ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
DSM-IV-TR Diagnostic Codes: 314.00; 314.01; 314.9
The following guidelines are to be considered within the context of the patient’s cultural, ethnic,
and spiritual values in order to maximize the accuracy of the diagnosis, the effectiveness of the
treatment, and the best possible outcomes for the patient and his/her family.
Diagnostic Guidelines:
1. Establish diagnostic accuracy as defined in DSM-IV-TR.
• onset of symptoms in childhood
• significant impairment in social, academic, or occupational functioning
• impairment from symptoms present in 2 or more settings
• three different subtypes; individuals presenting with symptoms of one subtype may
look behaviorally very different from those presenting with symptoms of another
subtype
2. Practitioner should conduct a comprehensive evaluation consisting of the following elements:
• clinical interview with parents
• clinical assessment of child or adolescent
• medical examination or information
• teacher(s) reports and review of school records
• behavior rating scale(s)
3. Routine use of psychological testing in the assessment of ADHD is not medically necessary
and the results of psychological testing do not confirm the diagnosis of ADHD. However,
psychological testing that assesses intellectual and academic functioning may be useful in
some cases to clarify the nature and impact of cognitive deficits and assist providers in
making appropriate treatment recommendations and interventions. It should be noted that
these tests are frequently outside of the approved mental health benefits.
4. Comorbidity with other behavioral, emotional, and academic problems is common.
Practitioners need to take this fact into account in making a differential diagnosis and in
developing treatment plans. Most frequent comorbid conditions include:
• Oppositional Defiant Disorder
• Conduct Disorder
• Mood Disorders
• Anxiety Disorders
• Learning Disabilities
• Substance Abuse Disorder
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•
Antisocial Personality Disorder (adults)
5. Consider cultural, age and gender issues. In particular, diagnosis is difficult in children
younger than age 4 due to wide variability in the characteristic behavior of preschoolers.
Symptoms are most pronounced in school-aged children, with inattention affecting academic
performance and impulsivity leading to breaking of rules and difficulty adhering to limits.
Overt symptoms usually become less conspicuous as children mature into early adolescence.
The disorder is much more prevalent in males than females.
Treatment Guidelines:
1. Given that there are many associated problems and high prevalence of comorbidity, a
multimodal approach to treatment of ADHD should be considered. Intervention strategies
might include elements from the following areas:
•
•
•
•
education about the disorder and parent training
medication
specific educational programs or behavioral interventions
individual, group and/or family therapy
2. Treatment planning considerations must take into account the course of the disorder, phase of
treatment, age of the patient, intellectual and academic issues, and family dynamics. If not
initially seen by a psychiatrist, a medication evaluation should take place within 60 days of
initial diagnosis. If there is a lack of response, or side-effects to treatment with medications,
then a consultation with a child psychiatrist or a general psychiatrist with child training or
experience is recommended.
3. Before pursuing specific interventions, clinicians must help both the individual with ADHD
and their family to understand the nature of the disorder, the specific goals of treatment, and
the effectiveness of various interventions.
4. Due to the chronic, pervasive nature and unremitting course of ADHD, two distinct phases of
treatment must be distinguished, each with differing goals and treatment emphases: Initial
Treatment Phase and the Continuation / Maintenance Treatment Phase.
5. Initial Treatment Phase:
Goal:
to select and implement intervention strategies that are likely to improve the
symptoms and functioning of children and adolescents with the disorder.
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Treatment Components:
a. Education about ADHD and parent training in behavioral management
• important intervention both to increase knowledge, understanding, and
management of ADHD, and facilitate parental adjustment to having a child
with the disorder
• parents can receive educational sessions or participate in structured program
in behavior management, depending on severity of symptoms, associated
problems and level of parental knowledge
• consider organized parent support groups or associations (e.g., CHADD)
• “patient education” important in helping children and adolescents with ADHD
cope effectively with symptoms and consequences of disorder
b. Medication
• pharmacological intervention is an essential element of overall treatment,
unless there is a very mild disorder or other circumstances contraindicate
medication use.
• stimulant medications and new non-stimulant medications represent most
appropriate and most frequently indicated treatment
• providers should carefully assess all individuals for response to the
medication, necessary titration of the medication, and potential side effects
• in cases where the individual is either non-responsive or demonstrate
significant side effects to one stimulant, experience indicates that positive
effects may still be achieved with other stimulant medications; non-stimulant
medications are now available for consideration as well
• other types of medications (e.g., antidepressants) have been used to treat
comorbid conditions
•
particularly complicated or complex cases (e.g., associated psychiatric
conditions) may best be treated by a child/adolescent psychiatrist rather than a
pediatrician or family practice physician
c. Educational interventions and programs are important in order to respond to the
frustration and failure in the classroom often experienced by youngsters with ADHD.
