source: AACAP (2007)
Screening for ADHD
Screening for ADHD should be part of every patient's mental health assessment [MS]. In any mental health assessment, the clinician should screen for ADHD by specifically asking questions regarding the major symptom domains of ADHD (inattention, impulsivity, and hyperactivity) and asking whether such symptoms cause impairment.
These screening questions should be asked regardless of the nature of the chief complaint. Rating scales or specific questionnaires containing the DSM symptoms of ADHD can also be included in clinic/office registration materials to be completed by parents before visits or in the waiting room before the evaluation.
If a parent reports that the patient suffers from any symptoms of ADHD that induce impairment or if the patient scores in the clinical range for ADHD symptoms on a rating scale, then a full evaluation for ADHD as set out in the next recommendation is indicated.
Evaluation of the preschooler, child, or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient's school or day care functioning, evaluation for comorbid psychiatric disorders, and review of the patient's medical, social, and family histories [MS].
The clinician should perform a detailed interview with the parent about each of the 18 ADHD symptoms listed in DSM-IV.
For each symptom, the clinician should determine whether it is present as well as its duration, severity, and frequency.
Age at onset of the symptoms should be assessed.
The patient must have the required number of symptoms (at least six of nine of the inattention cluster and/or at least six of nine of the hyperactive/impulsive criteria, each occurring more days than not), a chronic course (symptoms do not remit for weeks or months at a time), and onset of symptoms during childhood.
After all of the symptoms are assessed, the clinician should determine in which settings impairment occurs.
Because most patients with ADHD have academic impairment, it is important to ask specific questions about this area. This is also an opportunity for the clinician to review the patient's academic/intellectual progress and look for symptoms of learning disorders (see Recommendation 4).
Presence of impairment should be distinguished from presence of symptoms.
For instance, a patient's ADHD symptoms may be observable only at school but not at home.
Nonetheless, if the patient must spend an inordinate amount of time completing schoolwork in the evening that was not done in class, then impairment is present in two settings.
DSM-IV requires impairment in at least two settings (home, school, or job) to meet criteria for the disorder, but clinical consensus agrees that severe impairment in one setting warrants treatment.
After reviewing the ADHD symptoms, the clinician should interview the parent regarding other common disorders of childhood.
In general, it is most logical to next gather data from the parent regarding ODD and CD.
Then, the clinician should explore whether the patient has symptoms of depression (and associated neurovegetative signs), mania, anxiety disorders, tic disorders, substance abuse, and psychosis, or evidence of a learning disability.
Other practice parameters of the AACAP contain specific recommendations on eliciting symptoms of these disorders in children and adolescents.
The parent should complete one of the many standardized behavior rating scales that have well established normative values for children of a wide range of ages and genders. Scales in common use are listed in Table 1 of the original guideline document. These scales not only yield a measure of ADHD behaviors but also tap into other psychiatric symptoms that could be comorbid with ADHD or may suggest an alternative psychiatric diagnosis. It is advisable for the clinician to request a release of information from the parent to obtain a similar rating scale from the patient's teacher(s). It is important to note that such rating scales do not by themselves diagnose ADHD, although parent or teacher ratings of inattention or hyperactivity/impulsivity that fall in the upper fifth percentile for the patient's age and gender are reason for serious concern. If the teacher cannot provide such a rating scale or the parent declines permission to contact the school, then materials from school, such as work samples or report cards, should be reviewed or inquired about.
Family history and family functioning should be assessed.
Because ADHD is highly heritable, a high prevalence of ADHD is likely to be found among the patient's parents and siblings.
Family history of other significant mental disorders (affective, anxiety, tic, or CD) is helpful in determining the nature of any comorbid disorders, although a comorbid disorder should not be diagnosed solely on the basis of a family history of that comorbid disorder.
Social history of the family should be examined.
Because patients with ADHD perform better in structured settings, any factors in the family that create an inconsistent, disorganized environment may further impair the patient's functioning. Information regarding any physical or psychological trauma the patient may have experienced (including multiple visits to the emergency room) should be gathered as well as any current psychosocial stressors.
The clinician should obtain information about the patient's perinatal history, developmental milestones, medical history, and mental health history (especially any previous psychiatric treatment). Delays in reaching developmental milestones or in social/language development suggest language disorders, mental retardation, or pervasive developmental disorders. Assessment of developmental milestones is particularly important in the evaluation of the preschooler because many developmental disorders are associated with attention problems and hyperactivity.
