american academy of pediatrics prevalence … lists in review papers; references from the prac-tice...

AMERICAN ACADEMY OF PEDIATRICS

Prevalence and Assessment of Attention-Deficit/HyperactivityDisorder in Primary Care Settings

Ronald T. Brown, PhD*; Wendy S. Freeman, PhD*; James M. Perrin, MD‡; Martin T. Stein, MD§;Robert W. Amler, MD¶; Heidi M. Feldman, MD, PhDi; Karen Pierce, MD#; and Mark L. Wolraich, MD**

ABSTRACT. Research literature relating to the preva-lence of attention-deficit/hyperactivity disorder (ADHD)and co-occurring conditions in children from primarycare settings and the general population is reviewed asthe basis of the American Academy of Pediatrics clinicalpractice guideline for the assessment and diagnosis ofADHD. Epidemiologic studies revealed prevalence ratesgenerally ranging from 4% to 12% in the general popu-lation of 6 to 12 year olds. Similar or slightly lower ratesof ADHD were revealed in pediatric primary care set-tings. Other behavioral, emotional, and learning prob-lems significantly co-occurred with ADHD. Also re-viewed were rating scales and medical tests that could beemployed in evaluating ADHD. The utility of using bothparent- and teacher-completed rating scales that specifi-cally assess symptoms of ADHD in the diagnostic pro-cess was supported. Recommendations were made re-garding the assessment of children with suspectedADHD in the pediatric primary care setting. Pediatrics2001;107(3). URL: http://www.pediatrics.org/cgi/content/full/107/3/e43; prevalence, attention-deficit/hyperactivitydisorder, primary care.

ABBREVIATIONS. ADHD, attention-deficit/hyperactivity disor-der; TRI, Technical Resources International; DSM, Diagnostic andStatistical Manual; DISC, Diagnostic Interview Schedule for Chil-dren; EEG, electroencephalogram; ERP, event-related potential.

Attention-deficit/hyperactivity disorder (ADHD)has defining features of inattention, overactiv-ity, and impulsivity.1 It is the most frequently

encountered childhood-onset neurodevelopmentaldisorder in primary care settings. Symptoms fre-quently co-occur with other emotional, behavioral,and learning problems, including oppositional defi-ant disorder, conduct disorder, depression, anxiety,and learning disabilities. The cause of ADHD is un-known, and multiple pathways may lead to the phe-notypic expression of the disorder.2

Public awareness of ADHD has increased, and thedisorder represents a public health concern with sig-

nificant effects on children’s functioning across mul-tiple areas.2 Referrals to health care professionals forchildren suspected of having the disorder continue ata high rate, and changes in the health care system inthe United States have placed increasing demands onprimary care pediatricians to diagnose and managethe disorder. It is now recognized that ADHD is achronic condition that will persist over the life span.2

The American Academy of Pediatrics Committeeon Quality Improvement Subcommittee on Atten-tion-Deficit/Hyperactivity Disorder synthesized aclinical practice guideline for the diagnosis and eval-uation of children with ADHD.3 This report willhighlight the empirical literature review on whichthis practice guideline is based. The subcommitteeworked with Technical Resources International(TRI), Washington, DC, under the auspices of theAgency for Healthcare Research and Quality, to de-velop an evidence base addressing questions regard-ing the prevalence, co-occurring conditions, and di-agnostic tests for ADHD. For a full account of theliterature review, see the technical review compiledby Green, Wong, Atkins, Taylor, and Feinleib.4

Given the widespread attention ADHD has re-ceived, it is important to examine the epidemiologyof this disorder and methods to assess it. Because ofthe paucity of data regarding preschoolers and ado-lescents with ADHD, the literature review focusedon studies involving elementary-school-aged chil-dren. Specifically, 4 key questions provided theframework for the development of the technical re-view.4 They are as follows:

1. What is the prevalence of ADHD and co-occur-ring behavioral, emotional, and learning disordersin the general population of 6 to 12 year olds inthe United States?

2. What is the prevalence of ADHD and co-occur-ring conditions in 6 to 12 year olds coming toprimary care providers in the United States?

3. How accurate and reliable are behavior ratinginstruments in screening for ADHD?

4. How useful are medical screening tests in diag-nosing ADHD?

For the review, 507 articles and 10 published ratingscale manuals were compiled from empirical articles;traditional databases (Medline, PsychINFO); refer-ence lists in review papers; references from the Prac-tice Parameters for the Assessment and Treatment of

From the *Department of Pediatrics, Medical University of South Carolina,Charleston, South Carolina; ‡Massachusetts General Hospital for Children,Harvard Medical School, Boston, Massachusetts; §University of Californiaat San Diego, San Diego, California; ¶US Department of Health and HumanServices, Atlanta, Georgia; iUniversity of Pittsburgh, Pittsburgh, Pennsyl-vania; #Children’s Memorial Hospital, Chicago, Illinois; and **VanderbiltUniversity, Nashville, Tennessee.Received for publication Dec 18, 2000; accepted Dec 18, 2000.PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-emy of Pediatrics.

