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ADHD – Assessment & Diagnosis
Attention Deficit Hyper Activity Disorder according to Singh (2002) is a developmental disorder that is brain based and most often effect’s children. This developmental disorder can be characterized as a disorder in which affects one’s self control; primary aspects include difficulty with attention, impulse control, and activity levels usually diagnosed prior to the age of seven (Willoughby, 2003). It is estimated that nearly 4 to 12 percent of school age children have a type of ADHD (Pediatrics, 2000).
There are primarily three sub-types of ADHD. Inattentive sub-type 1 is ADHD which those who manifest inattention without the presence of hyperactivity and impulsivity (Barkley, 2005). There is also ADHD sub-type 2 with symptomolgy related to hyperactivity and impulsivity (Barkley, 2005). Finally, there is ADHD combined sub-type which expresses the presence of all core characteristics of inattention, hyperactivity and impulsivity. According to Pediatrics (2000) early diagnosis and management of these conditions can redirect these youth for greater educational and psychosocial outcomes.
According to Kamphaus & Campbell (2006) complexity and differences in core symptomatology regarding the nature of this disorder brings forth the logical assumption; that if a clinician is to test and evaluate an individual for ADHD, the assessment must be dynamic with the utilization of many different testing scales, different methods and information that will be collected across 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 Defiant Disorder, Conduct Disorder, and Depression (Pediatrics, 2000). A clinician according to Pediatrics (2000) should realize that a thorough assessment may also occupy as many as three visits by the patient and family.
In order to effectively account for the complex and dynamic variables in regards to ADHD symptomatology, there are specific processes in which one must assess in order to gain an accurate picture for diagnosis, with special emphasis and analysis of information obtained from the child, parents and teachers if possible (Barkley, 2005).
Areas of the assessment involving multiple areas and procedures of collecting data:
1. Historical Assessment (Social, Family, Medical, Prenatal / Developmental, and Educational)
2. Use of interviews, observations and examinations
Accessing a thorough history includes multiple areas of assessment. According to Mercugliano, Power, & Blum (1999) a practitioner must first be aware that many of the problems children with ADHD confront will manifest themselves within the areas of behavior, academics and social interaction. Because of these areas of concern a clinician must assess prenatal / developmental, social, family, medical, educational histories and utilize interviews, observations and examinations as a process to collecting data (Mercugliano, et. al., 1999). Throughout data collection DSM IV criteria should 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 states that one must find 6 or more symptoms either within the areas of inattention or the areas of hyperactivity / impulsivity, and these symptoms must have been present for at least 6 months, many before the age of 7yrs, must create impairment and been observed within at least two primary systems including; work, school, or society (Quinn, 1997). The family, medical, developmental, educational and social histories are of great importance in regards to understanding if the child’s manifestation of behavioral symptomatology within multiple systems is a result of ADHD or a dysfunctional environment or health problem (Mercugliano, et. al., 1999). Assessment of the educational realm is of great importance due to the fact that many of the difficulties with behavior, learning, and performing that ADHD creates can first be identified at school (Barkley, 2005). It is usually that first transition from a child’s home to spending 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 during investigation of these areas includes the recommended use of a semi-structured interview (Schroeder & Gordon, 2002). When interviewing the 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 to acquiring information in a flexible semi-structured format. For the purpose of this paper, this interview is utilized as a guide to gaining relevant areas of information, and integrating proper assessment and testing processes within each primary area (Schroeder & Gordon, 2002). The CAIS has clear and specific areas of investigation. Included in the following are primary areas a clinician should consider:
1. Reason for referral
2. Social context concerns
3. Assessing general / specific areas
CAIS – Schroeder & Gordon, (2002)
This interviewing system entails primary areas of historical analysis as described by
Mercugliano, et. al., (1999). It would be valuable to utilize many sources of information when implementing the interview process; such as interviewing children, parents and teachers. This interview system is clear in analysis of the context, the reasons for referral and difficulties of interaction. This interviewing system also emphasizes general and specific areas of concern (Schroeder & Gordon, 2002).
The social contextual inquiry is important due to the DSM IV criteria of behaviors that if not contextualized may be present due to other environmental circumstances and or may be an indication of another disorder. Social aspects and interactions for children with ADHD must be investigated according to the child and parental perceptions. An investigation of social interactions may indicate dysfunction of the frontal lobe that clearly influences ones ability to judge social cues and the inhibition of correct perceptions of emotional expression within social situations (Cherkes-Julkowski, Sharp, & Stolzenberg, 1997). A clinician should also investigate transitions and adaptation problems within social situations that could be the result of difficulties in understanding social interactions. According to Cherkes-Julkowski, Sharp, & Stolzenberg (1997) the Vineland Social Adaptive Scale has been reliable and may be effective in rating a child’s social adaptive abilities. This rating scale would assess for a clinician important areas related to ADHD symptomatology including; communication, daily living skills, socialization, motor skills and maladaptive behavior (Wodrich, 1997). The standard scoring is represented by a mean of 100 (Wodrich, 1997). A clinician would seek areas of the behavior rating in which indicate low average to below average areas. Below average or a score of 85 or less, especially with a deviation of 15 points or more between other adaptive scores may indicate serious difficulty in adaptive abilities.