The clinician should next interview the child or adolescent. For the preschool or young school-age child (5-8 years old), this interview may be done concurrently with the parent interview.
Older children and adolescents should be interviewed separately from parents, as older children and teenagers may not reveal significant symptoms (depression, suicide, or drug or alcohol abuse) in the presence of a parent.
Clinicians should be prepared to conduct a separate interview even with a younger child in many clinical situations, such as if the patient appears at risk of abuse or there is evidence of significant family dysfunction. The primary purpose of the interview with the child or adolescent is not to confirm or refute the diagnosis of ADHD.
Young children are often unaware of their symptoms of ADHD, and older children and adolescents may be aware of symptoms but will minimize their significance.
The interview with the child or adolescent allows the clinician to identify signs or symptoms inconsistent with ADHD or suggestive of other serious comorbid disorders.
The clinician should perform a mental status examination, assessing appearance, sensorium, mood, affect, and thought processes.
Through the interview process, the clinician develops a sense of whether the patient's vocabulary, thought processes, and content of thought are age-appropriate.
Marked disturbances in mood, affect, sensorium, or thought process suggest the presence of psychiatric disorders other than or in addition to ADHD.
If the patient's medical history is unremarkable, laboratory or neurological testing is not indicated [NE]. There are few medical conditions that "masquerade" as ADHD, and the vast majority of patients with ADHD will have an unremarkable medical history. Children suffering a severe head injury may develop symptoms of ADHD, usually of the inattentive subtype. Encephalopathies generally produce other neurological symptoms (language or motor impairment) in addition to inattention. Hyperthyroidism, which can be associated with hyperactivity and agitation, rarely presents with ADHD symptoms alone but with other signs and symptoms of excessive thyroid hormone levels.
The measurement of thyroid levels and thyroid-stimulating hormone should be considered only if symptoms of hyperthyroidism other than increased activity level are present.
Exposure to lead, either prenatally or during development, is associated with a number of neurocognitive impairments, including ADHD. If a patient has been raised in an older, inner-city environment where exposure to lead paint or plumbing is probable, then serum lead levels should be considered. Serum lead level should not be part of routine screening.
Children with fetal alcohol syndrome or children exposed in utero to other toxic agents have a higher incidence of ADHD than the general population.
Unless there is strong evidence of such factors in the medical history, neurological studies (EEG, MRI, SPECT, or PET) are not indicated for the evaluation of ADHD. Specifically, the Council on Children, Adolescents, and Their Families of the American Psychiatric Association has warned against the exposure of children to intravenous radioactive nucleotides as part of the diagnosis or treatment of childhood psychiatric disorders, citing both a lack of evidence of validity and safety issues. [American Psychiatric Association: Brain Imaging and Child and Adolescent Psychiatry\With Special Emphasis On Single Photon Emission Computed Tomography (SPECT)]
Psychological and neuropsychological tests are not mandatory for the diagnosis for ADHD, but should be performed if the patient's history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient's intellectual ability [OP].
Low scores on standardized testing of academic achievement frequently characterize ADHD patients. The clinician must determine whether the academic impairment is secondary to the ADHD, if the patient has ADHD and a learning disorder, or if the patient has only a learning disorder and the patient's inattentiveness is secondary to the learning disorder. Academic impairment is commonly due to the ADHD itself. Many months or years of not listening in class, not mastering material in an organized fashion, and not practicing academic skills (not doing homework, etc.) leads to a decline in achievement relative to the patient's intellectual ability. If the parent and teacher report that the patient performs at (or even above) grade level on subjects when given one-to-one supervision (a patient can do all of the problems on a test when held in from recess), then a formal learning disorder is less likely. In some cases, the patient may engage in leisure activities that require the skill (e.g., reading science fiction novels) but avoid reading a history book in preparation for an exam. In such cases, it is more appropriate to treat the ADHD and then determine whether the academic problems begin to resolve as the patient is more attentive in learning situations. However, if there is no clear evidence of an improvement in academic performance in 1 to 2 months despite improvement of the ADHD, then psychological testing for learning disorders is indicated.
In other cases, symptoms of learning/language disorders are present that cannot be accounted for by ADHD. These include deficits in expressive and receptive language, poor phonological processing, poor motor coordination, or difficulty grasping fundamental mathematical concepts. In such cases, psychological testing will be needed to identify whether these deficits are related to a specific learning disorder. In the vast majority of cases, these learning disorders will be comorbid with the ADHD, and it is recommended strongly that the patient's ADHD be optimally treated before such testing. It could then be firmly concluded that any deficits identified are clearly the result of a learning disorder and not due to inattention to the test materials.
