Prevalence and Assessment of Attention-Deficit/Hyperactivity Disorder in

Primary Care Settings

Ronald T. Brown, Wendy S. Freeman, James M. Perrin, Martin T. Stein, Robert W.
Amler, Heidi M. Feldman, Karen Pierce and Mark L. Wolraich
Pediatrics 2001;107;43-
DOI: 10.1542/peds.107.3.e43

This information is current as of May 29, 2006

The online version of this article, along with updated information and services, is
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http://www.pediatrics.org/cgi/content/full/107/3/e43

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 AMERICAN ACADEMY OF PEDIATRICS

Prevalence and Assessment of Attention-Deficit/Hyperactivity

Disorder 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, PhD储; Karen Pierce, MD#; and Mark L. Wolraich, MD**

ABSTRACT. Research literature relating to the preva- nificant effects on children’s functioning across mul-
lence of attention-deficit/hyperactivity disorder (ADHD) tiple areas.2 Referrals to health care professionals for
and co-occurring conditions in children from primary children suspected of having the disorder continue at
care settings and the general population is reviewed as a high rate, and changes in the health care system in
the basis of the American Academy of Pediatrics clinical the United States have placed increasing demands on
practice guideline for the assessment and diagnosis of
ADHD. Epidemiologic studies revealed prevalence rates
primary care pediatricians to diagnose and manage
generally ranging from 4% to 12% in the general popu- the disorder. It is now recognized that ADHD is a
lation of 6 to 12 year olds. Similar or slightly lower rates chronic condition that will persist over the life span.2
of ADHD were revealed in pediatric primary care set- The American Academy of Pediatrics Committee
tings. Other behavioral, emotional, and learning prob- on Quality Improvement Subcommittee on Atten-
lems significantly co-occurred with ADHD. Also re- tion-Deficit/Hyperactivity Disorder synthesized a
viewed were rating scales and medical tests that could be clinical practice guideline for the diagnosis and eval-
employed in evaluating ADHD. The utility of using both uation of children with ADHD.3 This report will
parent- and teacher-completed rating scales that specifi- highlight the empirical literature review on which
cally assess symptoms of ADHD in the diagnostic pro- this practice guideline is based. The subcommittee
cess was supported. Recommendations were made re-
garding the assessment of children with suspected
worked with Technical Resources International
ADHD in the pediatric primary care setting. Pediatrics (TRI), Washington, DC, under the auspices of the
2001;107(3). URL: http://www.pediatrics.org/cgi/content/ Agency for Healthcare Research and Quality, to de-
full/107/3/e43; prevalence, attention-deficit/hyperactivity velop an evidence base addressing questions regard-
disorder, primary care. ing the prevalence, co-occurring conditions, and di-
agnostic tests for ADHD. For a full account of the
literature review, see the technical review compiled
ABBREVIATIONS. ADHD, attention-deficit/hyperactivity disor-
der; TRI, Technical Resources International; DSM, Diagnostic and by Green, Wong, Atkins, Taylor, and Feinleib.4
Statistical Manual; DISC, Diagnostic Interview Schedule for Chil- Given the widespread attention ADHD has re-
dren; EEG, electroencephalogram; ERP, event-related potential. ceived, it is important to examine the epidemiology
of this disorder and methods to assess it. Because of
the paucity of data regarding preschoolers and ado-

A
ttention-deficit/hyperactivity disorder (ADHD)
lescents with ADHD, the literature review focused
has defining features of inattention, overactiv-
on studies involving elementary-school-aged chil-
ity, and impulsivity.1 It is the most frequently
dren. Specifically, 4 key questions provided the
encountered childhood-onset neurodevelopmental
framework for the development of the technical re-
disorder in primary care settings. Symptoms fre-
view.4 They are as follows:
quently co-occur with other emotional, behavioral,
and learning problems, including oppositional defi- 1. What is the prevalence of ADHD and co-occur-
ant disorder, conduct disorder, depression, anxiety, ring behavioral, emotional, and learning disorders
and learning disabilities. The cause of ADHD is un- in the general population of 6 to 12 year olds in
known, and multiple pathways may lead to the phe- the United States?
notypic expression of the disorder.2 2. What is the prevalence of ADHD and co-occur-
Public awareness of ADHD has increased, and the ring conditions in 6 to 12 year olds coming to
disorder represents a public health concern with sig- primary care providers in the United States?
3. How accurate and reliable are behavior rating
From the *Department of Pediatrics, Medical University of South Carolina, instruments in screening for ADHD?
Charleston, South Carolina; ‡Massachusetts General Hospital for Children, 4. How useful are medical screening tests in diag-
Harvard Medical School, Boston, Massachusetts; §University of California nosing ADHD?
at San Diego, San Diego, California; ¶US Department of Health and Human
Services, Atlanta, Georgia; 储University of Pittsburgh, Pittsburgh, Pennsyl- For the review, 507 articles and 10 published rating
vania; #Children’s Memorial Hospital, Chicago, Illinois; and **Vanderbilt scale manuals were compiled from empirical articles;
University, Nashville, Tennessee.
Received for publication Dec 18, 2000; accepted Dec 18, 2000.
traditional databases (Medline, PsychINFO); refer-
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- ence lists in review papers; references from the Prac-
emy of Pediatrics. tice Parameters for the Assessment and Treatment of

