ADHD and behavioral disorders: Assessment, management, and an update from DSM-5

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ABSTRACTBehavioral disorders in pediatric patients—primarily attention deficit hyperactivity disorder (ADHD)—pose a clinical challenge for health care providers to accurately assess, diagnose, and treat. In 2013, updated diagnostic criteria for behavioral disorders were published, including ADHD and a new diagnostic entity: disruptive mood dysregulation disorder. Revised criteria for ADHD includes oldest age for occurrence of symptoms, need for symptoms to be present in more than one setting, and requirement for number of symptoms in those aged 17 and older. Assessment of ADHD relies primarily on the clinical interview, including the medical and social history, along with the aid of objective measures. The clinical course of ADHD is chronic with symptom onset occurring well before adolescence. Most patients have symptoms that continue into adolescence, and some into adulthood. Many patients with ADHD have comorbid disorders such as depression, disruptive behavior disorders, or substance abuse, which need to be addressed first in the treatment plan. Treatment of ADHD relies on a combination of psychopharmacologic, academic, and behavioral interventions, which produce response rates up to 80%.



Behavioral disorders in pediatric patients—primarily attention deficit hyperactivity disorder (ADHD)—pose a clinical challenge for health care providers to accurately assess, diagnose, and treat. In 2013, the criteria for several disruptive behavioral disorders were updated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),1 their first major revisions since 1994. Among the most clinically relevant changes were revisions to the diagnosis of ADHD and the creation of a new diagnostic entity: disruptive mood dysregulation disorder (DMDD).

This article focuses on the updated diagnostic criteria published in the DSM-5 for behavioral disorders, describes the assessment of ADHD, and summarizes management strategies.



This disorder is a chronic, neurologically based illness characterized by a persistent pattern of inattention and/or hyperactivity and impulsivity that are more inappropriate or disruptive than those in other children of a comparable age resulting in functional impairment in multiple settings, and these behaviors have been present for at least 6 months. Revised diagnostic criteria in DSM-5 used the same two categories for ADHD symptoms—inattention and hyperactivity-impulsive behaviors—but modified several diagnostic requirements.

Revised criteria

Impairment before age 12 instead of age 6. As a neuro­developmental disorder, ADHD usually starts at a young age; teenagers presenting with newly developed ADHD-type symptoms probably do not have ADHD and efforts should be made to rule out other illnesses or social dynamics. The DSM-5 raised the age limit for onset of qualifying symptoms to before 12 years (previously by age 6) primarily to capture a cohort of pediatric patients, typically female, who present solely with inattention symptoms and may not display overt functional impairment early on.

Symptoms required in at least two settings. Symptoms must be present in at least two settings to qualify for a diagnosis of ADHD. This ensures that the behaviors occur globally; they do not occur just at school or at home but occur in both places.

Fewer symptoms required for diagnosis in adolescents. Although the diagnostic criteria retain the same symptoms as those in DSM-IV for different age groups, individuals aged 17 and older are now required to display only five or more inattentive or hyperactive-impulsive symptoms. Previously, at least six were required.

Partial remission criteria

The concept of partial remission was introduced in DSM-5. This acknowledges that two-thirds of children diagnosed with ADHD do not have symptoms that functionally impact activities of daily living beyond age 18.

Oppositional defiant disorder

In DSM-5, oppositional defiant disorder (ODD) is defined by emotional and behavioral symptoms grouped into three categories:

  • Constant anger or irritability
  • Argumentative or defiant behavior (arguing with authority figures)
  • Vindictiveness.

Because defiant behavior may represent difficulty with self-control, ODD is associated with executive functioning deficits that are present in ADHD. Children with ODD tend to perform best in situations in which they can dominate or exert authority. To qualify as ODD, the pattern of behavior must be consistent for longer than 6 months. A severity rating was added based on pervasiveness of ODD symptoms. Otherwise the diagnosis did not change.