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Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity Disorder5; recently publishedjournal articles; citations suggested by members ofthe American Academy of Pediatrics; and a databaseof bibliographies on studies involving the Child Be-havior Checklist rating scale.6 A physician and psy-chologist specializing in ADHD independently ratedeach article and manual for sound empirical evi-dence addressing the 4 questions. Criteria used toevaluate the appropriateness of a study are pre-sented in Table 1. Application of the inclusion andexclusion criteria yielded 87 articles and 10 manualsfor inclusion in the review.4

PREVALENCE OF ADHDMost studies of ADHD have come from referral

populations seen in tertiary care centers. They, there-fore, reflect unknown sampling biases and cannotprovide estimates of rates of ADHD in unreferredpopulations. Thus, to address the epidemiology ofADHD, we reviewed the prevalence of ADHD incommunities, schools, and primary care settings.Also investigated was the prevalence of co-occurringconditions in the general population and primarycare settings.

Prevalence of ADHD and Co-occurring Conditions inthe Community Samples

Studies in which diagnostic instruments were ad-ministered to 6- to 12-year-olds from representative

community samples or school settings were consid-ered.7–16 All used Diagnostic and Statistical Manual(DSM) criteria for ADHD, although different edi-tions were used. Three studies used DSM-III,17 6used DSM-III-R,18 1 used DSM-III-R and DSM-IV,1and 1 used DSM-IV. See Table 2 for the criteriaemployed in the various editions. For studies usingDSM-III and DSM-III-R criteria to diagnose ADHD,prevalence rates ranged from 4%12 to 26%.11 How-ever, 9 of the 10 investigations revealed prevalencerates between 4% and 12% (median: 5.8%). The in-vestigation reporting the outlier prevalence rate of26% examined the smallest sample of children, andall children in that investigation were from a single,inner-city elementary school.11 These methodologi-cal limitations may have contributed to a spuriouslyinflated estimate for the prevalence of ADHD in thegeneral population. Across studies, setting (ie, com-munity vs school), gender, and diagnostic nomencla-ture (DSM-III vs DSM-III-R criteria), all affected theprevalence rates. Specifically, the mean prevalencerates of ADHD were higher in community samples(10.3% for community samples vs 6.9% for schoolsamples), higher among males (9.2% for males vs3.0% for females), and higher among children whowere diagnosed according to DSM-III-R criteria(10.3% for DSM-III-R vs 6.8% for DSM-III criteria).

At the time that the American Academy of Pedi-atrics practice guideline was synthesized and thetechnical report was compiled, sufficient research

TABLE 1. Inclusion Criteria for Studies

Factor Criteria

Definition of ADHD andcomorbidities

ADHD with criteria from DSM-III,† DSM-III-R,‡ and DSM-IV§Co-occurring conditions: learning disabilities, depression, anxiety, conduct disorder,

and oppositional defiant disorderCombinations of the 5 co-occurring conditions allowed in Questions 1 and 2

(prevalence questions)None of the 5 co-occurring conditions for Questions 3 and 4 (assessment questions)

Patient population Boys and girls 6 to 12 years oldRepresentative populationNon-referred populations (for prevalence estimates)Absence of moderate to severe mental retardation, pervasive developmental

disorders, and severe psychiatric disordersNorth American studies for Questions 1 and 2 (prevalence questions)Any countries for Questions 3 and 4 (assessment questions)

Setting and provider population All settings allowed in Questions 3 and 4 (assessment questions)Limited settings for Questions 1 and 2 (prevalence questions): general population

(Question 1)—community and school surveys; primary care setting (Question 2)—pediatricians and family or general practice physicians

Behavior screening tests for ADHD Selected behavior checklists and rating scales (parent and teacher reports)Outcomes of interest for behavior

screening tests (Question 3)Accuracy for ADHD: sensitivity, specificity, positive predictive valueAccuracy for referral population (for broad-band checklists)Effect size for discriminating referred from non-referred samples

Medical screening tests for ADHD(Question 4)

Selected medical and neurologic screening tests: electroencephalography, leadconcentration level, thyroid hormone level, imaging tests, continuous performancetests, hearing and vision screening

Outcomes of interest for medicalscreening tests (Question 4)

Prevalence of abnormal findings

Criteria for admissible evidenceand bibliographic databaseboundaries

Data from peer-reviewed published studiesLiterature published 1980 to 1997English languageDiagnostic (not treatment) outcomes

† American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American PsychiatricAssociation; 1980.‡ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, rev. Washington, DC: AmericanPsychiatric Association; 1987.§ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American PsychiatricAssociation; 1994.

