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Transcript
SCREENING AND
DIAGNOSING ADHD
IN PEDIATRICS
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of
academic medicine, and medical author. He graduated
from Ross University School of Medicine and has
completed his clinical clerkship training in various
teaching hospitals throughout New York, including King’s
County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has
passed all USMLE medical board exams, and has served as a test prep tutor and
instructor for Kaplan. He has developed several medical courses and curricula for a
variety of educational institutions. Dr. Jouria has also served on multiple levels in the
academic field including faculty member and Department Chair. Dr. Jouria continues
to serves as a Subject Matter Expert for several continuing education organizations
covering multiple basic medical sciences. He has also developed several continuing
medical education courses covering various topics in clinical medicine. Recently, Dr.
Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human
Anatomy & Physiology.
ABSTRACT
Attention Deficit Hyperactivity Disorder is a diagnosis that tends to cause a
lot of fear and confusion in parents and caregivers, but receiving the proper
information in a timely manner from health clinicians can help alleviate
many of those feelings. It includes a combination of symptoms, including
hyperactivity, impulsivity, and difficulty sustaining attention. Millions of
children struggle with these symptoms, which frequently ease as the patient
reaches adulthood. It is important for clinicians to carefully screen patients
according to current medical standards before making a diagnosis of
attention deficit hyperactivity disorder.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
Depending on their role and training, clinicians may or may not have primary
responsibility to diagnose ADHD; however, often nurses and therapists
contribute to the formulation of a diagnosis and plan of care through
observation and interaction with children, parents and teachers and rely
upon expert knowledge to use the right screening tool and methods to
identify behaviors and social challenges associated with ADHD.
Course Purpose
To prepare clinicians to have knowledge of pediatric ADHD, methods of
diagnosing associated disorders and behavioral outcomes, and to participate
in interprofessional collaborative treatment that involves the patient and
their family.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. _________________ are the primary neurotransmitters that
mediate frontal-lobe function.
a.
b.
c.
d.
Amino acids
Catecholamines
Gaba peptides
Acetlycholine derivites
2. The predominantly hyperactive/impulsive type of ADHD is
usually characterized by high energy and constant movement.
The classic manifestation(s) of this type of ADHD is/are
_____________.
a.
b.
c.
d.
Inattentiveness or lack of attention
Disorganization
Forgetfulness
All of the above
3. Children with predominantly ___________ type of ADHD face
barriers when trying to form social relationships with other
children due to their tendency to be easily angered and
provoked.
a.
b.
c.
d.
Inattentive
Impulsivity
Autistic
Hyperactivity
4. A comprehensive neurologic examination needs to be
performed in children with ADHD to rule out the possibility of
neurodegenerative disorders such as _______________.
a.
b.
c.
d.
Alzheimer’s Disease
Parksinson’s Disease
Adrenal leukodystrophy
Mad Cow disease
5. The formal diagnosis of ADHD in children, adolescents, and
adults usually occur in __________________.
a.
b.
c.
d.
School
Primary care settings
Secondary care settings
Home
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Introduction
According to the National Institute of Mental Health, attention deficit
hyperactive disorder or ADHD is a relatively common brain disorder that is
often diagnosed at childhood and continues to adolescence and adulthood.1
Children with ADHD sometimes exhibit uncontrollable behavioral symptoms
that are frequent and severe which interferes with their ability to cope at
school and live normal lives outside of it. Pediatric ADHD causes
hyperactivity and impulsivity and/or inattention in affected children. Many
children experience these behavioral issues at some time during their
childhood. However, in children with ADHD, these behavioral problems
persist over a long period of time. This course discusses the management
and diagnostic approaches that every health professional in contact with an
ADHD patient should be familiar with and understand.
ADHD: An Overview
To be diagnosed with ADHD, behaviors of hyperactivity, impulsivity and
inattentiveness must continue for at least six months and be present in two
environments such as home and school. Clinicians should be able to
diagnose this disorder early on to evaluate the patient and provide for all the
necessary pharmacotherapeutic and behavioral interventions that will
minimize symptoms and restore social and academic functions. An effective
management of ADHD requires a multidisciplinary team approach that
includes the patient, the family, the school, and the clinician.
History
The modern concept of attention deficit hyperactivity disorder (ADHD) as
defined by the Diagnostic and Statistical Manual IV (DSM-IV) is fairly new.
However, its hallmark symptoms of over activity, inattentiveness, and
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impulsiveness in children have been observed and recorded by physicians as
early as the 19th century. A notable example is Sir Alexander Crichton
(1978) who wrote a book entitled “On Attention and its Diseases”. In this
book, he defined ADHD as; “when any object of external sense, or of
thought, occupies the mind in such a degree that a person does not receive
a clear perception from any other one, he is said to attend to it”. Crichton
further records his observations of the progression of the disorder, and
wrote that ”when born with a person it becomes evident at a very early
period of life, and has a very bad effect, inasmuch as it renders him
incapable of attending with constancy to any one object of education. But it
seldom is in so great a degree as totally to impede all instruction; and what
is very fortunate, it is generally diminished with age”.2
The idea brought forth another idea, which was that ADHD is a pediatric
disorder which patients outgrow as they age. This idea of growing out of
ADHD was prevalent up until the late 1990s. It was only fairly recently that
scientific studies have shown otherwise; in fact, affected children diagnosed
with ADHD continue to exhibit the symptoms well into their adulthood.3
Another physician, Heinrich Hoffman, published a series of illustrated
children’s books depicting characters with symptoms of ADHD. One of the
most notable ones was Johnny Look-in-the-air, who was depicted as a boy
who exhibited telltale symptoms of inattention. In the book, Johnny was
always “looking at the sky and the clouds that floated by”, a symptom that
the American Psychiatric Association (APA) attributes to frequent distraction
by an extraneous stimuli.4
The scientific concept of ADHD started with the publication of Goulstonian
Lectures by the British pediatrician, Sir Frederic Still. In these lectures, he
described symptoms of abnormal defect of moral control in children with
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mental retardation, which are commonly seen today in patients diagnosed
with ADHD. Some of these symptoms are passionateness, spitefulness,
jealousy, lawlessness, dishonesty, and destructiveness. The common thread
that ties these symptoms together is immediate self-gratification with
disregard for the good of others or one’s self.5 Self-gratification is a major
problem in patients with ADHD. It is closely tied to impulsivity, one of the
identifying symptoms of ADHD.
It wasn’t until 1932 that Franz Kramer and Hans Pollow reported
hyperkinetic disorder as a single disorder, instead of part of residual effects
of encephalitis. The two German physicians described motor symptoms that
coincide with modern day’s diagnostic criteria for ADHD. Essentially, their
report established a concept of hyperkinetic disorder that closely resembles
the modern concept of ADHD. The earliest stimulant used to treat
hyperactivity symptoms in children was benzedrine. The drug resulted in
significant behavior improvement and school performance in some of the
children it was tested on.6,7
Epidemiology
The 2007 National Survey of Children's Health (NSCH) published a report on
the epidemiology of ADHD. The report showed an almost 22% increase in
the number of children between 4-17 years of age who were reported by
their parents to exhibit symptoms of attention-deficit/hyperactivity disorder.
This result reinforced to the medical community what it knows already, that
parents and guardians play a vital role in early detection and subsequent
treatment.8 As of 2007, there are approximately 5.4 million American
children with ADHD. Children with ADHD exhibit symptoms of either
inattention and hyperactivity or impulsivity, or both. These symptoms
interfere with not just the children’s social and academic functions at home,
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at school, or with friends but also strain the family ties with those who have
to bear this burden.
Pediatric ADHD is a public health concern. It affects all aspects of family life,
which include expectations of what a typical day is going to be like through
to expectations of school achievements, and relationships with family and
friends. Indeed, there are very difficult challenges for families to face day to
day, and with every passing year.8 The results of the NSCH survey were not
surprising; more pediatric health professionals have to deal with ADHD
patients. By 2007, 2.7 million children diagnosed with ADHD were reported
to be taking medication.8
The results of the NSCH also highlighted some significant demographic
prevalence previously reported by population-based studies. Specifically, the
study revealed a 2:1 or even a 3:1 ratio of boys to girls in terms of
diagnostic prevalence. These rates were also found to increase with age,
which was an expected finding since many parents were told of their
children’s ADHD diagnosis.8 The report also found a significantly greater
increase of prevalence among 15-17 year old adolescents as compared with
younger children. This suggested that clinicians may be encountering late
diagnosis, and subsequently delayed treatment interventions and
management of ADHD than in past years.8 This finding may also be
attributed to a decrease in stigma related to ADHD in the recent years and
greater acceptance of available treatment strategies.
The NSCH report also brought to light the prevalence of pediatric ADHD
among ethnic groups. In the past, the rates of ADHD in the United States
have been lower among the Latino groups compared with non-Latino
groups.8 Another significant finding in the report pointed to greater rates of
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diagnosis brought on by parent reporting among multiracial children. There
are, however, no clear indications of the driving factors behind this.8 Also, it
is worth noting that genes play a role in the development of ADHD. In any
population there will be a core group of children who, by virtue of their
genetic make up, are more prone to develop ADHD regardless of the
environmental factors surrounding them.8
There is also a dramatic difference among U.S. state regions in the
prevalence of pediatric ADHD reported by parents. It has been reported that
the state with the largest prevalence of parent-reported ADHD was North
Carolina at 15.6%, representing nearly a 63% increase in ADHD prevalence
from 2003 to 2007.8 These differences are not clearly understood but some
researchers attribute them to demographic factors. The risk for ADHD
increases as income decreases, this is usually brought on by lesserresourced educational services, fewer support systems for parents and
guardians, and greater behavioral problems combined with lesser
accessibility of adequate resources and services.8 This wide disparity may
also be due to some U.S. states having greater and more aggressive health
screening and diagnostic practices and protocols in place. States with
improved health prevention and screening practices have been reported to
have higher reports of prevalence rates. The more rigorous the screening
process, the greater the likelihood of finding more symptoms related to a
diagnosis of ADHD.8
Greater awareness and better screening efforts may be the two greatest
determining factors to diagnose ADHD. There has been quite a lot of
education in most recent years. The American Academy of Pediatrics, for
example, has really focused on quality improvement for pediatric practices,
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and the efforts around autism and ADHD have been focused on trying to
standardize the approach to screen and diagnose behavioral issues.8
Pathophysiology Of ADHD
Various neuropsychological studies propose a causal link between the frontal
cortex and the networks connecting them to the basal ganglia in the
pathophysiology of pediatric ADHD. These links are very important for many
decision-making functions and, therefore, also for attention and inhibition.
The frontal lobe is responsible for the majority of decision-making functions.
Magnetic Resonance Imaging (MRI) results of the right medial prefrontal
cortex in ADHD patients show clearly its diminished activation during
activities needing both inhibition of a planned motor response and timing it
to a sensory stimulation. The same images also exhibit weak right inferior
prefrontal cortical and left caudal stimulation during activities involving
timing of a motor response to a sensory stimulus.10
A study by Spinelli et al. explored the neural correlates that regulate
response inhibition deficits in pediatric ADHD. It studied closely the many
functional MRI brain activation activities of children between the ages of 8
and 13 years who were both diagnosed and not diagnosed with ADHD on a
go/no-go task. It found lapses in attention that preceded the response
inhibition errors in the children with no ADHD. It also found involvement of
brain circuitry in the response selection and control activation occurring
before these errors in children diagnosed with ADHD.3
Catecholamines are the primary neurotransmitters that mediate frontal-lobe
function. Neurotransmission mediated by the dopaminergic and
noradrenergic receptors seem to be the primary medication targets when
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treating ADHD. A decade-long study by the National Institute of Mental
Health (NIMH) found that the brains of children and teens with ADHD are 34% smaller in size compared to children without the disorder. The finding
also pointed out that pharmacologic treatment played no role in this case.
The greater the symptom severity of pediatric ADHD were, as rated by
parents and clinicians, the smaller were their frontal lobes, temporal gray
matter, caudate nucleus, and cerebellum.
The results from 357 healthy subjects, acquired from the NIH MRI Study of
Normal Brain Development, also found that a thinner cortex due to slow
cortical thinning process was linked to greater attention problem scores.
These results suggested an association between attention and cortical
maturation. Aside from the significant role of neurotransmission, pathways,
and frontal lobe involvement, certain imaging studies have started exploring
the involvement of 5-hydroxytryptamine or serotonin in the pathology of
ADHD.10-11 Even though the brain’s motor areas are innervated by serotonin
projections, there has been no link between this neurotransmitter and ADHD
motor pathology to date. However, there have been associations made to
attention-related activation. A change in 5-HT activity seems to be partly to
blame for the difficulties with perceptual sensitivity and appropriate
recognition of the relative significance of stimulation. Additionally, prior twin
studies has suggested that traits of hyperactivity and inattentiveness were
strongly inheritable.12
Types Of ADHD
There are three different types of pediatric attention deficit hyperactivity
disorders. The disorder is also sometimes called hyperkinetic disorder in
other literature, most notably the World Health Organization (WHO)
Integrated Classification of Diseases (ICD). The classification is based on
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varying degrees of maladaptive patterns of impulsivity, inattention and
hyperactivity. The names and other descriptors applied to the disorder are
based on how children afflicted by it behave under the observation of
specialists. Impulsivity refers to the child’s tendency to carry on actions that
are thoughtless and premature, usually without forethought. Hyperactivity
denotes the excessive movement that is usually restless and shifting in
nature. Inattention is described as being disorganized in thought that
prevents efforts to sustain attention or focus in a given thought or concept.13
It is more commonly diagnosed in children and adolescents, with boys
accounting for a larger percentage of the affected population.
The epidemiology of pediatric ADHD in the U.S. has previously been
discussed. However, it is worth noting that its prevalence worldwide is much
more varied because of the different diagnostic and classification criteria that
differ between countries. Unfortunately, there are some countries wherein
diagnosis is not even made because of the lack of proper guidelines and
protocols for it. In the United Kingdom, for example, because of the lack of
proper guidelines, only 0.9-3.6% (depending on age) of the population was
reportedly diagnosed with pediatric ADHD, including any ADHD types.14 On
the other hand, in the U.S., because of the advent of more generalized and
broader clinical guidelines in place, a greater number of the pediatric
population is screened, showing 10% of the pediatric population being
affected. To date, there are approximately 7.5% of children worldwide
diagnosed with ADHD, with male children accounting for a greater share of
this percentage. Specifically, the male children outnumber the female
children.15 However, the worldwide data on ADHD tends to be controversial
because of the possibility of males being overly diagnosed with the problem
than females due to their behaviors during play and other forms of social
interactions.
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Attention deficit hyperactivity disorder is referred to as a form of
hyperkinetic disorder in the WHO’s International Statistical Classification of
Diseases and Related Health Problems, Revision 10 (ICD-10),13 and in the
American Psychological Association (APA) Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) scheme of diagnoses. The
diagnostic criteria set forth by these organizations do not focus on the
theories surrounding the etiology of the problem, but rather on the
behavioral symptoms that children exhibit at school, at home, and at other
social settings. Because of the wide differences in the symptoms seen in
patients with the disorder, ADHD is subdivided into three types. These types
are based on the most predominant symptom and behavioral pattern seen in
the patient: 1) predominantly inattentive, 2) predominantly hyperactive and
impulsive, and 3) combination of both. Each of these types is discussed in
detail in the following sections.
A great number of parents are more likely to report having observed the
signs and symptoms of ADHD in their children when they are very young.
Most ADHD cases tend to be diagnosed during the preschool years. However,
this is not always the case. Some cases of ADHD are diagnosed only during
their school years when the children begin interactions with other children,
and their behaviors and attitudes can then be compared to them.
During infancy years, children with ADHD are usually characterized as being
fussy and temperamental. They are also more likely to have sleep problems.
Toddlers usually exhibit an observable on the go attitude, ready to bolt or
run anytime. They also are more likely to attempt multitasking, putting their
hands into doing several things at the same time. One of the most common
problems seen in this age is when they show a tendency for breaking toys
and setting out to dismantle other things around the house. Parents usually
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report exhaustion because of having to stop them from running around the
house during the day or trying to stop them from jumping on beds and
couches. Parental desperation also sets in when they do not listen to
commands or pay attention when the parent talks to them.16
Once these children enter school, ADHD can cause a lot of problems for
them, as well as for their parents and teachers. Teachers often find it
difficult to instruct children with ADHD symptoms of impulsivity and
inattentiveness, which often interfere with their learning progress and
academic performance. The habit of fidgeting or moving from one seat to
another causes disruption in classroom activity as well as frequent tapping
on tables or making unnecessary sounds using pencils. Because these
children are easily distracted, environmental noises like rustling of leaves or
flapping of birds’ wings steals away their focus from lessons at hand, and
subsequently causes poor academic performance. This manifests in mistakes
committed because of haste, forgetfulness when it comes to home works