Purely learning-disordered patients are often inattentive when struggling with material in the area of their disability (a reading-disordered patient is inattentive when he or she must read) but do not have problems outside such a restricted academic setting. Patients with learning disorders alone do not show symptoms of impulsivity or hyperactivity. Children and adolescents with learning disorders may be oppositional with regard to schoolwork, and the clinician is consulted as to whether ADHD is the cause of the oppositional behavior. If a careful interview shows the absence of full criteria for ADHD and if the emergence of the oppositional behavior is clearly correlated with academic demands, then a primary learning disorder is more likely.
Psychological testing of the ADHD patient usually consists of a standardized assessment of intellectual ability (IQ) to determine any contribution of low general cognitive ability to the academic impairment, and academic achievement. Neuropsychological testing, speech-language assessments, and computerized testing of attention or inhibitory control are not required as part of a routine assessment for ADHD, but may be indicated by the findings of the standard psychological assessment.
Recommendation 5. The clinician must evaluate the patient with ADHD for the presence of comorbid psychiatric disorders [MS]. The clinician must integrate the data obtained with regard to comorbid symptoms to determine whether the patient meets criteria for a separate comorbid disorder in addition to ADHD, the comorbid disorder is the primary disorder and the patient's inattention or hyperactivity/impulsivity is directly caused by it, or the comorbid symptoms do not meet criteria for a separate disorder but represent secondary symptoms stemming from the ADHD.
When patients with ADHD meet full DSM-IV criteria for a second disorder, the clinician should generally assume the patient has two or more disorders and develop a treatment plan to address each comorbid disorder in addition to the ADHD. Children with ADHD commonly meet criteria for ODD or CD. In young children these disorders are nearly always present concurrently. Similarly, if a patient meets full DSM-IV criteria for major depressive disorder or a specific anxiety disorder, the clinician is most likely dealing with a comorbid disorder. Most often, the onset of the depressive disorder occurs several years after the onset of ADHD, whereas anxiety disorders have an earlier onset concurrent with the ADHD. A comorbid diagnosis of mania should be considered in ADHD patients who exhibit severe mood lability/elation/irritability, thought disturbances (grandiosity, flight of ideas), severe aggressive outbursts ("affective storms"), and decreased need for sleep or age-inappropriate levels of sexual interest. Mania should not be diagnosed solely on the basis of the severity of the ADHD symptoms or aggressive behavior in the absence of the manic symptoms listed above. Acutely manic ADHD patients generally require mood stabilization before treatment of the ADHD. The choice of a treatment regimen, particularly pharmacological intervention, is often influenced by the nature of the patient's comorbid disorder and which disorder is currently the most impairing of major life activities. Older adolescents with ADHD should be screened for substance abuse disorders, as they are at greater risk than teenagers without ADHD for smoking and alcohol and other illegal substance abuse disorders.
In other cases, another primary psychiatric disorder produces impairment of attention or impulse control. Impaired attention is caused by primary depressive/anxiety disorders, and those with primary mania have impaired impulse control and judgment. If a patient has no history of ADHD symptoms during childhood but develops inattentiveness and poor concentration only after the onset of depression or mania, then the affective disorder is most likely primary. Patients with adolescent-onset ODD or CD are often described as impulsive or inattentive, but often do not meet full criteria for ADHD or had few ADHD symptoms in early childhood.
Finally, some associated problems may stem from the ADHD itself and not be a separate disorder. Patients with ADHD may develop associated symptoms of dysphoria or low self-esteem secondary to the frustrations of living with ADHD. In such cases, the dysphoria is related specifically to the ADHD symptoms and there is an absence of pervasive depression, neurovegetative signs, or suicidal ideation. If such dysphoria is a result of the ADHD, then it should respond to successful treatment of the ADHD. The distractibility or impulsivity of ADHD patients may often be interpreted as oppositional behavior by caretakers or children. Mild mood lability (shouting out, crying easily, quick temper) is also common in ADHD. It is important to note that such associated symptoms do not reach the level of a separate DSM disorder; are temporally related to the onset of the ADHD; are often consistent with, although somewhat excessive, for the social context; and dissipate once the ADHD is successfully treated.