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had not yet accumulated on the prevalence of ADHDusing DSM-IV criteria. One study that was available,however, was an investigation by Wolraich et al19

conducted with 4323 school children ranging fromkindergarten to fifth grade. In addition to assessingDSM-IV symptoms, Wolraich and colleagues exam-ined the level of impairment in children’s academicand behavior functioning. Consistent with the dataprovided by others,8,15 the investigators found anoverall prevalence rate of 6.8% when each of theADHD subtypes (primarily inattentive type, com-bined type, and primarily hyperactive/impulsivetype) was considered. Of interest is the finding that,when DSM-IV impairment criteria were not consid-ered, 16% of the sample qualified for a diagnosis,with many more males than females meeting criteria.This finding underscores the importance of incorpo-rating functional impairment when making a diag-nosis of ADHD. Without due consideration of theDSM-IV functional impairment criterion, the fre-quency of ADHD diagnosis may be spuriously high.Wolraich and colleagues19 offered support for theDSM-IV diagnostic subtypes of ADHD, with most ofthe children meeting criteria for either the predomi-nantly inattentive subtype (3.2%) or the combinedsubtype (2.9%). More studies need to be conducted todetermine the distribution of children with ADHDacross the subtypes.

Three studies20–22 examined prevalence rates ofADHD among elementary school children in thegeneral population who had been screened forsymptoms of behavior problems. Formal diagnosticinstruments were administered only to children whowere identified in the initial screening procedure.The average prevalence rate approached 4%.

A high proportion of children with ADHD haveother related conditions, and several investigatorshave assessed co-occurring conditions. In the techni-cal review, Green et al4 presented studies assessingco-occurring ADHD and oppositional defiant disor-der,12,14,16 conduct disorder,7,12,14,16 and depressiveand anxiety disorders.14,21 Calculations of the meanprevalence rates across studies were highest for op-positional defiant disorder (35.2%), followed by con-duct disorder and anxiety disorders (25.7% and25.8%), and depressive disorders (18.2%).

In the 1 investigation that employed DSM-IV cri-teria, Wolraich and colleagues19 found that rates ofco-occurring oppositional defiant disorder, conductdisorder, anxiety disorder, and depressive disorderwere similar to those found in the studies previouslymentioned. Of interest, Wolraich et al found mark-edly different patterns of co-occurring disorders ac-cording to diagnostic subtype. When they examinedthe inattentive subtype, significantly fewer childrenhad co-occurring disruptive behavior disorders (ie,oppositional defiant disorder, conduct disorder)compared with the hyperactive/impulsive and com-bined subtypes. In addition, children with the pre-dominantly hyperactive/impulsive subtype evi-denced fewer co-occurring internalizing (ie, anxiety,depressive) and learning problems. Thus, externaliz-ing disorders (ie, oppositional defiant disorder, con-duct disorder) seem to be associated with the hyper-

active/impulsive dimension of ADHD; internalizingdisorders (ie, anxiety, depression, learning disabili-ties) seem to be more frequently associated with theinattention dimension of the disorder.

The rate of co-occurrence between ADHD andlearning disabilities is difficult to establish becausefew studies have employed DSM criteria for learningdisorders. As a result, many studies were not in-cluded in this review. August and Garfinkel7 exam-ined the prevalence of specific reading disabilityamong children with ADHD. For children to be clas-sified as having a specific reading disability, childrenhad to be reading disabled relative to their peers ofthe same chronological age and relative to their gen-eral level of intellectual functioning. Twenty-twopercent of their sample of children with ADHD metthese criteria. In the study by Wolraich and col-leagues,19 only 11% of the children classified as hav-ing ADHD according to DSM-IV criteria were re-ported to have learning disabilities. The lower rate oflearning disabilities in that study may reflect the useof a restrictive methodology to classify children aslearning disabled,4 with the classification simplybased on teachers’ indication of whether the childhad a learning disability diagnosis. Clearly, addi-tional research regarding the co-occurrence ofADHD and learning disabilities is needed.

Prevalence of ADHD and Co-occurring Conditions inthe Pediatric Office Setting

Significant changes in the health care system haveplaced increasing demands on pediatric primary careproviders to assess and manage children whopresent with ADHD symptoms. Some research hassuggested that children’s symptom display may dif-fer as a function of psychiatric versus pediatric clinicsetting.23 Numerous studies have examined thesymptoms of children with ADHD evaluated in psy-chiatric settings, but not enough attention has beendevoted to children evaluated in primary care of-fices.