and assigned tasks, and an inability to follow directions.16,18
Outside academic settings, children with ADHD also face difficulties in
forming social relationships and networks. They are often labeled as being
bossy or too aggressive, or simply being too difficult to be with by teachers
and fellow peers. As a result, they are avoided by classmates and not invited
or deliberately not included in games and other social activities outside the
classroom. This reaction is understandable since children with ADHD have a
hard time cooperating with other children during play, and are more often
unwilling to wait for their turn to play. Additionally, they also tend to be
accused of having the habit of constantly interrupting people. Rejection often
occurs, which creates an environment wherein they feel unwelcomed,
uninvited, and isolated. Such an environment promotes the undesired
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symptoms of impulsivity and destructive behaviors, which is very dangerous
as adolescence approaches if left undiagnosed.
During adolescence, the accumulated feelings of isolation and deprived
friendships foster other negative outcomes such as refusal to go to school or
cutting classes. Adolescents with ADHD are given harsher punishments
compared to normal children. The mode of disciplinary actions taken against
them often includes detention, suspension of varying lengths of time and, in
worse cases, expulsion from school.16-21
A study by Wender (2000) found pediatric patients with ADHD manifested
symptoms well into their adult years, as opposed to the common belief that
children with the problem “outgrow” their behavior.22 It has also been found
that an approximately 30-50% of children who were diagnosed with ADHD
continued to manifest symptoms into adulthood despite being treated during
their childhood years. Adults with ADHD are also more likely to manifest
behaviors such as restlessness, impaired social interactions, nervousness,
episodes of depression, and very low threshold for stress and frustration. In
addition to these symptoms, they are also found to have higher risks of
developing psychiatric and other personality disorders, resort to drug and
alcohol use, face numerous battles with the law, and are generally more
impulsive than their peers.3,22
Predominantly Inattentive Type of ADHD
Predominantly inattentive type of ADHD is most commonly referred to as
Attention Deficit Hyperactivity Disorder-Predominantly Inattentive (ADHD-PI).
This type was first introduced in the mid-1990s with the introduction of the
DSM-IV Category of Mental Illnesses.4 Among the three types, this is the
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more uncommon type and also harder to diagnose. ADHD-PI is usually
characterized by plain fatigue, which may be a sign of laziness or both.
The classic manifestations of this type of ADHD are inattentiveness or lack of
attention, disorganized tasks and thoughts, forgetfulness, and obvious
attitude to procrastinate regardless of the importance of their
accomplishment. Although these symptoms are also found in the other two
types, it should be noted that in children with predominantly inattentive
ADHD, these symptoms are usually accompanied with episodes of lethargy
or excessive fatigue, and decreased or almost no symptom of the usual
hyperactivity or impulsivity seen in other types.17
The two main characteristics of this subtype are 1) deficient or diminished
concentration when faced with tasks and chores, and 2) presence of severe
fatigue when asked to focus attention on activities related to learning. These
two characteristics are especially evident in children who suddenly express
fear or revulsion when activities requiring greater focus and attention are
given to them, or when they are asked to be part of a group performing
such tasks.17
These children tend to show abhorrence and avoidance of any planned work,
especially when it is structured and requires long hours of focus and
attention to detail. Such responses occur even when a concept that is
related to the task is not new to them, or could be something that they even
excel at. On the other hand, when these children are assigned a task or an
activity they find to be interesting, they are noted to spend more time than
they used to in other tasks; although there is no study yet that proves these
children have higher success rates of finishing such tasks even in the
presence of increased interest.
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Children who suffer from inattentive type of ADHD usually face various
academic difficulties such as failure in several subjects, being labeled as
simply lazy or disinterested in learning, branded as a problematic student, or
given other negative feedbacks such as being incompetent and irresponsible.
The worst possible scenario that can happen is when these children
completely withdraw from school either by their own volition or through
administrative expulsion. The withdrawal from school and all its social and
academic opportunities only serve to delay such children’s social, intellectual,
and emotional development even more.
As children with ADHD-PI grow older, they may become aware of the
apparent differences between their own behavior and attitudes compared to
other children their age. They are most likely to notice that they behave
differently than their peers and that their actions and behaviors are not
generally acceptable most of the time to the people they interact with.
Because of this, they are also more likely to accept negative reactions and
perceptions of themselves by other people. When this happens, they tend to
create within themselves a negative sense of self and project it outside to
their environment and the people surrounding them. Because this behavior
sometimes gives them an illusion of protecting themselves from societal
stigma, they have the tendency to reinforce this behavior well into their
adolescence and adulthood if left untreated.
The false sense of protection children with ADHD tend to develop from
projecting negative perceptions of themselves onto others tends to fuel their
destructive behavior. Children who exhibit this type of behavior usually
experience problems in initiating and maintaining interpersonal relationships,
which can affect not only how they relate to people at school but also to the
whole society in general. This becomes an unending vicious cycle where the
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problems confound themselves and lead to subsequent ineffective coping
mechanisms. Results of various ineffective coping mechanisms may be
evident later on in life in terms of substance use (alcohol, narcotics or both),
development of self-destructive behaviors such as sexual promiscuities, and
other mental health disorders.17,18
If treatment of the inattentive type of ADHD is performed as soon as
diagnosis is made, children affected by ADHD-PI would be able to adapt
behaviors to enable them to adjust cognitively and to develop coping
mechanisms necessary to decrease the effects of inattentiveness while in
and out of school. Despite this, it is worth noting that the main problems
related to the disorder do not disappear entirely. They are simply controlled
and managed at a level where children with ADHD-PI are able to carry out
normal activities without or with minimal disruptive symptoms.
Also, when compared to the combined type of ADHD, children diagnosed
with the inattentive type have been found to perform with less favorable
outcomes. A prior meta-analysis of 37 studies conducted by Lane (2004)19 to
assess and compare the cognitive functions of different types of ADHD found
that children with the inattentive type have slower intellectual processes,
shorter attention spans, lower intelligence quotient, poorer memory, and
exhibit lesser fluency compared to those with the combined type of ADHD.
Predominantly Hyperactive/Impulsive Type of ADHD
The second type of ADHD is the predominantly hyperactive-impulsive type.
It is also the second most common type. The predominantly hyperactiveimpulsive type of ADHD has become one of the most well known
manifestations of ADHD in children, and even in some adults. This type is
usually diagnosed in childhood before the age of seven. Because the
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symptoms of the disorder are very similar to the other usual childhood
behaviors, many parents fail to recognize them and therefore delay their
children’s diagnosis. Some children were found to have already manifested
the disorder some 6 months or more before the diagnosis was made.17,18
One thing that most parents fail to recognize is that while some of the
symptoms of ADHD hyperactive-impulsive type are much more similar and
typical with other childhood behaviors, children with this type of ADHD
manifest them in a relatively extreme degree and oftentimes experience
great difficulty to control behavior. Children with this type of ADHD often
experience problems in social settings. Like other types of ADHD, they will
have great difficulty interacting with other people and creating meaningful
and lasting relationships with them. Friendship becomes a difficult goal for
them to attain due to the extreme behaviors they manifest, causing peers to
keep them out of their social circle or rejecting them outright.
Difficulty interacting with peers and peer rejection leads to the development
of depression during early childhood years, and the possibility of turning the
frustration and disappointment outward to other people in the form of
delinquency, substance use (alcohol and narcotics) and even self-destructive
behaviors. Self-destructive behaviors in early childhood years can be
manifested through refusal to eat even when hungry, engaging in selfmutilating behaviors, and performing actions they know would result in
punishment and other disciplinary actions.
One of the barriers these children face when trying to form social
relationships with other children is their tendency to be easily angered and
provoked.20-23 They easily show displays of ill temper. Apart from these most
common problems, children with predominantly hyperactive-impulsive ADHD
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also present with penmanship that is described as either poor or barely
legible, delays in speech and language development, and also delays in
motor skills development. Poor handwriting can be attributed to
developmental problems of their motor skills, which manifest usually as
hyperactivity. Language and speech problems can include episodes of
stuttering, stammering or both. Often, motor skill problem can be seen when
children with predominantly hyperactive type of ADHD usually bump into
things, or suffer from accidents due to poorly coordinated movements.
Symptoms presented by children with ADHD can be grouped as either
predominantly hyperactive or impulsive in nature. Those who manifest
hyperactive behaviors are usually seen exhibiting a sense of restlessness,
being fidgety or unable to stay still, and frequently fiddle with things when
not on the move. When these children are asked to take a seat, they usually
start squirming within the first 10 minutes and progress for the worst the
longer they remain seated. This is, in fact, one of the most commonly
reported troubles these children have at school. Additionally, these children
can also endlessly move about unless exhaustion causes them to stop or
slow down. They are generally unhappy with quiet and calm activities such
as doing schoolwork and watching television. Because of the risk of
exhaustion, children with predominantly impulsive type of ADHD are not
usually encouraged to participate in active sports since the activities
involved only seem to heighten their symptoms of hyperactivity and
restlessness.
Impulsive behaviors manifested by children with predominantly hyperactiveimpulsive type of ADHD are the reason behind failed attempts at building
and maintaining social relationships. The impulsiveness exhibited by these
children can be described as either minor or major. Minor symptoms include
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interrupting others during conversations and intrusive behaviors that may be
labeled by other people as being nosy.
Intrusive behaviors are also seen when children with this type of ADHD
suddenly insert themselves uninvited into activities of other children and
later on take over the entire game. Major symptoms of impulsiveness can be
manifested through unstable relationships or frequent fights with friends.
Waiting and being under pressure are other situations wherein these children
may find it hard to control themselves. Mood swings are also common
among them, as well as reckless thoughts and actions. These children also
tend to have shorter tempers, which can be highlighted by explosive
emotional outbursts or tantrums. These outbursts often happen at
inopportune times and places, putting the parents and other caregivers in
embarrassing positions especially when in the company of other people or in
a public place.
Clinicians, parents, caregivers, and teachers are prudent to remember that
the symptoms presented by children with hyperactive-impulsive type of
ADHD vary in severity and are prone to change over time. However, despite
the challenging symptoms that are associated with this particular type of
ADHD, these children also show longer attention spans, especially when they
are given tasks that they find particularly interesting.17,18
Combined Type of ADHD
The most common of the three types of pediatric ADHD is the combined type,
i.e., the combination of inattentive and impulsive symptoms. It is usually
diagnosed when children manifest both inattentiveness and hyperactivityimpulsiveness. Apart from being one of the most common, this particular
type of ADHD is also considered to be one of the worst types because of the
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greater behavioral symptoms children exhibit. For diagnosis of the combined
type of ADHD to be made, children would need to positively exhibit at least 6
symptoms of both types of ADHD (discussed later in this course). Due to the
number and mix of symptoms manifested, children with the combined type
usually suffer far more problems and associated symptoms than those who
only suffer from either one. Children with this diagnosis often have poor
prognosis and require long-term therapies.17
Since this type of ADHD is a combination of inattentiveness and
hyperactivity-impulsivity, children can develop severe restlessness that
carries on well into their adulthood, lack of focus and spur of the moment
tendencies, which impair important decision-making skills. Problems with
schoolwork and academic performance as well as interpersonal relationships
are also frequently seen with these children.17 The inattention or loss of
focus is usually seen intermittently during schoolwork, especially when tasks
requiring focus is handed to these children. They are also more likely to be
inattentive even when they are part of group-related activities. The
impulsiveness that these children exhibit reflects in the manner they choose
things and tasks, which often lead to frustration when they do not get their
way. Academic performance suffers because of their inability to finish tasks
and pay attention to classroom activity. It is not uncommon for these
children to fail their subjects and be recommended to repeat them the
following school term.
Symptoms related to inattentiveness manifest in individuals diagnosed with
the combined type as easy distractibility, inattention to details, forgetfulness,
and habits of starting on projects without actually finishing them. Moreover,
children with this type of ADHD are also more likely to express boredom
when it comes to doing schoolwork and other tasks, find it difficult to
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organize thoughts and activities, and follow and obey instructions given to
them. Wandering around the classroom or in hallways is a common
complaint from teachers handling these children, especially when their
diagnosis is not disclosed.
Hyperactivity symptoms that are evident in the combined type includes
excessive talkativeness, squirming in seats and being fidgety, constantly
moving around and having extreme trouble and discomfort at sitting still.
With the symptom of talkativeness, the child usually rambles on a lot of
things, which often do not make complete sense and in worst cases, say
inappropriate words and thoughts for their age. Also, impulsivity may be
highlighted in these children when they lose patience when waiting for their
turn or on other things, they exhibit the habit of randomly saying anything
without regard for others’ feelings, act out their frustrations and feelings,
and constantly interrupt people during speech or activity. Anger
management is also an issue with these children, causing them to lose favor
with both friends and their teachers.17
Due to the great difficulty of these children in handling interpersonal
relationships and their inept social skills, they have a very difficult time
forming and maintaining relationships among their peers. Often, they are
socially isolated because of the rejection they face from their peers and
other people around them. The continued isolation and lack of social support
leads to the development of depression, a marked reduction in their selfesteem, failure in school work and academics, and resorting to violent and
destructive behaviors.17
Apart from the aforementioned symptoms and problems encountered by
children with the combined type ADHD, they are also more likely to face
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higher risk of emotional and mental disorders in later life. One of the most
common related disorders that these children may face is the development
of conduct and oppositional defiant disorders.12,17 Conduct disorders first
become apparent when children with combined type ADHD do things without
any regard for others and their well being, and habitually violate rules and
the rights of other children. These children are frequently involved in
mindlessly taking other children’s belongings and acting out on their
frustrations. These children are also more likely to pick on smaller or
younger kids and bully them. These disruptive disorders are often met with
disciplinary actions and parents being called to the school to discuss their
children’s behavior. If the disorder remains untreated, it can very well
become the precursor of an anti-social personality disorder later on in
life.26,28
Oppositional defiant disorder, on the other hand, is seen when children
engage themselves in ongoing destructive patterns that is defined by
persistence of disobedience and triggered by anger and hostility. Also, these
children exude defiance against authoritative figures that are not typical of
children their age. It may be accompanied by extreme anger and
stubbornness that is also not exhibited by most children of the same age.
Aside from the risk of the developing conduct and oppositional defiant
disorders, children with the combined type of ADHD have higher risk of
developing bipolar disorder and other psychiatric problems. These other
psychiatric problems are often the result of their social isolation, neglect,
and stigma they’ve experienced early in life.
Presentation Of ADHD
As mentioned previously, Sir Alexander Crichton described attention deficit
hyperactivity disorder in the literature as early as 1798. In this work, he
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accepted the condition only as manifesting hyperactivity and therefore a part
of the normal human condition.2 However, it was George Still who, in 1902,
clearly described ADHD. The description he made then has since evolved into
what we know today as ADHD.5 In the prior section, it was mentioned that
ADHD has presenting symptoms that vary based on the specific type
affecting the individual. A child may manifest predominantly inattentive,
predominantly hyperactive/impulsive subtype, or the combined type of
ADHD. In the following sections, the patient history and physical
presentation of ADHD as well as how to best ascertain the ADHD category a
child falls into will be discussed.
Patient History
Conducting a thorough patient interview and gathering clinical data on a
child’s functional abilities is part of the initial intake and patient history. The
DSM-5 criteria are also used by many child psychologists in assessing the
presenting symptoms and play a significant role in the eventual diagnosis.30
It is also during this data gathering that significant information about
comorbid or preceding conditions are to be included. When taking the
patient history, clinicians need to pay attention to detail and exercise good
observation skills.
History of Present Illness
When recording the history of present illness, the clinician should use the set
of criteria outline by the American Psychiatric Association's Diagnostic and
Statistical Manual, Fifth Edition. In general, a confirmed diagnosis of ADHD is
made when the diagnostic criteria are met, which are reviewed below.12,30
To be diagnosed with predominantly inattentive type of ADHD, the patient
must present with six or more symptoms of inattention for children up to
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age 16, or five or more for adolescents 17 and older and adults. Symptoms
of inattention must have been present for at least 6 months, and they are
inappropriate for the patient’s developmental level, such as:

