ADHD – assessment and diagnosis

Attention Deficit Hyper Activity Disorder according to Singh (2002) is a brain disorder that is brain-based and most often affects children. This developmental disorder can be characterized as a disorder that affects one’s self-control; primary aspects include difficulty with attention, impulse control, and activity levels usually diagnosed before the age of seven (Willoughby, 2003). It is estimated that almost 4 to 12 percent of school-aged children have some type of ADHD (Pediatrics, 2000).

There are primarily three subtypes of ADHD. Inattentive subtype 1 is ADHD, such as those who exhibit inattention without the presence of hyperactivity and impulsivity (Barkley, 2005). There are also ADHD sub type 2 with symptom ulcer related to hyperactivity and impulsivity (Barkley, 2005). Finally, there is the ADHD combined subtype that expresses the presence of all core features of inattention, hyperactivity and impulsivity. According to Pediatrics (2000), early diagnosis and management of these conditions may redirect these adolescents to greater educational and psychosocial outcomes.

According to Kamphaus & Campbell (2006), complexity and differences in core symptomatology with respect to the nature of this disorder produce the logical assumption; that if a clinician is to test and evaluate an individual for ADHD, the assessment must be dynamic using many different test scales, different methods and information that will be collected in many different environments (p. 327). With this dynamic evaluation, one must also consider the presence or absence of other disorders so common with ADHD; such as learning disabilities, anxiety disorders, oppositional resistance disorder, behavioral disorder, and depression (Pediatrics, 2000). A clinician according to Pediatrics (2000) should realize that a thorough assessment can also occupy as many as three visits by the patient and family.

To be able to effectively account for the complex and dynamic variables of ADHD symptomatology, there are specific processes that need to be evaluated to get an accurate picture for diagnosis, with special emphasis and analysis of information obtained from the child, the parents. and teachers, if possible (Barkley, 2005).

Evaluation areas involving multiple areas and data collection procedures:

1. Historical Assessment (Social, Family, Medical, Prenatal / Development and Education)

2. Using interviews, observations and surveys

Figure 1.1

Access to a thorough history includes several assessment areas. According to Mercugliano, Power, & Blum (1999), a practitioner must first be aware that many of the problems children with ADHD will manifest in the areas of behavior, academics and social interaction. Because of these areas of concern, a clinician must assess prenatal / developmental, social, family, medical, educational history, and use interviews, observations, and studies as a data collection process (Mercugliano, et al., 1999). Throughout the data collection, DSM IV criteria must be identified and compared to patterns and consistencies that have resulted through data collection (Personal Communication, Darrell Moilanen LMSW, June 21, 2007). The DSM IV criteria explicitly state that 6 or more symptoms should be found, either in the inattention or hyperactivity / impulsive areas, and these symptoms must have been present for at least 6 months, many before the age of 7, to create impairment and has been observed within at least two primary systems including; work, school, or community (Quinn, 1997). Family, medical, developmental, educational, and social histories are of great importance in understanding whether the child’s manifestation of behavioral symptomatology in multiple systems is a result of ADHD or a dysfunctional environment or health problem (Mercugliano, et al., 1999). . Assessment of the field of education is of great importance due to the fact that many of the difficulties in the behavior, learning, and performance that ADHD creates can first be identified in school (Barkley, 2005). It is usually the first transition from a child’s home to spend much of their time at school that a child is first identified as having ADHD (Barkley, 2005).

