to understand new information [25] . The use of broadband behavior scales and psychometric testing may help to differentiate these problems from ADHD. (See "Psychosocial evaluation" below and see "Clinical features and evaluation of learning disabilities in children"). Other conditions to consider in children with symptoms of inattention, hyperactivity, and impulsivity include cognitive problems (mental retardation, fragile X syndrome), environmental factors (eg, stressful home environment, inappropriate educational setting), and various medical conditions such as hearing or visual impairment, diabetes mellitus, lead poisoning, asthma, fetal alcohol syndrome, thyroid abnormalities, sleep disorder, and seizure disorder (show table 3) [26-31] . These conditions usually can be differentiated from ADHD because their symptoms fluctuate with the course of disease. In contrast, the symptoms in ADHD are persistent and pervasive.

EVALUATION Overview — Children who are being evaluated for possible ADHD should undergo comprehensive medical, developmental, educational, and psychosocial evaluation [2,4,8,15,21] . Comprehensive evaluation is necessary to confirm the presence, persistence, pervasiveness, and functional complications of core symptoms (show table 1), exclude other explanations for core symptoms (show table 3), and identify comorbid psychiatric disorders. (See "Diagnostic criteria" above and see "Differential diagnosis" above and see "Comorbid disorders" below). The evaluation should include review of the medical, social, and family histories; clinical interviews with the parent and patient; review of information about functioning in school or daycare; and evaluation for comorbid psychiatric disorders [2,4,8,15,21] . The necessary information may be obtained in several ways, including in-person discussions, questionnaires, and Web-based tools, as described below. The complete evaluation may require several office visits [4] . Safety and injury prevention should be discussed at each visit because children with ADHD or symptoms of ADHD are at increased risk of intentional and unintentional injury compared with children without these symptoms. (See "Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents", section on Injuries). Because the differential diagnosis of ADHD is extensive and because comorbidity is a common finding, children should be reevaluated whenever the symptoms worsen or new symptoms emerge. (See "Differential diagnosis" above and see "Comorbid disorders" below). ADHD Toolkit — The National Initiative for Children's Healthcare Quality (NICHQ), in conjunction with the American Academy of Pediatrics (AAP), has developed a toolkit for primary care practitioners to assist in the evaluation and management of children with ADHD. The toolkit includes information for parents, copies of ADHD-specific questionnaires for parents and teachers, and an initial primary care evaluation form. IT can be downloaded through NICHQ (www.nichq.org/adhd.html, requires registration). Medical evaluation — The medical history should include prenatal exposures (eg, tobacco, drugs, alcohol), perinatal complications or infections, central nervous system infection, head trauma, recurrent otitis media, and medications [4] . Family history of similar behaviors is important because ADHD has a strong genetic component. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on Genetic factors). The examination should include measurement of height, weight, head circumference, and vital signs [4] . Dysmorphic and neurocutaneous findings should be noted. A complete neurologic examination, including assessment of vision and hearing, should be performed. The child's behavior in the office setting should be observed. However, this isolated assessment of behavior should be interpreted cautiously; symptoms of ADHD may not be apparent in the structured setting of the clinic visit [32] .

