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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 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-
lence of attention-deficit/hyperactivity disorder (ADHD)
and co-occurring conditions in children from primary
care settings and the general population is reviewed as
the basis of the American Academy of Pediatrics clinical
practice guideline for the assessment and diagnosis of
ADHD. Epidemiologic studies revealed prevalence rates
generally ranging from 4% to 12% in the general popu-
lation of 6 to 12 year olds. Similar or slightly lower rates
of 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 be
employed in evaluating ADHD. The utility of using both
parent- 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 suspected
ADHD in the pediatric primary care setting. Pediatrics
2001;107(3). URL: http://www.pediatrics.org/cgi/content/
full/107/3/e43; prevalence, attention-deficit/hyperactivity
disorder, primary care.
ABBREVIATIONS. ADHD, attention-deficit/hyperactivity disor-
der; TRI, Technical Resources International; DSM, Diagnostic and
Statistical Manual; DISC, Diagnostic Interview Schedule for Chil-
dren; EEG, electroencephalogram; ERP, event-related potential.
A
ttention-deficit/hyperactivity disorder (ADHD)
has defining features of inattention, overactiv-
ity, and impulsivity.1 It is the most frequently
encountered childhood-onset neurodevelopmental
disorder 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 the
disorder represents a public health concern with sig-
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 California
at San Diego, San Diego, California; ¶US Department of Health and Human
Services, Atlanta, Georgia; 储University of Pittsburgh, Pittsburgh, Pennsyl-
vania; #Children’s Memorial Hospital, Chicago, Illinois; and **Vanderbilt
University, 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.
http://www.pediatrics.org/cgi/content/full/107/3/e43 PEDIATRICS Vol. 107 No. 3 March 2001
Downloaded from www.pediatrics.org by on May 29, 2006
nificant effects on children’s functioning across mul-
tiple areas.2 Referrals to health care professionals for
children suspected of having the disorder continue at
a high rate, and changes in the health care system in
the United States have placed increasing demands on
primary care pediatricians to diagnose and manage
the disorder. It is now recognized that ADHD is a
chronic condition that will persist over the life span.2
The American Academy of Pediatrics Committee
on Quality Improvement Subcommittee on Atten-
tion-Deficit/Hyperactivity Disorder synthesized a
clinical practice guideline for the diagnosis and eval-
uation of children with ADHD.3 This report will
highlight the empirical literature review on which
this practice guideline is based. The subcommittee
worked with Technical Resources International
(TRI), Washington, DC, under the auspices of the
Agency 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 the
literature review, see the technical review compiled
by Green, Wong, Atkins, Taylor, and Feinleib.4
Given the widespread attention ADHD has re-
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-
lescents with ADHD, the literature review focused
on studies involving elementary-school-aged chil-
dren. Specifically, 4 key questions provided the
framework 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 disorders
in the general population of 6 to 12 year olds in
the United States?
2. What is the prevalence of ADHD and co-occur-
ring conditions in 6 to 12 year olds coming to
primary care providers in the United States?
3. How accurate and reliable are behavior rating
instruments in screening for ADHD?
4. How useful are medical screening tests in diag-
nosing ADHD?
For the review, 507 articles and 10 published rating
scale 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
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Children, Adolescents, and Adults with Attention-
Deficit/Hyperactivity Disorder5; recently published
journal articles; citations suggested by members of
the American Academy of Pediatrics; and a database
of bibliographies on studies involving the Child Be-
havior Checklist rating scale.6 A physician and psy-
chologist specializing in ADHD independently rated
each article and manual for sound empirical evi-
dence addressing the 4 questions. Criteria used to
evaluate the appropriateness of a study are pre-
sented in Table 1. Application of the inclusion and
exclusion criteria yielded 87 articles and 10 manuals
for inclusion in the review.4
PREVALENCE OF ADHD
Most studies of ADHD have come from referral
populations seen in tertiary care centers. They, there-
fore, reflect unknown sampling biases and cannot
provide estimates of rates of ADHD in unreferred
populations. Thus, to address the epidemiology of
ADHD, we reviewed the prevalence of ADHD in
communities, schools, and primary care settings.
Also investigated was the prevalence of co-occurring
conditions in the general population and primary
care settings.
