Question:

Liliana sent me three questions about the best practices for AD/HD assessment. My response this month concerns what parents can expect from an ideal assessment. Thank you, Liliana!

Answer:

1. To what extent should parents be confident with the pediatrician diagnosis and to what extent is it better to consider getting a complete psychological evaluation before starting any treatment?

In May, 2000, the American Academy of Pediatrics (AAP) published guidelines for diagnosis of AD/HD. Although pediatricians are qualified to diagnose AD/HD, competence varies significantly from physician to physician. When parents have a choice of physicians, they should look for one who has had experience diagnosing and providing ongoing treatment for the disorder. When seeking a physician, parents should ask about the number of children with AD/HD that the physician has seen and if they are familiar with the AAP guidelines. Both the school and family and possibly community members such as scout leaders and coaches, should be involved in the diagnostic process because to qualify for a diagnosis of AD/HD, behaviors need to occur in at least two settings.

If a child is diagnosed with the disorder and the parents are thinking about treatment with medication, they should also ask the physician what she or he typically does for follow-up treatment. Children change and grow over time and frequent follow-up is essential. Ideally, the physician should see the child in person rather than simply consulting with the parent by phone as is sometimes the practice.

Other persons qualified to diagnose AD/HD are clinical and school psychologists, psychiatrists and neurologists. Schools have an affirmative obligation to evaluate a child aged 3 - 22 years and can complete all but the medical component of an assessment. Many experts recommend that parents request an initial assessment by the school since this is free of charge. A school-based assessment should make use of more than one standardized test. Parents will need to communicate their request in writing.

Part of the diagnostic process should be to screen for co-existing (co-morbid) conditions that some experts have reported in up to two-thirds of children with AD/HD. A complete psychological assessment would be recommended after the initial screening if the diagnostician finds that other mental health conditions and learning disabilities that might be contributing to the symptoms.

2. What would be the ideal way to diagnose ADHD?

Diagnosis is based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV) published by the American Psychiatric Association. A comprehensive evaluation contains three components:

• Behavioral
• Educational
• Medical

Parents should expect the diagnostic process to require more than just an office visit. Often diagnosis takes place over 2-3 days. The American Academy of Pediatrics (AAP) has provided guidelines for the assessment process. These guidelines provide information about the "gold standard" for the physician diagnosing AD/HD. Parents should expect:

• A thorough medical and family history.
• A medical examination for general health and neurological status.
• Standardized behavior rating scales.
• Observation of the child's behavior
• Psychological testing to screen for cognitive ability and social and emotional adjustment.

Standardized rating scales should include at least one scale that is specific to AD/HD. If concerns have been expressed at school, as is generally the case, the child's teacher should be involved in the assessment process. A behavioral observation at the school site should take place. The child's productivity in completing classwork should be evaluated and compared to that of his/her classmates. Teachers can do this by interview, work samples and/or by anecdotal records.

Clinicians should rule out AD/HD if the child's behavior seems to be better explained by Pervasive Developmental Disorder (PDD), schizophrenia or other psychotic disorder. Although not very common, pediatric Bipolar Disorder can be mistaken for AD/HD.

3. What is the first step to follow when parents are advised from schools that their child might have ADHD?

Most concerns about whether a child has AD/HD are initially investigated by a multidisciplinary student study team at the school site. The first step for parents to take when they are advised that their child might have AD/HD is to seek an assessment from a qualified clinical psychologist, pediatrician, psychiatrist, neurologist, or school psychologist. As mentioned in question 1, the school psychologist at their child's school site is qualified to diagnose AD/HD and can often do this free of charge. The school is not, however, able to suggest that the child be placed on medication or to recommend specific medication of any kind. This must be done by a qualified physician.

RESOURCES:

Committee on Quality Improvement, Subcommittee on Attention-Deficit/ Hyperactivity Disorder. “Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder.” Pediatrics vol. 103 No. 5 May, 2000

Reiff, Michael, MD, Editor with Sherill Tippins. (2004) ADHD: A Complete Authoritative Guide. American Academy of Pediatrics.

U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs (2003) Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home. Washington, D.C. 20202. Available for free download at: www.ed.gov/pubs/edpubs.html