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american academy of pediatrics' guidelines

In May 2000, after more than two years of deliberation, the American Academy of Pediatrics (AAP) issued a set of standards and guidelines to aid clinicians in the diagnosis of ADHD. The AAP is the nation's largest pediatrics organization, consisting of 55,000 members who are pediatricians, pediatric surgeons, and other medical doctors who specialize in pediatric medicine. In issuing the guidelines, the academy targeted both pediatricians and family practitioners, who, some reports say, are responsible for 60-70 percent of ADHD diagnoses and the majority of the prescriptions.[1]

With the new guidelines, the AAP attempts to provide practitioners with more guidance than the DSM-IV criteria for diagnosing ADHD furnishes. According to James Perrin, a co-chair of a panel of experts convened to develop the new guidelines, the DSM-IV criteria have not proven "user-friendly" to primary care physicians in their daily practices. This has led, in turn, to confusion about the symptoms that must be present in order to diagnose a child with ADHD and, perhaps, overdiagnosis of the disorder.[2]

In order to dispel some of the confusion, the AAP decided to focus its criteria on recommendations that will be of practical use to clinicians. For instance, where the DSM-IV simply requires practitioners obtain assessments of a child's behavior, the AAP puts forth methods for gathering that information. Practitioners may use open-ended questions such as "What are your concerns about your child's behavior in school?" or more focused questions, semi-structured interviews and questionnaires. Further, to prepare families for the breadth of the ADHD evaluation, clinicians are urged to use a pre-visit questionnaire wherein the parents or guardians are told that the clinician is interested in evaluating the child's school performance as well.

The AAP guidelines also emphasize the importance of assessing coexisting conditions. According to the AAP's research, one-third of all children with ADHD also suffer from one or more coexisting conditions. When appropriate, the AAP recommends that children presenting with ADHD symptoms should also be evaluated for conduct and mood disorders, anxiety and learning disabilities.

The academy, which was praised for its effort on the editorial pages of some of the nation's papers[3], put forth six separate recommendations in the practice guidelines:

  • Clinicians should initiate an evaluation for ADHD for any child, 6 to 12 years old, who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems.
  • A positive diagnosis requires that the child meet the DSM-IV criteria for ADHD.
  • Clinicians must obtain evidence directly from the parents/caretakers regarding the core symptoms of ADHD in various settings, the age of onset, the duration of the symptoms, and the child's degree of impairment. They may use behavior ratings scales, such as the Conners Ratings Scale, to aid in the diagnosis, though the efficacy of such scales has not been proven definitively.
  • Not only should clinicians require direct evidence from the parents or caretaker regarding the core symptoms of ADHD, but also from the classroom teacher or other school professional. Again, the AAP determines that assessment tools for teachers, such as ratings scales, could assist in the ADHD evaluation.
  • The evaluation must include an assessment of coexisting conditions.
  • Finally, the AAP recommends that other diagnostic tests be discarded in determining an ADHD diagnosis. Screening for high lead levels, for example, or abnormal thyroid hormone levels should not be considered a routine corollary in the ADHD diagnosis.


Read the entire Clinical Practice Guidelines.

[1] "How do you know if it's attention deficit/hyperactivity disorder?; Diagnosis guidelines are designed to help physicians distinguish the problem from other kid-related difficulties, such as misbehavior," by Jane E. Allen, Los Angeles Times, May 8, 2000, p. S3.

[2] "Pediatricians Pay Extra Attention to ADHD," by Don Colburn, The Washington Post, 9 May 2000.

[3] See "Ritalin Map: New Guidelines Should Quiet Shrill Debate," The Columbus Dispatch, 6 May 2000, p. A12. And "ADHD: Getting It Right," The Seattle Times, 4 May 2000, p. B6

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