Prevalence of ADHD and Co-occurring Conditions in
the 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 6
used DSM-III-R,18 1 used DSM-III-R and DSM-IV,1
and 1 used DSM-IV. See Table 2 for the criteria
employed in the various editions. For studies using
DSM-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 prevalence
rates between 4% and 12% (median: 5.8%). The in-
vestigation reporting the outlier prevalence rate of
26% examined the smallest sample of children, and
all children in that investigation were from a single,
inner-city elementary school.11 These methodologi-
cal limitations may have contributed to a spuriously
inflated estimate for the prevalence of ADHD in the
general population. Across studies, setting (ie, com-
munity vs school), gender, and diagnostic nomencla-
ture (DSM-III vs DSM-III-R criteria), all affected the
prevalence rates. Specifically, the mean prevalence
rates of ADHD were higher in community samples
(10.3% for community samples vs 6.9% for school
samples), higher among males (9.2% for males vs
3.0% for females), and higher among children who
were 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 the
technical report was compiled, sufficient research

TABLE 1. Inclusion Criteria for Studies

Factor
Definition of ADHD and
comorbidities
Patient population
Setting and provider population
Behavior screening tests for ADHD
Outcomes of interest for behavior
screening tests (Question 3)
Medical screening tests for ADHD
(Question 4)
Outcomes of interest for medical
screening tests (Question 4)
Criteria for admissible evidence
and bibliographic database
boundaries
† 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.
Criteria
ADHD with criteria from DSM-III,† DSM-III-R,‡ and DSM-IV§
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)
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)
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
Selected behavior checklists and rating scales (parent and teacher reports)
Accuracy for ADHD: sensitivity, specificity, positive predictive value
Accuracy for referral population (for broad-band checklists)
Effect size for discriminating referred from non-referred samples
Selected medical and neurologic screening tests: electroencephalography, lead
concentration level, thyroid hormone level, imaging tests, continuous performance
tests, hearing and vision screening
Prevalence of abnormal findings
Data from peer-reviewed published studies
Literature published 1980 to 1997
English language
Diagnostic (not treatment) outcomes

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had not yet accumulated on the prevalence of ADHD
using DSM-IV criteria. One study that was available,
however, was an investigation by Wolraich et al19
conducted with 4323 school children ranging from
kindergarten to fifth grade. In addition to assessing
DSM-IV symptoms, Wolraich and colleagues exam-
ined the level of impairment in children’s academic
and behavior functioning. Consistent with the data
provided by others,8,15 the investigators found an
overall prevalence rate of 6.8% when each of the
ADHD subtypes (primarily inattentive type, com-
bined type, and primarily hyperactive/impulsive
type) 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 the
DSM-IV functional impairment criterion, the fre-
quency of ADHD diagnosis may be spuriously high.
Wolraich and colleagues19 offered support for the
DSM-IV diagnostic subtypes of ADHD, with most of
the children meeting criteria for either the predomi-
nantly inattentive subtype (3.2%) or the combined
subtype (2.9%). More studies need to be conducted to
determine the distribution of children with ADHD
across the subtypes.
Three studies20 –22 examined prevalence rates of
ADHD among elementary school children in the
general population who had been screened for
symptoms of behavior problems. Formal diagnostic
instruments were administered only to children who
were identified in the initial screening procedure.
The average prevalence rate approached 4%.
A high proportion of children with ADHD have
other related conditions, and several investigators
have assessed co-occurring conditions. In the techni-
cal review, Green et al4 presented studies assessing
co-occurring ADHD and oppositional defiant disor-
der,12,14,16 conduct disorder,7,12,14,16 and depressive
and anxiety disorders.14,21 Calculations of the mean
prevalence rates across studies were highest for op-
positional defiant disorder (35.2%), followed by con-
duct disorder and anxiety disorders (25.7% and
25.8%), and depressive disorders (18.2%).
In the 1 investigation that employed DSM-IV cri-
teria, Wolraich and colleagues19 found that rates of
co-occurring oppositional defiant disorder, conduct
disorder, anxiety disorder, and depressive disorder
were similar to those found in the studies previously
mentioned. Of interest, Wolraich et al found mark-
edly different patterns of co-occurring disorders ac-
cording to diagnostic subtype. When they examined
the inattentive subtype, significantly fewer children
had 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-
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active/impulsive dimension of ADHD; internalizing
disorders (ie, anxiety, depression, learning disabili-
ties) seem to be more frequently associated with the
inattention dimension of the disorder.
