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Attention Deficit Hyperactivity Disorder (ADHD) - Ongoing Assessment

Overview

Ongoing assessment of children with attention deficit hyperactivity disorder (ADHD) includes monitoring target outcomes and assessing for adverse effects of treatment to guide adjustments in medication and other interventions. Coexisting conditions that may interfere with treatment response should be considered whenever new challenges arise. The American Academy of Pediatrics (AAP) has noted that undertreatment may also be harmful and recommend that children with ADHD need frequent re-evaluation to ensure that treatment is optimal. [Wolraich: 2011]

Screening

The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that screening for major symptoms of ADHD should be part of any mental health assessment. [Pliszka: 2007]

Diagnostic Criteria

DSM-IV criteria for diagnosis of ADHD are detailed on the Initial Diagnosis page.

Pearls And Alerts

When treatment fails or improvement is not sustained, consider that the child is under-treated. Medications should be titrated to maximum doses without adverse side effects instead of relying on milligram-per-killogram recommendations to ensure adequate treatment of symptoms. When improvement is not sustained, consider that the child may not be receiving medication on a regular basis; this may be more common in families where parents also have symptoms of ADHD.[Wolraich: 2011]

When treatment fails, consider a co-morbid condition. Many children with attention deficit hyperactivity disorder (ADHD) have co-morbid conditions, including learning disabilities, mood, anxiety, and behavioral disorders, family dysfunction, and/or Tourette syndrome. For a detailed discussion, see [Pliszka: 2007]. Associated behavioral disorders include oppositional defiant disorder, conduct disorder, and substance abuse. Treatment of ADHD will be less than ideally effective if these conditions are not also treated. The clinician should suspect a co-morbid condition under the following conditions:

  • lack of improvement in behavioral symptoms despite appropriate treatment/services for ADHD
  • persistent school underachievement or school avoidance
  • parental concern for a comorbid condition
  • low self-esteem, anxiety, irritability, sleep disturbance, and/or sadness
  • negative/oppositional behaviors
  • substance abuse
Comorbid conditions vary somewhat by the developmental stage of the child. In early childhood, learning disorders, oppositional defiant disorder, obsessive compulsive disorder, and Tourette syndrome are observed. In late childhood and early adolescence, conduct disorder, bipolar and major depressive disorder, and substance abuse may emerge as well.

Evaluation, diagnosis, and management is a continuous process with frequent evaluation and subsequent changes in management as necessary.[Wolraich: 2011]

History And Examination

Critical components of ongoing assessment include current functioning at home and school and success and/or side effects of treatment methods (behavioral and medication-based).

Interim History

Ask about recent medical problems, growth, appetite, and possible side effects of medication for ADHD. Periodic repetition of behavior scales (see Tools below) completed by parents and teachers or subjective reports can be very helpful. Ask about mood, interactions with peers, adherence to prescribed medication or therapies.

Developmental and Educational Progress

Ask families to bring current school records to evaluate success of treatment. Periodic use of checklists and/or rating scales can assist in guiding therapy adjustments.

Social and Family Functioning

Inquire about behavior and functioning in the home setting and consistency or changes of medication, use of complementary/alternative treatments. Ask about parenting challenges.

Physical Exam

Growth Parameters

Ht | Wt | BMI Because stimulant medications may cause appetite suppression, follow weight closely. Although stimulants may slow height some extent when first started, this effect appears to decrease over time. Eventual height may be minimally reduced with prolonged stimulant use. [Faraone: 2008] [Pliszka: 2006]

Vital Signs

HR | RR | BP Hypertension may be seen, albeit rarely, in individuals treated with stimulant medications.

Testing

Sensory Testing

Routine vision screening and, if indicated, hearing screening are appropriate.

Other Testing

If treatment does not seem to be effective, consider using a validated screening tool to diagnose co-morbid conditions. The following are appropriate for use in primary care settings:

Subspecialist Collaborations and Other Resources

Although a child may be referred to a sub-specialist for assessment, treatment should be in the Medical Home using a chronic care, special health care needs approach with frequent evaluation and changes in management if necessary. [Wolraich: 2011]

Behavioral Pediatrics (see Services below for relevant providers)

Often has experience with more challenging cases and can be helpful for consultation or referral.

