David Rabiner, Ph.D. Research Professor, Duke University
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David Rabiner, Ph.D.
ADHD: Suggestion Evaluation
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
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.
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.
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.
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
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.
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.
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