Two groups of investigators reported on the prev-alence of ADHD in the primary care setting,24–26 andtheir findings were presented in the technical review.Lindgren et al26 examined 457 consecutive 6- to 12-year-old patients from primary care settings. Preva-lence of ADHD under different inclusion criteria (ie,8 vs 10 symptoms) was estimated. Symptoms wereassessed from parents’ reports based on DSM-III-Rcriteria. As might be expected, prevalence rates dif-fered according to cutoff criteria. A prevalence of11.2% occurred when the cutoff was 8 symptoms. Alower prevalence rate (3.7%) was revealed with themore conservative 10-symptom cutoff. In contrast toconcerns expressed in the popular media that thisdisorder is overdiagnosed by pediatricians,27 thedata here suggest that prevalence rates of ADHD inprimary care settings are similar to rates in generalpopulation studies.

In an epidemiologic study conducted in Pittsburghby Costello and colleagues,24–25 300 children wereassessed from a pool of 789 patients from 2 healthmaintenance organization clinics. The Diagnostic In-terview Schedule for Children (DISC),28 a structured

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TABLE 2. Diagnostic Criteria for ADHD Across Versions of the Diagnostic and Statistical Manual

* American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980† American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, rev. Washington, DC: American Psychiatric Association, 1987‡ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994


psychiatric interview assessing DSM-III criteria, wasadministered by a psychiatric social worker. Whenconsidering parent reports on the DISC, findingswere that 1.4% of the children met DSM-III criteriafor a diagnosis of attention-deficit disorder with hy-peractivity, and 0.2% met criteria for attention-deficitdisorder without hyperactivity. Fewer cases wereidentified using children’s reports on the DISC, com-pared with parent reports, indicating that relianceonly on children’s reports may show the prevalencerate to be falsely low. This finding underscores theimportance of collecting parent interview data. Theprevalence rates reported by Costello and col-leagues24–25 were much lower than those reported byLindgen et al,26 probably because older editions ofthe DSM yielded lower rates of the disorder.

Lindgren et al26 and Costello et al25 showed prev-alence rates of co-occurring conditions with ADHDranging from 9% to 38% across disorders. The mostprevalent co-occurring conditions were oppositionaldefiant disorder and anxiety disorder, each with aprevalence rate of 38%. The prevalence rates of de-pression and conduct disorder (each at 9%) werelower in the primary care setting than those found inthe studies of ADHD in the general population. Chil-dren considered to have more severe psychiatric dis-turbances, like depression and conduct disorder,may be triaged to child psychiatric clinics as opposedto pediatric primary care settings. Nonetheless, co-existing conditions are clearly evident among chil-dren seen in the primary care setting and merit thecareful attention of the primary care provider.

SummaryExamination of the data revealed that prevalence

rates of ADHD generally range from 4% to 12% ofthe elementary school population when the DSM-III,DSM-III-R, or DSM-IV is used,1,17–18 with higherrates of the disorder among males and with higherrates reported from school settings than communitysettings. Only 2 studies provided information on theprevalence of ADHD in primary care settings, with 1reporting 11% of children met criteria for ADHD,and the second reporting that less than 2% of chil-dren met criteria for the disorder. Additional re-search examining the prevalence of this disorder inpediatric settings is needed. Overall, the findingsregarding the prevalence of ADHD support theAmerican Academy of Pediatrics clinical practiceguideline3 assertion that it is reasonable for primarycare pediatricians to initiate an evaluation for ADHDwhen children present with symptoms that includeinattention, hyperactivity, impulsivity, academic un-derachievement, and behavior problems.

ADHD frequently co-occurs with additional emo-tional, behavioral, and learning problems in commu-nity and primary care settings, with disruptive be-havior disorders being most common, followed byinternalizing and learning problems. Finally, the in-vestigation that examined conditions co-occurringwith the DSM-IV subtypes supported the currentnosology that conceptualizes ADHD as a 2-dimen-sional disorder.19 Interestingly, co-occurring disrup-tive behavior problems seem to have more frequent

associations with the hyperactive/impulsive dimen-sion of ADHD, whereas internalizing and learningproblems are more strongly associated with the in-attentive dimension of the disorder. Thus, as recom-mended in the clinical practice guideline,3 the eval-uation of ADHD should include evaluation for otherconditions that may co-occur with the disorder.

ASSESSMENT OF ADHDAssessment of ADHD in the primary care settings

may include both behavior rating scales and medicaland laboratory tests. The utility of these instrumentsin the identification of ADHD was examined.

Behavior Rating ScalesA widely employed tool for the assessment of

ADHD has been the use of behavior rating scales andchecklists. These scales can be completed by parents,teachers, and other informants. The informant isasked to summarize the extent to which the childexhibits particular behaviors over a specified time.The advantages of behavior rating scales includeease of administration, cost effectiveness, and therange of information provided by multiple infor-mants. These instruments can be classified into eitherbroad-band checklists or ADHD-specific measures.ADHD-specific measures are those that specificallyassess the core symptoms of the disorder, whereasbroad-band checklists measure a variety of child be-havior problems. Regarding broad-band ratingscales, information obtained may include scores thatsum across all types of child behavior problems (ie,total global scale scores), scores that sum across typesof internalizing problems such as depression andanxiety (ie, internalizing scale scores), and scores thatsum across types of externalizing problems such asaggression and conduct problems (ie, externalizingscale scores). Some measures provide scores for sub-scales that assess adaptive behavior. To be includedin the technical review,4 it was required that theADHD-specific and broad-band rating scales in-cluded a parent version of the scale and had norma-tive data available. Also, broad-band checklists hadto include subscales designed to measure symptomsassociated with ADHD. The rating scales reviewedare listed in Table 3.