The general areas inquiry within the interviewing system is of importance for many reasons, however connecting investigation 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 society is key (Kamphaus & Campbell, 2006). This area of the interview would indicate for the clinician past and current developmental status, family characteristics, environmental characteristics, consequences of behavior, medical status and history (Schroeder & Gordon, 2002).
An initial developmental and prenatal investigation would consider the presence or historical occurrences of prenatal infections, exposure to alcohol or cocaine usage, elevated led exposure, maternal cigarette smoking, brain injuries, syndromes disorders, genetic predisposition, as well as prematurely (Barkley, 2005; Quinn, 1997). According to Schroeder & Gordon (2002) although many of these factors influence etiology of ADHD, a primary factor a clinician should consider are genetic factors. According to Faraone, Biederman, Mennin, Gershon and Tsuang (1996) nearly 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, the child’s early temperament features, and inquire about early development of motor, language, intellectual, cognitive, academic, emotional and social functioning
(Quinn, 1997; Schroeder & Gordon, 2002).
Due to self regulatory issues of younger children, a clinician should acquire about the infants mood, adaptability, sleep, and other indicators of temperament early in the interview process with the parents. An effective tool a clinician can utilize or inquire from the child’s pediatrician and allow the mother to complete in order to assess temperament is the Carey’s Revised Infant Temperament Questionnaire (Quinn, 1997).This tool measures nine areas and the results indicate difficult to easy children within five diagnostic areas (Quinn, 1997). The actual behavior characteristics that are rated include; activity, rhythmicity, approach, adaptability, intensity, mood, persistence, distractibility, and threshold (Quinn, 1997).
According to Schroeder & Gordon (2002) if suspicion of developmental deficits exists for school age children then a psycho educational assessment may be utilized in order to identify problematic areas. Primary tools usually associated with a psycho educational assessment in which a clinician could 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 is also very important. Other tools utilized include information from CA60 reviews regarding educational history and in-classroom observation information. The WISC-III for measuring a child’s I.Q. can be valuable in assessing possible deviations that indicate deficits in areas that ADHD may be causing problems. According to Mercugliano et. al., (1999) the areas a clinician should investigate regarding inattention within the results of the WISC-III includes areas of processing speed and freedom from distractibility. Vast deviations within these areas could indicate problems with inattention. Other deviations of 15 to 20 points or more between categories such as; verbal and performance IQ may suggest strengths or weaknesses in visuospatial or language functioning (Mercugliano et. al., 1999). The WIAT achievement test seeks to assess many areas within the realm of educational functioning (Wodrich, 1997).
A clinician should investigate through comparison the differences between the IQ scores and the achievement scores within the analysis. According to Mercugliano et. al., (1999) a significant deviation of 12 points or more between the full scale IQ score and any of the subtest (basic reading, math reasoning, spelling, reading comprehension, numerical operations, listening comprehension, oral expression and written expression) of the WIAT may indicate deficits in ability within the subtest areas (Wodrich, 1997). One may then expect to find when assessing for ADHD on the WIAT, a child’s score representing a significantly lower score (below 85 with a SD of at least 15) from their full IQ score within the sub-test areas, quite possibly indicating a learning disability. This would be consistent with current research with Barkley (2005) in which he states that up to 25 to 30 percent of those suffering with ADHD also have a learning disability.
The CBCL or Achenbach Behavior Rating Scale is a wide-range rating scale which should be utilized or the results should be requested from the local school system. The CBCL could assist a clinician in assessing areas prevalent to DSM-IV criteria including; an understanding of the behavior based upon different environments (school / home), based upon who witnesses or experiences the behavior (child, parent, teacher), and social competence / behavior analysis based upon normed criteria of age and gender which seeks to identify normal or abnormal behaviors (Mercugliano, et. al., 1999). This rating scale is very useful in that a clinician can assess possible DSM-IV comorbid problems on two broad scales of internalization and externalization (Kamphaus & Campbell, 2006). The rating scale also included eight subscales in (somatic problems, withdrawn, anxiety / depression, social problems, thought problems, attention problems, delinquent behavior and aggressive behavior) that would assist a clinician in identifying the probable existence of some type of ADHD or some type of comorbid mental disorder.
