Everyone in a private practice setting who works with ADD/ADHD children or adults is going to have their own opinion on how ADD should be diagnosed. Some clinics take the perspective that “more is good,” and will recommend a large battery of tests, often costing many thousands of dollars. Other clinics, typically with hurried physicians, will simply give a brief rating scales to the parent and then make a quick diagnosis and prescribe treatment. Unfortunately neither of these extremes are in the patient’s best interest.
There are two big problems in “Attention Deficit Disorder-Land” out there right now. The first big problem is over-diagnosis. There are some people out there who are diagnosed as having attention disorder, that do not have it. It is not uncommon for someone with depression, or anxiety, or specific learning disabilities, or early onset bi-polar disorder, or Tourette’s Syndrome, to be diagnosed as ADD/ADHD. This is often the result of a diagnostic “work-up” which is too brief and does not take into account the many reasons why a child might be inattentive, impulsive, or over-active. The second problem that I see is a great under-diagnosis of ADD where it should be diagnosed. This happens most often in the school setting where the school psychologist writes his report perfectly describing an ADD individual, then refuses to use the label “ADD” in his report anywhere. It also often happens in therapist’s offices where the therapist is not familiar with ADD, and only sees the characteristic behaviors as “acting out behaviors” due to family problems, etc.
Some studies suggest that only one out of three people who have an attention disorder will get help. Two out of three people who have an attention disorder will never receive a diagnosis or treatment. They will never really know what it is that’s bothered them through their life. So we have two problems. One is over-diagnosis and the other is under-diagnosis. So how do you know?
Well, you need to have a righteous diagnosis, a good diagnosis. What would that entail? How should ADD/ADHD be diagnosed? The unfortunate thing is that there are many kids who have been diagnosed based on only a parent interview that lasts about four minutes and a real quick rating sheet, taken in the doctor’s office. It’s unfortunate that that’s all that happens and the diagnosis is made, because that could lead to real problems.
ADD/ADHD is a category found in the Diagnostic and Statistical Manual, version Four (DSM-IV). The diagnostic criteria is divided into sub-groups: Attention Deficit Hyperactivity Disorder, Primarily Inattentive Type; ADHD, Primarily Impulsive-Hyperactive Type; and ADHD, Combined Type. Without having copied the DSM-IV, we have summarized the criteria for you below.
Here are the things that we recommend, if you have a child that you think needs to be diagnosed or ought to be looked at if he has this problem. Here are the things we think you need to do:
In-Depth Parent Interview
First, there should be an “adequate” physical exam by the child’s pediatrician or family practice doctor. This doesn’t have to be an extensive, expensive exam, but should be able to rule out possible problems like Mononucleosis, Thyroid problems, lead poisoning (if it is common in your area), and potential attentional problems caused by medications, such as allergy medications. Then, with a clean bill of health, we move on to step two. . .
Number two, there should be a good parent interview.
It’s absolutely essential that somebody sits down with the parents and spends 45 minutes to an hour with them. The therapist (Usually a psychologist or other mental health professional. Only get counseling/therapy from professionals who have a lot of experience treating this disorder. Therapists who do not have a lot of experience with this disorder will just waste your money and probably blame you , the parents, for the child’s disorder.) needs to find out what’s going on now, why did the parents pick up the phone and call now instead of last week, and so on. A good developmental history needs to be taken. There are some real interesting things you can find out, when you find out: How did mom do during pregnancy; were there any problems at all; any exposure to drugs or alcohol. When did he learn to walk or crawl? How about speech development? Did he have very many ear infections? All of those kinds of things are important. Any head injury, any high fevers, any seizures? Head injuries and seizures can look just like ADD, but aren’t. They may require different treatment options.
Then a good family history is great. The pedigrees or family trees of ADD kids are often very similar. Look at one and you may say, “Gee, there’s no wonder this kid has it,” because most of the time, about 80 percent of the time, you can trace the impact of this gene as it runs through families causing things like obsessive-compulsiveness, depression or alcoholism, attention disorders or learning disabilities throughout the family. So family history is important, and then to make a good differential diagnosis you must know if in the parents’ opinion, is the child depressed? Does he have anxiety problems? Is he hallucinating? Is he delusional? Is it a head injury? Is it a seizure disorder? Those kinds of things. You want to make sure you are on the right track. In depth parent interviews are very important, and without one it is hard to know if you have a good diagnosis or not.