http://www.pediatrics.org/cgi/content/full/107/3/e43 PEDIATRICS Vol. 107 No. 3 March 2001 1 of 11

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Children, Adolescents, and Adults with Attention- community samples or school settings were consid-
Deficit/Hyperactivity Disorder5; recently published ered.7–16 All used Diagnostic and Statistical Manual
journal articles; citations suggested by members of (DSM) criteria for ADHD, although different edi-
the American Academy of Pediatrics; and a database tions were used. Three studies used DSM-III,17 6
of bibliographies on studies involving the Child Be- used DSM-III-R,18 1 used DSM-III-R and DSM-IV,1
havior Checklist rating scale.6 A physician and psy- and 1 used DSM-IV. See Table 2 for the criteria
chologist specializing in ADHD independently rated employed in the various editions. For studies using
each article and manual for sound empirical evi- DSM-III and DSM-III-R criteria to diagnose ADHD,
dence addressing the 4 questions. Criteria used to prevalence rates ranged from 4%12 to 26%.11 How-
evaluate the appropriateness of a study are pre- ever, 9 of the 10 investigations revealed prevalence
sented in Table 1. Application of the inclusion and rates between 4% and 12% (median: 5.8%). The in-
exclusion criteria yielded 87 articles and 10 manuals vestigation reporting the outlier prevalence rate of
for inclusion in the review.4 26% examined the smallest sample of children, and
all children in that investigation were from a single,
PREVALENCE OF ADHD inner-city elementary school.11 These methodologi-
Most studies of ADHD have come from referral cal limitations may have contributed to a spuriously
populations seen in tertiary care centers. They, there- inflated estimate for the prevalence of ADHD in the
fore, reflect unknown sampling biases and cannot general population. Across studies, setting (ie, com-
provide estimates of rates of ADHD in unreferred munity vs school), gender, and diagnostic nomencla-
populations. Thus, to address the epidemiology of ture (DSM-III vs DSM-III-R criteria), all affected the
ADHD, we reviewed the prevalence of ADHD in prevalence rates. Specifically, the mean prevalence
communities, schools, and primary care settings. rates of ADHD were higher in community samples
Also investigated was the prevalence of co-occurring (10.3% for community samples vs 6.9% for school
conditions in the general population and primary samples), higher among males (9.2% for males vs
care settings. 3.0% for females), and higher among children who
were diagnosed according to DSM-III-R criteria
Prevalence of ADHD and Co-occurring Conditions in (10.3% for DSM-III-R vs 6.8% for DSM-III criteria).
the Community Samples At the time that the American Academy of Pedi-
Studies in which diagnostic instruments were ad- atrics practice guideline was synthesized and the
ministered to 6- to 12-year-olds from representative technical report was compiled, sufficient research

TABLE 1. Inclusion Criteria for Studies

Factor Criteria
Definition of ADHD and ADHD with criteria from DSM-III,† DSM-III-R,‡ and DSM-IV§
comorbidities Co-occurring conditions: learning disabilities, depression, anxiety, conduct disorder,
and oppositional defiant disorder
Combinations 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 old
Representative population
Non-referred populations (for prevalence estimates)
Absence of moderate to severe mental retardation, pervasive developmental
disorders, and severe psychiatric disorders
North 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 Accuracy for ADHD: sensitivity, specificity, positive predictive value
screening tests (Question 3) Accuracy for referral population (for broad-band checklists)
Effect size for discriminating referred from non-referred samples
Medical screening tests for ADHD Selected medical and neurologic screening tests: electroencephalography, lead
(Question 4) concentration level, thyroid hormone level, imaging tests, continuous performance
tests, hearing and vision screening
Outcomes of interest for medical Prevalence of abnormal findings
screening tests (Question 4)
Criteria for admissible evidence Data from peer-reviewed published studies
and bibliographic database Literature published 1980 to 1997
boundaries English language
Diagnostic (not treatment) outcomes
† 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.