Utilization of the CA60 review and the child observation would be of great importance. Through a qualitative analysis of the child observation and CA60 review, or perhaps the child’s discipline record, one could associate many behaviors with either attention or hyperactive / impulsive problems or both. A clinician may discover excessive disorganization, lack of follow through, a child who is easily distracted, and other factors contributing to inattention (Schroeder & Gordon, 2002). A clinician may also discover a child who excessively fidgets in class, acts out in disruptive manners, seems to have problems waiting for their turn and represents factors of hyperactivity / impulsivity (Schroeder & Gordon, 2002). Regardless of such findings, the usage of the psycho educational assessment within a clinician’s analysis of behaviors, social interactions, and achievement is a priority and must be directed by the clinician or obtained from the schools for review before any probable conclusion of the existence of ADHD.
Identifying family characteristics, environmental circumstances and consequences of behavior assist the clinician in identifying family structure, boundies, expectations and roles of members. During this analysis it can 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 issues in perception and to the degree they conceptualize it. This would give a clinician a better understanding of the possible conflict within the family system and give greater understanding of the behaviors, and if behaviors meet DSM IV criteria. A thorough investigation is important due to many families with children who suffer from ADHD experiencing very dysfunctional, chaotic and inconsistent family systems (Cherkes-Julkowski, Sharp, & Stolzenberg, 1997). Other important areas of consideration for a clinician during the interview included; parenting styles, genetic influences and coexisting disorders of other family members which could be identified through a genealogical assessment (McGoldrick & Gerson, 1985; Mercugliano, et. al., 1999).
The assessment of medical conditions and history may assist with identifying past medical appointments and problems. Inquiry may contribute to understanding if some medical problems may be contributing to attention difficulties (Mercugliano, et. al., 1999). Pharmacological considerations may also be identified, co-morbid disorders, reoccurring 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 may be obtained thorough questioning and an intake questionnaire upon first visit (Quinn, 1997; Schroeder & Gordon, 2002). For further inquiry it would be practical 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 should document through out their interview with the child and inquire with a physician if the child was found to have any physical anomalies. According to Quinn (1997) anomalies are prevalent especially among those children associated with hyperactivity.
Physical anomalies that the clinician can observe in session or through physician inquiry of infants and toddlers include; the fourth finger longer than the middle; the third toe longer than the second; ears set lower upon the head; other anomalies of the mouth, face and head (Barkley, 2005; Quinn, 1997). A clinician should also investigate low birth weight history; 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 ear and or vision difficulties. According to Schroeder & Gordon (2002) children that experienced attention problems in elementary school were associated with having inner ear problems 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 usage of Positron Emission Tomography (PET) or Magnetic Resonance Imaging (MRI), they do claim that these processes are very effective in identifying brain structure and function that relates to the presence of ADHD. A clinician could utilize such medical records or suggest parents consider a process that includes these types of examinations to confirm physical abnormalities; considering that the diagnosis of ADHD is behaviorally based. According to Barkley (2005) indications that ADHD may be present would include the confirmation of less blood flow to the pre-frontal cortex regions of the brain, less brain activity from the frontal cortex as well as smaller size of the cortex regions.
Specific areas of behavior including; the persistence of behavior, changes in behavior, the severity and frequency relate to criteria of the DSM IV in regards to the question criteria the DSM uses with words such as “excessively” and “easily” when assessing child behavior (Schroeder & Gordon, 2002; Kamphaus & Campbell, 2006). Understanding if the behavior has been consistent for at least 6 months and before the age of 7yrs. would be substantial (Kamphaus & Campbell, 2006). Specifying the behavior of course will assist in indicating if the child is experiencing inattention or hyperactivity/impulsiveness types of behaviors in order to categorically identify the type of ADHD present. The DSM also indicates the need to effectively understand how “often” does the behavior occur, and it is this frequency and persistence section of the specific areas part of the interview that is so important in regards to diagnosis (Centers for Disease Control, 2007; Schroeder & Gordon, 2002).
It seems clear that if clinicians are to assist with the diagnosis of children suffering with ADHD they must utilize a number of assessment tools depending upon preference and circumstance. A clinician must identify significant features of behavior and compare the child’s behavior to other students and children by age and gender when making inferences regarding behavior. Clinicians should continue to pursue strategies that reflect results from multiple environments, and from multiple participants who have witnessed the behavior. This utilization of different perspectives and a gaining of knowledge from others subjective experiences would allow a clinician to gain a more accurate portrayal of circumstances. The greater amount of patterned characteristics and consistent interactions that a clinician can extract from relevant areas of the child’s life and with the utilization of interviews, instruments and observations, the more reliable and valid a final confirmation of diagnosis can be obtained. However, as a therapist and clinician my information and assessment can only express so much credibility. In regards to ADHD a proper and final diagnosis would be made by a medical doctor.
Applegate, J. S., & Shapiro, J. R., (2005) Neurobiology for Clinical Social Work; Theory
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