Suggestions include:
• conveying results and recommendations of assessment evaluations to teachers
and other educational specialists to influence them to target appropriate
academic and behavioral programs and resources to the child
• encouraging parents to become knowledgeable about various federal and state
laws and regulations that may help them secure appropriate resources or
placements for their child
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•
•
•
providing parents and/or school personnel with knowledge and materials
regarding appropriate classroom structure
training child in organizational and time management skills
maintaining periodic contact with school personnel
d. Therapy
• not all children with ADHD will need therapy; comprehensive assessment
should identify specific problems and deficits that may need management or
remediation through therapy
• modalities may include behavior therapy, individual and/or group therapy for
child, individual therapy for parent where parental psychopathology may
undermine or impede child’s progress in treatment, or family therapy where
significant problems exist in communication, relationships or parenting
practices
6. Ordering/Sequencing of Treatments
•
•
•
•
•
pharmacological treatment is generally indicated indicated in cases where ADHD has
been diagnosed
psychosocial interventions in conjunction with medications produce a better outcome
than either modality alone
where ADHD is comorbid with another disorder, nature of comorbid condition may
influence ordering of treatment
where ADHD is comorbid with another psychiatric disorder, some form of concurrent
psychotherapy is usually indicated
where parental or family dysfunction may impede progress in treatment, some form
of concurrent psychotherapy for parent(s) or family therapy is warranted
7. Continuation or Maintenance Treatment Phase
•
•
•
Goal: to preserve and build upon progress or improvements achieved during the
initial treatment phase
multimodal approach implemented during initial treatment phase should be
continually evaluated, and medication doses should be regularly monitored for
effectiveness and continued response to treatment.
Note: Alternative treatment strategies such as Neurofeedback, Biofeedback, and EEG
monitoring in the treatment of ADHD, have not been clinically evaluated sufficiently
to reach an accepted national standard of practice at this time.
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References:
Anderson J.C., Williams S., McGee R. & Silva P.A. (1987). DSM-III disorders in preadolescent
children: Prevalence in a large sample from the general population. Archives of General
Psychiatry, 44: 69-76.
Barkley R.A. (1990). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and
Treatment. New York: The Guilford Press.
Biederman J., Farone S.V., Milberger S., et al. (1996) Predictors of persistence and remission of
ADHD into adolescence: Results from a four- year prospective follow-up study. Journal
of the American Academy of Child and Adolescent Psychiatry. 35:3, 343-351.
Biederman J., Newcorn J. & Sprich S. (1991). Comorbidity of attention deficit
hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American
Journal of Psychiatry, 148: 564-577.
Gordon, M. (1995) How to Operate an ADHD Clinic or Subspecialty Practice. DeWitt, NY: GSI
Publications, Inc.
Hinshaw, S.P. (1994). Attention Deficits and Hyperactivity in Children. Thousand Oaks, CA:
Sage Publications.
March J.S., Wells K. & Conners C.K. (1996). Attention- deficit/hyperactivity disorder: Part II.
Treatment strategies. Journal Practical Psychiatry and Behavioral Health, 23-32.
Richters J.E., Arnold L.E., Jensen P.S., et al. (1994). NIMH collaborative multisite multimodal
treatment study of children with ADHD: I. Background and rationale. Journal of the
American Academy of Child and Adolescent Psychiatry. 34:8, 987-1000.
Szatmari P., Offord D.R. & Boyle M.H. (1989) Ontario child health study: Prevalence of
attention deficit disorder with hyperactivity. Journal of Child Psychology and Psychiatry.
30, 19-230.
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Appendix A
ADHD Diagnosis and Treatment for Adults
Interest has been growing among both clinicians and researchers concerning the assessment and
treatment of ADHD in adults. Heightened public awareness of the disorder and its myriad
effects have led increasing numbers of adults to seek professional evaluation to confirm whether
or not they suffer from ADHD. Adults with ADHD often suffer from a lack of organization,
frustration, and feelings of failure. The following guidelines highlight various considerations in
the process of assessing and treating adults with ADHD
Assessment
•
Symptoms of ADHD in adults may be manifested differently than in children or adolescents.