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had not yet accumulated on the prevalence of ADHD active/impulsive dimension of ADHD; internalizing
using DSM-IV criteria. One study that was available, disorders (ie, anxiety, depression, learning disabili-
however, was an investigation by Wolraich et al19 ties) seem to be more frequently associated with the
conducted with 4323 school children ranging from inattention dimension of the disorder.
kindergarten to fifth grade. In addition to assessing The rate of co-occurrence between ADHD and
DSM-IV symptoms, Wolraich and colleagues exam- learning disabilities is difficult to establish because
ined the level of impairment in children’s academic few studies have employed DSM criteria for learning
and behavior functioning. Consistent with the data disorders. As a result, many studies were not in-
provided by others,8,15 the investigators found an cluded in this review. August and Garfinkel7 exam-
overall prevalence rate of 6.8% when each of the ined the prevalence of specific reading disability
ADHD subtypes (primarily inattentive type, com- among children with ADHD. For children to be clas-
bined type, and primarily hyperactive/impulsive sified as having a specific reading disability, children
type) was considered. Of interest is the finding that, had to be reading disabled relative to their peers of
when DSM-IV impairment criteria were not consid- the same chronological age and relative to their gen-
ered, 16% of the sample qualified for a diagnosis, eral level of intellectual functioning. Twenty-two
with many more males than females meeting criteria. percent of their sample of children with ADHD met
This finding underscores the importance of incorpo- these criteria. In the study by Wolraich and col-
rating functional impairment when making a diag- leagues,19 only 11% of the children classified as hav-
nosis of ADHD. Without due consideration of the ing ADHD according to DSM-IV criteria were re-
DSM-IV functional impairment criterion, the fre- ported to have learning disabilities. The lower rate of
quency of ADHD diagnosis may be spuriously high. learning disabilities in that study may reflect the use
Wolraich and colleagues19 offered support for the of a restrictive methodology to classify children as
DSM-IV diagnostic subtypes of ADHD, with most of learning disabled,4 with the classification simply
the children meeting criteria for either the predomi- based on teachers’ indication of whether the child
nantly inattentive subtype (3.2%) or the combined had a learning disability diagnosis. Clearly, addi-
subtype (2.9%). More studies need to be conducted to tional research regarding the co-occurrence of
determine the distribution of children with ADHD ADHD and learning disabilities is needed.
across the subtypes.
Three studies20 –22 examined prevalence rates of Prevalence of ADHD and Co-occurring Conditions in
ADHD among elementary school children in the the Pediatric Office Setting
general population who had been screened for Significant changes in the health care system have
symptoms of behavior problems. Formal diagnostic placed increasing demands on pediatric primary care
instruments were administered only to children who providers to assess and manage children who
were identified in the initial screening procedure. present with ADHD symptoms. Some research has
The average prevalence rate approached 4%. suggested that children’s symptom display may dif-
A high proportion of children with ADHD have fer as a function of psychiatric versus pediatric clinic
other related conditions, and several investigators setting.23 Numerous studies have examined the
have assessed co-occurring conditions. In the techni- symptoms of children with ADHD evaluated in psy-
cal review, Green et al4 presented studies assessing chiatric settings, but not enough attention has been
co-occurring ADHD and oppositional defiant disor- devoted to children evaluated in primary care of-
der,12,14,16 conduct disorder,7,12,14,16 and depressive fices.
and anxiety disorders.14,21 Calculations of the mean Two groups of investigators reported on the prev-
prevalence rates across studies were highest for op- alence of ADHD in the primary care setting,24 –26 and
positional defiant disorder (35.2%), followed by con- their findings were presented in the technical review.
duct disorder and anxiety disorders (25.7% and Lindgren et al26 examined 457 consecutive 6- to 12-
25.8%), and depressive disorders (18.2%). year-old patients from primary care settings. Preva-
In the 1 investigation that employed DSM-IV cri- lence of ADHD under different inclusion criteria (ie,
teria, Wolraich and colleagues19 found that rates of 8 vs 10 symptoms) was estimated. Symptoms were
co-occurring oppositional defiant disorder, conduct assessed from parents’ reports based on DSM-III-R
disorder, anxiety disorder, and depressive disorder criteria. As might be expected, prevalence rates dif-
were similar to those found in the studies previously fered according to cutoff criteria. A prevalence of
mentioned. Of interest, Wolraich et al found mark- 11.2% occurred when the cutoff was 8 symptoms. A
edly different patterns of co-occurring disorders ac- lower prevalence rate (3.7%) was revealed with the
cording to diagnostic subtype. When they examined more conservative 10-symptom cutoff. In contrast to
the inattentive subtype, significantly fewer children concerns expressed in the popular media that this
had co-occurring disruptive behavior disorders (ie, disorder is overdiagnosed by pediatricians,27 the
oppositional defiant disorder, conduct disorder) data here suggest that prevalence rates of ADHD in
compared with the hyperactive/impulsive and com- primary care settings are similar to rates in general
bined subtypes. In addition, children with the pre- population studies.
dominantly hyperactive/impulsive subtype evi- In an epidemiologic study conducted in Pittsburgh
denced fewer co-occurring internalizing (ie, anxiety, by Costello and colleagues,24 –25 300 children were
depressive) and learning problems. Thus, externaliz- assessed from a pool of 789 patients from 2 health
ing disorders (ie, oppositional defiant disorder, con- maintenance organization clinics. The Diagnostic In-
duct disorder) seem to be associated with the hyper- 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