Developmental and behavioral evaluation — The developmental and behavioral history should include specific information about the onset and course of ADHD symptoms, as well as information regarding psychological, medical, and developmental events that may provide an alternative explanation for the symptoms [4] . Information regarding developmental milestones, particularly language milestones, school absences, and psychosocial stressors, should be obtained. Parent-child interactions should be observed. The behavioral assessment should focus on determining the age of onset of the core symptoms of ADHD, the duration of symptoms, the settings in which the symptoms occur, and the degree of functional impairment [2,4,8] . The information regarding core symptoms can be obtained through the use of open-ended questions or from ADHD-specific rating scales, described below [2] . If open-ended questions are used, the examiner must document the presence of the relative behaviors from the DSM-IV (show table 1). (See "Rating scales" below). Educational evaluation — The educational assessment should focus on documentation of the core symptoms in the educational setting. Information from the school should include completion of an ADHD-specific rating scale and a narrative summary of classroom behavior and interventions, learning patterns, and functional impairment [2] . In addition, copies of report cards and samples of school work should be obtained. (See "Rating scales" below). The pediatric care provider should review the results of school-based multidisciplinary evaluations if such evaluations have been performed [2] . The teachers who provide the information should have regular contact with the child for a minimum of four to six months if they are to comment reliably on the persistence of symptoms. In the United States, schools are federally mandated to perform appropriate evaluations (eg, language, cognitive) at no cost to the family if a child is suspected of having a disability that impairs functioning (eg, ADHD or learning disability). (See "Support services for the care of chronically ill children", section on Education.) Obtaining information about the core symptoms of ADHD from professionals in after-school programs or other structured settings also may be helpful [2] . This information may be particularly useful if discrepancies exist between the parent's and teacher's reports of core symptoms. When such discrepancies occur, environmental factors (eg, different expectations, levels of structure, or behavior management strategies) may be contributing to the symptoms [2] . (See "Differential diagnosis" above). Psychosocial evaluation Rating scales — Various scales have been developed to collect structured observations of behavior (show table 2). These scales should be completed by parents and teachers for diagnosis, during medication titration, and at regular medication follow-up visits. (See "Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents"). ADHD-specific scales — ADHD-specific rating scales (also called narrow-band scales) focus directly on the symptoms of ADHD and can be used to establish the diagnosis of ADHD. The validity of ADHD rating scales in distinguishing children with ADHD

from age-matched control children varies depending upon the age of the child, the scale that is used, and the informant (eg parent, teacher, adolescent) [33] . ADHD-specific rating scales have a sensitivity and specificity of greater than 90 percent when used in an appropriate population [33,34] . However, most of the studies validating the use of rating scales have taken place in referral rather than primary care settings [2] . The NICHQ ADHD toolkit includes the Vanderbilt Assessment Scales, which can be downloaded and printed from the Web site (www.nichq.org/adhd.html, requires registration). The Vanderbilt has been validated in a community setting using longitudinal assessment and follow-up [35] . Broadband scales — Broadband scales assess a variety of behavioral symptoms, including, but not limited to, the core symptoms of ADHD; they assess internalizing and externalizing behaviors other than ADHD. Broadbased scales are not recommended to establish the diagnosis of ADHD because they are less sensitive and specific (<86 percent) than ADHDspecific scales [34] . However, broadband scales can help to identify comorbid conditions or narrow the differential diagnosis [36] . (See "Developmental and behavioral screening tests in primary care" section on Behavioral screening tests). Comorbid disorders — The evaluation should include assessment for comorbid disorders [4,8] . As many as one-half of children with ADHD have one or more comorbid conditions, including oppositional defiant disorder, conduct disorder, depression, anxiety disorder, and learning disabilities [37-39] . The comorbid conditions can be primary or secondary (eg, disorders that are exacerbated by the ADHD). In either case, they require treatment independent of the treatment for ADHD [40] . Oppositional defiant disorder — DSM-IV criteria for oppositional defiant disorder (ODD) include recurrent patterns of negativistic, defiant, disobedient, and hostile behavior toward authority figures [1] , and at least four of the following: - Often loses temper - Often argues with adults - Often actively defies or refuses to comply with adults' requests or rules - Often deliberately annoys people - Often blames others for his or her mistakes or misbehavior - Often is touchy or easily annoyed by others - Often is angry and resentful - Often is spiteful or vindictive In addition, the behavior must cause significant impairment in social or academic functioning, should not occur exclusively in conjunction with a psychotic or mood disorder, and must not meet criteria for a conduct disorder [1] . Children with ADHD-C or ADHD-HI subtypes of ADHD are at increased risk for developing behavior problems, including ODD [41-43] . Their excessive activity, impulsive response style, and disinhibited emotional expression frequently put them in conflict with parents and other