Often fails to give close attention to details or makes careless mistakes
in schoolwork, at work, or with other activities.

Often has trouble holding attention on tasks or play activities.

Often does not seem to listen when spoken to directly.

Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (i.e., loses focus, sidetracked).

Often has trouble organizing tasks and activities.

Often avoids, dislikes, or is reluctant to do tasks that require mental
effort over a long period of time (such as schoolwork or homework).

Often loses things necessary for tasks and activities (i.e., school
materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses,
mobile telephones).

Is often easily distracted

Is often forgetful in daily activities.
To be diagnosed with the impulsivity-hyperactivity type of ADHD, the patient
must present at least six or more symptoms of hyperactivity-impulsivity for
children up to age 16, or five or more for adolescents 17 and older and
adults. Symptoms of hyperactivity-impulsivity must have been present for at
least 6 months to an extent that is disruptive and inappropriate for the
person’s developmental level:

Often fidgets with or taps hands or feet, or squirms in seat.

Often leaves seat in situations when remaining seated is expected.

Often runs about or climbs in situations where it is not appropriate
(adolescents or adults may be limited to feeling restless).
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
Often unable to play or take part in leisure activities quietly.

Is often on the go acting as if driven by a motor.

Often talks excessively.

Often blurts out an answer before a question has been completed.

Often has trouble waiting his/her turn.

Often interrupts or intrudes on others (i.e., butts into conversations or
games).
Additionally, the following criteria must also be met:

Many of the major inattentive or hyperactive-impulsive symptoms are
already present before the child reached the age of seven.

The symptoms are also present in more than one setting such as both
the home and school. In adults, the symptoms can be seen at work.

There is also the presence of distress or impairment in a social or
academic context.

The present behavior is not suggestive of other mental health
disorders such as mood disorder, anxiety disorder, dissociative
disorder, or a personality disorder).
Past Medical History
The past medical history is important in providing clues as to the possible
triggers that precipitated the behavioral symptoms, other than ADHD itself.
The presence of other conditions that might have triggered the condition is
explored as well as the use of medications and other substances that can
cause side effects or interacted with ADHD medications.9,10
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Conditions that may exist prior to or after the diagnosis of ADHD in patients
include psychiatric problems, which affect approximately 30-50% of all
patients with ADHD. These problems are normally:
•
Disorders that are primarily considered as rooted in anxiety such as OCD
(obsessive compulsive disorder), panic disorder, GAD (generalized
anxiety disorder) and social phobia
•
Mood swings which are characteristic of bipolar disorder
•
Receptive or expressive communication disorders which can sometimes
occur simultaneously
•
Oppositional defiant disorders, or conduct disorders, specifically in
children with combined type of ADHD
•
Existence of depression in varying degrees
•
In rare cases, dissociative disorders
•
Eating disorders such as anorexia
•
Bed-wetting
•
Presence of learning difficulties other than lack of focus or attention
•
Sleep disturbances
•
Disorders that are psychotic in nature
•
Tic disorders such as Tourette syndrome
Coexistence of physiologic problems is not usually associated with the
presence of ADHD, but when these are present, they are usually an effect of
hyperactivity of these children. However, the coexistence of some diseases is
vigilantly assessed since some of the medications prescribed for these
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conditions might interact significantly with ADHD medications. These are
identified as:9,10
•
Stimulant drugs used for patients with coronary artery diseases may
interact with other stimulants given for inattention to increase
attention span.
•
Medications used for pediatric (and adult) patients with narrow-angle
glaucoma such as imipramine and desipramine may interact with
ADHD medications.
•
Medications used to treat patients with heart diseases may cause
significant drug-drug interactions when given concomitantly with
ADHD medications.
•
Cardiac glycosides such as digoxin causes negative chronotropic effect,
which has been shown to cause unwanted effects in patients on ADHD
medication therapy.
Pregnancy is also assessed in a child’s mother since most anti-ADHD
medications may exert fatal effects on the fetus, and should be included in
the child’s medical history.
Interactions with other medications and food supplements are also assessed,
which include:
•
Anticonvulsant drugs such as phenytoin
•
Medications used to treat pediatric hypertension
•
Drugs with caffeine content
•
Ephedra and pseudo-ephedrine-containing medications
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•
Drugs used to treat depression such as monoamine oxidase inhibitors
(MAOIs)
Family History
The family history of the child should also be assessed. Specifically, the
general health and wellbeing of the child and the parents need to be
carefully assessed, most especially of the mother. The following areas need
to be assessed to determine any influence family history may have on the
development of ADHD:3