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psychiatric interview assessing DSM-III criteria, was associations with the hyperactive/impulsive dimen-
administered by a psychiatric social worker. When sion of ADHD, whereas internalizing and learning
considering parent reports on the DISC, findings problems are more strongly associated with the in-
were that 1.4% of the children met DSM-III criteria attentive dimension of the disorder. Thus, as recom-
for a diagnosis of attention-deficit disorder with hy- mended in the clinical practice guideline,3 the eval-
peractivity, and 0.2% met criteria for attention-deficit uation of ADHD should include evaluation for other
disorder without hyperactivity. Fewer cases were conditions that may co-occur with the disorder.
identified using children’s reports on the DISC, com-
pared with parent reports, indicating that reliance ASSESSMENT OF ADHD
only on children’s reports may show the prevalence Assessment of ADHD in the primary care settings
rate to be falsely low. This finding underscores the may include both behavior rating scales and medical
importance of collecting parent interview data. The and laboratory tests. The utility of these instruments
prevalence rates reported by Costello and col- in the identification of ADHD was examined.
leagues24 –25 were much lower than those reported by
Lindgen et al,26 probably because older editions of Behavior Rating Scales
the DSM yielded lower rates of the disorder. A widely employed tool for the assessment of
Lindgren et al26 and Costello et al25 showed prev- ADHD has been the use of behavior rating scales and
alence rates of co-occurring conditions with ADHD checklists. These scales can be completed by parents,
ranging from 9% to 38% across disorders. The most teachers, and other informants. The informant is
prevalent co-occurring conditions were oppositional asked to summarize the extent to which the child
defiant disorder and anxiety disorder, each with a exhibits particular behaviors over a specified time.
prevalence rate of 38%. The prevalence rates of de- The advantages of behavior rating scales include
pression and conduct disorder (each at 9%) were ease of administration, cost effectiveness, and the
lower in the primary care setting than those found in range of information provided by multiple infor-
the studies of ADHD in the general population. Chil- mants. These instruments can be classified into either
dren considered to have more severe psychiatric dis- broad-band checklists or ADHD-specific measures.
turbances, like depression and conduct disorder, ADHD-specific measures are those that specifically
may be triaged to child psychiatric clinics as opposed assess the core symptoms of the disorder, whereas
to pediatric primary care settings. Nonetheless, co- broad-band checklists measure a variety of child be-
existing conditions are clearly evident among chil- havior problems. Regarding broad-band rating
dren seen in the primary care setting and merit the scales, information obtained may include scores that
careful attention of the primary care provider. sum across all types of child behavior problems (ie,
total global scale scores), scores that sum across types
Summary of internalizing problems such as depression and
Examination of the data revealed that prevalence anxiety (ie, internalizing scale scores), and scores that
rates of ADHD generally range from 4% to 12% of sum across types of externalizing problems such as
the elementary school population when the DSM-III, aggression and conduct problems (ie, externalizing
DSM-III-R, or DSM-IV is used,1,17–18 with higher scale scores). Some measures provide scores for sub-
rates of the disorder among males and with higher scales that assess adaptive behavior. To be included
rates reported from school settings than community in the technical review,4 it was required that the
settings. Only 2 studies provided information on the ADHD-specific and broad-band rating scales in-
prevalence of ADHD in primary care settings, with 1 cluded a parent version of the scale and had norma-
reporting 11% of children met criteria for ADHD, tive data available. Also, broad-band checklists had
and the second reporting that less than 2% of chil- to include subscales designed to measure symptoms
dren met criteria for the disorder. Additional re- associated with ADHD. The rating scales reviewed
search examining the prevalence of this disorder in are listed in Table 3.
pediatric settings is needed. Overall, the findings Effect sizes were calculated for each of these rating
regarding the prevalence of ADHD support the subscales. An effect size refers to the difference in
American Academy of Pediatrics clinical practice mean scores between 2 populations (eg, children re-
guideline3 assertion that it is reasonable for primary ferred with ADHD vs nonreferred children) divided
care pediatricians to initiate an evaluation for ADHD by an estimate of the individual standard deviation.
when children present with symptoms that include A larger effect size is more desirable because it sug-
inattention, hyperactivity, impulsivity, academic un- gests less overlap between the 2 populations. Hence,
derachievement, and behavior problems. an effect size of 1.0 or less would reflect substantial
ADHD frequently co-occurs with additional emo- overlap between the distribution of scores across the
tional, behavioral, and learning problems in commu- 2 populations. In contrast, an effect size of 3.0 sug-
nity and primary care settings, with disruptive be- gests little overlap between scores attained for the 2
havior disorders being most common, followed by populations, with the mean scores for the 2 popula-
internalizing and learning problems. Finally, the in- tions falling 3 standard deviation units apart. Con-
vestigation that examined conditions co-occurring sequently, one could consider the 2 populations rel-
with the DSM-IV subtypes supported the current atively distinct.
nosology that conceptualizes ADHD as a 2-dimen- A higher effect size is indicative of greater sensi-
sional disorder.19 Interestingly, co-occurring disrup- tivity and specificity of the measure. For example,
tive behavior problems seem to have more frequent assuming that the populations with and without the

