How Do You Know if It’s Attention Deficit/Hyperactivity Disorder?

Primary care doctors have a brand-new set of tools to help them screen school-age youngsters for attention deficit/hyperactivity disorder, a growing diagnosis that some experts say is too easily slapped on kids who misbehave.

The American Academy of Pediatrics, the nation’s largest pediatric group, last week issued guidelines to help distinguish attention deficit/hyperactivity disorder from other problems among children ages 6 to 12.

The guidelines ask doctors to do more than “take a patient history from a parent and say: ‘This sort of looks like ADHD,’ ” said Dr. James M. Perrin, a co-author of the guidelines and an associate professor of pediatrics at Harvard Medical School. “We’re asking them to be much more specific and precise, to start listing the actual behaviors and make sure they do meet criteria of ADHD.”

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The academy targeted pediatricians and family practitioners, the front-line doctors responsible for 60% to 70% of diagnoses of attention deficit/hyperactivity disorder and the majority of prescriptions for often-controversial medications said to help hyperactive kids focus better. Many of the children, for instance, take the stimulant Ritalin. (Little is known about its effects on preschoolers, who are also increasingly being given the drug.)

“One of the reasons we developed these guidelines is there were a lot of real strong requests from the practicing community to have better advice on how to make this diagnosis much more accurately and reliably,” Perrin said.

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The diagnostic guidelines will be followed by a set of treatment guidelines in late 2000 or early 2001, he said.

The directions, based on a review of the best-available scientific studies, were three years in the making, said Dr. Martin T. Stein, a co-author and pediatrics professor at UC San Diego. He said the treatment guidelines, devised by the same group of experts, will offer options such as behavioral management, making changes in the child’s environment and medications.

Perrin said the guidelines are meant to curb over- and under-diagnosis. Some children are being inappropriately diagnosed with attention deficit/hyperactivity disorder when they may simply be unruly; others who could benefit from professional attention are falling through the cracks of the medical system.

Studies indicate that 4% to 12% of school-age children have attention deficit/hyperactivity disorder, which Perrin said amounts to about 2 million to 2.5 million cases. Diagnoses among boys outnumber those among girls by 5 to 1, perhaps because boys more often demonstrate hyperactive behavior like jumping up in class or striking their peers. Girls more often have a problem with inattention, which is less likely to be recognized as attention deficit/hyperactivity disorder.

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According to the new guidelines:

* Doctors should routinely pursue an evaluation of attention deficit/hyperactivity disorder in children 6 to 12 who exhibit signs of a short attention span, hyperactivity, impulsiveness, difficulty focusing on schoolwork or other tasks, academic underachievement or an inability to sit still.

* A diagnosis of attention deficit/hyperactivity disorder requires the child’s symptoms to occur in at least two settings--such as home and school--and interfere with the child’s academic or social functioning for at least six months. The symptoms must also meet criteria established in the diagnostic manual of mental disorders developed by the American Psychiatric Assn.

* Establishing a diagnosis of attention deficit/hyperactivity disorder requires that parents or other caregivers as well as teachers or school professionals provide direct evidence of the major symptoms, as well as the age at which they began, their duration and the degree to which the child’s functioning is impaired.

* An evaluation should include an assessment for associated conditions, such as learning and language problems, aggression, disruptive behavior, depression or anxiety. About a third of children with attention deficit/hyperactivity disorder have such a co-existing condition.

* Other diagnostic tests, such as lead screening, brain imaging and thyroid hormone tests, do little to establish a diagnosis of attention deficit/hyperactivity disorder.

The guidelines were developed by a panel of medical and mental health experts with training in psychiatry, psychology, neurology, epidemiology, pediatrics, family practice and child development, along with educators.