Effect sizes were calculated for each of these ratingsubscales. An effect size refers to the difference inmean scores between 2 populations (eg, children re-ferred with ADHD vs nonreferred children) dividedby an estimate of the individual standard deviation.A larger effect size is more desirable because it sug-gests less overlap between the 2 populations. Hence,an effect size of 1.0 or less would reflect substantialoverlap between the distribution of scores across the2 populations. In contrast, an effect size of 3.0 sug-gests little overlap between scores attained for the 2populations, with the mean scores for the 2 popula-tions falling 3 standard deviation units apart. Con-sequently, one could consider the 2 populations rel-atively distinct.

A higher effect size is indicative of greater sensi-tivity and specificity of the measure. For example,assuming that the populations with and without the


disorder are normally distributed and have equalvariances, and considering the case whereby sensi-tivity equals specificity, an effect size of 3.0 would beassociated with a sensitivity and specificity of 0.94and a false-positive and false-negative rate of 6%.29

In contrast, an effect size of 1.0, under the sameconditions, would be associated with a sensitivityand specificity of 0.71, which is associated with afalse-positive and false-negative rate of 29%.29

Broad-band rating scales and checklists were eval-uated for their ability to discriminate children re-ferred for ADHD from their nonreferred peers. Table3 presents the broad-band rating scale studies thatallowed the calculation of effect sizes for total prob-lem, internalizing, externalizing, and adaptive func-tioning indices or subscales. The average effect sizeacross broad-band measures using total global scalescores was 1.5. Effect sizes using domain scales (ie,the internalizing, externalizing, and adaptive func-tioning scales) generally ranged from 0.7 to 1.4, withthe exception of the externalizing scales on the par-ent and teacher forms of the Conners’ Scales,30 whichhad significantly better discriminatory power. Takentogether, the findings do not provide sufficient evi-

dence to support a reliance on either broad-bandchecklist total problem indices or scales assessingexternalizing, internalizing, or adaptive behavior toscreen for or diagnose ADHD. However, these scalesmay be used for other purposes such as screening forco-occurring problems in other areas (eg, anxiety,depression, conduct problems).

Also available to practitioners are several ratingscales that specifically assess symptoms related toADHD. The studies that were reviewed usedADHD-specific measures to discriminate betweenchildren diagnosed with ADHD and typically devel-oping children. Because few studies used controlgroups with other psychiatric disorders (eg, learningdisabilities, conduct disorder), it is difficult to eval-uate the efficacy of these rating scales in differenti-ating children with ADHD from those with otherpsychiatric diagnoses. Table 4 presents studies ofADHD-specific rating scales. These studies allowedthe calculation of effect sizes for global ADHD symp-toms and subscales that assess specific types ofADHD symptoms (ie, inattention, impulsivity, over-activity). The overall range of effect sizes variedacross measures. Effect sizes for global ADHD symp-

TABLE 3. Broad-Band Checklists: Ability to Detect Referred Versus Nonreferred Participants*

Study BehaviorRating Scale

Age Gender EffectSize

Total ScalesAchenbach, 1991† CBCL/4-18-R 4–11 M 1.4

CBCL/4-18-R 4–11 F 1.3Achenbach, 1991‡ CBCL/TRF-R 5–11 M 1.2

CBCL/TRF-R 5–11 F 1.1Naglieri, LeBuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.0Conners, 1997 CPRS-R:L — MF 2.3

CTRS-R:L — MF 2.0Externalizing Scales

Achenbach, 1991† CBCL/4-18-R 4–11 M 1.2CBCL/4-18-R 4–11 F 1.0

Achenbach, 1991‡ CBCL/TRF-R 5–11 M 1.0CBCL/TRF-R 5–11 F 0.9

Naglieri, LeBuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.4Conners, 1997 CPRS-R:L-DSM-IV — MF 2.9

CTRS-R:L-DSM-IV — MF 2.0Internalizing Scales



Naglieri, Lebuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.6Adaptive Functioning Scales