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 TABLE 3. Broad-Band Checklists: Ability to Detect Referred Versus Nonreferred Participants*
Study Behavior Age Gender Effect
Rating Scale Size
Total Scales
Achenbach, 1991† CBCL/4-18-R 4–11 M 1.4
CBCL/4-18-R 4–11 F 1.3
Achenbach, 1991‡ CBCL/TRF-R 5–11 M 1.2
CBCL/TRF-R 5–11 F 1.1
Naglieri, LeBuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.0
Conners, 1997 CPRS-R:L — MF 2.3
CTRS-R:L — MF 2.0
Externalizing Scales
Achenbach, 1991† CBCL/4-18-R 4–11 M 1.2
CBCL/4-18-R 4–11 F 1.0
Achenbach, 1991‡ CBCL/TRF-R 5–11 M 1.0
CBCL/TRF-R 5–11 F 0.9
Naglieri, LeBuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.4
Conners, 1997 CPRS-R:L-DSM-IV — MF 2.9
CTRS-R:L-DSM-IV — MF 2.0
Internalizing Scales
Achenbach, 1991† CBCL/4-18-R 4–11 M 1.1
CBCL/4-18-R 4–11 F 1.1
Achenbach, 1991‡ CBCL/TRF-R 5–11 M 0.7
CBCL/TRF-R 5–11 F 0.7
Naglieri, Lebuffe, and Pfeiffer, 1994§ DSMD 5–12 MF 1.6
Adaptive Functioning Scales
Achenbach, 1991† CBCL/4-18-R 4–11 M 1.2
CBCL/4-18-R 4–11 F 1.1
Achenbach, 1991‡ CBCL/TRF-R 5–11 M 1.2
CBCL/TRF-R 4–11 F 1.2
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 and
Research; 1999.
* CBCL/4-18-R ⫽ Child Behavior Checklist for Ages 4 –18, Parent Form, Revised; TRF-R ⫽ Teacher
Report Form, Revised; DSMD ⫽ Devereaux Scales of Mental Disorders; CPRS-R:L ⫽ 1997 Revision of
the Conners Parent Rating Scale, Long Version; CTRS-R:L ⫽ 1997 Revision of the Conners Teaching
Rating 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 of
Vermont Department of Psychiatry; 1991.
§ Naglieri JA, Lebuffe PA, Pfeiffer SI. Devereaux Scales of Mental Disorders. San Antonio, TX: Harcourt
Brace; 1994.

