Clinical presentation and diagnosis

O ADHD is rarely encountered without comorbid conditions, and often is underdiagnosed. Between 40% and 75% of patients with ADHD will have one or more comorbidities (e.g., learning disabilities, oppositional defiant, conduct, anxiety, or depressive disorders).10 It is important to identify other coexisting conditions in patients with ADHD to select initial and modify ongoing treatment.

When a patient presents with inattention, hyperactivity, academic underachieve-ment, and/or relational problems, additional information about behavior in various settings should be gathered from the patient, family, and teachers/supervisors. The age of onset, frequency, severity, and duration of symptoms should be documented.10

The most useful diagnostic criteria for ADHD is the Diagnostic and Statistical Manual of Mental Health Disorders, 4th edition, Text Revision (DSM-IV-TR) (Table 42-1). The DSM-IV-TR defines three subtypes of ADHD: (a) predominately inattentive, (b) predominantly hyperactive/impulsive, and (c) combined, in which both inattentive and hyperactive symptoms are evident.11 Neuroimaging, electroencephalograms, and continuous performance examinations are investigational and not used clinically for diagnosis. It is recommended that parents and teachers complete a standardized rating scale based on the DSM-IV-TR criteria that measures various behaviors 12

of ADHD. These rating scales do not by themselves diagnose ADHD but are aids

to a careful history and interview in securing the diagnosis.

Although ADHD is considered a childhood disorder, signs and symptoms persist into adolescence in 40% to 80% of cases and into adulthood in approximately 60% of cases.1'9

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