adults. The increased conflict may lead to increased discipline and less positive reinforcement for the child. Under these circumstances, a potentially self-perpetuating pattern of oppositional defiant behavior can emerge. That is, the oppositional acts bring parental attention, which can be reinforcing for the child who rarely receives parental praise [42,44,45] . Conduct disorder — DSM-IV criteria for conduct disorder include a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated [1] . Additional symptoms include: - Aggression to people and animals - Destruction of property - Deceitfulness or theft - Serious violations of rules Anxiety disorder — Anxiety may develop in children with ADHD as a secondary disorder; however, in many cases anxiety appears to be independent of ADHD [37,43] . DSM IV criteria for anxiety disorder include: excessive anxiety and worry (apprehensive expectation), occurring on a majority of days for at least six months, about a number of events or activities (such as school performance) that the child finds difficult to control and is associated with at least one of the following [46] : - Restlessness - Easy fatigability - Difficulty concentrating - Irritability - Muscle tension - Sleep disturbance Depression — Depression is more common in ADHD-I and ADHD-C [47,48] . Children with ADHD and comorbid mood disorder may have family members with a history of major depressive disorder [49] . During adolescence, they are at increased risk for attempting suicide [50-52] . (See "Depression in adolescents: Epidemiology, clinical manifestations, and diagnosis" and see "Epidemiology and risk factors for suicidal behavior in children and adolescents"). Learning disability — Learning disabilities are more common in children with ADHD-I and ADHD-C [47,48] . (See "Clinical features and evaluation of learning disabilities in children"). Psychometric testing — Psychometric testing is not necessary for the routine diagnosis of ADHD and does not distinguish children with ADHD from those without ADHD [8,53] . Nonetheless, psychometric testing is valuable in narrowing the differential diagnosis because the core symptoms of ADHD can be related to delayed processing skills, language disorders, and learning disabilities.

Children with learning, language, visual-motor, or auditory processing problems can be difficult to distinguish from those with ADHD. The problems tend to be pervasive and persistent and can impair academic function through decreased comprehension or excessive frustration. Children with these problems may attempt to avoid tasks through inattention, getting out of their seats, or impulsively guessing at answers. On the other hand, children with ADHD may perform poorly on language and visual-spatial tasks [54-56] , particularly those that require sustained mental effort or are sensitive to impulsive responding (eg, multiple choice formats). Comprehensive neuropsychologic testing may help to clarify the diagnosis. Children with learning, language, visual-motor, or auditory processing problems usually perform poorly only in their particular problem area, whereas children with ADHD may perform poorly in several areas of evaluation. Assessment of verbal and nonverbal/performance skills with an intelligence measure such as the Wechsler Intelligence Scale for Children – Fourth Edition [57] or the Differential Abilities Scale [58] will help to identify language and/or visual-spatial processing deficits. Assessment of academic skills/achievement testing with a tool such as the Wechsler Individual Achievement Test - Second Edition [59] , or the Wide Range Achievement Test - Fourth Edition [60] will help to identify potential learning disabilities. (See "Clinical features and evaluation of learning disabilities in children"). Psychometric testing also can help to identify specific problem areas for children with ADHD, including abstract reasoning, mental flexibility, planning, and working memory, a collection of skills broadly categorized as executive function [12,13,54,61] . Neuropsychological assessment of these skills, as well as direct assessment of attention and behavioral disinhibition, often is desirable to facilitate diagnosis, plan environmental and behavioral interventions, and track progress of treatment [62-65] . Ancillary evaluation — Language, occupational therapy, or mental health evaluation may be necessary, if indicated by the history and physical examination, to evaluate other conditions that are being considered in the differential diagnosis. Similarly, other diagnostic tests (eg, blood lead levels, thyroid hormone levels, genetic testing, neuroimaging, and electroencephalography) are not indicated routinely to establish the diagnosis of ADHD, but may be warranted based upon the history and physical examination findings [2,4,8,66-73] . (See "Differential diagnosis" above). Quantitative EEG (qEEG) is a method of analyzing the electrical activity of the brain to derive quantitative patterns that may correspond to diagnostic information and/or cognitive deficits [74] . Several studies have demonstrated differences in qEEG between groups of children with ADHD and normal children [75-80] . However, these studies are limited by non-random assignment, lack of blinding, failure to consider comorbidities, and/or failure to control for pharmacologic therapy [74,78,81] . In addition, the specificity of the findings for ADHD has not been demonstrated [81] . Although qEEG may prove to be helpful in the diagnosis and/or classification of ADHD in the future, at present, there is insufficient evidence to support its use in clinical populations [78,81] .