The first and primary way of collecting data while examining these areas is the recommended use of a semi-structured interview (Schroeder & Gordon, 2002). When interviewing parents and children, it is important to use open-ended questions and a structured fixed format (Kamphuas & Campbell, 2006). The CAIS or Comprehensive Assessment to Intervention System according to Schroeder & Gordon (2002) is an excellent format for obtaining information in a flexible semi-structured format. For the purpose of this article, this interview is used as a guide to obtain relevant information areas and integrate proper assessment and testing processes within each primary area (Schroeder & Gordon, 2002). CAIS has clear and specific areas of investigation. Included in the following are primary areas that a clinician should consider:

1. Reason for referral

2. Social context concerns

3. Evaluation of general / specific areas

CAIS – Schroeder & Gordon, (2002)

Figure 1.2

This interview system involves primary areas of historical analysis as described by

Mercugliano, et. al., (1999). It would be valuable to use many sources of information when implementing the interview process; such as interviews with children, parents and teachers. This interview system is evident in the analysis of the context, the reasons for referral, and the difficulty of interaction. This interview system also emphasizes general and specific areas of concern (Schroeder & Gordon, 2002).

The social contextual study is important because of the DSM IV criteria for behavior that, if not contextualized, may be present due to other environmental conditions and or may be an indication of another disorder. Social aspects and interactions for children with ADHD should be investigated according to the child’s and parents’ view. A study of social interactions may indicate frontal bone dysfunction that clearly affects one’s ability to judge social cues and inhibit correct perceptions of emotional expression in social situations (Cherkes-Julkowski, Sharp, & Stolzenberg, 1997). A clinician should also investigate transitions and adaptation issues within social situations that may be a result of difficulties in understanding social interactions. According to Cherkes-Julkowski, Sharp, & Stolzenberg (1997), the Vineland Social Adaptive Scale has been reliable and can be effective in assessing a child’s social adaptability. This rating scale will, for a clinician, assess important areas related to ADHD symptomatology including; communication, daily living, socialization, motor skills, and poorly adapted behavior (Wodrich, 1997). The standard score is represented by an average of 100 (Wodrich, 1997). A clinician would look for areas of the behavioral assessment that indicate low-average to below-average. Below average or a score of 85 or below, especially with a difference of 15 points or more between other adaptive scores may indicate serious difficulties with adaptability.

The general inquiry within the interview system is important for many reasons, but it is important to link research with the DSM IV criteria regarding the need for most behaviors to be identified within two specific areas or systems related to work, school or community (Kamphaus & Campbell, 2006). This area of ​​the interview would indicate to the clinician the past and current developmental status, family characteristics, environmental characteristics, consequences of behavior, medical status, and history (Schroeder & Gordon, 2002).

An initial developmental and prenatal study would consider the presence or historical occurrence of prenatal infections, exposure to alcohol or cocaine use, increased lead exposure, maternal cigarette smoking, brain damage, syndrome, genetic predisposition, and premature (Barkley, 2005; Quinn, 1997) . According to Schroeder & Gordon (2002), although many of these factors influence the etiology of ADHD, one primary factor that a clinician must consider is genetic factors. According to Faraone, Biederman, Mennin, Gershon, and Tsuang (1996), almost 84% of adults with ADHD had at least one child with ADHD, (Schroeder & Gordon, 2002) and 52% of these adults had two or more children with ADHD. According to Mercugliano, et. al., (1999) & Schroeder and Gordon (2002), a clinician should assess developmental status and milestones, early childhood temperament functions, and ask for early development of motor, language, intellectual, cognitive, academic, emotional, and social functioning.

(Quinn, 1997; Schroeder & Gordon, 2002).

Due to self-regulatory problems in younger children, a clinician must acquire the infant’s mood, adaptability, sleep and other indicators of temperament early in the interview process with parents. An effective tool that a clinician can use or inquire with the child’s pediatrician and allow the mother to fill in to assess temperament is Carey’s Revised Infant Temperament Questionnaire (Quinn, 1997). This tool measures nine areas, and the results indicate difficult for light children in five diagnostic areas (Quinn, 1997). The actual behavioral characteristics assessed include; activity, rhythmicity, approach, adaptability, intensity, mood, persistence, distractibility, and threshold (Quinn, 1997).