The rate of co-occurrence between ADHD and
learning disabilities is difficult to establish because
few studies have employed DSM criteria for learning
disorders. As a result, many studies were not in-
cluded in this review. August and Garfinkel7 exam-
ined the prevalence of specific reading disability
among children with ADHD. For children to be clas-
sified as having a specific reading disability, children
had to be reading disabled relative to their peers of
the same chronological age and relative to their gen-
eral level of intellectual functioning. Twenty-two
percent of their sample of children with ADHD met
these 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 of
learning disabilities in that study may reflect the use
of a restrictive methodology to classify children as
learning disabled,4 with the classification simply
based on teachers’ indication of whether the child
had a learning disability diagnosis. Clearly, addi-
tional research regarding the co-occurrence of
ADHD and learning disabilities is needed.
Prevalence of ADHD and Co-occurring Conditions in
the Pediatric Office Setting
Significant changes in the health care system have
placed increasing demands on pediatric primary care
providers to assess and manage children who
present with ADHD symptoms. Some research has
suggested that children’s symptom display may dif-
fer as a function of psychiatric versus pediatric clinic
setting.23 Numerous studies have examined the
symptoms of children with ADHD evaluated in psy-
chiatric settings, but not enough attention has been
devoted 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 and
their 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 were
assessed from parents’ reports based on DSM-III-R
criteria. As might be expected, prevalence rates dif-
fered according to cutoff criteria. A prevalence of
11.2% occurred when the cutoff was 8 symptoms. A
lower prevalence rate (3.7%) was revealed with the
more conservative 10-symptom cutoff. In contrast to
concerns expressed in the popular media that this
disorder is overdiagnosed by pediatricians,27 the
data here suggest that prevalence rates of ADHD in
primary care settings are similar to rates in general
population studies.
In an epidemiologic study conducted in Pittsburgh
by Costello and colleagues,24 –25 300 children were
assessed from a pool of 789 patients from 2 health
maintenance 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

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psychiatric interview assessing DSM-III criteria, was
administered by a psychiatric social worker. When
considering parent reports on the DISC, findings
were that 1.4% of the children met DSM-III criteria
for a diagnosis of attention-deficit disorder with hy-
peractivity, and 0.2% met criteria for attention-deficit
disorder without hyperactivity. Fewer cases were
identified using children’s reports on the DISC, com-
pared with parent reports, indicating that reliance
only on children’s reports may show the prevalence
rate to be falsely low. This finding underscores the
importance of collecting parent interview data. The
prevalence rates reported by Costello and col-
leagues24 –25 were much lower than those reported by
Lindgen et al,26 probably because older editions of
the DSM yielded lower rates of the disorder.
Lindgren et al26 and Costello et al25 showed prev-
alence rates of co-occurring conditions with ADHD
ranging from 9% to 38% across disorders. The most
prevalent co-occurring conditions were oppositional
defiant disorder and anxiety disorder, each with a
prevalence rate of 38%. The prevalence rates of de-
pression and conduct disorder (each at 9%) were
lower in the primary care setting than those found in
the 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 opposed
to pediatric primary care settings. Nonetheless, co-
existing conditions are clearly evident among chil-
dren seen in the primary care setting and merit the
careful attention of the primary care provider.
Summary
Examination of the data revealed that prevalence
rates of ADHD generally range from 4% to 12% of
the elementary school population when the DSM-III,
DSM-III-R, or DSM-IV is used,1,17–18 with higher
rates of the disorder among males and with higher
rates reported from school settings than community
settings. Only 2 studies provided information on the
prevalence of ADHD in primary care settings, with 1
reporting 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 in
pediatric settings is needed. Overall, the findings
regarding the prevalence of ADHD support the
American Academy of Pediatrics clinical practice
guideline3 assertion that it is reasonable for primary
care pediatricians to initiate an evaluation for ADHD
when children present with symptoms that include
inattention, 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 by
internalizing and learning problems. Finally, the in-
vestigation that examined conditions co-occurring
with the DSM-IV subtypes supported the current
nosology that conceptualizes ADHD as a 2-dimen-
sional disorder.19 Interestingly, co-occurring disrup-
tive behavior problems seem to have more frequent
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associations with the hyperactive/impulsive dimen-
sion of ADHD, whereas internalizing and learning
problems 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 other
conditions that may co-occur with the disorder.
ASSESSMENT OF ADHD
Assessment of ADHD in the primary care settings
may include both behavior rating scales and medical
and laboratory tests. The utility of these instruments
in the identification of ADHD was examined.
