ADHD/ADD: Suggested Evaluation Guidelines

David Rabiner, Ph.D. Research Professor, Duke University

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David Rabiner, Ph.D.
Duke University

ADHD: Suggestion Evaluation Guidelines

It is a common misperception that a child, adolescent, or adult can be tested for Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder. After reviewing the diagnostic criteria for ADHD/ADD, however, it should be clear that no single test could accomplish this task. This is because making the diagnosis requires that all of the following judgments be made:

* Does the child show a sufficient number of ADHD/ADD symptoms to possibly warrant the diagnosis?;

* Have these symptoms persisted for at least 6 months and are they present at a level that is developmentally inappropriate?;

* For a child older than 7, was there impairment from symptoms prior to this age?

* Do the symptoms cause impairment in more than one setting (e.g. home and school)?;

* Do the symptoms cause clinically significant impairment in academic, social, or occupational functioning?

* Are the symptoms better accounted for by another psychiatric condition?

Clearly, questions such as these can
not be adequately addressed 
by any single test.

What then, is a reasonable procedure for making this diagnosis? Unfortunately, although DSM-IV specifies what the diagnostic criteria for ADHD/ADD are, it provides no guidelines for deciding whether these criteria are met. Different practitioners will employ different diagnostic procedures, and opinions about what constitutes an appropriate evaluation may vary considerably. With this caveat in mind, the following is a set of general guidelines that seem reasonable to me:

A child's parents and teachers are in the best position to provide information about the presence and intensity of Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder symptoms. Because parents and teachers may have different perceptions of the same child, input from both is essential.

It is just not possible for a physician or psychologist, no matter how skilled and experienced they may be, to make this determination based on the childish behavior in their office. In fact, it is not uncommon for a child with ADHD/ADD to display virtually no symptomatic behavior during an initial office visit. This is because the intensity of ADHD/ADD symptoms will vary considerably across settings, and during an individual meeting with an unfamiliar adult, these symptoms may not be evident at all. Therefore, for a physician to rule out ADHD/ADD because no problematic behavior is observed during their examination is incorrect.

An excellent way to help determine whether enough symptoms are present to possibly warrant an Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder diagnosis is to have parents and teachers complete standardized behavior rating scales.

In order to be diagnosed with ADHD/ADD, symptoms must be present to a degree that is considered "developmentally inappropriate". This means that the child must display the symptoms more persistently and intensely than the vast majority of other children the same age.

Standardized behavior rating scales can assist in determining this by comparing the amount of difficulty reported about a particular child to what is typically reported by parents and teachers of a child the same gender and age. For example, if a childish parents and teacher report that he displays more problems with attention and hyperactivity than over 95% of children his age, than it is clear that they are observing an unusual amount of difficulty.

Behavior rating scales that are commonly used in evaluating children for Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder are the Child Behavior Checklist, the Connors Rating Scales, and the Attention Deficit Disorder Evaluation Scale. All these ratings scales have separate versions for parents and teachers.

Formal psychological testing may be a necessary part of an Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder evaluation, but tests themselves can not be used in isolation to make the diagnosis.

As described above, the most critical information used to diagnose ADHD/ADD is provided by parents and teachers. Children themselves will sometimes confirm the presence of ADHD/ADD symptoms, but are not always reliable informants.

Parents can be dismayed that an "objective" test is not available to determine whether their child has ADHD/ADD. Unfortunately, no such test exists. That does not mean, however, that testing is not an important part of many evaluations.

Tests that are frequently used in ADHD/ADD evaluations include those which assess a child's intellectual ability and academic achievement level. Because many children with ADHD/ADD have academic difficulties, IQ and achievement testing are often necessary to determine whether a child may have a specific learning disability in addition to Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder. This testing should not be used to decide whether the child has ADHD/ADD, but can provide information that is essential to appropriate educational planning. In my opinion, this type of testing need not be done routinely as it is time consuming and expensive. When a child is doing well academically, for example, this testing is less necessary than when there are important academic problems. You should be aware, however, that some professionals believe academic testing should be a routine part of an ADHD/ADD evaluation.

In recent years, computerized tests of attention called Continuous Performance Tests (CPT) have been developed as an effort to provide an "objective" measure of children's attention and impulsivity. These tests require the child to push or not push certain keys depending on what symbols appear on a computer screen. In contrast to the typical computer game, they are purposely designed to be repetitive and boring. To do well, the child must pay close attention to what is appearing on the screen and refrain from making impulsive errors.

As a group, children with ADHD/ADD do perform worse on this type of test than other children. In cases where a child does poorly, there is an excellent chance that ADHD/ADD will be an appropriate diagnosis. Many children with ADHD/ADD perform quite adequately on this task, however, so doing well does not necessarily rule out ADHD/ADD as a correct diagnosis. Perhaps these tests will be further refined to provide the accurate and objective information that could be used to establish the diagnosis of ADHD/ADD with certainty. Currently, however, they are best used selectively and always need to be considered in conjunction with other information collected about the child.

In addition to gathering specific information on Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder symptoms, it is extremely important to obtain a comprehensive assessment of the child's overall level of functioning. This will generally require interviews with parents and with the child.

This is critical for several reasons. First, it is necessary to rule out other psychiatric conditions besides ADHD/ADD as the cause of the childish symptoms. Second, there are many difficulties that often go along with ADHD/ADD including academic problems, oppositional behavior, emotional problems, and social problems. In addition to determining whether or not ADHD/ADD is present, therefore, appropriate treatment planning requires that a child's functioning in these other areas be carefully evaluated. For example, when important academic difficulties are present, treatment needs to include a specific plan for addressing these problems. Similarly, if a child with ADHD/ADD is also having emotional difficulties (parents can often be unaware of such issues), these need to be directly addressed.

The importance of taking a comprehensive look at a child's functioning as opposed to focusing strictly on the ADHD/ADD question cannot be overemphasized. In large part, this is because it is often these associated problems, and not the primary Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder symptoms themselves, that are most responsible for the negative outcomes that many ADHD/ADD children experience. When these associated problems are identified and dealt with, the prognosis will be much better.

My own opinion is that this aspect of the evaluation is best done by a mental health professional who specializes in working with children (e.g. child psychologist or child psychiatrist) than by a general physician. This person will be generally have more experience in conducting a comprehensive assessment of a child's emotional, behavioral, academic, and social functioning.

It is important that a child have a thorough medical examination as part of the evaluation to rule out possible medical causes for symptoms (e.g. hearing or vision problems) and to identify any other medical issues that may need to be considered.

If the guidelines suggested above are followed, you should feel confident that the information required to make an accurate diagnosis and develop an appropriate treatment plan have been collected. It is important to emphasize, however, that these procedures involve elements of judgment. The professional who evaluates your child should be able to logically explain the reasoning and judgment that went into his or her diagnostic decision and to provide a clear rational for treatment recommendations. At the current time, there is no procedure or test that can be used to make the diagnostic decision with absolute certainty. Parents are well advised to keep this in mind, and to ask questions about aspects of the evaluation that are unclear.

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