Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: Closing Diagnostic, Communication, and Treatment Gaps

Screening 

The clinician should screen for ADHD as part of any well-child visit or mental health assessment. Screening for ADHD is accomplished by asking specific questions about the major symptoms of the condition (i.e., inattention, impulsivity, and hyperactivity) and determining whether such symptoms cause impairment (Pliszka, 2007). General open-ended questions can include questions about how school is going or whether the child takes advantage of any of the school's support services. The health care provider also can use a screening instrument such as the Pediatric Symptom Checklist, which asks more specific questions (Jellinek et al., 1988). This screening tool is available as a parent checklist for evaluation of younger children or as a youth self-report checklist for evaluation of adolescents. It contains columns corresponding with the frequency (never, sometimes, or often) of specific ADHD symptoms, such as inability to sit still, lack of interest in school, excessive daydreaming, irritability, trouble concentrating, trouble sleeping, unnecessary risk taking, and refusal to share. Screening questions about inattentiveness as well as hyperactivity/impulsivity should be asked by the clinician regardless of the nature of the chief complaint prompting the patient's visit (Pliszka).

Patient evaluation 

Evaluation of the child or adolescent with possible ADHD has many facets. The patient's history is a cornerstone in the diagnostic assessment. Therefore, the evaluation should include detailed interviews with both the child and parents related to ADHD symptoms. Feedback about symptoms in the school setting should be sought from the child's teachers (Langberg et al., 2008, Nass, 2005, Pliszka, 2007).

Interview questions should pertain to symptoms of inattention, impulsivity, distractibility, and hyperactivity both at school and at home (Langberg et al., 2008, Pliszka, 2007). During the interview, the clinician also should perform a mental status examination, assessing appearance, sensorium, mood, affect, and thought processes that might suggest a psychiatric disorder other than ADHD (Pliszka). Interviews with young children can be conducted concurrently with parent interviews in most cases. However, older children and adolescents should be interviewed separately from their parents because they may not reveal significant symptoms (e.g., depression, substance abuse) in the presence of their parents (Goldenring and Cohen, 1988, Goldenring and Rosen, 2004; Pliszka). One method of conducting an adolescent interview is use of the HEADSS approach (Home, Education, Activities, Drugs, Sexuality, Suicide/depression) (Goldenring & Cohen), which has been expanded to HEEADSSS, to include Eating and Safety from injury/violence (Goldenring & Rosen). The questionnaire was designed to help practitioners encourage adolescents to answer tough questions in about 10 to 20 minutes (Goldenring & Cohen; Goldenring & Rosen). Beginning with general open-ended questions about home, school, and general activities helps to build the patient's trust prior to asking questions related to drugs and sexuality. It is important to assure the adolescent that any information revealed is confidential and to make the patient feel comfortable. Asking non-threatening, open-ended questions without assumption as to what is the “normal” response is most effective for obtaining information from an adolescent (Goldenring & Rosen).

The interview with the parents should address all previously mentioned symptoms of ADHD and the duration, frequency, severity, and age of onset for each symptom. Family history and functioning should be assessed because of the significant genetic component in the etiology of this condition (Faraone et al., 2005; Pliszka). If one person in a family is diagnosed with ADHD, there is a 25% to 35% probability that any other family member also has ADHD, compared with a 4% to 6% probability for someone in the general population (Attention Deficit Disorder Association, 1998). Across studies of ADHD in twins, the heritability of the condition was estimated to be 76% (Faraone et al., 2005).

The patient's academic/intellectual progress should be reviewed with special attention to learning disorders because these often are present in children with ADHD. Parents of children with ADHD should complete one of the many standardized behavior rating scales that have well-established normative values for children (Langberg et al., 2008, Pliszka, 2007). It is important to note that information from parents may be influenced by attitudes or stigma associated with an ADHD diagnosis and the potential need for long-term therapy, social background, personal agendas, varying observational skills, and beliefs about the validity of questionnaires used to aid in diagnosis (Nass, 2005, To, 2005). Information from teachers should be considered in light of how well they know the child. Elementary school teachers, who spend the entire day with a child, are likely to provide more relevant information than a high school teacher, who sees the adolescent only for a short time each day (Nass).