Developmental Pediatrics (see Services below for relevant providers)

A referral may be helpful in a child not responding to treatment, particularly when developmental issues are a question.

Child Psychiatry (see Services below for relevant providers)

Particularly helpful when co-morbid conditions, such as mood or anxiety disorders, may be confounding treatment.

Child Psychology (see Services below for relevant providers)

Consider when full psychological testing is not available through the school district and/or if learning disabilities are suspected. May also be helpful in designing and implementing behavioral plans and therapies.

Clinical Classification

The three forms of ADHD in children, as defined by the DSM-IV-TR, have presentations that may vary considerably based on developmental age, severity, environment, co-morbid conditions, and other factors. The forms are:
  • ADHD, inattentive type, where symptoms of inattention are the main problem
  • ADHD, hyperactive-impulsive type, where symptoms of hyperactivity and impulsivity impair functioning
  • ADHD combined type, where symptoms of both inattention and hyperactivity/impulsivity are present
Toddlers with the hyperactive/impulsive type may be constantly physically active, running in circles, and climbing on furniture, whereas adolescents with this type may engage in risky behaviors and sports. Preschoolers with the inattentive type may have difficulty attending to the reading of a picture book, whereas adolescents may have difficulty finishing homework and performing required tasks. It is important to consider developmental age when deciding whether the level of inattentiveness and/or hyperactivity is abnormal. A child with the cognitive level of a 5 year old, although he may be twice that age, usually has the activity level and attention span of a 5 year old.

Medical Conditions Causing Diagnosis

As part of the evaluation of a child with possible ADHD, there are a number of conditions that must be ruled out. These include:
  • Tourette syndrome - ask about a history of waxing and waning tics. See the Tourette Syndrome
  • seizures - particularly absence seizures - Ask about a history of blank stares and interruptions in activity.
  • sleep disorders - Frequent interruptions in sleep due to obstructive or central apnea may lead to symptoms of ADHD. A sleep study may be helpful if sleep problems are a possibility.
  • hyperthyroidism - consider blood testing if other signs of hyperthyroidism are present (increased heart rate and blood pressure, nervousness, irritability, diarrhea)
  • anxiety or depression either chronic or in reaction to a situation in the home or school such as illness in the family
  • underlying autism spectrum disorder - ADHD may overlap with these disorders.
  • fetal alcohol syndrome or other underlying genetic syndrome may present with symptoms of ADHD
  • vision or hearing problems may appear as symptoms of ADHD, especially in young children - Consider testing if there are any concerns.
  • developmental disabilities such as language and learning problems may be confused with ADHD - A psychological assessment may be helpful if these are being considered.
  • children with intellectual disabilities may have attention spans equal to their developmental age.

For more detail, see the Differential Diagnosis section on the Initial Diagnosis page.

Comorbid Conditions

Common disorders that may coexist with ADHD are listed below. The Related Issue pages and other Diagnosis Modules offer additional information on some disorders.

Resources

Information & Support

For Professionals

ADHD Information (Natl. Resource Center on ADHD)
The National Resource Center on ADHD is a cooperative venture of CHADD and the CDC, offering information about all aspects of attention-deficit hyperactivity disorder (ADHD). Services include the ability to email in specific questions.

ADHD resources (Intermountain Healthcare)
A wonderful collection of ADHD-related tools, forms, and patient education materials; available for download; part of Intermountain Healthcare's Mental Health Integration Clinical Program.

For Parents and Patients

Support

CHADD
Children and Adults with Attention Deficit/Hyperactivity Disorder is a national non-profit organization providing education, advocacy and support for individuals with AD/HD. Numerous local chapters can be found through the web site.

General

ADHD (Medline Plus)
Medline Plus is a service of the National Library of Medicine and National Institutes of Health; this Health Topic page provides links to numerous high-quality sources of information about ADHD for patients and their families.