According to Schroeder & Gordon (2002), if there is a suspicion of developmental deficits for school-aged children, a psycho-educational assessment can be used to identify problem areas. Primary tools usually associated with a psycho-educational assessment where a clinician can request the results from the local school system are the Wechsler Individual Achievement Test and the Wechsler Intelligence Scale for Children. The Achenbach rating scales (CBCL) for the child, parent and teacher are also very important. Other tools used include information from CA60 reviews about educational history and classroom observation information. WISC-III for measuring a child’s I.Q. can be valuable in assessing possible discrepancies that indicate deficits in areas where ADHD can cause problems. According to Mercugliano et. et al., (1999) the areas that a clinician should investigate for inattention within the results of WISC-III include areas of treatment speed and freedom from distractibility. Large discrepancies in these areas may indicate problems of inattention. Other deviations of 15 to 20 points or more between categories such as; verbal and performance IQ may indicate strengths or weaknesses in visuospatial or linguistic functioning (Mercugliano et al., 1999). The WIAT performance test seeks to assess many areas of educational functioning (Wodrich, 1997).

A clinician should, by comparison, examine the differences between the IQ scores and the outcomes within the analysis. According to Mercugliano et. al., (1999) a significant difference of 12 points or more between the full scale IQ score and any of the subtests (basic reading, mathematical reasoning, spelling, reading comprehension, numerical operations, listening comprehension, oral and written expression) WIAT may indicate deficiencies in ability within the subtest areas (Wodrich, 1997). Then, when assessing for ADHD on WIAT, one can expect to find a child’s score representing a significantly lower score (below 85 with an SD of at least 15) based on their full IQ score within the sub-test areas, possibly indicating a learning disability. This would be in line with current research with Barkley (2005), where he states that up to 25 to 30 percent of those suffering from ADHD also have a learning disability.

The CBCL or Achenbach behavior rating scale is a broad scale to use or the results to be requested from the local school system. CBCL could help a clinician assess areas common to DSM-IV criteria, including; an understanding of behavior based on different environments (school / home), based on who witnessed or experienced the behavior (child, parent, teacher) and social competence / behavior analysis based on normed criteria for age and gender seeking to identify normal or abnormal behavior (Mercugliano, et al., 1999). This rating scale is very useful in that a clinician can evaluate possible DSM-IV comorbid problems on two broad scales of internalization and externalization (Kamphaus & Campbell, 2006). The rating scale also included eight subscales (somatic problems, withdrawal, anxiety / depression, social problems, thought problems, attention problems, criminal behavior and aggressive behavior) that would help a clinician identify the probable existence of a type of ADHD or type of comorbid mental disorder. .

Applying the CA60 review and observation of children would be of great importance. Through a qualitative analysis of child observation and CA60 review, or perhaps the child’s discipline record, many behaviors could be associated with either attention or hyperactive / impulsive problems or both. A clinician may detect excessive disorganization, lack of follow-up, a child who becomes easily distracted, and other factors that contribute to inattention (Schroeder & Gordon, 2002). A clinician may also discover a child who is excessively fixating in class, acting out in disruptive manners, appears to have trouble waiting their turn, and represents factors of hyperactivity / impulsivity (Schroeder & Gordon, 2002). Regardless of such findings, the use of psycho-educational assessment within a clinician’s analysis of behavior, social interactions, and performance is a priority and must be led by the clinician or obtained from schools for review before any likely conclusion about the existence of ADHD.

Identifying family characteristics, environmental circumstances, and consequences of behavior helps the clinician identify family structure, boundaries, expectations, and roles for members. During this analysis, it may be useful according to Mercugliano, et. al., (1999) to better understand family dynamics and gain a full understanding of how parents understand their child’s behavioral problems in perception and to the extent that they conceptualize it. This would give a clinician a better understanding of the potential conflict in the family system and provide a greater understanding of the behavior and whose behavior meets DSM IV criteria. A thorough study is important because of many families with children suffering from ADHD who experience highly dysfunctional, chaotic, and inconsistent family systems (Cherkes-Julkowski, Sharp, & Stolzenberg, 1997). Other important areas of consideration for a clinician during the interview included; parental models, genetic influences, and coexisting disorders of other family members that could be identified through a genealogical assessment (McGoldrick & Gerson, 1985; Mercugliano, et al., 1999).

