A few weeks ago the American Academy of Pediatrics published the new practice guidelines for the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). These guidelines are supposed to help pediatricians and other primary care physicians in the care of kids with ADHD. Although I agree with most aspects of the guidelines, I am not surprised that the guidelines created significant controversy among psychologists because many aspects of these guidelines are limited, and arguably may not improve the care of kids with this condition.
So, here are some thoughts that may help parent navigate the complex process of ADHD diagnosis.
Currently, the general consensus among psychiatrists and psychologists is that ADHD is diagnosed based on the criteria included in the Diagnostic and Statistical Manual of Mental Disorders – 4th Edition (DSM-IV – Click here for the full diagnostic criteria for ADHD and a discussion of the proposed changes for the new DSM-5). Although I won’t summarize the full criteria here, I want to talk about four important aspects of the diagnosis of ADHD, some of which are often disregarded by clinicians resulting in questionable diagnoses.
Aside for some additional details, ADHD is diagnosed when a child:
- Displays a minimum number of specific symptoms that are maladaptive and inconsistent with developmental level;
- The symptoms are observed in 2 or more settings;
- The symptoms don’t occur exclusively (or aren’t due to) a number of other neurodevelopmental conditions; and
- There is clear evidence that the symptoms result in clinically significant impairment in the kid’s social, educational, or personal functioning.
On that note, the role of the recent guidelines by the American Academy of Pediatrics (AAP) is to provide clinicians with clear instructions about the procedures that they should follow to determine whether a child meets the criteria presented above.
In sum, the AAP states that:
A. The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.
This first guideline is not too controversial since there is evidence that the proper identification and treatment of young kids can improve the kids’ outcomes (e.g., better academic performance, social functioning, etc).
B. To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) criteria have been met (including documentation of impairment in more than 1 major setting), and information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care.
Here the guidelines become limited. The problem is that this specific guideline does not tell the pediatrician HOW to make sure that the kid meets DSM-IV criteria other than by obtaining information from parents and teachers, etc. What does “obtaining information” mean in terms of actual practice?
There are two key issues regarding this guideline that pediatricians and parents should keep in mind.
First, the behaviors (symptoms) reported by the parent or teacher must be inconsistent with developmental level. This means that the problem behavior must be in excess of what is expected for the child’s age. But… in excess according to whom? That is, who decides what is appropriate for each age? The pediatrician? The parent? How much hyperactivity or inattention is “expected” in a child age 5? How about a child age 8? Does the sex of the child matter in terms of what is “expected” for a specific age? The questions are endless.
This is a problem that does not have an easy answer, but clinicians should at the minimum use well validated parental and teacher questionnaires that have been properly “normed,” which the guidelines do not mandate. These questionnaires allow the clinician to compare the parent and teacher reports to those of thousands of other parents, which helps the clinician determine whether the child’s behaviors are in excess to what is usually seen in children of his/her age.
Although there are some limitations with these questionnaires, I would be extremely skeptical of a clinician that makes a diagnosis of ADHD based simply on a brief interview with the parent without having the parent and multiple teachers complete these questionnaires.
The second, and much more complicated issue is that, according to the DSM-IV, the symptoms must result in clinically significant impairment in the kid’s social, educational, or personal functioning. What does this mean? Specifically, what does “clinically significant impairment” means and how is it determined? That is, who decides that the child is experiencing impairment due to his/her symptoms? Is a parent’s concern about the kid’s academic functioning enough evidence of impairment? How about a teacher’s frequent complains about the child? Is that enough evidence of impairment? The guidelines call for “documentation of impairment in more than 1 setting,” which is a good start, but it is not clear what this actually means in terms of actual practice by the clinician.
The problem is that there is no definition as to what clinically significant impairment is, and how it should be measured or documented, and relying only on the reports of a parent or a teacher has some limitations. For example, a child may be labeled a problem child by one teacher while other teachers may have no issues whatsoever with the child’s behavior. Similarly, a parent may complain extensively about his/her son’s behavior while the other parent may think that nothing is really wrong. Who is right and who is wrong?
This highlights the issue that determining whether the symptoms are causing impairment is not easy, and requires significant effort on the part of the clinician. Thus, I would be skeptical of any clinician that makes a diagnosis after talking only to one parent or one teacher (although in some unique cases this may be appropriate or necessary). Instead, clinicians should obtain information about level of impairment from as many people as possible, including both parents or guardians and multiple teachers. I would also be skeptical of clinicians that make a diagnosis after only asking whether specific symptoms are present or not, without using specific questionnaires to assess impairment or at least paying attention to how much the symptoms are affecting the child’s functioning. For example, clinicians should ask to see the kid’s report cards, talk to multiple teachers, and document specifically how the behaviors affect the child at home.
Finally, the AAP states that:
C. Clinicians should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions (quality of evidence B/strong recommendation).
The problem here is that the AAP guidelines did not indicate who or how such assessment should be made. Although Pediatricians can screen for these conditions, Pediatricians in general are not trained (nor have the time, sadly) to conduct the type of comprehensive evaluations needed to properly diagnose most of these conditions. Therefore, my interpretation of this guideline is that pediatricians should refer the child to other professionals in order to obtain the necessary evaluation that would “rule out” the possible presence of these conditions.
Therefore, I would be skeptical of a clinician that makes a diagnosis without at least asking questions that suggest that the clinician is screening for the possibility that the child may have another condition, such as conduct or learning problems, depression, anxiety, and other neurodevelopment disorders (e.g., autism).
I sum, when considering whether your pediatrician or other healthcare provider has properly diagnosed your child, you should ask yourself the following questions:
- Did the evaluation include long questionnaires completed by me, other adults living at home, and multiple teachers, coaches, etc?
- Did the clinician pay attention to how and if these symptoms are affecting my child, such as by asking for my kid’s report cards and talking to teachers and family members?
- Did the clinician rule out other conditions. For example, did clinician recommend that my child should get an evaluation for learning disabilities, or did he/she suggest that I see a child psychologist/neuropsychologist to rule out the presence of a mood/behavior or other developmental problem?
If you answered no to any of these questions, I would recommend getting a second opinion about your child’s diagnosis.
Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management (2011). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents PEDIATRICS, 128 (5), 1007-1022 DOI: 10.1542/peds.2011-2654
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