ADHD (Healthy Children)
HealthyChildren.org, developed by the American Academy of Pediatrics; this page links to over 90 articles on the site discussing various aspects of ADHD evaluation and management.

What is ADHD? (KidsHealth)
Sponsored by Nemours Foundation, KidsHealth provides health information for parents, kids, and teens; this is the parent's page on ADHD; see the tabs at the top for the pages focused on kids and teens.

Practice Guidelines

Brown RT, Amler RW, Freeman WS, Perrin JM, Stein MT, Feldman HM, Pierce K, Wolraich ML.
Treatment of attention-deficit/hyperactivity disorder: overview of the evidence.
Pediatrics. 2005;115(6):e749-57. PubMed abstract / Full Text

Pliszka S.
Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. PubMed abstract

Subcommittee on Attention-Deficit/Hyperactivity Disorder Committee on Quality Improvement.
Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder.
Pediatrics. 2001;108(4):1033-44. PubMed abstract

Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text

Tools

Caring for Children with ADHD Toolkit (AAP)
A toolkit for clinicians from the American Academy of Pediatrics. Can be ordered (cost is reduced for AAP members) from the linked-to page. Members may download the components of the Toolkit at no charge from the Member Center. The Toolkit contains: Diagnosis - checklists for teachers and parents, and diagnostic tools for clinical use. Treatment - guidelines for therapy plans, setting treatment goals, medication dosing. Parent Information and Support - "Understanding ADHD" booklet, information about school issues, other parenting resources. Resources - Information on coding, billing, and reimbursement, Internet resources for parents, teachers, and clinicians.

Conners 3rd Edition ADHD Assessment (Pearson)
Conners 3rd Edition ADHD Assessment may be obtained from this and other websites, usually at some cost. To be administered to parents and teachers of children and Adolescents 6-18 years old; Self-report, 8-18 years old.

Pediatric Symptom Checklist (Bright Futures)(PDF Document 47 KB)
A free psychosocial screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a checklist for parents or youth to complete and scoring instructions.

The Achenbach Child Behavior Checklist
A variety of screening tools are available, including the basic checklist forms.

Vanderbilt Scales (Bright Futures)
The parent and teacher Vanderbilt scales may be downloaded for free from the Bright Futures website.

Services

Behavioral Pediatrics

See all Behavioral Pediatrics services providers (6) in our database.

Child Psychiatry

See all Child Psychiatry services providers (15) in our database.

Child Psychology

See all Child Psychology services providers (59) in our database.

Developmental Pediatrics

See all Developmental Pediatrics services providers (4) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

PubMed search on ADHD

Waxmonsky J.
Assessment and treatment of attention deficit hyperactivity disorder in children with comorbid psychiatric illness.
Curr Opin Pediatr. 2003;15(5):476-82. PubMed abstract

Reiff MI, Stein MT.
Attention-deficit/hyperactivity disorder evaluation and diagnosis: a practical approach in office practice.
Pediatr Clin North Am. 2003;50(5):1019-48. PubMed abstract

NIH Consens Statement.
Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD).
NIH Consens Statement. 1998;16(2):1-37. PubMed abstract / Full Text

Spencer T, Biederman J, Wilens T.
Attention-deficit/hyperactivity disorder and comorbidity.
Pediatr Clin North Am. 1999;46(5):915-27, vii. PubMed abstract

Authors

Author: Lynne M Kerr, MD, PhD - 5/2009
Contributing Author: Robyn Nolan, MD - 9/2010
Reviewing Author: Jeffrey Schmidt, MD - 9/2010
Content Last Updated: 10/2011

Page Bibliography

Faraone SV, Biederman J, Morley CP, Spencer TJ.
Effect of stimulants on height and weight: a review of the literature.
J Am Acad Child Adolesc Psychiatry. 2008;47(9):994-1009. PubMed abstract

Pliszka S.
Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. PubMed abstract

Pliszka SR, Matthews TL, Braslow KJ, Watson MA.
Comparative effects of methylphenidate and mixed salts amphetamine on height and weight in children with attention-deficit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry. 2006;45(5):520-6. PubMed abstract

Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text