Although manifestations of ADHD are typically present before the age of 7, delayed or
missed diagnoses are not unusual.
a) Inattention may be manifested through: difficulty in completing projects; inconsistent
work performance; trouble maintaining an organized living or work space; etc.
b) Hyperactivity or impulsivity may be manifested through: inability to relax or persist in
sedentary activities; restlessness or other motor overactivity; difficulty delaying
gratification; excessive seeking of stimulation; etc.
•
Differential diagnosis is particularly challenging.
a) Individuals with established ADHD in childhood or adolescence are at greater risk for
developing concurrent disorders later (e.g., mood disorders, substance abuse, antisocial
personality disorder)
b) Smptoms of disturbed attention and problems in organization may be present in many
different disorders, either psychiatric or medical
c) An individual with a history of childhood or adolescent ADHD may present with
symptoms of another disorder, which may or may not be related to ADHD, depending in
part upon whether the ADHD persisted into adulthood or resolved at an earlier age.
•
Components of an evaluation for ADHD in adulthood should include a clinical interview
with the individual, as well as with spouse or significant other. In addition, other components
might include:
a) adult behavioral rating scales (e.g., ADHD Adult Rating Scale)
b) previous school records and report cards (when available)
c) records of previous psychiatric evaluations or treatment, especially in childhood (when
available)
d) interview with the individual's parent (if possible)
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e) selected tests to assess attention, memory and academic achievement (e.g., Wender Utah
Rating Scale)
•
In cases where substance use and/or abuse is suspected to be causing or exacerbating
presenting symptoms, it is advisable that the individual undergo a comprehensive chemical
dependency evaluation.
Treatment
•
There is evidence that pharmacological interventions (particularly with stimulants) may
improve symptoms and functioning in some adults with ADHD.
•
Individuals recommended for pharmacotherapy should first undergo a physical examination.
•
It is necessary to treat severe psychiatric conditions (e.g., mood or anxiety disorders,
substance abuse) prior to or concurrent with initiating a treatment strategy targeting ADHD.
•
Abstinence from alcohol, drugs, and cigarettes may lead to a remission of ADHD symptoms,
particularly in the withdrawal phase.
•
Co-occurring substance abuse raises issues. For individuals with a substance abuse history
and/or higher substance abuse potential, treatment with antidepressants (rather than
stimulants) may be preferable. In addition, where ADHD in the presence of Substance
Abuse, the Substance Abuse treatment may be compromised because of the inattention,
impulsivity and continued lack of self-confidence related to the ADHD.
•
Psychological and psychosocial treatments, emphasizing educational and behavioral
approaches, may be beneficial as an adjunct to medication therapy. Areas of focus may
include:
-
life management skills (e.g., organization, time management, etc.)
anger management
stress management
symptom management
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References:
Acenbach T.M., Howell C.T., McConaughy S.H., & Stanger C. (1995). Six-year predictors of
problems in a national sample: III. Transitions to young adult syndromes. Journal of the
American Academy of Child and Adolescent Psychiatry, 34: 658-669.
Barkley R.A., Fischer M., Edelbrock C.S. & Smallish L. (1990) The
adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year
prospective follow-up study. Journal of the American Academy of Child and Adolescent
Psychiatry. 29, 546-557.
Biederman J., Faraone S.V., Spencer, T., et al. (1993). Patterns of psychiatric comorbidity,
cognition, and psychosocial functioning in adults with attention-deficit hyperactivity
disorder. American Journal of Psychiatry, 150: 1792-1798.
Mannuzza S., Klein R.G., Bessler A., et al. (1993). Adult outcomes of hyperactive boys:
Educational achievement, occupational rank, and psychiatric status. Archives of General
Psychiatry, 50: 565-576.
Murphy K. (1994). Guarding against overdiagnosis of ADHD in adults. The ADHD
Report, 2:6, 3-4.
Wilens T.E., Spencer T., Biederman J. (1994) Role of medication in the
treatment of adult attention deficit disorder. In K.G. Nadeau (Ed.) Attention Deficit
Hyperactivity Through the Lifespan. New York: Brunner/Mazel.
Wilens, T.E., Biederman J, and Spencer TL. ADHD across the lifespan. Annual Review of
Medicine. 2002: 53: 113-131
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Appendix B
ADDITIONAL RESOURCES
Below is a listing of various resources to assist parents, teachers, and individuals in living with
and managing ADHD.
1)
Information Sources and National Organizations
Children and Adults with Attention Deficit Disorder (C.H.A.D.D.)