The AAP has compiled a “tool kit” for the assessment and management of ADHD; this kit includes several recommended diagnostic tools for use in children with ADHD, including the National Initiative for Children's Healthcare Quality (NICHQ) ADHD Primary Care Initial Evaluation Form, the NICHQ Vanderbilt Assessment Scale–Parent Informant, and the NICHQ Vanderbilt Assessment Scale–Teacher Informant (AAP, 2008). Table 2 summarizes four common behavior rating scales suitable for use in primary care and includes advantages and disadvantages of each (Collett et al., 2003, Woodard, 2006).

Table 2. Comparison of common ADHD rating scales used in primary care

	Scale	Age range	Description	Advantages	Disadvantages
	Connors Rating Scale Revised (CRS-R)	3-17 y	•Based on DSM-IV criteria •Assesses wide variety of common behavior problems (e.g., sleep, eating, peer group problems) •Revised scale updates age- and sex-normative data and factor structure •Available in both short and long, parent, teacher, and self-report versions	•Large normative base •Multiple observer forms •Abbreviated forms aid in treatment monitoring •French version	•Few items regarding comorbidities •Somewhat redundant •Complete version is lengthy
	Brown Attention Deficit Disorder Scale (BADDS) for Children and Adolescents	3-12 y, parent and teacher; 8-12 y, self-report; 12-18 y, self-report	•Unlike other scales based on DSM-IV criteria, BADDS measures executive functioning associated with ADHD •Also measures developmental impairments •Separate rating scales for 3-7 y, 8-12 y, 12-18 y •The scale should be administered in an interview format, especially the parent and youth self-report	•Measures inattentive ADHD •Only scale that accounts for inattentive behavior as a function of age •Strong psychometrics	•Minimal data about use in clinical settings
	Vanderbilt ADHD Rating Scale	6-12 y, parent and teacher forms	•Newer scale based on DSM-IV criteria •Both parent and teacher form •Similar to CRS-R and SNAP-IV •Assesses for comorbidities and school functioning	•Screens for comorbidities (oppositional defiant disorder, anxiety, depression) •Spanish and German versions •Available online •Psychometrically strong scales	•Newer scales that lack sufficient data to establish their validity •Normative data from only one U.S. region •No self-report scales
	Swanson, Nolan, and Pelham IV (SNAP)	5-11 y, parent and teacher rating scale	•One of the first scales based on DSM-IV criteria •Frequently used in ADHD research	•Scoring available online •Same scale used for both parent and teacher •Measures comorbidity	•Lack of published psychometrics and normative data •Brief assessment of comorbidities

ADHD, Attention-deficit/hyperactivity disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Reprinted with permission from Pediatric Nursing Journal, 2006, Volume 32, Number 4, pp. 363-370. Reprinted with permission of the publisher, Jannetti Publications, Inc., East Holly Avenue, Box 56, Pitman, NJ 08071-0056; (856) 256-2300; Fax (856) 589-7463; Web site: www.pediatricnursing.net. For a sample copy of the journal, please contact the publisher.

Because few medical conditions have symptoms similar to those of ADHD, laboratory testing and neurologic imaging generally are not recommended if the patient's medical history is not remarkable (Langberg et al., 2008, Pliszka, 2007). Psychological and neuropsychological tests also are not necessary for many patients with ADHD. However, such tests should be performed if the patient's history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient's overall intellectual ability. For example, if the parent and teacher report that the patient performs at or above grade level when given one-to-one supervision or participates in leisure activities (e.g., reading science fiction novels) requiring a skill that the patient lacks in the school environment, it is likely that treatment of the ADHD will begin to resolve achievement deficits. If academic performance does not show clear improvement in 1 to 2 months despite improvement in ADHD symptoms, then psychological testing for learning disorders is indicated (Pliszka).

