AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
Practice Parameters for the Assessment and Treatment
of Children, Adolescents, and Adults
with Attention-Deficit/Hyperactivity Disorder
These parameters were developed by Mina Dulcan, M.D., principal author, and the Work Group on Quality Issues: John E. Dunne, M.D., Chair and William Ayres, M.D., past Chair; Valerie Arnold, M.D.; R. Scott Benson, M.D.; William Bernet, M.D.; Oscar Bukstein, M.D.; Joan Kinlan, M.D.; Henrietta Leonard, M.D.; William Licamele, M.D.; and Jon McClellan, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. and Christine M. Miles. The authors wish to thank Diane Schetky, M.D. for her thoughtful review. These parameters were made available to the entire Academy membership for review in October 1997 and were approved by the Academy Council on February 14, 1997. They are available to AACAP members on the World Wide Web (www.aacap.org). The first edition of the these parameters was developed by the AACAP Work Group on Quality Issues chaired by Steven Jaffe, M.D., and was published in Journal of the American Academy of Child and Adolescent Psychiatry 30:i-iii, 1991.
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? 1997 by the American Academy of Child and Adolescent Psychiatry.
AB STRACT
These practice parameters review the literature on children, adolescents, and adults with Attention-Deficit/Hyperactivity Disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. All together they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated at 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement are usually required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms. Key words: attention-deficit/hyperactivity disorder, psychopharmacology, methylphenidate, dextroamphetamine, practice parameter.
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AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
INTRODUCTION
Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders of childhood and adolescence. Recent clinical experience and research document the continuation of symptoms into adulthood. These parameters, therefore, cover the full age spectrum, although far more is known about this disorder in children and adolescents than in adults.
Terms that have been used historically for children with distractibility, impulsivity and usually also overactivity include minimal brain dysfunction/damage (MBD), hyperkinetic reaction, and hyperkinesis. Diagnostic terminology and criteria have changed considerably since the publication of the DSM-III. For purposes of these parameters, however, attention deficit disorder (ADD), attention deficit disorder with hyperactivity (ADD-H), hyperactivity, and attention-deficit/hyperactivity disorder (ADHD) will be considered to be interchangeable, unless specified otherwise. The DSM-III (American Psychiatric Association,1980) term ADD without hyperactivity, the DSM III-R (American Psychiatric Association, 1987) term undifferentiated ADD, and the DSM-IV category ADHD, predominantly inattentive type, are not identical, but are roughly equivalent.
LITERATURE REVIEW
The literature on ADHD is voluminous. Books and journals published from 1985 through the first half of 1996 were reviewed in detail, with older references included where pertinent. An asterisk in the References section marks key references. Completeness of coverage was assured by the search of tables of contents of the 100 journals in the Current Awareness series of Western Psychiatric Institute and Clinic and by National Library of Medicine searches using keywords: ADHD, psychopharmacology, dexedrine, methylphenidate, and pemoline. Finally, the authors drew on their own experience and that of expert colleagues.
DIAGNOSTIC CRITERIA
There are two groups of nine symptoms each: inattention and hyperactivity-impulsivity (subdivided into two groups). Inattention includes failing to give close attention to details or making careless mistakes, difficulty sustaining attention, not listening, not following through, difficulty organizing, avoidance or dislike of sustained mental effort, losing things, easily distracted, and forgetful. Hyperactivity includes six symptoms: fidgety, out of seat, running or climbing excessively, difficulty playing quietly, ?on the go? or as if ?driven by a motor,? and talking excessively. The three impulsivity symptom criteria are: blurting out answers, difficulty awaiting turn, and often interrupting or intruding on others.
ADHD is divided into three types, according to the presence or absence of six or more symptoms in each symptom group. These types are: predominantly inattentive, predominantly hyperactive-impulsive, and combined (both sets of symptoms). At least some symptoms must have been present before the age of seven years. The behaviors used to meet the criteria must be inconsistent with the patient’s developmental level and intellectual ability and have been present for at least six months. Functional impairment must be present in two or more settings, with clinically significant impairment in social, academic, or occupational functioning. By definition, the diagnosis of ADHD cannot be made if the symptoms occur exclusively in the presence of a pervasive developmental disorder, schizophrenia, or other psychotic disorder or if they are better accounted for by another psychiatric disorder.
Signs of ADHD may not be observable when the patient is in highly structured or novel settings, engaged in an interesting activity, receiving one-to-one attention or supervision, or in a situation with frequent rewards for appropriate behavior. Conversely, symptoms typically worsen in situations that are unstructured, minimally supervised, boring, or require sustained attention or mental effort (American Psychiatric Association, 1994). Core deficits include impairment in rule-governed behavior across a variety of settings and relative difficulty for age in inhibiting impulsive response to internal wishes or needs or external stimuli (Barkley, 1994).