Behavior Rating Scales
A widely employed tool for the assessment of
ADHD has been the use of behavior rating scales and
checklists. These scales can be completed by parents,
teachers, and other informants. The informant is
asked to summarize the extent to which the child
exhibits particular behaviors over a specified time.
The advantages of behavior rating scales include
ease of administration, cost effectiveness, and the
range of information provided by multiple infor-
mants. These instruments can be classified into either
broad-band checklists or ADHD-specific measures.
ADHD-specific measures are those that specifically
assess the core symptoms of the disorder, whereas
broad-band checklists measure a variety of child be-
havior problems. Regarding broad-band rating
scales, information obtained may include scores that
sum across all types of child behavior problems (ie,
total global scale scores), scores that sum across types
of internalizing problems such as depression and
anxiety (ie, internalizing scale scores), and scores that
sum across types of externalizing problems such as
aggression and conduct problems (ie, externalizing
scale scores). Some measures provide scores for sub-
scales that assess adaptive behavior. To be included
in the technical review,4 it was required that the
ADHD-specific and broad-band rating scales in-
cluded a parent version of the scale and had norma-
tive data available. Also, broad-band checklists had
to include subscales designed to measure symptoms
associated with ADHD. The rating scales reviewed
are listed in Table 3.
Effect sizes were calculated for each of these rating
subscales. An effect size refers to the difference in
mean scores between 2 populations (eg, children re-
ferred with ADHD vs nonreferred children) divided
by 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 substantial
overlap between the distribution of scores across the
2 populations. In contrast, an effect size of 3.0 sug-
gests little overlap between scores attained for the 2
populations, 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
5 of 11
 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
variances, and considering the case whereby sensi-
tivity equals specificity, an effect size of 3.0 would be
associated with a sensitivity and specificity of 0.94
and a false-positive and false-negative rate of 6%.29
In contrast, an effect size of 1.0, under the same
conditions, would be associated with a sensitivity
and specificity of 0.71, which is associated with a
false-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. Table
3 presents the broad-band rating scale studies that
allowed the calculation of effect sizes for total prob-
lem, internalizing, externalizing, and adaptive func-
tioning indices or subscales. The average effect size
across broad-band measures using total global scale
scores 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, with
the exception of the externalizing scales on the par-
ent and teacher forms of the Conners’ Scales,30 which
had significantly better discriminatory power. Taken
together, the findings do not provide sufficient evi-
dence to support a reliance on either broad-band
checklist total problem indices or scales assessing
externalizing, internalizing, or adaptive behavior to
screen for or diagnose ADHD. However, these scales
may be used for other purposes such as screening for
co-occurring problems in other areas (eg, anxiety,
depression, conduct problems).
Also available to practitioners are several rating
scales that specifically assess symptoms related to
ADHD. The studies that were reviewed used
ADHD-specific measures to discriminate between
children diagnosed with ADHD and typically devel-
oping children. Because few studies used control
groups with other psychiatric disorders (eg, learning
disabilities, conduct disorder), it is difficult to eval-
uate the efficacy of these rating scales in differenti-
ating children with ADHD from those with other
psychiatric diagnoses. Table 4 presents studies of
ADHD-specific rating scales. These studies allowed
the calculation of effect sizes for global ADHD symp-
toms and subscales that assess specific types of
ADHD symptoms (ie, inattention, impulsivity, over-
activity). The overall range of effect sizes varied
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
yielded the highest effect sizes, and the School Situ-
ations Questionnaire31 the lowest effect sizes. When
specific symptoms were examined separately, the
effect sizes were again variable. Overall, the effect
sizes were slightly greater for subscales assessing
specific symptoms compared with indices of com-
bined ADHD symptoms. Across symptoms, effect
sizes ranged from 3.1 to 5.5 when considering the
Swanson, Nolan, and Pelham (SNAP) Checklist32,33
and the Conners Abbreviated Teacher Questionnaire
Hyperactivity Index,34 with significantly lower effect
sizes by the inattention and hyperactivity subscales
of the Attention-Deficit Disorder Comprehensive
Teacher Rating Scale—Parent version.35
Summary
Overall, rating scales of specific ADHD symptoms
were more useful in diagnosis than global indices on
broad-band checklists. Among the ADHD-specific
rating scales that were reviewed, the ADHD Index
and the DSM-IV Symptoms Scale of the 1997 revision
of the Conners’ Rating Scale30 and the Hyperactivity
and Inattention Subscales of the SNAP Checklist32
performed well in discriminating between children
with ADHD and normal controls. It should be noted,
however, that while parent- or teacher-completed
broad-band scales are not recommended to specifi-
cally diagnose ADHD, global rating scales may be
useful to screen for co-occurring problems. Given the
recommendations set forth in the practice guideline3
that the assessment of ADHD requires evidence of
symptomatology from caregivers and school person-
nel (ie, teachers), we endorse the use of behavior
rating scales as a time-efficient and cost-effective
means to gather data regarding the display of the
core symptoms of ADHD. In addition, the collection
of behavior ratings from teachers and caregivers will
fulfill the DSM requirement that there be cross-situ-
ational evidence of the disorder. Although rating
scales are convenient for use in the pediatric office
setting, we caution against their use in isolation.