INDICATIONS FOR REFERRAL — Evaluation by a pediatric specialist (eg, a psychologist, psychiatrist, neurologist, educational specialist, or developmental-behavioral pediatrician) is indicated for children who are younger than six years of age or in whom the following diagnoses are of concern [2,40] : Mental retardation Developmental disorder (eg, speech or motor delay) Learning disability Visual or hearing impairment History of abuse Severe aggression Seizure disorder Comorbid learning and/or emotional problems Chronic illness that requires treatment with a medication that interferes with learning Children who continue to have problems in functioning despite treatment INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Symptoms and diagnosis of attention deficit hyperactivity disorder in children"). We encourage you to print or e-mail this topic, or to refer patients to our public Web site, www.uptodate.com/patients, which includes this and other topics. SUMMARY AND RECOMMENDATIONS Attention deficit hyperactivity disorder (ADHD) is a behavioral condition with core symptoms of inattention, hyperactivity, and impulsivity. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning. (See "Core symptoms" above). The diagnosis of ADHD requires that the child meet the criteria defined by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (show table 1). (See "Diagnostic criteria" above). The differential diagnosis for ADHD includes other behavioral and emotional conditions, medical, developmental, and environmental problems (show table 3). Most of these conditions may coexist with ADHD and require simultaneous treatment. (See "Differential diagnosis" above and see "Comorbid disorders" above). Evaluation for ADHD requires comprehensive medical, developmental, educational, and psychosocial evaluation to confirm the presence, persistence, pervasiveness, and functional complications of core symptoms (show table 1), exclude other causes of core symptoms (show table 3), and identify comorbid psychiatric disorders. (See "Overview" above). The evaluation for ADHD requires information about the child's behavior in more than one setting (eg, home and school or afterschool program). ADHD-specific behavior scales (show table 2) can be used to gather this information from the parents and teacher(s). (See "Educational evaluation" above and see "Rating scales" above). The evaluation for ADHD should include an assessment for comorbid conditions. (See "Comorbid disorders" above). Psychometric testing is not necessary for the routine diagnosis of ADHD. However, it is valuable in narrowing the differential diagnosis and planning the approach to management. (See "Psychometric testing" above). The evaluation for ADHD does not require blood lead levels, thyroid hormone levels, neuroimaging, or electroencephalography unless these tests are indicated by findings in the clinical evaluation. (See "Ancillary evaluation" above). Children who have been diagnosed with ADHD should be reevaluated whenever the symptoms worsen or new symptoms emerge. (See "Differential diagnosis" above and see "Comorbid disorders" above). REFERENCES Attention-deficit and disruptive behavior disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision, American Psychiatric Association, 2000. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000; 105:1158. Sleator, EK, Ullmann, RK.

