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How to make a DSM-IV–compliant diagnosis when the child’s behavior in school cannot be assessed.
Supplementation of parent symptom reports with clinical data may work as an alternative diagnostic strategy in some cases of suspected ADHD, according to a team of researchers from Boston University School of Medicine in Massachusetts.1 The team was seeking a strategy that would allow clinicians to make a DSM-IV–compliant diagnosis in situations in which assessment of child behavior in the school setting-generally considered a key component to proper diagnosis-cannot be obtained.
Although teacher/school-generated reports of child behavior, along with parent-based reports, are largely considered to be fundamental to an ADHD diagnosis (reports from 2 settings being required for a DSM-IV–compliant diagnosis), teacher reports are often not included in real-life diagnostic assessments. Challenges in care coordination in the primary care setting are, in part, to blame. This oversight can result in misdiagnosis and inappropriate treatment, particularly among children from lower-income households.
To evaluate whether clinical data could adequately bolster parent-evaluated symptom reports to a degree that would ensure diagnostic accuracy, the researchers conducted a stepwise multivariate analysis using baseline and outcomes data from a randomized, controlled trial (NCT01275378) of ADHD among 156 urban-dwelling children, age 6 to 12 years.1,2 Most participants in this urban cohort were children of color (60% African American, 27% Hispanic), and 69% were male.
Expert diagnostic evaluations-conducted by a child psychiatrist, a developmental behavioral pediatrician, and a team of case workers-were based on results of parent and teacher Vanderbilt ADHD Diagnostic Rating Scale reports in relation to each child’s clinical history. Data audits ensured that all assessments were in compliance with DSM-IV guidelines.
Teacher reports are often not included in real-life diagnostic assessments. This and other oversights can result in misdiagnosis and inappropriate treatment, particularly among children from lower-income households.
A positive ADHD diagnosis was more common in children aged 7 years and younger than in those older than 7 years (42% vs 27%; P = .05). Children in the ADHD-positive group were more likely to have been retained in grade (32% vs 20%), less likely to have parents with a history of substance abuse (6% vs 21%), and more likely to have oppositional defiant symptoms (47% vs 23%; P = .002) and anxiety or depressive symptoms (14% vs 8%), compared with those in the ADHD-negative group.
The researchers took baseline clinical data (child age, history of grade retention, presence of anxiety or depressive symptoms, presence of oppositional defiant symptoms, and lack of parent substance abuse history) and added the findings, in stepwise fashion, to results of the parent-completed Vanderbilt ADHD Diagnostic Rating Scale report only.
The researchers found that the parent Vanderbilt rating scale report alone had a 56% rate of accuracy in predicting an ADHD diagnosis. The predictive ability increased to 78% when age and grade retention were added to the model.
When all covariates (child age, grade retention, anxiety or depression symptoms, and lack of parental substance abuse) were added to parent Vanderbilt rating scale results, the predictive validity increased to 84% (95% confidence interval, 52% - 99%).
Although the researchers cautioned that their findings support the established premise that teacher reports are vital to an accurate ADHD diagnosis, the findings also suggest that treatment could be initiated with reasonable confidence in children age 7 years and younger who meet certain clinical characteristics, as described in their study, when diagnostic teacher/school-based reports cannot be obtained.
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1. Silverstein M, Hironaka LK, Feinberg E, et al. Using clinical data to predict accurate ADHD diagnoses among urban children. Clin Pediatr (Phila). 2016;55:326-332.
2. Silverstein M, Hironaka LK, Walter HJ, et al. Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial. Pediatrics. 2015;135(4):e858-e867.