Age during or prior to pregnancy

General physical condition of the mother during pregnancy

Dietary intake

Intake of medications and other supplements

Use of alcohol and cigarette

Substance use problems, if any
Developmental History
Children of all ages are affected by ADHD, which can go on until adulthood.
ADHD affects children during the stages of growth and development in a
variety of ways, therefore it is considered to be a chronic lifetime disorder.3
However, it has also been a common consideration in research studies
conducted to treat the preschool years as a particular point of concern since
it is during this time that ADHD is usually diagnosed. Also, when children
with ADHD are diagnosed as early as this stage, there is a higher rate of
success to prevent the onset of any psychopathological conditions that can
follow.3
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There are a variety of templates that can be for the developmental history.
To better understand the developmental history of a child with ADHD, it is
best to study it according to the respective stages of growth and
development.
ADHD During the Preschool Age
The assessment and diagnosis of children with ADHD in the preschool stage
is usually achieved by means of rating scales and observations of the
behavioral pattern.3,9 A rating scale is to be used during the assessment of
these children and should include, but not be limited to the following
symptoms.31
•
Difficulty to maintain prolonged attention
•
An increased level of distractibility
•
The state of being on the go most of the time
•
Running around the house and climbing onto furniture excessively
•
Difficulty to follow instructions
•
Observed difficulty and discomfort in having to remain still
It is also during this developmental age that a higher rate of coexisting
conditions and complications can start to appear, with approximately a
majority of children developing disorders such as oppositional defiant
disorder, communication disorders and anxiety-related disorders. Because of
this outcome, it is important that ADHD cases diagnosed in the preschool
age be treated as soon as possible, otherwise these symptoms may
negatively impact the child’s development.25,31-33
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ADHD Among Children in the School-Age and Adolescence
In the school-age group ADHD cases are reported to be increasing, with
boys making up the greater part of the prevalence rate than girls. Apart
from the use of rating scales, which are more applicable during the
preschool age, the diagnosis of ADHD in this group also includes interviews
with people who are usually with the child (parents, teachers, other
relatives, etc.), as well as asking children above the age of 11 to self-report
symptoms. Apart from this, computerized diagnostic testing is carried out to
determine the child’s attention span and regulation. This includes inhibition
of stimuli, division of attention and flexibility of reaction. The child’s ability to
maintain attention is also assessed, with parameters such as vigilance in
focusing, endurance of attention over time and activity, and ability to stay
alert as the focus of the assessment.12,35,36
Since this stage is crucial to the child’s future development, there is high risk
for negative impact to the child if left untreated. There is the possibility of
functional impairment during adolescence. The data indicates that children
during school age and adolescence exhibit oppositional behaviors and some
cases with coexisting anxiety disorders. Since development is usually
impaired or delayed, children with ADHD at this stage might experience
learning problems and difficulty in keeping up with peers and academic
demands at school.17
Aggressive behavior is also very common in this stage, leaving children with
ADHD having to face difficulties in interpersonal relationships. It is also at
this stage that affected children experience decreased motivation to do or
achieve something. As the child grows older, so does the extent of emotional
problems that are oftentimes the consequences of being rejected by peers,
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the rejection and harsh treatment from teachers, and the nagging feeling of
being different from anyone else.17
ADHD in Adulthood
One of the primary things about ADHD that clinicians and parents need to
recognize is that often as children grow into adulthood their symptoms and
other associated problems not only persist, but are also magnified with more
than of half of the adult population with ADHD showing unremitting
behavioral problems. These problems occur regardless of the gender of the
individual. Moreover, the most common problems coexisting with ADHD as
the child grows to adulthood appears to include a substance use problem,
antisocial behaviors, borderline personality disorder, and the presence of
disorders involving mood. These have been found to exist due to a strong
relationship with the neurobiological processing mechanisms involved in
ADHD and these disorders.17,27
There is also evidence that suggests that an individual with ADHD can
experience problems with general emotional health and social wellbeing due
to the negative influence brought about by the aforementioned comorbidities
and other impairments that go along with them. Adults who have ADHD also
exhibit difficulty in carrying out their daily duties, which can very well lead to
the development of problems at home, at work and in social situations
where socially acceptable behaviors are expected.
Emotional problems throughout a person’s lifespan with ADHD tend to be
common because there is poor regulation of emotions, and this problem can
result in poor interactions with other people. The presence of negative social
interactions can also heighten the psychological impact of the problem in the
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individual, thereby increasing the risk of developing other comorbid
conditions that are psychiatric in nature. This risk and its associated severity,
however, are parallel with the characteristics of the patient and the
availability of necessary support and resources.
Physical Assessment
Physical assessment of the patient with ADHD can be performed in various
ways. It can be performed through thorough examination of the physical
attributes or with the help of diagnostic and other imaging studies. Since the
condition primarily affects the structure and function of the brain, one of the
most common diagnostic tests conducted is the use of imaging technology to
assess for structural and functional changes.
Studies on Brain Function
As mentioned in the previous sections, imaging studies have revealed that
children diagnosed with ADHD show a substantial reduction of the brain
volume, most specifically in the left side, with the prefrontal cortex being the
part that is most severely affected.11 There is also involvement of the
pathways that serve as connection between the striatum and the prefrontal
cortex. These images support the theory that a frontal lobe dysfunction is a
major pathologic cause in ADHD, being responsible for many of its
associated symptoms of inattention, impulsivity, and hyperactivity. On the
other hand, the cerebellar region and other regions of the brain may also be
involved since it has been found that there are indeed significant differences
in the functioning of brain systems in people with and without ADHD.10,11
Apart from imaging studies, tests involving neurotransmitters and their
normal functioning in patients with ADHD are also helpful. In the past, one
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of the emerging ideas concerning the role of neurotransmitters in the brain
function of patients with ADHD is the observed increased amount of
dopamine transporters. This is significant since this is the mechanism by
which hyperactivity is attributed in ADHD patients. However, it has been
proven by a research study that the elevation of dopamine transporter
numbers in the brain is an adaptive process that is a response to the
administration of stimulant medications.10-12
Studies also suggest that individuals who are diagnosed with ADHD may
have a lower threshold of arousal, which is attributed to the brain’s effort to
compensate for the greater stimulation it is subjected to, causing a
disruption in the attention span and the acting out of behaviors that are
hyperactive in nature. Generally speaking, the root cause of all these
abnormal processes is attributed to the apparent abnormalities in which the
dopamine system generates a response when stimulated. Apart from
abnormalities within the dopamine system, children with any type of ADHD
have also been found to exhibit abnormal levels of other neurotransmitters
such as serotonin, cholinesterase, adrenalin, and GABA. These
neurotransmitters and their pathways, as a result of ADHD, have been found
by researchers to be altered.34,35,37
Executive function is also affected in individuals diagnosed with ADHD, and
causes significant difficulty. The executive functions include mental
processes that are necessary to carry out and regulate daily tasks and to
control and perform the management of daily tasks. Impaired executive
function leads to problems with keeping track of time, organizing things, the
habit of procrastinating things excessively, problems with achieving and
maintaining concentration, speed in processing impulses and information,
regulation of emotions, the use of working memory and problems with an
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individual’s short term memory. This is the exact opposite in people who do
not have ADHD, where the short-term memory functions well enough.
The problem with executive functioning occurs in approximately half of
ADHD children, and increases as the brain undergoes a phase of maturation
and the demands placed upon it becomes more complex with increasing age.
This is one of the primary reasons why patients with ADHD do not often
manifest the full extent of problems in executive functioning until later on in
life.
Neuropsychological Assessment Findings and Executive Functioning
Neuropsychological tests and its value in the diagnosis of ADHD have been
gaining popularity in the last 30 years. A substantial amount of research
studies have also been undertaken in an effort to clarify the pathologic
profile of children diagnosed with ADHD. In addition, these tests are also
performed to determine the presence of executive function deficits in
children with ADHD.41 As mentioned previously, executive functions are
mental processes that allow children to carry out, control and manage daily
tasks. These processes are neurocognitive in nature and help children
achieve and maintain skills to solve problems and to achieve future goals.
Executive functions regulate the following:

Execution and inhibition of a response

Ability to carry on information self-updates

Working memory necessary to process such information

Task capacity and switching when necessary

Interferences in thought processes

Organization and planning of things

Perseverance to finish started tasks
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
Orientation of the visual-spatial dimension

Working memory for both spatial and verbal context
There are several theories linked to the relationship of executive functions
and the neuropsychological findings in children with ADHD. The Inhibitory
Control Deficit Theory presents the idea of neurological impairment patterns
characterized by general abnormalities in the development of inhibitory
control. The resulting deficits are usually related to memory problems
(specifically verbal in nature), attention and focus dysfunctions, incapacity to
sustain attention, and problems involving the working memory as it relates
to abstract thinking and problem-solving. This section highlights past and
present theories related to ADHD and neuropsychological development.40-43
The Delay Aversion Theory proposes a biological-based impairment in
children with ADHD, which causes them to exhibit intolerance to delays that
in turn affects their cognitive functioning and behavior in general. The ability
to tolerate delays is measured by a tool known as the Choice Delay Task.
Another theory involves the Cognitive-Energetic Model that proposes
neurocognitive problems are caused by the presence of abnormalities in the
information processing at the state and computational levels of the brain.42
State level functioning is responsible for controlling efforts essential to
complete tasks, as well as the capacity to be aroused or excited, and the
activation of the mind to perform such tasks. On the other hand,
computational functioning is responsible for the organization of motor
movements, the capacity to search and encode information in the mind, and
decision-making. This theory also suggests that an imbalance and overlap in
functioning causes the problems associated with ADHD to arise and persist.
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The Theory of Sluggish Cognitive Tempo is rooted in the premise that there
is a difference in the manifestation of inattention in patients, depending on
the specific type of ADHD. The most common differences between the
different types are the time for information retrieval and processing, levels
of alertness, and the level of difficulty in making sense of orientation and
memory. Another paradigm called the Multiple Pathway Model emphasizes
and examines parallels that occur between the neuropsychological deficits
present as core symptoms of ADHD and the domains of regular
temperament based on the propositions made by other neuropsychological
models.
Other Physical Assessment Findings
Apart from the changes that children with ADHD exhibit in imaging studies
done on the brain as well as the tests on neurotransmitter levels and their
pathways, there are also other physical assessment findings that are
commonly seen among these patients. Other physical findings in ADHD
children are discussed here.12,50-52,54
Among these findings is the presence of sensory deficits. Sensory deficits in
these children may appear either as auditory problems or visual impairment
and are often the reason why children are often disorganized in their
thoughts and lack attention or focus on objects. The sensory deficits hinder
the ability to interpret stimuli correctly and use it to carry out meaningful
tasks and behavior. These deficits however should be assessed thoroughly
as they may be interpreted as core symptoms and not associated physical
disorders related to ADHD.
A comprehensive neurologic examination needs to be performed in children
with ADHD to rule out the possibility of neurodegenerative disorders such as
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neuronal ceroid lipofuscinosis and adrenal leukodystrophy. Also, symptoms
that may be related to these neurodegenerative disorders such as regression
or a plateau that occurs during development, hyperactivity, easy
distractibility and behaviors that are off-kilter should be observed and noted.
General physical examination must also be performed along with vital
neurologic examination.
The physical examination procedures should include assessment of the
abdomen of the child to check for the presence of organ enlargement
(organomegaly). The clinician must also consider performing a funduscopic
assessment especially if a neurodegenerative disorder is strongly suspected.
Lead toxicity and its resulting morbidities such as mental retardation and
hypothyroidism (most specifically cretinism) should also be ruled out.
Motor movements and their associated strength and reflexes of the tendons
and joints must also be thoroughly assessed since these are usually
misleading in the diagnosis of ADHD, especially in children who present with
school problems. Also, gait and balance should be assessed since both are
usually affected in children with ADHD. Abnormalities, although they appear
subtly, such as poor coordination of rapid and sequential movements are
present in most children. The most common manifestation of the problem
with coordination and rapid-sequential movements is seen when they are
asked to perform tasks such as tapping the fingers and toes and patting the
hands. These are to be done successively, one after the other to see their
capacity to carry them out successfully. If they are unable to do all these in
an assessment, it may be an indication of poor inhibitory control of motor
movements; a very strong reason why these children experience great
difficulty in staying still and finishing tasks. These difficulties in gait, balance
and coordination are especially very apparent in school-age children.
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Other findings may reveal that children with ADHD are also dyslexic and
present with tongue wiggling movements, and these children tend to
perform poorly and awkwardly when asked to do diagnostic procedures,
such as the finger-to-thumb-touch exercise.
The clinician must also pay close attention and focus on certain dysmorphic
features that may be present in children with ADHD. These might indicate a
deeper problem, which may be genetic in nature. Examples of these genetic
problems may include, but are not limited to:

Fragile X Syndrome (higher rates are prevalent in female patients than
in males)

Klinefelter

Turner’s syndrome
During physical evaluation the skin should be inspected properly to assess
for the presence of lesions, which is indicative of neurocutaneous disorders
(i.e., neurofibromatosis type I and tuberous sclerosis). These are mostly
present in children who exhibit learning difficulties associated with ADHD.
The most important thing to remember when performing an assessment of
the child’s history and physical evaluation is to remain objective about the
symptoms and their severity levels. Knowledge of neurocognitive behaviors
and how it affects the manner in which children with ADHD behave are also
vital to determine their severity and how their interplay results in the
behavior, cognitive capacity, impulse control, and the overall appearance
and demeanor of the affected children.
Diagnosis Of ADHD
The diagnostic criteria set forth by the American Psychiatric Association’s
Diagnostic and Statistical Manual-Fourth Edition had been briefly outlined in
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the prior section. The National Institute of Health and Care Excellence
(NICE) guidelines for diagnosing ADHD in children will be now be discussed.
Both guidelines are similar and are used as a standard by many mental
health clinicians.
The diagnosis of ADHD is made by breaking down the symptoms in two
classes based on presenting symptoms: inattentive and hyperactiveimpulsive. According to the National Institute of Health and Care Excellence
(NICE) guidelines, a diagnosis of ADHD is made when at least 6 out of 9
symptoms outlined below are present. This is also referred to as a combined
type of diagnosis.

Symptoms are chronic in nature, i.e., present for at least 6 months.

Maladaptive symptoms cause functional impairment functionally in
more than one area of life.

Symptoms are inconsistent with the level of development and not
attributed to other forms of mental disorders.
The diagnostic criteria for diagnosing ADHD has become so comprehensive
that an increasing number of children especially females and adolescents are
being diagnosed with the disorder and treated with stimulant medication for
longer periods of time. Getting the diagnosis correct through various tests
will also highlight the short-term symptomatic and academic improvement of
the affected children.9,12,16
Key Assessment Criteria
While diagnosis is primarily focused on the assessment of the symptoms of
ADHD manifested in the patient, health clinicians must take care not to
overlook the inputs of parents, caregivers, and teachers. Additionally, they
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must also consider the role and effects of stress on the patient. Essentially,
the key assessment criteria are listed below as:

Detection of core problem areas such as inattention, hyperactivity and
impulsivity

Comparison between these characteristics in the suspected patient and
other normal children of same age group

The onset and duration of symptoms

Difficulties and challenges at home, school and other social settings

Negative effects of these characteristics on the general development
and psychosocial adjustment

Presence of certain learning disabilities and other cognitive and mental
health disorders

Presence of other cognitive behavioral problems or mental disorders
coexisting with the symptoms of ADHD
The most common and persistent symptoms forming the basis of diagnostic
criteria for ADHD are listed below.12,17

Inattention, which has been present for a period of at least 6 months
or over and is damaging for the normal development of the child.