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disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry 1991; 148:564. Lam, LT. Attention deficit disorder and hospitalization owing to intra- and interpersonal violence among children and young adolescents. J Adolesc Health 2005; 36:19. Brent, DA, Perper, JA, Goldstein, CE, Kolko, DJ. Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988; 45:581. Nasser, EH, Overholser, JC. Assessing varying degrees of lethality in depressed adolescent suicide attempters. Acta Psychiatr Scand 1999; 99:423. Doyle, AE, Biederman, J, Seidman, LJ, Weber, W. Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit-hyperactivity disorder. J Consult Clin Psychol 2000; 68:477. Aman, CJ, Roberts, RJ Jr, Pennington, BF. A neuropsychological examination of the underlying deficit in attention deficit hyperactivity disorder: frontal lobe versus right parietal lobe theories. Dev Psychol 1998; 34:956. Nigg, JT, Swanson, JM, Hinshaw, SP. Covert visual spatial attention in boys with attention deficit hyperactivity disorder: lateral effects, methylphenidate response and results for parents. Neuropsychologia 1997; 35:165. Purvis, KL, Tannock, R. Language abilities in children with Attention Deficit Hyperactivity Disorder, reading disabilities, and normal controls. J Abnorm Child Psychol 1997; 25:133. Wechsler, D. Wechsler Intelligence Scale for Children: 4th Edition. Harcourt Assessment, Inc., San Antonio, TX 2003. Elliott, C. Differential Ability Scales. The Psychological Corporation, San Antonio, TX 1990. Wechsler Individual Achievement Test-Second Edition. The Psychological Corporation, San Antonio, TX 2001. Glutting, JJ, Wilkinson, GS. Wide Range Achievement Test – 3. Wide Range, Inc., Wilmington, DE, 2006. Rubia, K, Taylor, E, Smith, AB, et al. Neuropsychological analyses of impulsiveness in childhood hyperactivity. Br J Psychiatry 2001; 179:138. Hale, JB, Hoeppner, JA, DeWitt, MB, et al. Evaluating medication response in ADHD: cognitive, behavioral, and single-subject methodology. J Learn Disabil 1998; 31:595. Kempton, S, Vance, A, Maruff, P, et al. Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children. Psychol Med 1999; 29:527. Risser, MG, Bowers, TG. Cognitive and neuropsychological characteristics of attention deficit hyperactivity disorder children receiving stimulant medications. Percept Mot Skills 1993; 77:1023. Tannock, R, Ickowicz, A, Schachar, R. Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. J Am Acad Child Adolesc Psychiatry 1995; 34:886. Dulcan, M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attentiondeficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 1997; 36:85S. Zametkin, AJ, Ernst, M. Problems in the management of attention-deficit-hyperactivity disorder. N Engl J Med 1999; 340:40. Kahn, CA, Kelly, PC, Walker, WO Jr. Lead screening in children with attention deficit hyperactivity disorder and developmental delay. Clin Pediatr (Phila) 1995; 34:498. Gittelman, R, Eskenazi, B. Lead and hyperactivity revisited. An investigation of nondisadvantaged children. Arch Gen Psychiatry 1983; 40:827. Elia, J, Gulotta, C, Rose, SR, Marin, G. Thyroid function and attentiondeficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1994; 33:169. Weiss, RE, Stein, MA, Trommer, B, Refetoff, S. Attention-deficit hyperactivity disorder and thyroid function. J Pediatr 1993; 123:539. Stephen, E, Kindley, AD. Should children with ADHD and normal intelligence be routinely screened for underlying cytogenetic abnormalities?. Arch Dis Child 2006; 91:860. Bastain, TM, Lewczyk, CM, Sharp, WS, et al. Cytogenetic abnormalities in attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2002; 41:806.

Krull, KR, Growge, MR, Strogher, DS. Quantitative Electroencephalography and Neurofeedback. In: Pediatric Neurospsychology Intervention. Hunter & Donders, 2007 (in press). Lazzaro, I, Gordon, E, Li, W, et al. Simultaneous EEG and EDA measures in adolescent attention deficit hyperactivity disorder. Int J Psychophysiol 1999; 34:123. Lazzaro, I, Gordon, E, Whitmont, S, et al. Quantified EEG activity in adolescent attention deficit hyperactivity disorder. Clin Electroencephalogr 1998; 29:37. Chabot, RJ, Merkin, H, Wood, LM, et al. Sensitivity and specificity of QEEG in children with attention deficit or specific developmental learning disorders. Clin Electroencephalogr 1996; 27:26. Snyder, SM, Hall, JR. A meta-analysis of quantitative EEG power associated with attention-deficit hyperactivity disorder. J Clin Neurophysiol 2006; 23:440. Swartwood, JN, Swartwood, MO, Lubar, JF, Timmermann, DL. EEG differences in ADHD-combined type during baseline and cognitive tasks. Pediatr Neurol 2003; 28:199. Kuperman, S, Johnson, B, Arndt, S, et al. Quantitative EEG differences in a nonclinical sample of children with ADHD and undifferentiated ADD. J Am Acad Child Adolesc Psychiatry 1996; 35:1009. Barry, RJ, Clarke, AR, Johnstone, SJ. A review of electrophysiology in attentiondeficit/hyperactivity disorder: I. Qualitative and quantitative electroencephalography. Clin Neurophysiol 2003; 114:171. GRAPHICS DSM-IV criteria for attention deficit hyperactivity disorder Presence of either 1 or 2 1. Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly 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) Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) Is often easily distracted by extraneous stimuli Is often forgetful in daily activities 2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected 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) Often has difficulty playing or engaging in leisure activities quietly Is often "on the go" or often acts as if "driven by a motor" Often talks excessively Impulsivity Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others (eg, butts into conversations or games) Additional criteria Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age seven years. Some impairment from the symptoms is present in two or more settings (eg, at school [or work] and at home). There must be clear evidence of clinically significant impairment in social, academic or occupational functioning. Adapted with permission from American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C., 1994. Copyright © 1994 American Psychiatric Association. Ratings scales in the assessment and monitoring of AD/HD Scales Behaviors Assessed Broad Band Assessment Conners' Rating Scale (revised): Long form Combined measure of oppositional, cognitive problems, hyperactivity, anxiousness/shyness, perfectionism, social problems, psychosomatic illnesses, restlessness/impulsiveness, emotional lability, DSM-IV symptoms scale, DSM-IV inattentive, DSM-IV hyperactive-impulsive Behavior Assessment System for Children* Hyperactivity, aggression, conduct problems, anxiety, depression, somatization, atypicality, withdrawal, attention problems, learning problems, lack of adaptability/social/leadership/study skills