Parent and Teacher Rating Scales Third, parent rating scales are very good. The scale we like is by Ned Owens out of Texas. Keith Connors has a fine tool that you have probably seen if you are involved with ADD at all. There are three or four good rating scales out there on the market today. It is very important for the parents to fill out these rating scales. Ideally you get the teachers to fill them out too.
Now, we are in the summer right now, and that’s not going to be possible in most cases. But ideally you want the teacher’s input because they see 30, 32, 35 kids every single day, year in and year out and they know what is normal behavior and what is not. Just as a parentheses, one of the things we have noticed is that lately we are having more trouble with the teacher rating scales because the teachers ten years ago, eight years ago, five years ago used to rate the kids pretty reliably compared with the normal kids in the class, the non-ADD kids in the class. But what we are seeing lately is very often the teachers are comparing the child that we want rated against the worst kid in the class, who might be totally off the wall. And so the rating scale comes back that the child we want rated isn’t much of a problem at all. So sometimes we have to give the directions to the teachers and rate them versus “normal kids,” not against the worst kids in the class.
Clinical Interview with the Child
Thoughts on Psychological Tests
the TOVA Test
Fourth, an in-depth clinical interview with the child is important. This interview is needed to determine the child’s reality testing, his degree of maturity, his degree of verbal skills, and so on. Ask the child if he’s hallucinating. Sometimes he is, but he hasn’t told anyone. Ask the child if he’s anxious. Some kids have tremendous fears, but have not shared them with anyone. There is a lot going on with kids that their parents are not aware of.
Next, psychological testing can be helpful. We used to give tests such as the WISC-R, an IQ test, the Wide Range Achievement Test (WRAT), and the Bender-Gestalt test, which is a visual motor integration test. Bored already? Well, they are boring things. But they can be helpful. There are certain patterns that you would see on these tests that can be helpful, but it’s art, it’s not science at that point. It’s art to look at certain patterns, but they are not “diagnostic” for ADD/ADHD. It’s not something that you could stake your claim on in terms of testing, but it can help them if the kid has a real low IQ, or a major learning disability, it could be a clue that there is something else going on instead of an attention disorder.
What we find to be very valuable is the Test of Variables of Attention (TOVA). The TOVA is an extremely boring computer test that requires the kids to respond to a target stimulus by pressing a button, or to not respond when there’s a non-target stimulus. The fact that it is so boring is a work of genius because it helps them differentiate between kids who have trouble with “boring,” and kids who do all right with “boring.” So the TOVA is really a terrific tool that should never be given just by itself. It needs to be given in the context of the whole diagnostic workup, but it’s really very valuable. Also, we can give the TOVA with no medication, and then if medication is going to be used down the road, we can give the TOVA again with medication in their system and actually find out if he is at the right dosage or not, or how well he responds to that particular dose of that particular medication. Very helpful tool.
Clinical observation of the child is very important. If possible, ideally, somebody observes the child in the classroom. In the real world, we don’t know anybody in private practice who can go out in the classroom to observe a child these days, but if a school nurse, school psychologist can go observe them, it can be very, very helpful.
Obtaining an EEG from a neurologist is rarely helpful. EEGs will show some differences from non-ADD children. Typically there is excessive slow brainwave activity, particularly in the Theta band (4-7 Hz.). However, ninety-five percent of all ADD kids have “normal” EEGs. What we mean by “normal” is they don’t have big epileptic spikes, things like that, that a neurologist would say that are “abnormal.” But when you compare them side by side with a non-ADD kid, they are much different. An EEG may be helpful if the child is going to be treated through EEG biofeedback, but in terms of being helpful for a diagnostic work-up, it is rarely helpful. However, if the parent interview revealed that the child had some potential neurological problem, as seen in sleep walking, or a history of seizures, and so on, then an EEG would be a good idea.
Summary In summary, then, an adequate diagnostic interview, designed to give an accurate diagnosis a very high percentage of the time, while not costing the family thousands of dollars, would look like this:
Physical Exam - Office Visit
Clinical Interview - Parents (45-60 minutes)
Clinical Interview - Child (45-60 minutes)
Parent and Teacher Rating Scales
Office visit to review information and develop treatment plan
That’s it! If there are further diagnostic questions, then more testing would be required. But in the vast majority of cases, this is all that is needed to make a highly reliable diagnosis. Except for the physician’s examination, the cost for this should be about $400-500.
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