Hyperactivity and impulsive behavior in children up to age of 16 years,
which has been present for a period of 6 months and is disruptive and
inappropriate for the normal development of the child.
Diagnostic Approaches
There are various approaches used by health clinicians when forming a
diagnosis of ADHD in children. It involves a complete assessment process,
which examines the characteristic features and the fulfillment of diagnostic
criteria mentioned previously. They include the severity of the problems,
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extent to which the problems are affecting the child’s life, characteristic
symptoms, probable cause or origin of the problem, and the presence of
other clinical problems including those that are physical, cognitive or mental.
The different diagnostic modules include a stepwise process, which includes
a clinical interview and an establishment of the rating scale for parents and
teachers. Other assessment criteria includes direct observation in
educational settings such as schools, play schools, and cognitive and
neuropsychological assessment of developmental and literacy skills. These
are secondary and may or may not be included in the diagnostic process.
It is also imperative to mention here that diagnosis, care and management
in the primary care setting are more important when compared with
psychiatric clinics. Pediatricians are in agreement that children with ADHD
known to have received their diagnosis and management from a primary
care facility face lesser comorbid psychiatric disorders and milder symptoms
associated with other mental disorders as compared with their counterparts
who received theirs at psychiatric clinics. It has also been studied that
children with ADHD are more likely to exhibit the prototypical symptoms of
the disorder; they have higher levels of comorbidities related to mood,
anxiety, and disruptive behavior and impairments in their cognitive,
interpersonal and academic functions.17,50,60 Generally speaking, those
children diagnosed in pediatric practices have fewer comorbid conditions and
dysfunctions when compared with their counterparts diagnosed in child
psychiatry clinics. In the U.S., mental health professionals use the DSM-5 to
help them in their diagnosis of children with ADHD symptoms. Many
European and other countries rely on the International Classification of
Diseases (ICD) to make their diagnosis.
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Pre-diagnostic Intervention and Referral
Prior to a formal diagnosis of ADHD, the school or primary care clinician may
refer children and adolescents with behavior problems suggestive of ADHD
for participation in parent-training and education programs. The diagnosis of
ADHD in children, adolescents, and adults usually occur in secondary care
settings.
According to the NICE guidelines, there are several points to remember
when identifying and referring suspected ADHD patients:17,112
•
Universal screening for ADHD should not be undertaken in nursery,
primary and secondary schools.
•
When a child or young person with disordered conduct and suspected
ADHD is referred to a school's special educational needs coordinator
(SENCO), the SENCO, in addition to helping the child with their
behavior, should inform the parents about local parent-training and
education programs.
•
Referral from the community to secondary care may involve health,
education and social care professionals (for example, primary care
clinicians, pediatricians, educational psychologists, SENCOs, social
workers) and care pathways can vary locally. The person making the
referral to secondary care should inform the child or young person's
primary care clinician.
•
When a child or young person presents in primary care with behavioral
and/or attention problems suggestive of ADHD, primary care clinicians
should determine the severity of the problems, how these affect the
child or young person and the parents or caregivers and the extent to
which they pervade different domains and settings.
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•
If the child or young person's behavioral and/or attention problems
suggestive of ADHD are having an adverse impact on their
development or family life, health clinicians should consider:
 a period of watchful waiting of up to 10 weeks
 offering parents or caregivers a referral to a parent-training and
education program (this should not wait for a formal diagnosis of
ADHD)
•
If the behavioral and/or attention problems persist with at least
moderate impairment, the child or young person should be referred to
secondary care, such as a child psychiatrist, pediatrician, ADHD
specialist or CAMHS (Child and Adolescent Mental Health Services) for
assessment.
•
If the child or young person's behavioral and/or attention problems are
associated with severe impairment, referral should be made directly to
secondary care, such as a child psychiatrist, pediatrician, ADHD
specialist or CAMHS for assessment.
•
Group-based parent-training and education programs are
recommended in the management of children with conduct disorders.
•
Primary care clinicians should not make the initial diagnosis or start
drug treatment in children or young people with suspected ADHD.
•
A child or young person who is currently treated in primary care with
methylphenidate, atomoxetine, dexamfetamine, or any other
psychotropic drug for a presumptive diagnosis of ADHD, but has not
yet been assessed by a specialist in ADHD in secondary care, should
be referred for assessment to a child psychiatrist, pediatrician, ADHD
specialist or CAMHS as a matter of clinical priority.
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Identification and Referral in Adults with ADHD
Adults presenting with symptoms of ADHD in primary care or general adult
psychiatric services, who do not have a childhood diagnosis of ADHD, should
be referred for assessment by a mental health clinician trained in the
diagnosis and treatment of ADHD, where there is evidence of typical
manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that:

Began during childhood and have persisted throughout life.

Are not explained by other psychiatric diagnoses (although there may
be other coexisting psychiatric conditions).

Have resulted in or are associated with moderate or severe
psychological, social and/or educational or occupational impairment.
Adults who have previously been treated for ADHD as children or young
people and present with symptoms suggestive of continuing ADHD should be
referred to adult psychiatric services for assessment. The symptoms should
be associated with at least moderate or severe psychological and/or social or
educational or occupational impairment.3
Diagnosis of Children with ADHD
A correct diagnosis of ADHD in children involves conducting multiple
assessment methods, such as:

Diagnostic interview with the child’s parents and/or teachers

Behavior rating scales completed by parents and teachers

Direct observations of classroom and playground behavior

Assessment of academic functioning
Academic skills are tested through examination of completed written work
and administration of curriculum-based measurement probes. Formal tests
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utilizing assessment instruments such as IQ tests, standardized achievement
tests, or other neuropsychological tests are performed as means of
identifying students with ADHD. Psychoeducation and medical tests have
proven to be beneficial in ruling out other comorbid conditions or
complications such as learning disabilities, mental retardation, and allergies
that may mimic the symptoms of ADHD behaviors.43
A comprehensive neuropsychological testing is performed to assist in
confirming the diagnosis of ADHD. Children with ADHD may perform poorly
is several areas of evaluation including tests involving learning skills,
language skills, visual-motor skills or auditory processing mechanisms. To
measure verbal and nonverbal performance skills, intelligence measure
scales such as Wechsler Intelligence scale for children or Differential Abilities
Scale are employed to help identify the language and visual-spatial
processing impairments present. Similarly, the Wechsler Individual
Achievement Test is used to assess academic skills and achievements while
the Wide Range Achievement test is used to identify potential learning
disabilities.
Psychometric testing is also conducted to identify specific problem areas for
children with ADHD that may include abstract reasoning, mental flexibility,
planning and working memory, and executive functions, which is a mixture
of various skills. Neuropsychological assessment of these skills is performed
to directly measure and assess the attention and behavioral disinhibition,
which is significant in facilitating diagnosis and planning pharmacological,
environmental and behavioral interventions as well as assessment of the
treatment progress.43
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Interviewing The Patient With ADHD
A pediatrician, psychiatrist, child psychologist or a specialist nurse usually
serve as interviewer and carries out the clinical interview of the patient,
parent or even teachers to investigate the key characteristic features
presented by the patient suspected of having ADHD. A structured format is
used for the interview to allow for a systematic analysis.
Information gathering before the interview involves several stages. A
support staff member instead of the clinician usually carries out the first
stage of the diagnostic interview. It is at this stage that the examiner can
collect information using a variety of ways, without actually meeting face to
face. Information is collected through phone interviews and a packet of
questionnaires or behavior rating forms, and various methods are
highlighted in this section.17,43,56-66,71,88,98
The phone interview gives crucial information conducted by a well-trained
staff member; otherwise, it is a lost opportunity. Once a parent calls to
request an evaluation, the interviewer must collect the following
information:
1.
Ask the reason for the evaluation request. The interviewer must
take note of how the parent poses their questions, for example, was
it open-ended such as, What’s wrong with my child? Or was it a
specific one, such as Does my child have ADHD?
2.
Who referred the parent or family? The interviewer must find out if
it was a self-referral or did members read or view a TV program
about ADHD? Did the child’s teacher or school psychologist or
pediatrician refer them to the facility?
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3.
Have the parents and child already seen another professional who
suspected ADHD but needed a second opinion or diagnostic
confirmation? The interviewer needs to confirm if the child has been
previously evaluated or tested by someone else or if the family
needs a reevaluation of ADHD that was diagnosed when the child
was younger.
4.
Does the child have any other diagnosed conditions, especially
mental or developmental disorders? The interviewer must take note
of coexisting mood disorders, substance abuse, and developmental
and cognitive delays.
5.
Has the child already undergone treatment with medications? The
interviewer must ask the parent if the evaluation is specifically for
the child’s response to the medication instead of an initial diagnostic
assessment. If the child is on stimulant medication, the interviewer
must ask the parent if he/she can consent to withholding the
medication on the day or the day before the evaluation to allow
observations of the unmedicated behaviors during the evaluation.
Ultimately, the phone interview should clarify and leave no room for doubt
as to the reason for the evaluation request. The quality of the content of the
diagnostic interview depends on the questions mentioned above, which in
turn will give the clinician a basic foundation upon which to conduct the
interview.
Additionally, the information gathered from the telephone interview also
permits the clinician to start some of the initial procedures. Specifically, it is
important at this point to do the following:

Get appropriate releases of information to allow reports of previous
professional evaluations that may be required later.
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
Get in touch with the child’s current physician for further information on
health status and medication treatment, if any.

Get the results of the latest evaluation from the child’s school.

Send the packet of questionnaires for parents and teachers to fill up.
These questionnaires are usually posed in behavior rating format that
must be completed and returned prior to the setting of the initial
appointment with the clinician. Along with these questionnaires, the
parent must not forget to include the written release of information
permission form.

Get any useful information from social services that may be part of
providing services to the child.
As mentioned previously, packets of questionnaires need to be sent out to
parents and teachers at school in advance, after the telephone interview but
ahead of the initial evaluation appointment with the clinician. In fact, many
referred children and parents are often not given an appointment date until
such packets of information are filled up and returned to the clinic. This
ensures that the packets are completed without delay, allowing the clinicians
to review them prior to the scheduled meeting with the parents and the child.
The system of information collection mentioned above makes the evaluation
process very efficient in its collection of important information. Due to the
growing cost-consciousness mindsets towards mental health evaluations,
especially in managed care settings, efficient evaluation processes are very
important to implement and maintain. On top of the initial indirect
evaluation costs, the time spent interacting directly with the parents and the
child are usually limited and at a premium.
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Along with the set of questionnaires and request of consent of release of
information forms, the packet also usually contains the following:

A cover letter from the professional asking the parents to complete the
packet of information

A general instruction guide

A child and family information form

A developmental and medical history form
Some clinicians may also include any other behavior rating scales into this
packet that may or may not specifically assess ADHD symptoms such as:
1.
Child Behavior Checklist
2.
Behavior Assessment System for Children
3.
Rating scale form from the Barkley and Murphy clinical manual
The rating scale from the Barkley and Murphy clinical manual allows the
clinician to get information ahead of the first patient encounter regarding the
presence of symptoms of behavioral disorders common to children such as
oppositional defiant disorder (ODD) and conduct disorder (CD), as well as
ADHD symptoms and their severity. Both ODD and CD are frequent
occurrences among children referred for ADHD, and knowing about their
presence ahead of the appointment is useful to the clinician in formulating
the right questions to ask. Should the clinician require a more
comprehensive rating scale of executive function deficits that are almost
always tied with ADHD, the Barkley Deficits in Executive Functioning Scale –
Children and Adolescents or the Behavior Rating Inventory of Executive
Functioning may be used. In addition to that, clinicians who require
assessment of adaptive behavior may find the results of the Normative
Adaptive Behavior Checklist administered on the scheduled evaluation day
useful.
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Dysfunctional life activities are an important criterion requirement for all
psychiatric disorders outlined in the DSM-5. Some information on
impairment can be gleaned from the face pages of the CBCL (Child Behavior
Checklist) or BASC-2 (Behavior Assessment System for Children). The use of
a rating scale of impairment has been introduced in the recent years and
may be inserted with this packet of other forms for gathering information on
the fifteen various aspects of life activities in children.
Lastly, the Home Situations Questionnaire (HSQ) may also be sent out along
with the other contents of the packet or administered on the day of the
scheduled patient evaluation to allow the clinician a quick understanding of
the frequency and severity of the child’s disruptive behavior in several home
settings.185 The information obtained from the HSQ will also allow clinicians
to open up dialogue on situations pertaining to these during the evaluation
and later on, such as during the parent-training program.
On top of the questionnaires, telephone interview, and rating scales,
clinicians may also need to obtain and review previous records prior to the
scheduled evaluation interview. These records may include:

Academic report cards

Standardized testing results

Medical records such as neurological, audio test, optometric, speech,
and occupational therapy results