Diagnosis of ADHD in the preschool child 

Diagnosis of ADHD in the preschool child may be difficult. Common features of ADHD in this group include aggressiveness, noncompliance, inappropriate and demanding behaviors, a high level of negative social behavior, less adaptive behavior, poor cooperation, dislike by other children, and self-reported friendship difficulties. Preschool children with ADHD also are likely to have comorbid oppositional defiant disorder and language impairment (Armstrong & Nettleton, 2004). It is most important to remember that core symptoms of ADHD in preschool children are essentially the same as those in school-aged children and include higher levels of motor activity, low frustration tolerance impulsivity, inability to sustain attention, distractibility, and poorly organized behavior (Armstrong & Nettleton; Harpin, 2005, Woodard, 2006). However, it should be recognized that many conditions might result in symptoms that overlap with those of ADHD in preschool children. These include a sudden change in the child's life (e.g., the death of a parent or grandparent, parents' divorce, or a parent suddenly becoming unemployed), undetected seizures, such as absence or temporal lobe seizures, a chronic middle ear effusion that causes intermittent hearing problems, medical disorders that may affect brain functioning, underachievement caused by learning disability, and anxiety or depression (National Institute of Mental Health, 2008). Differential diagnosis of ADHD and identification of comorbidities in preschool children with ADHD can be aided by use of specific diagnostic tools for mood and anxiety disorders, such as the Preschool Feelings Checklist (Luby, Heffelfinger, Koenig-McNaught, Brown, & Spitznagel, 2004).

Improving diagnosis of ADHD in adolescents 

Substantial literature exists indicating that the diagnosis of ADHD in adolescents and young adults is more difficult than in younger children (Nahlik, 2004, Weiss and Murray, 2003). In addition to previously mentioned considerations of information obtained from high school versus elementary school teachers and the increased prevalence of psychiatric comorbidities, adolescents may be less forthcoming with information and less willing to cooperate with clinicians (Goldenring & Cohen, 1988; Nahlik). Also, older adolescents may identify problems associated with ADHD (e.g., procrastination, lack of motivation, mood lability, and low self-esteem), rather than the core symptoms, as their primary concern (Nahlik; Weiss & Murray).

Close attention to a number of different factors and use of specific techniques can improve diagnosis of ADHD in adolescents. It is particularly important to be alert for symptoms of inattention, which are more likely to be present than motor restlessness in adolescents with ADHD (Hurtig et al., 2007, Nahlik, 2004, Wolraich et al., 2005). Careful use of input from informants also is important for accurate diagnosis of ADHD in adolescents. Establishing good rapport with the adolescent during the diagnostic process (e.g., through use of the HEADSS approach) is particularly important given the difficulty in gaining good cooperation from these patients (Nahlik). The high risk of comorbidity in adolescents with ADHD makes it particularly important to be attentive to signs of substance abuse, mood and/or anxiety disorders, and high-risk behaviors in these patients (Wolraich et al.).

Many traditional rating scales are based on experience with childhood ADHD and do not take into account relatively subtle symptoms first presenting in adolescence. However, some rating scales are appropriate for evaluation of adolescent patients. These scales include the Brown Attention-Deficit Disorder Scales, the Child Attention Profile, the Connors' Parent Rating Scale–Revised, the DSM-IV-TR behavior checklists, the Attention Problems Scale–Teacher Report Form, the Behavior Assessment System for Children Parent Rating Scale, the Behavior Assessment System for Children Teacher Rating Scale, the Child Behavior Checklist, and the Connors-Wells Adolescent Self-Report Scale (Nahlik, 2004, Wolraich et al., 2005).

Adherence 

Although pharmacotherapy repeatedly has been shown to be effective for the treatment of patients with ADHD, significant problems may be associated with the use of these medications. One of the most important problems is poor adherence (Gau et al., 2006). A large number of reasons exist for poor treatment adherence, including the requirement of multiple daily doses, stigmatization, inconvenience, and diversion and misuse of medication (Gau et al.). Adherence to treatment with pharmacotherapy for ADHD may become more difficult in adolescents than in children, and there is a steady decline in adherence with age (Hazell, 2007). There are many potential reasons for this decline in adherence, including the fact that adolescents have greater control over their treatment than children; embarrassment associated with having to take medication away from home; difficulty in gaining weight (particularly in boys); suppression of spontaneity; and dysphoric effects of treatment (Hazell). Emergence of comorbid depression or anxiety and increased risk of substance abuse also may contribute to lower adherence to therapy in adolescent patients with ADHD (Hazell). Factors that have been shown to be associated with better adherence include a stable family with high caregiver efficacy and satisfaction with medication, absence of oppositional defiant disorder, higher starting dose of medication, and younger age (Faraone et al., 2007, Swanson, 2003, Thiruchelvam et al., 2001).