Conduct disorder: Purposeful aggression

The hallmarks of conduct disorder are purposeful aggression (eg, bullying), destruction of property, deceitfulness or theft, and serious violation of rules (eg, running away from home, repeat truancy). Some consider conduct disorder to be a separate illness from ODD, whereas others consider it a continuum of the same disorder. Conduct disorder can manifest as violence, as in initiating physical fights, or it can manifest in behaviors such as truancy, stealing, lying, and running away from home without the physical-aggression aspect.

Intermittent explosive disorder

Failure to control aggressive impulses defines intermittent explosive disorder (IED). The aggressive outbursts can be verbal or behavioral and tend to be impulsive. A small subset of children display isolated aggression out of proportion to provocation. The disorder tends to manifest at ages 3 or 4, and a diagnosis requires a stable environment with no significant early childhood trauma. Most often these symptoms are seen in children with intellectual disabilities or an autism spectrum disorder.

Disruptive mood dysregulation disorder

A new diagnostic category in DSM-5 is termed disruptive mood dysregulation disorder (DMDD). This captures many children who previously would have been diagnosed with pediatric bipolar disorder, even though most of them do not fulfill criteria for bipolar disorder as adults. The presence of baseline irritability separates this disorder from IED, which requires intermittent rapid and severe outbursts. The severe temper outbursts of DMDD must be recurrent, with an average of three occurrences per week, and have background irritability. The symptoms must have a duration of at least 12 months and be present in two settings. A diagnosis of DMDD cannot be made earlier than age 6, with onset before age 10.


The clinical interview in conjunction with objective scales is the primary tool for diagnosing ADHD. The most frequent source of information is from the parents followed by the child’s schoolteachers. Patient interview, although unreliable in young children, should also be part of the assessment. Comparing the patient’s functional impairment against children of a similar age is necessary for an ADHD diagnosis.

The medical history can help rule out children with asthma or allergy being treated with corticosteroids and those with hypothyroidism and hyperthyroidism whose symptoms often fulfill the diagnostic criteria for ADHD.2,3 Symptoms of ADHD also may appear suddenly after a traumatic brain injury or other neurologic event.4 Other psychiatric illnesses, especially learning disorders, mood disorders, anxiety, other disruptive behavior disorders, or substance abuse, can mimic ADHD.

Ruling out other factors from a social history (eg, family conflict, bullying, sleep deprivation, being overscheduled with activities) adds to the reliability of an ADHD diagnosis. For example, repetitive uprooting and frequent changes in schools can cause academic problems that may be mistaken for ADHD, and use of stimulants may have failed to improve symptoms in these children.

Assessment scales

Pediatric assessment scales that can be performed in an office are more practical than standardized clinical assessments (Table 1). The Vanderbilt ADHD Diagnostic Teacher Rating Scale correlates highly with a diagnosis of ADHD. We use the Vanderbilt ADHD Diagnostic Parent Rating Scale for children up to age 1 year. Other scales track symptoms and functional impairment over time and can be administered before the patient’s appointment. The Conners Third Edition scale can be used to establish a baseline before initiating therapy and to help monitor changes over time.

Standardized tests to bolster the utility of the clinical interview include the Diagnostic Interview Schedule for Children and Adolescents and the Schedule for Affective Disorders and Schizophrenia in School-Age Children–Present and Lifetime Version. Free training is available regarding use of some of these standardized tests.

Developmental course, risk factors

The clinical course of ADHD is chronic. The onset of hyperactivity usually occurs at age 3 or 4, with combined hyperactivity and inattention usually appearing from ages 5 to 8.5,6 The evolution of symptoms is progressive and constant. Between 50% and 80% have symptoms that continue into adolescence, and in about 40%, symptoms continue into adulthood.7,8 Some children with ADHD have a temperament-neuropsychological profile characterized by aggressiveness, irritability, and mood lability. Deficits in planning, delayed aversion, and temporal processing are present.

Risk factors include prematurity, prenatal complications, an anoxic event, nutritional deficits (specifically iron and zinc), and lack of appropriate socialization.9–11 The disorder is heritable, which is usually clear from the clinical interview. Rates of delinquency and peer rejection are high. This may result in secondary comorbidity such as emotional, disruptive, or substance abuse problems.

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