8181 Professional Place, Suite 201
Landover, MD 20785
Ph (8005) 233-4050
FAX (301) 306-7090
C.H.A.A.D. is a national nonprofit organization of parents, health care professionals, and
educators whose mission is to better the lives of individuals with ADD and those who care for
them. C.H.A.A.D. currently has over 30,000 members organized in over 600 local and state
chapters. The organization accomplishes its mission through family support and advocacy,
public and professional education, and encouraging scientific and educational research.
Attention Deficit Disorder Association (ADDA)
P.O. Box 972
Mentor OH 44061
Ph (800) 487-2282 - Support Group Referral and General Information Line
Attention Deficit Information Network (AD-IN)
475 Hillside Avenue
Needham, MA 02194
Ph (617) 455-9895
Both ADDA and AD-IN serve as information and referral networks for assisting individuals,
parents, teachers, and mental health professionals in locating various resource materials on
ADHD (e.g., books, manuals, other printed material, videos, etc.) and identifying local support
groups or networks in a given area.
Chesapeake Institute - ADD Resource Bank
1000 Thomas Jefferson St., NW, Suite 400
Washington, D.C. 20007
Ph (202) 342-5600
FAX (202) 944-5454
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Information Sources and National Organizations (cont.)
The Chesapeake Institute has a contract to disseminate various materials from the U.S.
Department of Education's comprehensive review of ADHD research. As part of this project,
they have produced a very helpful and comprehensive resource directory entitled "Where Do I
Turn? A Resource Directory of Materials About Attention Deficit Disorder"
Exceptional Children's Assistance Center (ECAC)
P.O. Box 16
Davidson, NC 28036
Ph (800) 962-6817
ECAC is a federally funded program to aid families of children with special needs. They offer
referrals, parent and individual educational information, an ADD packet, a newsletter, lending
library and other information.
2)
Books & Manuals (unless otherwise noted, all books and manuals are available from
the ADD Warehouse at 1-800-233-9273)
General References
Barkley, R.A. (1995) Taking Charge of ADHD. New York: Guilford Press.
Barkley, R.A. (1990) Attention-Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment. New York: Guilford Press.
Barkley, R.A. (1987) Defiant Children: A Clinician's Manual for Parent Training.
New York: Guilford Press.
Brigham, T.A. (1988) Working with Troubled Adolescents: A Self-Management
Program. New York: Guilford Press.
Coleman, W.S. Attention Deficit Disorders, Hyperactivity, and Associated Disorders:
A Handbook for Parents and Professionals. (Available from Calliope Books, 2115
Chadbourne Avenue, Madison, WI 53705).
Copeland, E.D. Medications for Attention Disorders and Related Medical Problems.
Fontenelle, D.H. (1992) Are You Listening? Attention Deficit Disorders. New Jersey:
Prentice Hall.
Forehand, R. & McMahon, R. (1981) Helping the Noncompliant Child: A Clinician's
Guide to Parent Training. New York: Guilford Press.
Fowler, M.C. (1990) Maybe You Know My Kid: A Parent's Guide to Identifying,
Understanding, and Helping Your Child with ADHD.
Friedman, R.J. & Doyal T. Attention Deficit Disorder and Hyperactivity.
Garber, S. & Spizman, M.R. If Your Child is Hyperactive, Impulsive, Distractible...
Goldstein, S. & Goldstein, M. (1990) Managing Attention Disorders in Children: A Guide for
Practitioners. New York: Wiley.
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Gordon, M. (1990) ADHD/Hyperactivity: A Consumer's Guide. (Available from GSI
Publications, P.O. Box 746, DeWitt NY 13214).
Greenberg, G.S. & Horn, W.F. (1991) Attention Deficit Hyperactivity Disorder:
Questions and Answers for Parents. Champaign, IL: Research Press.
Hinshaw, S.P. (1994) Attention Deficits and Hyperactivity in Children. Thousand Oaks,
CA: Sage.
Ingersoll, B. (1988) Your Hyperactive Child: A Parent's Guide to Coping with ADD.
Ingersoll, B. & Goldstein, S. Attention Deficit Disorder and Learning Disabilities:
Realities, Myths, and Controversial Treatments.
Latham, P. & Latham, P. ADD and the Law. Washington, D.C: JKL Communications.
Michelson, L., Sugai, D.P., Wood, P. & Kazdin, A.E. (1983) Social Skills Assessment
and Training with Children: An Empirically Based Handbook. New York: Plenum.
Parker, H.C. (1988) The ADD Hyperactivity Workbook for Parents, Teachers and Kids.
Patterson, G.R. (1982) Coercive Family Processes. Eugene, OR: Castalia.