Individual educational plans

Psychoeducational testing results

Psychological testing results

Psychotherapy results
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A comparable packet of information may also need to be mailed to the
teachers of the child, along with parental written permission obtained
beforehand. The contents of the packet do not usually include the medical
and developmental history form or any adaptive behavior survey that may
have been present in the packet for parents. However, the packet for
teachers could contain the teacher version of the CBCL or BASC, the School
Situations Questionnaire (SSQ), and the same rating scale for assessing
ADHD symptoms from the Barkley & Murphy clinical manual. The Social
Skills Rating System can also be inserted into the packet for inclusion should
the clinician require more comprehensive information on the child’s social
problems at school and academic incompetencies.
Information gathering through surveys, questionnaires and rating scales
utilized by teachers allows the clinician to see the teacher’s assessment of
the child’s academic performance at grade level in several subjects, and in
group-administered achievement or aptitude tests. It also allows the clinician
a subjective impression of the child’s overall mood and behavioral
functioning. Some clinicians may also contact the teacher for a brief
telephone interview before the scheduled evaluation appointment with the
parents and the child. Otherwise, a teacher-clinician meeting may also be
appropriate after the evaluation appointment with the parents and the child.
After receiving the completed parent and teacher packets, an appointment
date for the evaluation may be set for the family. It is not unusual for clinics
and facilities to send out a confirmation of the appointment, along with a
short guide on preparation tips for the evaluation. The guide provides
parents information on what to expect on the day of the evaluation and what
information to gather before the appointment. It usually answers some of
the questions they may have about the appointment and helps to put them
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at ease. The scheduled evaluation usually consists of three important
elements: 1) Parental and child interview, 2) Completion of self-report rating
scales by the parents, and 3) Psychological testing, if needed.
Interview of the Child
The main objective behind interviewing the child is to gather information
about the complete set of problems, patient history, along with information
on family, health, social life, education, and demography. An interview of the
patient and the family provides significant information on the various coping
mechanisms they have tried in order to deal with the problem. It also gives
the interviewer a picture of the impact of these problems on the child and
the family. Any other information that may be necessary to assess the
condition of the patient and helpful in the correct diagnosis and intervention
planning is also gathered through the clinical interview.
Interview of the child involves the following:

A duration of approximately 2 to 3 hours arranged over two sessions

A session with parents and teachers to facilitate the gathering of relevant
information

A session with the patient alone
Interview of the Parent
The input of the parent is crucial to the thorough assessment of the patient.
Health professionals usually need the parent’s input on the child’s behaviors
in conjunction with the observed behavior. Questionnaires are given to
parents to help health professionals quantify their responses.
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The diagnostic interviews of parents as well as the completed behavior rating
scales of their child are helpful in determining the severity of the ADHD
symptoms based on the guidelines provided by either NICE or American
Psychiatric Association’s DSM-5 diagnostic criteria. They also provide the
clinician with relevant information related to the developmental, medical,
and family history of the patient.
The interview of the parent offers several advantages to the ultimate
diagnosis of the child.
•
It creates a necessary bridge between the parents, the child, and the
interviewer that is very important in encouraging parental cooperation
during the later stages of assessment and treatment.
•
It is an apparent source of very detailed information about the child
and family, often giving the interviewer specific parental views of the
child’s behavioral problems. It can single out specific details that may
prove to be crucial during the later stages of the assessment.
•
It can very easily show the severity of stress that parents are going
through as a result of the child’s problems. It can help the interviewer
assess the general psychological wellbeing of the parent.
Sometimes, an interview can even reveal a genetic component to the
behavioral symptoms, i.e., parental personality or psychiatric problems such
as depression and hostility. There are two things to remember at this
juncture. Firstly, interviewers must be wary of over-interpreting any informal
observations made by parents during this clinic visit. They must not also
jump into conclusions when observing the child during such visits. This is
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because the office behavior of ADHD children is more likely to be “good”
than that observed at home. Such observations can only raise assumptions
about possible parent-child interaction issues, which can be examined in
greater depth with parents during the end of the interview as well as during
later direct behavioral observations of parent and child when playing and
performing tasks together. At the end of this part, the interviewer must
inquire how the immediate behavior of the child compares to that observed
at home in the presence of other adults.
Secondly, it may not be wise to engage the parent in this type of interview
in the presence of the child. This is because the presence of the child may
make parents less than forthcoming about their answers especially when
sensitive issues are asked and brought to light. They may not wish to further
sensitize or inflame the child unnecessarily or create another issue for
hostility and difficulties at home. Other interviewers may choose to have the
child present during the interview and are heedless of the potential problems
it poses to the already delicate parent-child relationship. Still, some parents
may use the interview as an opportunity to embarrass the child by
mentioning the behavioral deficiencies in public. Nevertheless, the
interviewer must always discuss and reconsider the issues and review with
each parent the pros and cons of having the child present before the start of
each interview.
The first parent interview can help steer the focus to parental perceptions of
the child’s problems on significant and more particular controlling events in
the family. Parents have the tendency to emphasize past or developmental
causes generally when discussing their child’s problems, such as the
behavior or actions that lead to failure at certain academic subjects or
parental decisions that led to the problem such as placement of the child in
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daycare, and an early divorce. This type of interactional dialogue can help
transfer parental focus to more current antecedents and consequences
surrounding child behaviors, thus, preparing them for the first stages of
parent training in child management skills.
The interview is designed to formulate a diagnosis as well as develop
management and therapy recommendations. Although diagnosis is not
always a prerequisite for treatment planning (an account of the
developmental and behavioral dysfunctions are often sufficient), the
diagnosis of ADHD, however, is very useful especially when it comes to
predicting the developmental course and prognosis for the child, determining
eligibility for certain unique educational settings, and predicting possible
patient response to a trial on stimulant medication. Several pediatric
behavioral problems are believed to develop over a short span of time, in as
many as 75% of the cases. However, ADHD is considered a lifelong condition,
which requires greater caution when giving future prognosis and careful
preparation of the family for coping with problems that may be encountered
in later life.
The interview may serve as a stress reliever for the parent, particularly if the
initial interview is also the first time that professional involvement is
encountered or sought. The interviewer should take care not to hurry along
the interview, and give sufficient time to allow parents to ventilate their
distress, hostility, or frustrations. It may also be the time for parents to
point out their distress, confusion, or unsuccessful and hostile past
encounters with professionals and educators, as well as well-intentioned but
often misinformed relatives who have tried to help.
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Similar to other distressing disorders, interviewers may need to show
compassion and empathy for parents of children with ADHD; a professional
approach that can provide an open environment conducive for an honest and
forthcoming interview. It can help establish rapport and encourage parental
participation in subsequent treatment recommendations. When done
correctly, parents will respond positively and feel that they have finally found
someone who really understands their child’s behavior problems and the
distress they have experienced in trying to remedy them. These
recommended approaches are not part of rigid guidelines. Rather, they may
be followed when interviewing parents of ADHD children. Each interview is
different and the approach must be tailored specifically to each individual
child’s case and parental circumstances.
Generally speaking, relevant information to be obtained from the interview
process with the parent must include, but not limited to:

Demographic information

Child-related information

School-related information

Details about the parents, and other family members

Information on availability of community resources
Interview of the Teacher
The teachers are also another valuable source of information whose input
into the complete assessment of suspected ADHD children is crucial. They
are the primary persons who can provide the health professional with the
patient’s developmental progress as it relates to academic and non-academic
performances. Their input is important criterion in the assessment of the
patient.
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Teachers may also be required to provide specific information about the
social and academic functioning of the student. They are provided with a
structured questionnaire and interviewed independently by the health
clinician.
The interview with teachers constitutes the first line of the stepwise
diagnostic process in identifying students with ADHD. It provides clinicians
important clues on the severity and frequency of symptoms, since almost all
school-age children spend the majority of their time at school, not at home.
While interviewing teachers and rating their observations, it is important for
the clinician to assess and reconcile the present behavior in both the
classroom and clinic settings. Observations need to be conducted on more
than one occasion; the frequency of both the on- and off- task behaviors
including both motor and vocal actions. Teachers should also provide data
regarding the productivity, accuracy, and progress of the child.
Psychometric Testing
Psychological and psychometric assessments are important tools in the
diagnosis of ADHD in children. Its significance is especially apparent in cases
where the clinical picture obtained from parents or teachers are ambiguous;
for example, their objectivity during the whole process may be less than
expected. A clinical child psychologist uses skill and training to provide a
proper and accurate cognitive assessment of the patient’s abilities and
achievement.
Research has established that children with ADHD symptoms form a
heterogeneous group and exhibit a wide range of cognitive problems. These
children show many apparent differences from normal children in various
performance tests such as mental control and cognitive effort. This is why a
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neuropsychological assessment measure to assess children is very important
in order to classify the case as either ADHD alone or with other mental
disabilities. This neuropsychological assessment measure is useful in
diagnosing and planning the interventions. It may also be used in the
differential diagnosis of ADHD.
The clinical psychologist also takes assessment tests to determine whether
there are any learning difficulties such as poor literacy skills, dyslexia, or
other problems including dyscalculia (math difficulties) or non-verbal
learning difficulties. This assessment helps in the detection of the problems
related to attention, which is an integral part of the treatment and
management plan.
Other problems that need to be assessed before making a diagnosis are
global learning disabilities especially in ADHD cases of predominantly
hyperkinetic disorder. The therapy must be based on the patient’s
intellectual level, which is assessed using psychometric assessment. The
damage to memory, attention or other cognitive factors also needs to be
investigated with the help of clinical psychologists. Various tests are
performed for the psychological assessment, which include:

Test of everyday attention for children

Visual and auditory attentional subtests in neuropsychological batteries
for children

Auditory continuous performance test for children
These neuropsychological tests are extremely helpful in guiding the health
professional when making psychological decisions and interventions.
Conventional psychological tests can detect the presence of inattention and
impulsiveness. They are also very useful in identifying any cognitive
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disabilities, which may worsen the problems of ADHD and present
complications for its management. The presence of a borderline IQ score,
memory problem, or a specific learning disability underlines the need for a
comprehensive treatment program. ADHD sufferers may score poorly in
conventional IQ tests such as Weschler Intelligence Scale for Children
(WISC) or Weschler Adult Intelligence Scale (WAIS). These scales measure
their relative strengths and weakness in different given tasks. Additionally,
they also perform poorly in auditory immediate memory, working memory,
and processing speed tasks. Since the conventional tests are inadequate in
detecting attention deficits, locomotor hyperactivity, and cognitive
impulsivity, many psychologists complement their neuropsychological tests
with computerized tests of attention.
Educational Testing For The ADHD Patient
It is a well-known fact that various psychological and developmental
disorders co-exist in children diagnosed with or being evaluated for ADHD.
Poor school performance may sometimes indicate a learning disability.
Hence, a need for educational testing arises in order to determine whether
there is a variation between the learning potential and the actual academic
progress, which may later on indicate the presence of a learning disability.
Educational and psychoeducational tests are performed to create an overall
assessment of the child being evaluated for ADHD. Different educational
tests such as Woodcock-Johnson Tests of Achievements are utilized to
assess the learning ability of the child. This particular test is intended to
assess what the child has learnt from the school or daily life. Educational
tests assess what the child has learned in school. They are needed to assess
the child’s information processing dysfunction, which is generally found
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concomitantly with ADHD. This is significant since its presence will put a
severe blow to the child’s academic achievements.
NICE clinical guidelines have suggested that educational testing is able to
demonstrate global learning disabilities and intellectual status. Continuous
performance tests need to be taken to assess the cognitive impairments
involving the memory and attention.
Educational and psychoeducational tests are also used to determine the
processing mechanisms of the brain, test of intelligence such as the WAISIII, and the way information is processed. The various brain process
mechanisms give a clear picture on the learning ability of the child with or
suspected to have ADHD. An assessment of educational achievement is also
used to clearly demonstrate the impact on the child’s learning ability at
school. Educators and psychologists also make use of standard cores to
determine the learning disability profile of the child based on their cognitive
potential and academic achievement. A low average range and poor result
on the performance intelligence quotient are some indicators of poor
cognitive skills.
Educational and psychological tests both are required to diagnose a possible
learning disability in children with ADHD; the main reason for the relative
weakness and academic impairment at school. Educational tests clearly
demonstrate that a poor achievement is not a measure of learning disability.
Psychological tests such as the WAIS III breakdown the cognitive abilities
into various phases and use them to measure the child’s ability to process
various types of information. The various educational tests, which are used
in the diagnosis of ADHD in children are highlighted below.
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
Woodcock Johnsons test of achievement

Wechsler individual achievement tests

Wide range achievement test

Other achievement measure
Psychoeducational assessments measure the functional and performance
areas of difficulty in children suffering from ADHD. Specifically, they
measure:

The rate of completion of a given work

Attention to detail

Concentration in studying for exams

Attention in classroom lectures

Organizational skills

Management of time

Self-monitoring
Evidence suggests that there is a strong correlation between the presence of
learning disorders and ADHD. There is a high number of children with ADHD
who also have a specific academic skill deficit and/or learning disorder
manifested in areas such as reading, written language, or mathematics.
Educational tests that provide IQ scores are helpful in identifying the various
learning disabilities including reading disorder, mathematics disorder,
disorder of written expression, and developmental coordination disorder. The
presence of inattentiveness is also an indication of subnormal intelligence,
which can be detected through psychoeducational tests. Educational
assessment will also determine whether the academic difficulties
experienced by the student are due to ADHD, learning disabilities or both. It
will also be able to assess with certainty whether the symptoms are due to
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the presence of a primary stage of ADHD or a learning disability since the
two often not only coexist but also overlap in occurrence.
There is evidence that academic performance problems may be present even
in children who have adequate cognitive abilities as seen in standard
educational and psychological tests. It has also been found that persistent
and increasing behavioral symptoms of ADHD may very well disrupt the
academic skill acquisition and performance of the child.
Conners’ Parent and Teacher Rating Scales
Various tests are performed for the purpose of diagnosing ADHD. The
Conners’ parent and teacher rating scales have been found to be useful in
the assessment of both children diagnosed with ADHD and those suspected
of it and pending diagnosis. In fact, clinical studies have recommended the
use of Conners’ teachers and parent rating scales in the assessment of
ADHD. These scales have been reported to accurately classify the problems
and symptoms, which were designed to assess ADHD. It has also been
reported by the same clinical study that teachers, when compared to parents,
rated students diagnosed with ADHD to exhibit greater levels of behavioral
difficulties and provided more sensitive, specific, and overall accurate
assessment. This is why teachers have been given free access and
administration of the rating scales to students. The results obtained from
such tests are not only very accurate but also predictive.
The Conners’ rating scale was developed by Dr. C. Keith Conners to assist in
the assessment and evaluation of children with or suspected of ADHD. It is a
screening questionnaire that has to be answered by both parents and
teachers. As part of the comprehensive assessment and diagnosis tests, it is
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designed in such a way that it can be easily administered and scored. It is
also often referred to as Conners’ test.
The two versions of the Conners’ scale are long and short and can be
successfully administered to children between the ages of 3 to 17 years. The
longer version contains about 80 questions for parents and 59 questions for
teachers. The shorter version on the other hand contains about 27 questions
for parents and 28 for teachers. The cores are evaluated and interpreted by
a clinician in combination with other diagnostic tools to make a final and
accurate assessment.
The parent and teachers tests are applicable to children between 6 to 18
years. A self-administered test is appropriate for children aged between 8 to
18 years. It uses both observer ratings and self-report ratings to help assess
and evaluate ADHD symptoms of attention deficit or hyperactivity. It also
evaluates behavior problems in children and adolescents. It is also used in
the differential diagnosis of oppositional defiant disorder and conduct
disorder.
The Conners’ test helps the clinician or child psychologist in assessing the
behavior of the child as observed by the parent or the teacher. As mentioned
previously, the test is intended for parents, teachers and
children/adolescents (who rate their own behaviors) themselves to answer.
It can be completed within a time period of 5 to 30 minutes depending on
the version of the test used, i.e., short or the long version. The Conners’ test
is also employed during routine assessment of children’s mental status in
schools, mental health clinics, residential treatment centers, pediatric offices
and other community health settings. The test is available in three different
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scoring options inclusive of paper and pencil, software and Conners 3
interpretive update.
The clinicians obtain a clear picture of a child’s everyday behavior through
people who interact with the child daily - the parents and teachers. Hence,
the Conners’ test has been cited as an invaluable diagnostic tool in
measuring hyperactivity in children and adolescents. It is also taken during
follow up examination for future assessment of the child. The Conners’ test
has been found to be helpful in evaluating and assessing the following:

Hyperactivity in children and adolescents

Behavior of children through the eyes of those who interact with the
child regularly such as teachers and parents

Information regarding the mental acumen so that further treatment
and management can be applied effectively

Important and integral information regarding the child to facilitate the
conclusions, diagnosis, and treatment and condition management
decisions
Conners’ rating scale is associated with several advantages:

It provides a large prescriptive data base

It offers a multidimensional approach

It is applicable to managed care situations
The different psychological characteristics measured by the Conners’ test are
general psychopathology, inattention, hyperactive or impulsive behavior,
learning disorder, executive functioning, aggression, relationship with peers,
relationship with family, inattention due to ADHD, and oppositional defiant
disorder or conduct disorder.
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Brown Attention Deficit Scales (BADDS)
Brown Attention Deficit Disorder Scales are used to clinically evaluate the
deficiency in executive function and emotional difficulties. These scales are
composed of five subscales, which are used to measure difficulties in work
organization and activation, sustaining attention and concentration,
sustaining energy and efforts, management of affective interference and the
utilization of working memory and accessing recall.
The deterioration in executive function which occurs in ADHD is cited as one
of the most compelling reasons for the manifestation of behavioral
symptoms such as poor concentration, impaired working memory, problems
related to shifting among tasks, and prioritizing and planning complex sets
of tasks or completing long term projects at work or school. Problems with
self-regulation and control of emotional behaviors are also observed in
children suffering from ADHD, which may also be evaluated using BADDS.
Various research studies have reported that self-reporting scales such as
Brown Attention Deficit Disorder Scales are useful in the assessment and
diagnosis of ADHD clinical symptoms in children and adults. They have also
been cited as the best rating scale along with ADHD rating scale when it
comes to making the most accurate clinical diagnosis of attention deficit
hyperactivity disorder in children.
Devised by Dr. Thomas Brown, the Brown Attention Deficit Disorder Scales
provide a consistent measure of ADHD in children and adolescents.
Considered to exhibit a cutting edge technique, the scales assess, evaluate
and diagnose the executive cognitive function of children and adolescents
affected with ADHD. These scales are largely used by psychologists,
physicians, psychiatrists, school psychologists and other educational,
medical or mental health professionals involved in child disorders and
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trained to diagnose ADHD. They are appropriate for a wide range of age
groups of children and adolescents:

Children 3 to 7 years of age

Children 8 to 12 years of age

Adolescents 12 to 18 years of age

Adults 18 years and above
The Brown Attention Deficit Disorder Scale is considered to be particularly
useful in the following situations.

Assessing children and adolescents who may benefit from an accurate
diagnosis of ADD or ADHD

The comprehensive assessment of those who are suspected to have
ADD or ADHD

Supervision of the effectiveness of the treatment, management, and
follow up visits
The BADDS is available in several formats:
•
Paper and pencil
•
Clinical interview
•
Software
BADDS is also used in many clinical trials and research studies involving
ADHD.
Continuous Performance Test
Another widely used diagnostic tool in the assessment of ADHD is the
Continuous Performance Test (CPT). It provides a measure of sustained
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attention and relies on the inhibition of cognition. The test has been found to
be essentially useful in the diagnosis of sustained attention deficit such as
ADHD in children as well as those at greater risk of developing pediatric
schizophrenia between the ages of 6 and 15 years.
The continuous performance test is a standardized test, which is
administered using a computer. The test format consists of single letters
presented on a computer screen at varying rates: once per second, once
every 2 seconds, and once every 4 seconds. Many versions of the continuous
performance test are available, with versions differing in their stimuli, event,
rate, and signal probability. These are used to assess and evaluate the three
major symptoms of ADHD, of inattention, hyperactivity and impulsivity.
The Continuous Performance Test is an impressive test of vigilance or
sustained attention. It has been successfully employed in the assessment of
patients who sustained a traumatic brain injury (TBI) as well as those who
are epileptics. It has also been successful in the assessment of long-standing
ADHD children.
The CPT is also available in its visual and auditory versions for children
suspected of psychiatric disorders and auditory attention difficulties. Both
versions are important adjuncts in the clinical diagnosis of ADHD but cannot
be used solely for the purpose of assessment and evaluation. The Conners’
Continuous Performance Test can yield the following important information
in children with ADHD:

Response time

Alterations in the reaction time, the rate of alteration in the reaction
time and consistency of the result

Confidence index
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
Commission errors

Omission errors
Studies have reported that children with ADHD and low sleep efficiency can
actually improve their performance when given pharmacotherapy, resulting
in moderate levels of arousal, which are presumed to assist in vigilance
performance. It has also been found by various studies that sleep efficiency
in children with ADHD show moderate performance in the continuous
performance test when given either a placebo or methylphenidate.
The concept of the Continuous Performance Test was originally developed by
Mackworth and later on developed further and used by other clinicians to
assess the neuropsychological performance deficits of children with ADHD.
Multiple researchers have shown that children with ADHD consistently show
performance deficits and perform poorly on the continuous performance test.
Similar to the other diagnostic tests mentioned previously, it is a common
clinical tool used by many clinicians, and forms an integral part of the ADHDfocused neuropsychological batteries.
Continuous performance testing has also been found to be useful in
differentiating the developmental deficit symptoms between children with
ADHD and those of normal children although there is insufficient evidence to
point out exactly which behavioral symptoms may be. Specifically, the test is
useful in predicting the presence of many ADHD symptoms and provides a
reliable confirmation of the relationship between neuropsychological tasks
and ADHD.
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Integrated Visual and Auditory Continuous Performance Test
The Integrated Visual and Auditory Continuous Performance Test (IVA-CPT)
is another diagnostic tool used by clinicians in the diagnosis of ADHD. Study
data have reported it to be particularly effective in diagnosing ADHD in
younger children. The sensitivity and specificity of IVA-CPT has been
reported to be higher for children in the age group of 6 to 9 years.
The IVA-CPT test is a combined auditory and visual continuous performance
test, which is utilized by the clinicians in making an accurate diagnosis of
ADHD in children, adolescents and adults. The results of the test provide
clinicians’ data related to the child’s ability to concentrate and impulsivity. It
also helps in the differential diagnosis of the three different types of ADHD
discussed in the previous section. The test is predominantly used to
diagnose and differentiate the three types of attention deficit/hyperactivity
disorders, which are ADHD-predominantly inattentive type, ADHDpredominantly hyperactive-impulsive type, and ADHD-combined type.
The IVA-CPT is a diagnostic tool that assesses auditory and visual attention
on the same task. Research studies have clearly demonstrated how low
performance on an IVA-CPT task results in poor educational and work
performances, which are in children suffering from ADHD. One major
drawback of the IVA-CPT test is that it cannot differentiate clearly between
patients with ADHD and those exhibiting ADHD-like symptoms due to a
traumatic brain injury. It forms one of the important components of a
multimodal diagnostic assessment of individuals with psychological disorders.
Together with the clinical interview and various rating scales, many clinicians
especially use the IVA-CPT in order to diagnose children that have
psychological disorders.
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Various behavioral scales and IVA-CPT are used together to detect
differences in the behaviors, which may have clinical relevance and are
considered necessary in the diagnostic test battery. The IVA-CPT is the only
test that can verify the significant abnormal brain patterns related to poor
attention functioning. The test lasts for almost 13 minutes and presents 500
trials of visual and auditory 1’s and 2’s in a pseudo-random manner, which is
based on predetermined shifting between the visual and auditory modalities.
The test taker is required to click only when “1” is seen or heard, and inhibit
clicking when “2” is seen or heard. During certain parts of the test, the “1”
appear more often than the “2”, creating a response set that invites errors
due to commission, or impulsiveness. During alternating parts of the test,
the “1” can occur less often which in turn invites more errors due to
omission, or inattention, since the subject must remain watchful while
waiting to hear or see “1”.
The IVA-CPT test comprises four categories:

Attention

Response control

Attribute

Validity
Scores from each category are presented either as raw or quotient scores.
The basis for statistical analysis is similar to those used in many IQ tests; all
quotient scores have a mean of 100 and a standard deviation of 15. These
familiar guidelines make it easy to interpret the IVA-CPT results. The score
interpretation provides adequate information about the learning abilities
such as balance and readiness, and the rate of information processing. The
two main diagnostic scales of the IVA-CPT are the Full Scale Response
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Control Quotient and the Full Scale Attention Quotient scores. The Response
Control Quotient scores are obtained from three visual and auditory
elements, as highlighted below.
Prudence:
Prudence measures impulsivity and response inhibition, which are made
apparent by three different types of errors of commission.
Consistency:
Consistency measures the general reliability and variability of response
times. It is also helpful in measuring the ability to stay on task.
Stamina:
Stamina provides a comparative look at the average reaction times of right
responses during the first 200 trials to the last 200 trials. The score obtained
here is helpful in identifying problems related to sustaining attention and
effort over time.
The Full Scale Attention Quotient is obtained from different auditory and
visual attention quotients. The Attention Quotient scores depend on equal
measures of three visual and auditory elements of vigilance, focus and speed.
•
Vigilance:
Vigilance measures inattention, which is made apparent by two
different types of mistakes of omission.
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•
Focus:
Focus measures the total variability of mental processing speed for all
right responses.
•
Speed:
Speed measures the average reaction time for all right responses
during the test. It is very helpful in identifying attention-processing
problems associated with slow discriminatory mental processing.
Additionally, the IVA-CPT attribute scales provide a wealth of information
about the learning styles of test takers. These are identified as:
•
Balance:
Balance specifies the test taker’s preferred information processing
modality, i.e., whether visual or audio stimulation derives faster
response times.
•
Readiness:
Readiness specifies the test taker’s response time to processing
information either when demand is quicker or slower. It also provides
a small clue to inattention when the test taker exhibits inability to keep
up with the demand.
IVA-CPT validity scales consist of auditory and visual elements of
comprehension, persistence and sensory/motor scales.
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
Comprehension:
Comprehension singles out random responding, preventing the faulty
interpretation of other IVA scale scores. Studies have pointed this to be a
very sensitive subscale in discriminating ADHD.

Persistence:
Persistence is a motivation measure based on the test taker’s response
when asked to perform another task. This measure is also indicative of
motor or mental fatigue.