Many different types of interventions have the potential to improve adherence to therapy in patients with ADHD. For example, it has been shown that behavioral treatment is more acceptable than medication at initial diagnosis, and it may be useful to begin treatment with this approach (Swanson, 2003). Socioeconomic and demographic factors can affect adherence (e.g., adherence is poorer in Black and Asian populations than in the White population) (Faraone et al., 2007), and there is a need for culturally appropriate education targeted to all groups about the risks and benefits of treatment.

Dose optimization 

Nurse practitioners or other clinicians managing the patient with ADHD should carefully follow up with the patient and adjust the dose of medication to optimize outcomes. Once a child responds, there is no universally agreed-upon criterion for how much the symptoms must change before the clinician stops increasing the dose (Greenhill, Pliszka, & Dulkan, 2002). Clinicians should begin with the recommended starting dose according to the prescribing information of the agent used. If symptom control is not achieved, the dose generally should be increased in weekly increments (5-10 mg per dose for methylphenidate or 2.5-5 mg for amphetamines) (Greenhill et al.).

Three approaches are commonly used in clinical practice: prescribe and wait, gradually increase the dose until behavior improves, or increase the dose until adverse effects appear and then reduce the dose to the level before they appeared (Greenhill et al., 2002, Manos et al., 2007). Alternatively, clinicians may elect to use a fixed-dose titration trial in which a full set of different doses is switched on a weekly basis. At the end of the trial, the parent and clinician can meet to decide which dose worked best for the child. The advantage of such a full-dose trial is that a child is less likely to miss a high dose that might yield additional improvement (Greenhill et al.). During the titration process, it is important to gain reliable information about the child's behavior, adverse effects, and treatment efficacy (Manos et al.).

Managing adverse effects 

Although the medications given for ADHD are relatively safe, some potential serious adverse effects need to be considered during treatment. In 2006, the Food and Drug Administration issued warnings involving sudden death with stimulant use in patients with pre-existing heart conditions. While sudden death is a risk in all patients with cardiac abnormalities and related diseases (e.g., hypertension), stimulants can potentiate this effect. However, with proper screening, the risk to the patient can be minimized (U.S. Food and Drug Administration, 2006). Because there is no cost-effective way to identify the few patients with these abnormalities, in-depth cardiovascular screening of all patients is not recommended (Greenhill et al., 2002). The clinician should monitor the patient's blood pressure and heart rate, as well as listen to the heart at every visit. Baseline assessment of family history and symptoms is recommended. Significant family history (e.g., sudden death, cardiac arrhythmias, cardiomyopathy, syncope, and seizures) or symptoms that can indicate a cardiac condition (e.g., syncope, palpitations) warrant evaluation by a pediatric cardiologist (Vetter et al, 2008). In a recent publication, the American Heart Association recommends that because some cardiac conditions associated with sudden death might not be detected with routine physical examination, adding electrocardiography is reasonable (Vetter et al.). Parents and patients also should be advised to notify their health care provider if they experience symptoms indicative of undiagnosed cardiac problems after initiating therapy, such as shortness of breath, syncope, palpitations, or chest pain (U.S. Food and Drug Administration).

Loss of appetite resulting in failure to gain weight normally is an important adverse effect of pharmacotherapy for ADHD (Prince, Jensen, & Vierhile, 2006). Approaches to minimizing the impact of this problem include not forcing the child to eat meals, giving medication with meals, adding calorie-enhancing snacks to the diet, permitting grazing, and packing in calories at the beginning and end of the day (Prince et al.). In addition to weight loss, managing sleep problems that also may occur in patients receiving pharmacotherapy for ADHD includes asking about sleep patterns before starting medications, encouraging a sleep routine and behavior management, and adjusting/adding medications as needed (Prince et al.).

Drug abuse and dependence 

Medications used for the treatment of ADHD have significant potential for diversion and abuse, and this potential has been a concern among those involved in the management of patients with this condition. It has been estimated that abuse and dependence of stimulant medications used to treat ADHD may occur in as many as 20% of patients (Kroutil et al., 2006, Wilens et al., 2006). However, several newer stimulant agents, such as extended-release formulations, have been shown to reduce this abuse potential (Ciccone et al., 2007).