Adapted from Green M, Wong M, Atkins D, Taylor J, Feinleib M. Diagnosis of Attention-Deficit/Hyperactivity Disorder (Technical Review #3). Rockville, MD: Agency for Health Care Policy andResearch; 1999.* CBCL/4-18-R 5 Child Behavior Checklist for Ages 4–18, Parent Form, Revised; TRF-R 5 TeacherReport Form, Revised; DSMD 5 Devereaux Scales of Mental Disorders; CPRS-R:L 5 1997 Revision ofthe Conners Parent Rating Scale, Long Version; CTRS-R:L 5 1997 Revision of the Conners TeachingRating Scale, Long Version.† Achenbach TM. Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington, VT: Univer-sity of Vermont Department of Psychiatry; 1991.‡ Achenbach TM. Manual for the Teachers Report Form and 1991 Profile. Burlington, VT: University ofVermont Department of Psychiatry; 1991.§ Naglieri JA, Lebuffe PA, Pfeiffer SI. Devereaux Scales of Mental Disorders. San Antonio, TX: HarcourtBrace; 1994.


toms ranged from 1.3 to 3.7. The Conners’ scales30

yielded the highest effect sizes, and the School Situ-ations Questionnaire31 the lowest effect sizes. Whenspecific symptoms were examined separately, theeffect sizes were again variable. Overall, the effectsizes were slightly greater for subscales assessingspecific symptoms compared with indices of com-bined ADHD symptoms. Across symptoms, effectsizes ranged from 3.1 to 5.5 when considering theSwanson, Nolan, and Pelham (SNAP) Checklist32,33

and the Conners Abbreviated Teacher QuestionnaireHyperactivity Index,34 with significantly lower effectsizes by the inattention and hyperactivity subscalesof the Attention-Deficit Disorder ComprehensiveTeacher Rating Scale—Parent version.35

SummaryOverall, rating scales of specific ADHD symptoms

were more useful in diagnosis than global indices onbroad-band checklists. Among the ADHD-specificrating scales that were reviewed, the ADHD Indexand the DSM-IV Symptoms Scale of the 1997 revisionof the Conners’ Rating Scale30 and the Hyperactivityand Inattention Subscales of the SNAP Checklist32

performed well in discriminating between childrenwith ADHD and normal controls. It should be noted,however, that while parent- or teacher-completedbroad-band scales are not recommended to specifi-cally diagnose ADHD, global rating scales may beuseful to screen for co-occurring problems. Given therecommendations set forth in the practice guideline3

that the assessment of ADHD requires evidence ofsymptomatology from caregivers and school person-nel (ie, teachers), we endorse the use of behaviorrating scales as a time-efficient and cost-effective

means to gather data regarding the display of thecore symptoms of ADHD. In addition, the collectionof behavior ratings from teachers and caregivers willfulfill the DSM requirement that there be cross-situ-ational evidence of the disorder. Although ratingscales are convenient for use in the pediatric officesetting, we caution against their use in isolation.Information collected via rating scales must be sup-plemented with a clinical history, including age ofonset and duration of symptoms, and careful inter-view, which includes an assessment of the functionalconsequences of the behaviors.

Medical and Laboratory Screening TestsSeveral medical screening tests and laboratory

measures have been used to evaluate children withsuspected ADHD. These tests include blood leadlevels, thyroid function, radiographic assessment,electroencephalography, neurologic screening exam-inations, and continuous performance tasks, as wellas other miscellaneous laboratory assessments.

The association between elevated lead levels anddelays in cognitive functioning, including attentionproblems, has been consistently reported.36–37 Thisbegs the question regarding the utility of lead levelmeasurements in the assessment of ADHD. Six stud-ies were reviewed, with no statistically significantassociations in 3 of the investigations.38–40 One studyreported a positive association between lead leveland behavior problems.15 Two studies examinedchildren screened for disruptive behavior problemsand found associations between elevated lead levelsand behavior problems.41–42 However, because thesestudies did not assess ADHD, the extent to whichtheir findings may be applied to children with this

TABLE 4. ADHD-Specific Checklists: Ability to Detect ADHD Versus Normal Controls*

Study Behavior Rating Scales Age Gender Effect Size

Total ADHD Symptoms ScalesConners, 1997 CPRS-R:L-ADHD Index 6–17 MF 3.1

CTRS-R:L-ADHD Index 6–17 MF 3.3CPRS-R:L-DSM-IV Symptoms 6–17 MF 3.4CTRS-R:L-DSM-IV Symptoms 6–17 MF 3.7

Breen, 1989 SSQ-O-I 6–11 F 1.3SSQ-O-II 6–11 F 2.0

Hyperactivity SubscalesUllmann, Sleator, & Sprague, 1997 ACTeRS 6–14 MF 1.5Atkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 5.1Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 3.1Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 F 3.7Tarnowski, Prinz, & Nay, 1986 CATQ-HI 7 M 4.1

Inattention SubscalesUllmann, Sleator, & Sprague, 1997 ACTeRS—Parent Version 6–14 MF 2.0Atkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 4.2Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 3.5Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 F 4.0

Impulsivity SubscalesAtkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 5.5Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 4.7Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 F 4.0