Information collected via rating scales must be sup-
plemented with a clinical history, including age of
onset and duration of symptoms, and careful inter-
view, which includes an assessment of the functional
consequences of the behaviors.
Medical and Laboratory Screening Tests
Several medical screening tests and laboratory
measures have been used to evaluate children with
suspected ADHD. These tests include blood lead
levels, thyroid function, radiographic assessment,
electroencephalography, neurologic screening exam-
inations, and continuous performance tasks, as well
as other miscellaneous laboratory assessments.
The association between elevated lead levels and
delays in cognitive functioning, including attention
problems, has been consistently reported.36 –37 This
begs the question regarding the utility of lead level
measurements in the assessment of ADHD. Six stud-
ies were reviewed, with no statistically significant
associations in 3 of the investigations.38 – 40 One study
reported a positive association between lead level
and behavior problems.15 Two studies examined
children screened for disruptive behavior problems
and found associations between elevated lead levels
and behavior problems.41– 42 However, because these
studies did not assess ADHD, the extent to which
their findings may be applied to children with this

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disorder is unknown. These findings suggest an as-
sociation between elevated lead levels and a range of
behavior problems including inattention. However,
the routine use of lead screening as a diagnostic
indicator for ADHD is not supported. A key issue
here is that by elementary school age, children who
have had lead effects will almost always have normal
lead levels.
Abnormal thyroid function can produce a variety
of behavior effects in children, ranging from impair-
ments in concentration to severe neuropsychological
deficits.43 Four studies of thyroid function were re-
viewed, and none of the 4 showed an association
between abnormal thyroid levels and ADHD. In 3 of
the studies, none of the children with ADHD had
clinically significant thyroid dysfunction.44 – 46 In a
study by Weiss, Stein, Trommer, and Refetoff47 2% of
the ADHD cohort had abnormal thyroid levels com-
pared with ⬍1% of the comparison control group. In
total, these studies fail to support the use of thyroid
function tests to screen for ADHD.
Recent attention also has been devoted to investi-
gating whether there are morphologic differences
between the brain structures of individuals with
ADHD relative to their normally developing peers.
The technical review4 examined 9 studies that used
either computerized tomography or magnetic reso-
nance imaging to compare children with ADHD with
a comparison control group.48 –56 No differences
were found between children with ADHD and com-
parison controls in 2 of the investigations.50,56 In the
other 7 studies, asymmetries, differences in shape or
volume of the ventricles, and differences in brain size
occurred between ADHD and normally developing
children. In each of these studies, structures in the
children with ADHD were smaller than those of
comparison controls. These studies are provocative
and 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 or
other disruptive behavior disorders) have not been
included, the specificity of these findings to ADHD is
not clear. Furthermore, although some studies have
revealed significant group differences, the degree of
within group variance and overlap between groups
make imaging of little use for individual diagnostic
purposes. That is to say, the imaging findings do not
discriminate adequately between children with
ADHD and those without. For these reasons, the use
of imaging procedures is not currently supported as
a diagnostic tool for assessment of ADHD.
One of the most widely researched medical tests
for evaluating children with ADHD is the electroen-
cephalogram (EEG) to examine event-related poten-
tials (ERPs). Eight studies met criteria for inclusion in
Green and colleagues’4 technical review.10,57– 63
Overall, no major EEG abnormalities (ie, evidence of
seizure activity) were found for children with
ADHD. Several investigations reported minor differ-
ences in ERPs functioning, including longer latencies
at the P3 site,57 longer latencies of certain waves for
brainstem auditory-evoked potentials,58 more slow
waves and fewer ␣-waves,59 and asymmetry in peak
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amplitude evoked-response potentials.10 These find-
ings are variable and do not provide any compelling
evidence for a particular EEG pattern for patients
with ADHD.