ADHD IN CHILDREN AND ADOLESCENTS
ASSESSMENT
The parent interview is the core of the assessment process. It is often difficult to confirm the diagnosis of ADHD by the interview with the child or adolescent alone, since some children and most adolescents with ADHD are able to maintain attention and behavioral control while in the office setting. Many lack insight into their own difficulties and are not willing or able to report them accurately. Both the parent and child interviews are used to rule out other psychiatric or environmental causes of symptoms. Structured interviews of parents may be useful in assuring coverage of ADHD symptoms, or a DSM-IV symptom checklist may be used (Baumgaertel et al., 1995). Standardized interviews of children and adolescents are less useful for ADHD symptoms, but may aid in discovering alternative or comorbid diagnoses. Queries about family history of ADHD, other psychiatric disorders, and psychosocial adversity (e.g., poverty, parental psychopathology or absence, family conflict) are especially important because of their relationship to prognosis (Biederman et al., 1996).
SCHOOL-RELATED ASSESSMENT
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AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
It is essential to obtain reports of behavior, learning, and attendance at school, as well as grades and test scores. A standardized instrument is a convenient method for obtaining this information. Teachers, school social workers, or guidance counselors can provide information on interventions that have been attempted and their results. Psychoeducational testing is indicated to assess intellectual ability and to search for learning disabilities that may be masquerading as ADHD or may coexist with ADHD. Achievement testing will aid in educational planning.
RATING SCALES
Parent and teacher rating scales yield valuable information efficiently (Achenbach, 1991a; Barkley, 1990; Edelbrock and Rancurello, 1985; Edwards et al., 1995). Comparison to normative groups by age and sex can help distinguish normal variants in levels of attention, activity, and impulse control from ADHD. The broad-spectrum scales can also be used to screen for comorbidity. There are many choices (see Barkley, 1990 and Klein et al., 1994, for reviews), but the most commonly used and best normed and validated are the parent-completed Child Behavior Checklist (Achenbach, 1991a; Biederman et al., 1993b), the Teacher Report Form (TRF) of the Child Behavior Checklist (Achenbach, 1991b; Edelbrock et al., 1984), the Conners Parent and Teacher Rating Scales (Conners, 1969; Goyette et al., 1978), the ADD-H: Comprehensive Teacher Rating Scale (ACTeRS) (Ullmann et al., 1985a), and the Barkley Home Situations Questionnaire and School Situations Questionnaire (Barkley, 1990). The CAP (Child Attention Problems) (Barkley, 1990; Barkley et al., 1989) is a brief teacher rating scale derived from the Teacher Report Form of the Child Behavior Checklist (Achenbach, 1991b) that is convenient to use weekly to assess treatment outcome. It covers both overactivity/impulsivity and inattention symptoms. The Conners Abbreviated Teacher Rating Scale (Goyette et al., 1978) was developed to measure drug response. It is not ideal as a diagnostic screen, because it misses children with attention deficits without hyperactivity (Ullmann et al., 1985b) and is overinclusive of aggressive children. The IOWA Conners is a short form that was developed to separate the inattention and overactivity ratings from oppositional defiance (Loney and Milich, 1982; Pelham et al., 1989a). It is useful in following treatment progress in children with both ADHD and ODD. The AD/HD Diagnostic Teacher Rating Scale (ADTRS) uses DSM-IV criteria. Normative data are available (Wolraich et al, submitted). Use of the Academic Performance Rating Scale (DuPaul et al., 1991) ensures that academic achievement is not neglected in favor of behavioral performance.
In the absence of any intervention, rating scale scores tend to decline from the first administration to the second (Milich et al., 1980; Zentall and Zentall, 1986), and then rise with frequent repeated administration (Diamond and Deane, 1990). There appear to be halo and confounding effects between ADHD and aggression. For example, a child who is defiant toward the teacher is more likely to be rated as hyperactive or inattentive, regardless of the level of inattention or activity as measured by trained observers (Abikoff et al., 1993; Schachar, et al., 1986). Regular class teachers rate the same behavior as more hyperactive than do special education teachers (Abikoff et al., 1993).