Adapted from Green et al. Diagnosis of Attention Deficit Hyperactivity Disorder (Technical Review 3). Rockville, MD: Agency for Health CarePolicy and Research; 1999.* CPRS-R:L 5 1997 Revision of the Conners Parent Rating Scale, Long Version; CTRS-R:L 5 1997 Revision of the Conners TeachingRating Scale, Long Version; SSQ-O-I 5 Barkley’s School Situations Questionnaire—Original Version, Number of Problem Settings Scale;SSQ-O-II 5 Barkley’s School Situations Questionnaire—Original Version, Mean Severity Scale; ACTeRS 5 ADD-H: ComprehensiveTeacher Rating Scale; CATQ-HI 5 Conners Abbreviated Teacher Questionnaire—Hyperactivity Index.


disorder is unknown. These findings suggest an as-sociation between elevated lead levels and a range ofbehavior problems including inattention. However,the routine use of lead screening as a diagnosticindicator for ADHD is not supported. A key issuehere is that by elementary school age, children whohave had lead effects will almost always have normallead levels.

Abnormal thyroid function can produce a varietyof behavior effects in children, ranging from impair-ments in concentration to severe neuropsychologicaldeficits.43 Four studies of thyroid function were re-viewed, and none of the 4 showed an associationbetween abnormal thyroid levels and ADHD. In 3 ofthe studies, none of the children with ADHD hadclinically significant thyroid dysfunction.44–46 In astudy by Weiss, Stein, Trommer, and Refetoff47 2% ofthe ADHD cohort had abnormal thyroid levels com-pared with ,1% of the comparison control group. Intotal, these studies fail to support the use of thyroidfunction tests to screen for ADHD.

Recent attention also has been devoted to investi-gating whether there are morphologic differencesbetween the brain structures of individuals withADHD relative to their normally developing peers.The technical review4 examined 9 studies that usedeither computerized tomography or magnetic reso-nance imaging to compare children with ADHD witha comparison control group.48–56 No differenceswere found between children with ADHD and com-parison controls in 2 of the investigations.50,56 In theother 7 studies, asymmetries, differences in shape orvolume of the ventricles, and differences in brain sizeoccurred between ADHD and normally developingchildren. In each of these studies, structures in thechildren with ADHD were smaller than those ofcomparison controls. These studies are provocativeand will likely direct new research that has the po-tential to shed light on the pathogenesis of this dis-order. However, because other child psychiatric con-trol groups (eg, children with learning problems orother disruptive behavior disorders) have not beenincluded, the specificity of these findings to ADHD isnot clear. Furthermore, although some studies haverevealed significant group differences, the degree ofwithin group variance and overlap between groupsmake imaging of little use for individual diagnosticpurposes. That is to say, the imaging findings do notdiscriminate adequately between children withADHD and those without. For these reasons, the useof imaging procedures is not currently supported asa diagnostic tool for assessment of ADHD.

One of the most widely researched medical testsfor evaluating children with ADHD is the electroen-cephalogram (EEG) to examine event-related poten-tials (ERPs). Eight studies met criteria for inclusion inGreen and colleagues’4 technical review.10,57–63

Overall, no major EEG abnormalities (ie, evidence ofseizure activity) were found for children withADHD. Several investigations reported minor differ-ences in ERPs functioning, including longer latenciesat the P3 site,57 longer latencies of certain waves forbrainstem auditory-evoked potentials,58 more slowwaves and fewer a-waves,59 and asymmetry in peak

amplitude evoked-response potentials.10 These find-ings are variable and do not provide any compellingevidence for a particular EEG pattern for patientswith ADHD.

Over the years, various neuropsychologicalscreens, or soft sign assessments were believed toshed light on the pathogenesis of the ADHD disor-der. Five studies using such assessments met criteriafor inclusion in the technical review.4 Reeves andcolleagues64 found that children with ADHD evi-denced higher rates of neurodevelopment abnormal-ities than comparison control children on 9 tests ofsensorimotor coordination, but no differences be-tween groups were found for prenatal or perinatalproblems or speech problems. Trommer and col-leagues65 found that children with ADHD evidenceda greater number of errors on a psychomotor taskdesigned to assess inattention. However, the rangesfor the number of errors exhibited by the ADHD andcontrol group were similar, casting doubt on theclinical significance of this group difference. The re-maining 3 studies66–68 revealed no differences be-tween ADHD and comparison control children onvarious neurodevelopment tasks (eg, the RevisedNeurologic Examination for Subtle Signs, Mazessubtest of the Wechsler Intelligence Scales for Chil-dren). These findings do not support the use of neu-rodevelopment measures for diagnosis of ADHD.

