A few weeks ago the American Academy of Pediatrics published the new practice guidelines for the diagnosis and treatment of ADHD. These guidelines are to help professionals in the care of kids with ADHD. Although I agree with most aspects of the guidelines, they are creating significant controversy among psychologists. Many aspects of these guidelines show limitations, 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 is that a diagnosis of ADHD comes from criteria in the DSM4. Although I won’t summarize the full criteria here, I want to talk about four important aspects of the diagnosis. Some which clinicians often disregard, resulting in a 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 occur in 2 or more settings.
The symptoms don’t occur exclusively (or aren’t due to) other neurodevelopmental conditions.
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 is to provide clinicians with clear instructions. The guidelines relate to procedures that they should follow to determine whether a child meets the criteria.
In sum, the AAP states that:
A. The clinician should initiate an evaluation for ADHD for any child 4 -18 years of age who presents with academic or behavioral problems. Symptoms include inattention, hyperactivity, or impulsivity.
This first guideline is not too controversial. This is because there is evidence that the proper identification and treatment of young kids can improve the kids’ outcomes.
B. To make a diagnosis of ADHD, the primary care clinician should determine that DSM4 criteria is met. Also, be sure information is primarily from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care.
Here there is a limit to the guidelines. The problem is that this specific guideline do not tell the pediatrician HOW to make sure that the child meets DSM-IV criteria other than by obtaining information from parents and teachers. What does “obtaining information” mean in terms of actual practice?
There are two key issues regarding this guideline to keep in mind.
First, the behaviors (symptoms) reported must be inconsistent with developmental level. This means that the problem behavior must be in excess of what is typical for the child’s age. But… in excess according to whom? Who decides what is appropriate for each age? How much hyperactivity or inattention is “typical” in a child age 5? How about a child age 8? Does the sex of the child matter in terms of what is “typical” for a specific age? The questions are endless.
This problem does not have an easy answer. Clinicians should use specific parental and teacher questionnaires. These questionnaires allow the clinician to compare the parent and teacher reports to those of thousands of other parents. This helps the clinician determine whether the child’s behaviors are in excess for 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 simply on a brief interview with the parent. Information should include the parent and multiple teachers.
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. Specifically, what does “clinically significant impairment” mean 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.” This 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. This includes how to measure or document criteria. Additionally, relying only on the reports of a parent or a teacher has some limitations. For example, a child may have a table as a problem child by one teacher while other teachers may have no issues with the child’s behavior. Similarly, a parent may complain 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. This includes emotional or behavioral, developmental and physical conditions.
The problem here is that the AAP guidelines do not indicate who or how such assessment are made. Although Pediatricians can screen for these conditions. They generally are not trained to conduct the type of comprehensive evaluations to properly diagnose most of these conditions. Therefore, my interpretation of this guideline is that pediatricians should refer the child to other professionals. This will help 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 screening for the possibility that the child may have another condition. For example, conduct or learning problems, depression, anxiety, and other neurodevelopment disorders.
In sum, when considering whether your pediatrician or other healthcare professional is properly diagnosing your child, you should ask yourself the following questions:
Does the evaluation include long questionnaires completed by me, other adults living at home, and multiple teachers, coaches, etc?
Is the clinician paying attention to how and if these symptoms are affecting my child. For example, asking for my kid’s report cards and talking to teachers and family members?
Are other conditions ruled out. For example, did clinician recommend that my child should get an evaluation for learning disabilities? 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 your answer is no to any of these questions, I would recommend getting a second opinion about your child’s diagnosis.
ByNestor Lopez-Duran PhD
The reference: 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