Child Behavior Checklist/Teacher Report Form Somatic complaints, social/thought/attention problems, anxiety/ depression, aggressive/delinquent behavior, withdrawal Narrow Band Assessment ACTeRS: Boys' and girls' form Attention problems, hyperactivity, lack of social skills, oppositional AD/HD Rating Scale Symptoms of AD/HD according to DSM-IV criteria Childhood Attention Problems Scale§ Combined measure of attention problems, impulsivity, hyperactivity Conners' Rating Scale (revised): Short form Combined measure of oppositional, cognitive problems, hyperactivity, AD/HD index BASC Monitor Rating Scale Attention/adaptive problems, hyperactivity, problems with internalizing Disruptive Behavior Rating Scale¥ DSM-IV symptoms of ODD, AD/HD, and CD (parent-form only) Vanderbilt Assessment Scales Symptoms of AD/HD according to DSM-IV criteria; screen for comorbid conditions (oppositional-defiance, conduct, anxiety, depression) Assessment of Medication Side Effects Side Effects Rating Scale¥ Sleeping/appetite problems, staring/daydreaming, withdrawal, anxiety, irritability, somatic complaints, emotional lability, dizziness, tics Data from Conners, CK. Conners' Rating Scales - Revised User's Manual. Multi Health Systems Inc, New York, 1997. * Data from Reynolds, CR, Kamphaus, RW. Behavior Assessment System for Children - Manual. American Guidance Service, Inc, Circle Pine, MN, 1992. Data from Achenbach, TM. Manual for the Child Behavior Checklist. University of Vermont, Department of Psychiatry, Burlington, 1991; and Achenbach, TM. Manual for the Teachers Report Form. University of Vermont, Department of Psychiatry, Burlington, 1991. Data from Ullmann, RK, Sleator, EK, Sprague, RL. Psychopharmacol Bull 1984; 20:160. Data from DuPaul, GJ. J Clin Child Psychol 1991; 20:242. § Data from Edelbrock, C. Child Attention Problems Scale (unpublished manuscript). Penn State University, University Park, 1978. Data from Kamphaus, RW, Reynolds, CR. BASC Monitor for ADHD: Manual and Software Guide. American Guidance Service, Circle Pine, MN 1998.

¥ Data from Barkley, RA, Murphy, KR. Attention Deficit Hyperactivity Disorder: A Clinical Workbook. Guilford Press, New York 1998. Differential diagnosis for attention deficit hyperactivity disorder Developmental Normal variation Mental retardation Giftedness Learning disability Perceptual processing disorder Language disorder Pervasive developmental disorder Emotional/Behavioral Depression or mood disorder Anxiety disorder Oppositional defiant disorder Conduct disorder Obsessive compulsive disorder Post traumatic stress disorder Adjustment disorder Environmental Child abuse or neglect Stressful home environment Inadequate or punitive parenting Parental psychopathology Sociocultural differences Inappropriate educational setting Frequent school absence Medical

Sensory impairments Seizure disorder Sequelae of CNS infection/trauma Fetal alcohol syndrome Fragile X syndrome Lead poisoning Iron deficiency anemia Neurodegenerative disorder Tourette syndrome Thyroid disorder Diabetes mellitus Substance abuse Medication side effects (eg, bronchodilators, corticosteroids, isoniazid, neuroleptics) Undernutrition Sleep disorder Enuresis/encopresis Motor coordination disorder Stereotypic movement disorder Data from: Miller, KJ, Wender, EH. Attention deficit/hyperactivity disorder. In: Primary Pediatric Care, 4th ed, Hoekelman, RA (Ed), Mosby, St. Louis 2001. p.756. Attention-deficit and disruptive behavior disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision, American Psychiatric Association 2000.

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