Phelan, T. Hyperactivity and Attention Deficit Disorders.
Quinn, P.O. The College Student with ADD. New York: Magination Press.
Smith, S. Succeeding Against the Odds: How the Learning Disabled Can Realize Their
Promise.
Taylor, E.A. (Ed) (1986) The Overactive Child. Philadelphia: J.P. Lippincott.
Weiss, G. & Hechtman, L. (1993) Hyperactive Children Grown Up.
Weiss, L. Attention Deficit Disorder in Adults.
Wender, P.H. (1995) ADD in Adults. New York: Oxford University Press.
Wender, P.H. (1987) The Hyperactive, Child, Adolescent, and Adult.
Books for Children and Adolescents with ADHD
Galvin, M. Otto Learns About His Medication.
Gehret, J. Eagle Eyes: A Child's View of Attention Deficit Disorder.
Gordon, M. Jumpin Johnny Get Back to Work: A Child's Guide to ADHD/Hyperactivity.
(Available from GSI Publications, P.O. Box 746 DeWitt NY 13214).
Gordon, M. (1992) I Would if I Could: A Teenager's Guide to ADHD/Hyperactivity.
(Available from GSI Publications, P.O. Box 746, DeWitt NY 13214).
Gordon, M. My Brother's A World-Class Pain: A Sibling's Guide to ADHD (Available from GSI
Publications, P.O. Box 746, DeWitt NY 13214).
Kelly, K. & Ramundo, P. You Mean I'm Not Lazy, Stupid, or Crazy.
Moss, D.M. (1989) Shelly the Hyperactive Turtle.
Nadeau, K. A Survival Guide for High School and College Students with ADD. New
York: Magination Press.
Nadeau, K. & Dixon, E. Learning to Slow Down and Pay Attention.
Quinn, P.O. & Stern, J. Putting on the Brakes.
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Parenting the ADHD Child
Anderson, C. & Anderson, H. Negotiating the Special Education Maze.
Canter, L. Assertive Discipline for Parents. New York: Harper & Row Publishers.
Clarke, L. (1989) S.O.S.: Help for Parents.
Copeland, E. & Love, V. Attention, Please! A Comprehensive Guide for Successfully
Parenting Children with Atttention Deficit Disorders and Hyperactivity.
Goldstein, S. & Goldstein, M. (1992) Hyperactivity: Why Won't My Child Pay Attention.
Goldstein, S. & Goldstein, M. A Parent's Guide: Attention Deficit Hyperactivity Disorder
in Children.
Maxey, D.W. (1989) How to Own and Operate an Attention Deficit Kid. (Available from
HADD, 4231 Colonial Ave., SW, Building E, Suite 6, Roanoke, VA 24018).
McNamara, B. & McNamara, F. Keys to Parenting a Child with ADD. Barron's
Educational Series.
Phelan, T. 1-2-3: Magic: Training Your Preschooler and Preteen to Do What You Want
Them to Do.
Robin, A.L.. & Foster, S.L. (1989) Negotiating Parent-Adolescent Conflict: A
Behavioral Family Systems Approach. New York: Guilford Press.
Sloane, H. The Good Kid Book: How to Solve the 16 Most Common Behavior Problems.
Umansky, W. & Smalley, B.S. (1994) ADD: Helping Your Child. New York: Warner.
Teacher References
Canter, L. & Housner, L. Homework Without Tears. New York: Harper & Row Publishers.
Copeland, E. & Love, V. Attention without Tension.
Goldstein, S. & Goldstein, M. Teacher'ss Guide: Attention Deficit Hyperactivity Disorder
in Children.
Gordon, S.B. & Asher, M.J. (1994) Meeting the ADD Challenge: A Practical Guide
for Teachers. Champaign, IL: Research Press.
Levine, M. (1990) Keeping Ahead in School.
McCarney, S.B. The Attention Deficit Disorders Intervention Manual. (Available from
Hawthorne Educational Services, P.O. Box 7570, Columbia MS 65025).
Paine, S. Structuring Your Classroom for Academic Success.
Parker, H.C. (1992) ADAPT: Attention Deficit Accomodation Plan for Teaching.
Parker, H.C. (1992) The ADD Hyperactivity Handbook for Schools.
Rief, S. How to Reach and Teach ADD/ADHD Children.
Riegel, H. Beyond Maladies and Remedies.
Shapiro, E.S. & Cole, C.L. (1994) Behavior Change in the Classroom: Self-Management
Interventions. New York: Guilford Press.
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