Extended-release formulations minimize the sudden euphoric effect that is attributed to substance abuse potential, which is common with the immediate-release agents (Parasrampuria et al., 2007). Osmotic-release methylphenidate, a newer agent developed for the treatment of patients with ADHD, has been shown to reduce the potential for abuse by approximately 55% secondary to its novel extended-release formulation (Ciccone et al., 2007). In addition, lisdexamfetamine is formulated to not produce high dextroamphetamine levels when injected or snorted and thus may have lower abuse potential compared with conventional stimulants (Madaan, 2008). Therefore, utilizing newer long-acting agents may control the problematic abuse issues associated with this class of medications.

Complementary and alternative approaches to treatment 

A variety of complementary and alternative approaches have been used to manage patients with ADHD. These approaches include dietary supplementation with essential fatty acids or diets free of food additives and sugar, yoga, biofeedback, homoeopathy, massage, and cerebellar training (Bishop, 2007, Rojas and Chan, 2005). Although initial evidence for some emerging complementary or alternative therapies, such as fatty acid supplementation, yoga, massage, homeopathy, and green outdoor spaces, suggest potential benefits as part of an overall ADHD treatment plan, more rigorously designed studies are needed to support their use as effective alternatives to conventional monotherapy (Rojas & Chan).

Combining psychological/behavioral intervention with pharmacotherapy 

Results from the Multimodal Treatment Study of Children with ADHD study showed that careful medication management, which included provisions for support, encouragement, practical advice, educational materials, and dose and medication adjustments based on parent and patient feedback, was significantly superior to standard community care for relieving ADHD symptoms. Most patients receiving community care received ADHD medications (principally one of the stimulants) from their own primary care provider but received no study treatments. Although the addition of behavioral treatment to the medication management program did not result in further significant reductions in ADHD symptoms compared with medication management alone, combined therapy did result in superior reduction in ADHD symptoms compared with behavioral therapy or community care alone (The MTA Cooperative Group, 1999). The results suggest that careful follow-up of patients taking medications, in addition to primarily educational intervention, may provide the best outcomes for patients with ADHD.

Parental education 

Parental education also is an important part of the overall management of the child or adolescent with ADHD. Parents with adolescents who have ADHD should be educated about how to manage ADHD symptoms during a stage of the child's development when the emergence of abstract thinking, development of identity, individualization, risk-taking behaviors, and lability of mood are likely to occur (Prince et al., 2006). The importance of self-esteem during this stage also should be emphasized. A systematic literature review revealed that structured parental education can result in positive and sustained changes in both parental perceptions and objective measures of children's behavior (Barlow & Stewart-Brown, 2000).

Adolescents 

Communication with adolescent patients may be particularly difficult because they often object to treatment of their ADHD (Nahlik, 2004). Communication may be improved by assuring confidentiality, listening carefully to what they say, respecting their opinions, and validating their feelings. It also may be necessary to mediate disputes between parents and adolescent patients and help them achieve acceptable compromises about important issues such as autonomy, driving, and peer relationships. Adherence to pharmacotherapy in adolescent patients with ADHD can be enhanced by explaining the benefits of medication, adverse effects, and the possibility of trials off medications if needed (Prince et al., 2006).

Special populations 

Race and ethnicity are important variables that must be considered for both patients with ADHD and their parents. For example, Black parents may respond differently than White parents to behavioral cues from children and have different beliefs about the etiology of ADHD. They also may fear overdiagnosis or misdiagnosis of ADHD in their children and the associated stigma of mental illness. Black parents may be particularly concerned about the risks of pharmacotherapy for ADHD and are more likely to seek help from family members than from a health care professional (Bailey and Owens, 2005, Guevara et al., 2005, Hillemeier et al., 2007, Starr, 2007). Important sensitivities also exist regarding communication with Hispanic patients and their parents. A high stigma is associated with mental illness in this population, along with a distrust of the medications used for the treatment of ADHD. There also is a preference among some Hispanic groups for self-treatment and a holistic approach to the management of illness (Arcia, Fernández, & Jáquez, 2004; Starr).

Strategies that may be used to overcome cultural barriers to effective communication regarding ADHD include determining parents' expectations regarding their child's behavior at home and school. Gathering information from multiple settings about the child and his or her symptoms, providing education about the diagnosis and treatment of ADHD, and being culturally aware of differences in beliefs and attitudes about diagnosis and treatment will optimize communication and outcomes for families (Rothe, 2005, Starr, 2007).