disorder are normally distributed and have equal dence to support a reliance on either broad-band
variances, and considering the case whereby sensi- checklist total problem indices or scales assessing
tivity equals specificity, an effect size of 3.0 would be externalizing, internalizing, or adaptive behavior to
associated with a sensitivity and specificity of 0.94 screen for or diagnose ADHD. However, these scales
and a false-positive and false-negative rate of 6%.29 may be used for other purposes such as screening for
In contrast, an effect size of 1.0, under the same co-occurring problems in other areas (eg, anxiety,
conditions, would be associated with a sensitivity depression, conduct problems).
and specificity of 0.71, which is associated with a Also available to practitioners are several rating
false-positive and false-negative rate of 29%.29 scales that specifically assess symptoms related to
Broad-band rating scales and checklists were eval- ADHD. The studies that were reviewed used
uated for their ability to discriminate children re- ADHD-specific measures to discriminate between
ferred for ADHD from their nonreferred peers. Table children diagnosed with ADHD and typically devel-
3 presents the broad-band rating scale studies that oping children. Because few studies used control
allowed the calculation of effect sizes for total prob- groups with other psychiatric disorders (eg, learning
lem, internalizing, externalizing, and adaptive func- disabilities, conduct disorder), it is difficult to eval-
tioning indices or subscales. The average effect size uate the efficacy of these rating scales in differenti-
across broad-band measures using total global scale ating children with ADHD from those with other
scores was 1.5. Effect sizes using domain scales (ie, psychiatric diagnoses. Table 4 presents studies of
the internalizing, externalizing, and adaptive func- ADHD-specific rating scales. These studies allowed
tioning scales) generally ranged from 0.7 to 1.4, with the calculation of effect sizes for global ADHD symp-
the exception of the externalizing scales on the par- toms and subscales that assess specific types of
ent and teacher forms of the Conners’ Scales,30 which ADHD symptoms (ie, inattention, impulsivity, over-
had significantly better discriminatory power. Taken activity). The overall range of effect sizes varied
together, the findings do not provide sufficient evi- across measures. Effect sizes for global ADHD symp-

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TABLE 4. ADHD-Specific Checklists: Ability to Detect ADHD Versus Normal Controls*
Study Behavior Rating Scales Age Gender Effect Size
Total ADHD Symptoms Scales
Conners, 1997 CPRS-R:L-ADHD Index 6–17 MF 3.1
CTRS-R:L-ADHD Index 6–17 MF 3.3
CPRS-R:L-DSM-IV Symptoms 6–17 MF 3.4
CTRS-R:L-DSM-IV Symptoms 6–17 MF 3.7
Breen, 1989 SSQ-O-I 6–11 F 1.3
SSQ-O-II 6–11 F 2.0
Hyperactivity Subscales
Ullmann, Sleator, & Sprague, 1997 ACTeRS 6–14 MF 1.5
Atkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 5.1
Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 3.1
Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 F 3.7
Tarnowski, Prinz, & Nay, 1986 CATQ-HI 7 M 4.1
Inattention Subscales
Ullmann, Sleator, & Sprague, 1997 ACTeRS—Parent Version 6–14 MF 2.0
Atkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 4.2
Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 3.5
Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 F 4.0
Impulsivity Subscales
Atkins, Pelham, & Licht, 1985 DSM-III SNAP Checklist 7–12 MF 5.5
Horn, Wagner, & Ialongo, 1989 DSM-III-R SNAP Checklist 7–11 M 4.7
Horn, 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 Care
Policy and Research; 1999.
* CPRS-R:L ⫽ 1997 Revision of the Conners Parent Rating Scale, Long Version; CTRS-R:L ⫽ 1997 Revision of the Conners Teaching
Rating Scale, Long Version; SSQ-O-I ⫽ Barkley’s School Situations Questionnaire—Original Version, Number of Problem Settings Scale;
SSQ-O-II ⫽ Barkley’s School Situations Questionnaire—Original Version, Mean Severity Scale; ACTeRS ⫽ ADD-H: Comprehensive
Teacher Rating Scale; CATQ-HI ⫽ Conners Abbreviated Teacher Questionnaire—Hyperactivity Index.

