|
August 1, 2006
Consultant for Pediatricians. Vol. 5 No. 8 Special Issue: Focus on ADHD ADHD: A Guide to Assessment and Diagnosis
MICHAEL I. REIFF, MD
University of Minnesota
Dr Reiff is associate professor of pediatrics and medical director of the Autism Spectrum Disorder Clinic at the University of Minnesota in Minneapolis. He is also a member of the executive committee of the developmental behavioral section of the American Academy of Pediatrics and the author of ADHD: A Complete and Authoritative Guide, published by the American Academy of Pediatrics.
ABSTRACT: The high prevalence of attention deficit hyperactivity disorder (ADHD) makes it critical that primary care pediatricians feel comfortable diagnosing and treating most affected children and adolescents. ADHD can be thought of as a spectrum of "attentional disorders" rather than a single entity. An evaluation for ADHD is indicated when there are concerns about attention problems, hyperactivity, or impulsivity. Difficulties with organization, forgetfulness, careless work, procrastination, difficulty in completing or turning in homework, and/or high-risk behaviors provide reasonable grounds for considering such an evaluation. The diagnosis requires that children meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV) criteria at home and at school. There needs to be some indication that problems were present before the child's seventh birthday, and that the symptoms are causing significant functional problems. The Vanderbilt Scales are among the many checklists used by parents and teachers to screen for ADHD; they contain the DSM-IV criteria and screens for conditions that commonly coexist with ADHD. Even if the criteria for ADHD are met, the diagnosis should not be made unless the child also has significant difficulty in functioning.
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed bio-behavioral disorder of childhood. It occurs in 6% to 9% of children--about the same prevalence as childhood asthma. It is also one of the most controversial diagnoses in children; parents are often perplexed about whether ADHD is underdiagnosed or overdiagnosed, or undertreated or overtreated. A good deal of this confusion stems from the fact that there are no laboratory tests, imaging studies, or psychological testing profiles that can be used to make the diagnosis. Theories abound about the cause of ADHD. These include the impact of genetic factors, variations in temperament and emotional reactivity, neurologic factors, and a host of environmental influences on the developing brain. ADHD is a heterogeneous condition, and many diverse biologic and environmental factors--alone or in combination--can result in the behaviors that lead to the diagnosis of ADHD. The core symptoms of ADHD are inattention, hyperactivity, and impulsivity; the case vignette in the Box illustrates typical ways in which these manifest. The disorder can be thought of as a spectrum of "attention disorders" rather than a single entity. Because of the high prevalence of ADHD, and because pediatricians have many opportunities to screen for ADHD before parents might be alerted to seek care, evaluation and management of ADHD are important and doable tasks for primary care pediatricians. The American Academy of Pediatricians' Guidelines for Evaluation and Diagnosis of ADHD describe a format for evaluating a child with ADHD from an evidence-based or best practice perspective.1 This article is organized around those recommendations. GUIDELINES FOR DIAGNOSING ADHD Questions about ADHD can come from parents or teachers. When attention problems or hyperactivity or impulsivity are the concerns, an evaluation is indicated. If you want to screen or conduct some surveillance, you might consider using a questionnaire that can be given to parents of school-aged children at well-child or other non-acute visits. The kinds of questions that could be asked include:
During adolescent health supervision visits, questions can be modified. Ask about difficulties with organization, forgetfulness, careless work, procrastination, and/or difficulty in completing or turning in homework. Inquire, too, about high-risk behaviors, including truancy, substance abuse, oppositional behavior, fighting, and sexual activity. Any positive responses provide reasonable grounds for considering an evaluation for ADHD. Kevin: A Struggling Third Grader Kevin is an 8-year-old third grader. His parents first became concerned about him when his kindergarten teacher pointed out that he was more rambunctious than his peers. Otherwise, he did very well. He had more difficulty in first grade but did well academically. This pattern continued in second and third grade, but by grade 3 he had some difficulty with peers and often disrupted the class. He is now beginning to fall behind in reading. He no longer wants to write, and his teacher is concerned about his messy work. Kevin is also having difficulty with friendships because he always needs to be first in line and wants to have things his way on play dates. At home he has difficulty following through on his parent’s requests. His parents wonder if he will outgrow all of this. They have viewed him as a typical energetic boy, and have been hesitant to bring him in for medical attention because they don’t want him to be labeled. On their first visit to your office, Kevin’s mother shows you the Vanderbilt Scale that was filled out by Kevin’s teacher (Figure).
|
|||
© 1996 - 2008 CMPMedica LLC, a
United Business Media company
Privacy Statement -
Your California Privacy rights -
Terms of Service