Over the years, various neuropsychological
screens, or soft sign assessments were believed to
shed light on the pathogenesis of the ADHD disor-
der. Five studies using such assessments met criteria
for inclusion in the technical review.4 Reeves and
colleagues64 found that children with ADHD evi-
denced higher rates of neurodevelopment abnormal-
ities than comparison control children on 9 tests of
sensorimotor coordination, but no differences be-
tween groups were found for prenatal or perinatal
problems or speech problems. Trommer and col-
leagues65 found that children with ADHD evidenced
a greater number of errors on a psychomotor task
designed to assess inattention. However, the ranges
for the number of errors exhibited by the ADHD and
control group were similar, casting doubt on the
clinical significance of this group difference. The re-
maining 3 studies66 – 68 revealed no differences be-
tween ADHD and comparison control children on
various neurodevelopment tasks (eg, the Revised
Neurologic Examination for Subtle Signs, Mazes
subtest 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 releasing
factor), and proteins69 –74 were also reviewed in the
TRI report.4 Each study reported findings suggestive
of possible biological differences between children
with ADHD and controls, but the findings were too
sparse 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 measures
poorly discriminated children with ADHD from
their normally developing peers. Both indices of in-
attention and indices of impulsivity provided by
continuous performance tasks were poor predictors
of ADHD, with most effect sizes lower than 1.0.4
Thus, the power of discrimination of these tests is not
sufficient to support their use in the assessment and
diagnosis of ADHD.
Summary
Many medical tests and laboratory assessments
have been investigated in relation to ADHD. Across
studies that included blood lead levels, morphologic
features, and thyroid abnormalities, no compelling
evidence supported an association between abnor-
malities on these various tests and the presence of
ADHD. Morphologic studies offered some prelimi-
nary support for brain-related differences between
children with and without the disorder, but addi-
tional studies with control groups of children with
other psychiatric and developmental disorders and
larger sample sizes will be necessary before brain
morphology 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 in
determining a diagnosis of ADHD.
CONCLUSIONS
Children with ADHD are frequently encountered
in the primary care setting. It is important that the
diagnosis of this condition by primary care providers
be based on procedures supported by evidence from
empirical 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 care
settings, as well as evidence regarding the utility of
behavior rating scales and medical tests in the assess-
ment process.
In community samples of school-aged children,
the prevalence rates of the disorder generally ranged
from 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 frequently
co-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% to
22% 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 children
presenting with hyperactive/impulsive symptoms.
With regard to assessment, behavior rating scales
and medical screening tests have been investigated.
ADHD-specific scales are reliable and valid for the
assessment of the disorder, but global or broad-do-
main scales are not. There is no compelling evidence
to support the use of medical and laboratory tests in
the 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 pediatricians
should be prepared to identify children with the
disorder. Clinicians should use ADHD-specific rat-
ing scales completed by caregivers and teachers in
their efforts to identify children suspected for
ADHD. Ratings from multiple informants should be
employed to ascertain the DSM-IV criterion of cross-
situational symptom display. Broad-band scales may
be useful in the identification of problems or symp-
toms that may co-occur with ADHD, but their use in
diagnosing ADHD is not supported. Also, the use of
medical and laboratory tests to diagnose ADHD is
not indicated. In addition to behavior rating scales, a
thorough history of symptoms and the effect of these
symptoms on the child’s current functioning should
be evaluated.
Examination of the literature summarized in the
technical review4 reveals important areas for addi-
tional investigation. For example, most of the litera-
ture used DSM-III and DSM-III-R criteria to identify
children with ADHD. Fewer studies using DSM-IV
criteria have addressed the prevalence and assess-
ment of ADHD. These questions need to be exam-
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ined with DSM-IV criteria and parameters associated
with the specific ADHD subtypes. Most research
conducted to date has predominantly reported on
samples of boys with ADHD. Investigations target-
ing girls with this disorder are sorely needed. As
well, research has primarily focused on elementary-
school-aged children; there is a need for investiga-
tions examining this disorder among preschoolers
and adolescents. Finally, the studies reviewed used
control groups composed of either nonreferred chil-
dren or typically developing comparison controls.
Greater efforts are needed to evaluate the specificity
of ADHD-specific rating scales in discriminating be-
tween children with ADHD and those with other
psychiatric disorders where ADHD does not co-oc-
cur.
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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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