toms ranged from 1.3 to 3.7. The Conners’ scales30 means to gather data regarding the display of the
yielded the highest effect sizes, and the School Situ- core symptoms of ADHD. In addition, the collection
ations Questionnaire31 the lowest effect sizes. When of behavior ratings from teachers and caregivers will
specific symptoms were examined separately, the fulfill the DSM requirement that there be cross-situ-
effect sizes were again variable. Overall, the effect ational evidence of the disorder. Although rating
sizes were slightly greater for subscales assessing scales are convenient for use in the pediatric office
specific symptoms compared with indices of com- setting, we caution against their use in isolation.
bined ADHD symptoms. Across symptoms, effect Information collected via rating scales must be sup-
sizes ranged from 3.1 to 5.5 when considering the plemented with a clinical history, including age of
Swanson, Nolan, and Pelham (SNAP) Checklist32,33 onset and duration of symptoms, and careful inter-
and the Conners Abbreviated Teacher Questionnaire view, which includes an assessment of the functional
Hyperactivity Index,34 with significantly lower effect consequences of the behaviors.
sizes by the inattention and hyperactivity subscales
of the Attention-Deficit Disorder Comprehensive Medical and Laboratory Screening Tests
Teacher Rating Scale—Parent version.35 Several medical screening tests and laboratory
measures have been used to evaluate children with
Summary suspected ADHD. These tests include blood lead
Overall, rating scales of specific ADHD symptoms levels, thyroid function, radiographic assessment,
were more useful in diagnosis than global indices on electroencephalography, neurologic screening exam-
broad-band checklists. Among the ADHD-specific inations, and continuous performance tasks, as well
rating scales that were reviewed, the ADHD Index as other miscellaneous laboratory assessments.
and the DSM-IV Symptoms Scale of the 1997 revision The association between elevated lead levels and
of the Conners’ Rating Scale30 and the Hyperactivity delays in cognitive functioning, including attention
and Inattention Subscales of the SNAP Checklist32 problems, has been consistently reported.36 –37 This
performed well in discriminating between children begs the question regarding the utility of lead level
with ADHD and normal controls. It should be noted, measurements in the assessment of ADHD. Six stud-
however, that while parent- or teacher-completed ies were reviewed, with no statistically significant
broad-band scales are not recommended to specifi- associations in 3 of the investigations.38 – 40 One study
cally diagnose ADHD, global rating scales may be reported a positive association between lead level
useful to screen for co-occurring problems. Given the and behavior problems.15 Two studies examined
recommendations set forth in the practice guideline3 children screened for disruptive behavior problems
that the assessment of ADHD requires evidence of and found associations between elevated lead levels
symptomatology from caregivers and school person- and behavior problems.41– 42 However, because these
nel (ie, teachers), we endorse the use of behavior studies did not assess ADHD, the extent to which
rating scales as a time-efficient and cost-effective their findings may be applied to children with this