The evaluation of medical conditions and history can help identify past medical appointments and problems. Inquiry can contribute to understanding if some medical problems can contribute to attention difficulties (Mercugliano, et al., 1999). Pharmacological considerations may also be identified, co-morbid disorders, repeated medical conditions, and other issues that may contribute to DSM IV criteria and or symptomatology of ADHD (Mercugliano, et al., 1999; Schroeder & Gordon, 2002). Much of this information can be thoroughly investigated and an intake questionnaire at first visit (Quinn, 1997; Schroeder & Gordon, 2002). For further examination, it would be convenient for a clinician to refer a child with family for a medical evaluation; including a physical and neurological examination (Mercugliano, et al., 1999). A clinician must document through their conversation with the child and consult with a doctor if the child was found to have physical abnormalities. According to Quinn (1997), anomalies are widespread, especially among the children associated with hyperactivity.

Physical aberrations that the clinician can observe in session or through medical examination of infants and young children include; the fourth finger longer than the middle; the third toe longer than the second; the ears at the bottom of the head; other abnormalities of the mouth, face and head (Barkley, 2005; Quinn, 1997). A clinician should also examine history of low birth weight; according to Quinn (1997), low birth weight was also associated with hyperactivity, poor language skills, and other difficulties. A clinician should also inquire if a child has experienced hearing or vision difficulties. According to Schroeder & Gordon (2002), children who experienced attention problems in elementary school were associated with problems with inner ear in early childhood. Other related medical assessments that a clinician would find valuable in confirming a diagnosis of ADHD include the use of modern technology. Although Barkley (2005) & Applegate and Shapiro (2005) do not endorse the consistent use of Positron Emission Tomography (PET) or Magnetic Resonance Imaging (MRI), they do not claim that these processes are very effective in identifying brain structure and function, which relates to the presence of ADHD. A clinician could use such medical records or suggest parents to consider a process that includes these types of studies to confirm physical abnormalities; considering that the diagnosis of ADHD is behavior-based. According to Barkley (2005), indications that ADHD might be present include confirmation of less blood flow to the pre-frontal cortex brain, less frontal cortex brain activity, and smaller size of cortex regions.

Specific behavioral areas including; the persistence of behavior, changes in behavior, severity, and frequency relate to the criteria of DSM IV with respect to the question criteria DSM uses with words such as “excessive” and “easy” in assessing children’s behavior (Schroeder & Gordon, 2002; Kamphaus & Campbell, 2006). Understanding of the behavior has been consistent for at least 6 months and before the age of 7. would be significant (Kamphaus & Campbell, 2006). Specifying the behavior will, of course, help indicate whether the child is experiencing inattention or hyperactivity / impulsivity of behavior to categorically identify the type of ADHD present. DSM also indicates the need to effectively understand how “often” behavior occurs, and it is this frequency and persistence section of the specific areas of the interview that is so important in terms of diagnosis (Centers for Disease Control, 2007; Schroeder & Gordon , 2002).

It seems that if clinicians are going to help with the diagnosis of children suffering with ADHD, they will need a number of assessment tools depending on preference and circumstance. A clinician must identify significant features of behavior and compare the behavior of the child with other students and children by age and gender when making behavioral conclusions. Clinicians must continue to pursue strategies that reflect results from multiple environments and from multiple participants who have witnessed the behavior. This application of different perspectives and a wealth of knowledge from the subjective experiences of others would allow a clinician to get a more accurate account of the circumstances. The greater the amount of patterned characteristics and consistent interactions a clinician can extract from relevant areas of the child’s life, and with the use of interviews, instruments and observations, the more reliable and valid a definitive confirmation of the diagnosis can be obtained. However, my information and assessment as a therapist and clinician can only express so much credibility. With regard to ADHD, a correct and definitive diagnosis will be made by a doctor.



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