OBSERVATION
Structured behavioral observation in naturalistic and laboratory settings (Barkley, 1990) may be used, but typically contribute more in measuring medication response (Barkley et al., 1988) than in diagnosis per se. Structured playroom observation may assist in distinguishing among boys who are hyperactive, aggressive, or both (Roberts, 1990). Observational systems have been developed for the classroom, lunchroom, and playground (Atkins et al., 1988, Gadow et al., 1990; 1996). An informal clinical observation of the classroom and a less structured situation, such as the playground or lunchroom, can provide important data regarding the child’s behavior, the teacher’s management style (Vitaro et al., 1995), and the salient characteristics of the social and academic environment.
MEDICAL EVALUATION
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Medical evaluation should include a complete medical history and a physical examination within the past 12 months. A re-evaluation may be indicated if the clinical condition has changed since the previous exam. History should include the patient’s use of prescribed, over-the-counter, and illicit drugs. Vision or hearing deficits should be ruled out. Routine screening for blood lead is likely to have a low yield (Kahn et al., 1995), and the clinical significance of even low lead levels is controversial and confounded by socioeconomic status, home environment, and maternal IQ (Schonfeld, 1993). If clinical or environmental risk factors are present, lead level should be measured, with treatment as necessary. Increased risk of ADHD has been linked to a rare genetic syndrome: generalized resistance to thyroid hormone (Hauser et al., 1993). Thyroid dysfunction does not, however, appear to be more common among clinically referred children with ADHD (Elia et al., 1994; Spencer et al., 1994). Thyroid function tests are indicated only in the presence of suggestive findings on the medical history or physical examination of clinical hypo- or hyperthyroidism, goiter, family history of thyroid disease, or decreased growth velocity. Other possible medical factors predisposing to ADHD include fragile x syndrome, fetal alcohol syndrome, G6PD deficiency, and phenylketonuria. Risk factors, which account for only a small part of the variance, include pregnancy variables such as poor maternal health, young age, use of alcohol, smoking, toxemia or eclampsia, postmaturity, and extended labor. Health problems or malnutrition in infancy appear to contribute. There are no data to support the use of hair analysis, and insufficient data to justify the routine measurement of zinc (McGee et al., 1990).
ANCILLARY EVALUATIONS
Speech and language evaluation may be suggested by the clinical findings. In special circumstances, occupational or recreational evaluation may provide supplementary information regarding motor clumsiness or adaptive skills.
TESTS
ADHD is a clinical diagnosis; there is no test for ADHD. Neuropsychological tests are useful to evaluate specific deficits suggested by history, physical examination, or basic psychological testing, but are not sufficiently helpful for diagnosis of ADHD to be routinely performed (Barkley and Grodzinsky, 1994; Schaughency et al., 1989). Good performance on individually administered testing does not rule out ADHD. EEG or neurological consultation is indicated only in the presence of focal signs or clinical suggestions of seizure disorder or degenerative condition. Although some children with ADHD have impaired motor coordination (Barkley, 1990), the measurement of neurological soft signs is not useful in the diagnosis of ADHD. There are insufficient data to support the usefulness of computerized EEG measures (neurometrics or brain mapping), event-related potentials, or neuroimaging as clinical tools, although they have promise in research (Levy and Ward, 1995).
Computerized tests of attention and vigilance (CPTs) (Barkley, 1990; Conners, 1985; Greenberg and Waldman, 1993; Swanson, 1985) are not generally useful in diagnosis because they suffer from low specificity and sensitivity (Lovejoy and Rasmussen, 1990; Trommer et al., 1988). They are useful, however, as research tools. Behavioral observations while performing the CPT discriminate ADHD children from other groups as well as or better than the CPT scores (Barkley, 1991). The correspondence between impulsive errors on the CPT and behavioral impulsivity has not been established (Abikoff and Klein, 1992). When used for assessment of medication efficacy, the applicability of results to the patient?s natural environment is unproven (Aman and Turbott, 1991; Cohen et al., 1989) or even absent (Elia et al., 1991). CPTs are not consistently sensitive to stimulant effects (Fischer and Newby, 1991). Also, task and contextual factors, such as the presence or absence of an adult, the instructions given to the patient, and the nature of feedback and contingencies, can substantially affect scores (Corkum and Siegel, 1993; Power, 1992). Concerns have been expressed regarding commercial CPT products (Milich et al., 1986a). A variety of techniques for measuring activity level exist (Conners and Kronsberg, 1985; Miller and Kraft, 1994; Teicher, 1996) but are of limited clinical utility, since hyperactivity per se is not typically the source of the most significant impairment (Tryon and Pinto, 1994). Usually, the important variable is not the total amount of activity, but its situational appropriateness. Actometers, actigraphs, and other tools may be useful for research purposes. An index combining characteristics of movement measured by infrared motion analysis and accuracy and variability of response on a CPT accurately distinguished ADHD boys from normal controls (Teicher et al., 1996).