Some isolated studies measuring neurotransmit-ters (eg, serotonin levels, dopamine receptors, epi-nephrine), hormones (eg, growth hormone releasingfactor), and proteins69–74 were also reviewed in theTRI report.4 Each study reported findings suggestiveof possible biological differences between childrenwith ADHD and controls, but the findings were toosparse and preliminary to indicate a definitive rela-tionship.

Finally, studies examining computerized and pen-cil and paper tests of sustained attention and impul-sivity (eg, continuous performance tests)7,33,75–84

were reviewed in the TRI report.4 These measurespoorly discriminated children with ADHD fromtheir normally developing peers. Both indices of in-attention and indices of impulsivity provided bycontinuous performance tasks were poor predictorsof ADHD, with most effect sizes lower than 1.0.4Thus, the power of discrimination of these tests is notsufficient to support their use in the assessment anddiagnosis of ADHD.

SummaryMany medical tests and laboratory assessments

have been investigated in relation to ADHD. Acrossstudies that included blood lead levels, morphologicfeatures, and thyroid abnormalities, no compellingevidence supported an association between abnor-malities on these various tests and the presence ofADHD. Morphologic studies offered some prelimi-nary support for brain-related differences betweenchildren with and without the disorder, but addi-tional studies with control groups of children withother psychiatric and developmental disorders andlarger sample sizes will be necessary before brainmorphology becomes useful in diagnosing ADHD.


Based on these data, it is recommended in the prac-tice guideline3 that laboratory and medical diagnos-tic tests discussed above not be used routinely indetermining a diagnosis of ADHD.

CONCLUSIONSChildren with ADHD are frequently encountered

in the primary care setting. It is important that thediagnosis of this condition by primary care providersbe based on procedures supported by evidence fromempirical investigations. Here findings were high-lighted from a comprehensive review of the litera-ture regarding the prevalence of ADHD and co-oc-curring conditions in community and primary caresettings, as well as evidence regarding the utility ofbehavior rating scales and medical tests in the assess-ment process.

In community samples of school-aged children,the prevalence rates of the disorder generally rangedfrom 4% to 12%, with similar or lower rates in pedi-atric samples. In the literature examined for the pur-pose of the technical review,4 the most frequentlyco-occurring disorder was oppositional defiant dis-order (33%), followed by conduct disorder and anx-iety disorder (each at ;25%). Approximately 20%had co-occurring depressive disorders, and 12% to22% had learning disabilities. Anxiety, depression,and learning disabilities were recently found to co-occur more frequently in children with the inatten-tive subtype of ADHD, and disruptive behavior dis-orders co-occurred more frequently in childrenpresenting with hyperactive/impulsive symptoms.With regard to assessment, behavior rating scalesand medical screening tests have been investigated.ADHD-specific scales are reliable and valid for theassessment of the disorder, but global or broad-do-main scales are not. There is no compelling evidenceto support the use of medical and laboratory tests inthe identification of ADHD.

The findings of this review have significant impli-cations for practice and research. Given the preva-lence rates of ADHD, primary care pediatriciansshould be prepared to identify children with thedisorder. Clinicians should use ADHD-specific rat-ing scales completed by caregivers and teachers intheir efforts to identify children suspected forADHD. Ratings from multiple informants should beemployed to ascertain the DSM-IV criterion of cross-situational symptom display. Broad-band scales maybe useful in the identification of problems or symp-toms that may co-occur with ADHD, but their use indiagnosing ADHD is not supported. Also, the use ofmedical and laboratory tests to diagnose ADHD isnot indicated. In addition to behavior rating scales, athorough history of symptoms and the effect of thesesymptoms on the child’s current functioning shouldbe evaluated.

Examination of the literature summarized in thetechnical review4 reveals important areas for addi-tional investigation. For example, most of the litera-ture used DSM-III and DSM-III-R criteria to identifychildren with ADHD. Fewer studies using DSM-IVcriteria have addressed the prevalence and assess-ment of ADHD. These questions need to be exam-

ined with DSM-IV criteria and parameters associatedwith the specific ADHD subtypes. Most researchconducted to date has predominantly reported onsamples of boys with ADHD. Investigations target-ing girls with this disorder are sorely needed. Aswell, research has primarily focused on elementary-school-aged children; there is a need for investiga-tions examining this disorder among preschoolersand adolescents. Finally, the studies reviewed usedcontrol groups composed of either nonreferred chil-dren or typically developing comparison controls.Greater efforts are needed to evaluate the specificityof ADHD-specific rating scales in discriminating be-tween children with ADHD and those with otherpsychiatric disorders where ADHD does not co-oc-cur.

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DOI: 10.1542/peds.107.3.e43 2001;107;e43Pediatrics

Amler, Heidi M. Feldman, Karen Pierce and Mark L. WolraichRonald T. Brown, Wendy S. Freeman, James M. Perrin, Martin T. Stein, Robert W.

Primary Care SettingsPrevalence and Assessment of Attention-Deficit/Hyperactivity Disorder in

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