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disorder is unknown. These findings suggest an as- amplitude evoked-response potentials.10 These find-
sociation between elevated lead levels and a range of ings are variable and do not provide any compelling
behavior problems including inattention. However, evidence for a particular EEG pattern for patients
the routine use of lead screening as a diagnostic with ADHD.
indicator for ADHD is not supported. A key issue Over the years, various neuropsychological
here is that by elementary school age, children who screens, or soft sign assessments were believed to
have had lead effects will almost always have normal shed light on the pathogenesis of the ADHD disor-
lead levels. der. Five studies using such assessments met criteria
Abnormal thyroid function can produce a variety for inclusion in the technical review.4 Reeves and
of behavior effects in children, ranging from impair- colleagues64 found that children with ADHD evi-
ments in concentration to severe neuropsychological denced higher rates of neurodevelopment abnormal-
deficits.43 Four studies of thyroid function were re- ities than comparison control children on 9 tests of
viewed, and none of the 4 showed an association sensorimotor coordination, but no differences be-
between abnormal thyroid levels and ADHD. In 3 of tween groups were found for prenatal or perinatal
the studies, none of the children with ADHD had problems or speech problems. Trommer and col-
clinically significant thyroid dysfunction.44 – 46 In a leagues65 found that children with ADHD evidenced
study by Weiss, Stein, Trommer, and Refetoff47 2% of a greater number of errors on a psychomotor task
the ADHD cohort had abnormal thyroid levels com- designed to assess inattention. However, the ranges
pared with ⬍1% of the comparison control group. In for the number of errors exhibited by the ADHD and
total, these studies fail to support the use of thyroid control group were similar, casting doubt on the
function tests to screen for ADHD. clinical significance of this group difference. The re-
Recent attention also has been devoted to investi- maining 3 studies66 – 68 revealed no differences be-
gating whether there are morphologic differences tween ADHD and comparison control children on
between the brain structures of individuals with various neurodevelopment tasks (eg, the Revised
ADHD relative to their normally developing peers. Neurologic Examination for Subtle Signs, Mazes
The technical review4 examined 9 studies that used subtest of the Wechsler Intelligence Scales for Chil-
either computerized tomography or magnetic reso- dren). These findings do not support the use of neu-
nance imaging to compare children with ADHD with rodevelopment measures for diagnosis of ADHD.
a comparison control group.48 –56 No differences Some isolated studies measuring neurotransmit-
were found between children with ADHD and com- ters (eg, serotonin levels, dopamine receptors, epi-
parison controls in 2 of the investigations.50,56 In the nephrine), hormones (eg, growth hormone releasing
other 7 studies, asymmetries, differences in shape or factor), and proteins69 –74 were also reviewed in the
volume of the ventricles, and differences in brain size TRI report.4 Each study reported findings suggestive
occurred between ADHD and normally developing of possible biological differences between children
children. In each of these studies, structures in the with ADHD and controls, but the findings were too
children with ADHD were smaller than those of sparse and preliminary to indicate a definitive rela-
comparison controls. These studies are provocative tionship.
and will likely direct new research that has the po- Finally, studies examining computerized and pen-
tential to shed light on the pathogenesis of this dis- cil and paper tests of sustained attention and impul-
order. However, because other child psychiatric con- sivity (eg, continuous performance tests)7,33,75– 84
trol groups (eg, children with learning problems or were reviewed in the TRI report.4 These measures
other disruptive behavior disorders) have not been poorly discriminated children with ADHD from
included, the specificity of these findings to ADHD is their normally developing peers. Both indices of in-
not clear. Furthermore, although some studies have attention and indices of impulsivity provided by
revealed significant group differences, the degree of continuous performance tasks were poor predictors
within group variance and overlap between groups of ADHD, with most effect sizes lower than 1.0.4
make imaging of little use for individual diagnostic Thus, the power of discrimination of these tests is not
purposes. That is to say, the imaging findings do not sufficient to support their use in the assessment and
discriminate adequately between children with diagnosis of ADHD.
ADHD and those without. For these reasons, the use
of imaging procedures is not currently supported as Summary
a diagnostic tool for assessment of ADHD. Many medical tests and laboratory assessments
One of the most widely researched medical tests have been investigated in relation to ADHD. Across
for evaluating children with ADHD is the electroen- studies that included blood lead levels, morphologic
cephalogram (EEG) to examine event-related poten- features, and thyroid abnormalities, no compelling
tials (ERPs). Eight studies met criteria for inclusion in evidence supported an association between abnor-
Green and colleagues’4 technical review.10,57– 63 malities on these various tests and the presence of
Overall, no major EEG abnormalities (ie, evidence of ADHD. Morphologic studies offered some prelimi-
seizure activity) were found for children with nary support for brain-related differences between
ADHD. Several investigations reported minor differ- children with and without the disorder, but addi-
ences in ERPs functioning, including longer latencies tional studies with control groups of children with
at the P3 site,57 longer latencies of certain waves for other psychiatric and developmental disorders and
brainstem auditory-evoked potentials,58 more slow larger sample sizes will be necessary before brain
waves and fewer ␣-waves,59 and asymmetry in peak morphology becomes useful in diagnosing ADHD.

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Based on these data, it is recommended in the prac- ined with DSM-IV criteria and parameters associated
tice guideline3 that laboratory and medical diagnos- with the specific ADHD subtypes. Most research
tic tests discussed above not be used routinely in conducted to date has predominantly reported on
determining a diagnosis of ADHD. samples of boys with ADHD. Investigations target-
ing girls with this disorder are sorely needed. As
CONCLUSIONS well, research has primarily focused on elementary-
Children with ADHD are frequently encountered school-aged children; there is a need for investiga-
in the primary care setting. It is important that the tions examining this disorder among preschoolers
diagnosis of this condition by primary care providers and adolescents. Finally, the studies reviewed used
be based on procedures supported by evidence from control groups composed of either nonreferred chil-
empirical investigations. Here findings were high- dren or typically developing comparison controls.
lighted from a comprehensive review of the litera- Greater efforts are needed to evaluate the specificity
ture regarding the prevalence of ADHD and co-oc- of ADHD-specific rating scales in discriminating be-
curring conditions in community and primary care tween children with ADHD and those with other
settings, as well as evidence regarding the utility of psychiatric disorders where ADHD does not co-oc-
behavior rating scales and medical tests in the assess- cur.
ment process.
In community samples of school-aged children,
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 Prevalence and Assessment of Attention-Deficit/Hyperactivity Disorder in
Primary Care Settings
Ronald T. Brown, Wendy S. Freeman, James M. Perrin, Martin T. Stein, Robert W.
Amler, Heidi M. Feldman, Karen Pierce and Mark L. Wolraich
Pediatrics 2001;107;43-
DOI: 10.1542/peds.107.3.e43
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