Sensory/Motor Scales:
These are used in the differential diagnosis of sensory and motor
symptoms of ADHD from other neuropsychological disorders exhibiting
similar deficits. Basically, it rules out possible neurological, psychological
or learning problems through slow simple response time.
The IVA-CPT has also been proven clinically significant in providing detailed
information about behavior and abilities with respect to sustaining attention,
inhibiting impulsive behavior, flexibility of thought and reasoning, and ability
to shift attention and continuously perform tasks. It has several advantages
when it comes to making a differential diagnosis of various psychological
disorders, including ADHD, which include:

Easy administration

Easy interpretation

Accuracy

Easy communication between the patients, parent, teacher and
clinician
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
Helpful in the objective assessment of the clinical results
Nadeau/Quinn/Littman ADHD Self-rating Scale for Girls
The Nadeau/Quinn/Littman ADHD self-rating scale is part of the
psychometric and educational testing in ADHD diagnosis of young girls. The
need for a specific test for girls arose because it was found in certain studies
that they make up almost 20% of the total hyperactive/impulsive group,
27% of the inattentive group, and 12% of the combined-type group. It has
also been seen that by following the currently available tests, many girls are
overlooked and, hence, creating the need for current diagnostic criteria that
is gender specific.
Girls are known to be biologically and neurologically different; they have
different attitudes towards socializing and verbalizing their emotions, and, as
such, they also face a different set of social norms. Based on these, it is
befitting to assume that girls face specific problems and exhibit different
behaviors compared to boys who are also living with ADHD.
The Nadeau/Quinn/Littman ADHD self-rating scale is a self-rating scale,
which specifically helps identify girls with ADHD. It constitutes a unique
checklist and comprises issues that are internal and cannot be observed by
others. This is not a definitive diagnostic tool, but provides a strong
indication of the possible problems specifically faced by girls. The girl, under
the supervision of a parent, teacher, or a clinical professional, should
complete the checklist provided in the test. Specifically, the test gives a
clear picture of the following points.

Problems with productivity or efficiency or initiation

Inattention or concentration deficit or distractibility
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
Social skills deficit

Hyperactivity

Self-control or impulsive behavior

Self-esteem related problems

Disorganization

Poor management of time

Anxiety or depression

Anxiety related to school

Emotional over reactivity

Sleep or arousal problem

Feeling of being misunderstood or criticized
Apart from this checklist, parents are also required to fill in or provide
information about any additional behavioral problems they may have
observed in the test taker.
IQ Testing
An IQ test is very helpful in diagnosing children with ADHD. Its diagnostic
usefulness is based on the very well known fact that children with ADHD do
not necessarily have lower intelligence when compared to asymptomatic
children, but may exhibit cognitive deficits, which are strong indications of
executive dysfunction. Such patients also exhibit symptoms of hyperactivity
and attention disorders.
Intelligence plays a significant role in executive function seen in ADHD. An
IQ test demonstrates the current negative effects of ADHD symptoms on
learning abilities. IQ tests are meant to assess the child for the ability to
respond to the environment and the ability to learn from past experiences.
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IQ tests administered to young people are intended to observe patterns of
behavior, which may be consistent with the symptoms of ADHD. It has been
reported by different studies that people with ADHD perform poorly on
intelligence tests compared to those considered without ADHD. Additionally,
it has also been seen that ADHD occurs as a valid diagnosis in children with
remarkably high IQ test scores.
The characteristics of ADHD in children with high IQ are similar to those with
low IQ. Psychiatric comorbidities and functional impairments are also found
to be comparable in both groups of children. Children with both high IQ and
ADHD experience more pronounced functional impact of ADHD and are at
greater risk of underachieving due to frustrations brought on by
misinterpretations of learning abilities and talents. Such children are also
more likely to experience negative psychosocial outcomes. Because of these,
there is greater awareness and need for correct diagnosis and treatment of
ADHD in children with varying degrees of cognitive function.
The drawback of intelligence tests is that these tests have limited rates of
success. The various intelligence tests used in children and adolescents as
ADHD diagnostic tools are listed below:

Weschler Intelligence Scale for Children (WISC)

Stanford Binet test

Achievement tests

Woodcock Johnson III

Wide Range Achievement Test
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Weschler Intelligence Scale for Children (WISC)
The Weschler Intelligence Scale for Children (WISC), briefly referred to
earlier in the study, was developed in 1949 and is currently the most
commonly used intelligence quotient test. The test is used to evaluate and
determine the verbal and performance skills of children. The scores are
obtained to arrive at a combined score, which is called the IQ score. The
derived IQ score is then used to compare individuals. The basic aptitudes
that can be measured with the application of this test are factual knowledge,
spatial skills, logical thinking and mathematical abilities. It can be used in
children between the ages of 6 years to 16 years.
The Wechsler intelligence scale for children has many subtests which are
used to measure perceptual organization, planning problem solving, nonverbal reasoning, direction of attention, visual sequences, analysis and
synthesis, visual-motor coordination, mental processing speed, spatial
relationships, and working memory. The subtests are useful in identifying
children suspected with ADHD.
Stanford Binet Test
The Stanford Binet Intelligence Scales test is applied to determine
knowledge of vocabulary, comprehension skills and recognition of visual
patterns. The use of this test can determine the typical age at which an
individual can answer specific questions. It tests the abilities for matrices,
vocabulary, and visual-spatial processing. It also tests the IQ, verbal IQ,
non-verbal IQ, quantitative reasoning, picture absurdities, and memory.
Additionally, the Stanford Binet Test shows variable differences of these
abilities between normal children and those with ADHD. It can also be used
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for differential diagnosis of other conditions such as learning disability, and
children with motor and speech problems.
Achievement Tests
Achievement tests are administered to determine the degree of academic
function with respect to specific school subjects such as oral language,
reading, writing, and math. They are tests based on an indirect measure of
intelligence.
It is not uncommon for children with ADHD who are very bright to still score
poorly in intelligence tests. They may not perform well in academic tests due
to a low IQ level. In these cases, achievement tests can provide a true and
exact indication of current academic functional abilities. Achievement tests
reveal that children with ADHD show a typical pattern of performance, which
is extremely helpful in making a correct diagnosis of ADHD. These tests are
also used in the differential diagnosis of concentration problems from a
simple lack of ability to concentrate.
Woodcock Johnson III
The Woodcock Johnson III is a standardized assessment tool that provides
an index of general intellectual acumen and ability, as well as specific
cognitive abilities. It is used to measure abilities inclusive of executive
process, cognitive fluency, broad attention, and working memory cluster.
Based on these measures, it is useful in differentiating children with ADHD
from those without it. This test tool includes factors representing the specific
cognitive abilities and their uses as separate constructs.
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The Woodcock Johnson III test was developed to determine general
intellectual ability, specific cognitive abilities, scholastic aptitude, oral
language skills and academic achievement. It is applicable to individuals
between the ages of 2 to 90 years old. One of its advantages is its easy
application in children who are slow, have reading disabilities, or who have
concentration problems for long periods of time. It is also useful in stating a
student’s areas of strength and academic characteristics of concern, their
learning style, and aptitude in any area, as well as any problems related to
perception. It is comprised of clusters and many subtests, which include:

Working memory cluster

Broad attention cluster

Cognitive fluency cluster

Executive processes cluster
The working memory clusters is made up of two subtests:

Numbers reversed

Auditory working memory
These subtests assess the ability to hold and manipulate information that is
of immediate memory. The broad attention cluster includes four subtests:

Attention capacity

Sustained attention

Selective attention

Auditory working memory
These subtests measure the ability to concentrate on attention resources
and manipulating information. The cognitive fluency cluster is made up of
three subtests:
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
Retrieval fluency

Decision speed

Rapid picture naming
These subtests measure fluency and speed in performing simple and
complicated cognitive tasks.
The executive processes cluster includes three subtests:

Concept formation

Planning

Pair cancellation
These tests measure abilities to develop and enact strategic planning,
proactive interference control and shift of mental set repeatedly.
Wechsler Individual Achievement Test
The Wechsler Individual Achievement Test (WIAT) is an achievement test
used in the determination of academic problem areas and other learning
disabilities. The test scores are also helpful in comparing the actual versus
expected performance and intelligence levels in growing children. There are
many subtests in this test, which can be administered to students without
any time limit, except for the written expression subtest, which has a time
limit for completion. The test is formatted to assess the child in various
academic areas such as reading, mathematics, written language and oral
language. It evaluates abilities associated with word reading, reading
comprehension, phonetic, numerical operations, math reasoning, spelling,
written expression, listening comprehension, and oral expression. The U.S.
edition of the test, WIAT-III test comprises 16 subtests.
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The other version, the WIAT-II test, has certain limitations. For example, the
test fails to assess and measure all parts of academic achievements. The
test only measures aspects of learning processes that occur in the traditional
academic settings such as reading, writing, mathematics and oral language.
It is not designed to accurately measure the academic giftedness of children
with high IQ or older adolescents.
Wide Range Achievement Test
The Wide Range Achievement Test (WRAT) is used to determine reading
recognition, spelling, and math computation in children with ADHD. This test
has two versions; the first version is used in children who are in the age
range of 5 to 11 years, and the second version is used in older children,
usually 12 years old and above. Using age as a reference point, it is also
beneficial in comparing one person with another to measure any alterations
in the learning ability and disability.
Brain Wave Testing
The U.S. Food and Drug Administration (FDA) has recently approved the first
medical scanning test to help in the diagnosis of ADHD in children by
measuring brain waves. The test makes use of the device, Neuropsychiatric
EEG-Based Assessment Aid (NEBA) system, to record the various types of
electrical waves produced by neurons in the brain and the frequency, which
these impulses are given off per second.
The NEBA system, approved for use by medical and mental health clinicians,
is used to test children between the ages of 6 years to 17 years to confirm
the diagnosis of ADHD, or to determine if further tests are required for an
assessment.
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The NEBA device is an EEG-based assessment aid and used as part of a
complete medical or psychological examination to confirm the diagnosis of
ADHD or evaluate the need for further diagnostic tests. The device works by
measuring the ratio of two standard brain waves, the theta and beta waves.
Research studies have reported that children with ADHD have a higher ratio
of theta to beta waves when compared with other asymptomatic children or
those who do not have ADHD. The test is non-invasive and lasts between 15
to 20 minutes. Its diagnostic usefulness depends on its results to paint a
more accurate picture of the behavioral symptoms to the clinician. It is
considered to be generally safe without any adverse effects.
A research trial conducted on approximately 275 children and adolescents
between the ages of 6 years to 17 years have shown that the use of NEBA
system helped the clinicians in making a more accurate and correct
diagnosis of ADHD when employed together with a clinical assessment for
ADHD, compared with clinical assessment alone.
Laboratory Testing
The validity of ADHD as a disorder is often called in question because of the
lack of a measurable biomarker. But like many mental disorders, the
absence of biomarkers has not deterred psychologists and medical experts
on finding ways to treat and manage it.
As discussed extensively in the previous sections, the diagnosis of ADHD is
based on a combination of history, presenting complaints and symptoms (for
example, behavioral problems), consistency of symptoms, and ruled out
possible explanations of the symptoms.
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Summary
Pediatric ADHD is a common developmental disorder that is characterized by
symptoms of hyperactivity, inattention and impulsivity of varying degrees. It
is often diagnosed in school age children, although children as young as 6
years old or below are also increasingly diagnosed. There are three major
steps in the diagnostic process of ADHD, which include a clinical interview,
medical examination, and establishment of the rating scale for parents and
teachers. Other assessment criteria includes direct observation in
educational settings such as schools, play schools, and cognitive and
neuropsychological assessment of developmental and literacy skills. These
are secondary and may or may not be included in the diagnostic process.
Children diagnosed with ADHD may also experience a variety of related
disorders or comorbidities. These comorbidities vary according to the
prevailing type of ADHD, their severity, as well as the developmental stage
of the child when they were first seen. These comorbidities are divided into
two broad categories of learning disorders and psychiatric disorders.
Because of the complexity of ADHD, its therapy requires a multimodal
approach. Psychotherapy, which includes behavioral interventions, and,
pharmacotherapy, are worthy topics related to the ongoing treatment of
ADHD that clinicians focused on pediatric treatment are encouraged to
pursue.
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Definition of Terms:
1. Hyperactivity: Refers to constant activity, being easily distracted,
impulsiveness, inability to concentrate, aggressiveness, and similar
behaviors.
2. Impulsivity: Refers to actions that are poorly conceived, prematurely
expressed, and unduly risky, or inappropriate to the situation.
3. Inattention: Refers to inability to focus
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1.
_______________________ are the primary neurotransmitters
that mediate frontal lobe function.
a.
b.
c.
d.
2.
The predominantly hyperactive/impulsive type of ADHD is
usually characterized by high energy and constant movement.
The classic manifestation(s) of this type of ADHD is/are:
a.
b.
c.
d.
3.
Alzheimer’s Disease
Parksinson’s Disease
Adrenal leukodystrophy
Mad Cow disease
What is a comorbidity of ADHD when children engage themselves
in ongoing destructive patterns that is defined by persistence of
disobedience and triggered by anger and hostility.
a.
b.
c.
d.
5.
Inattentiveness or lack of attention
Disorganization
Forgetfulness
All of the above
A comprehensive neurologic examination needs to be performed
in children with ADHD to rule out the possibility of
neurodegenerative disorders such as _______________.
a.
b.
c.
d.
4.
Amino acids
Catecholamines
Gaba peptides
Acetlycholine derivites
Autism
Antisocial Disorder
Oppositional defiant disorder
Asperger’s Syndrome
True or False. ADHD is considered a condition of childhood,
which requires less caution when giving future prognosis.
a. True
b. False
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6.
Children with attention deficit hyperactivity disorder are
_______ likely to have ________ levels of comorbidities related
to mood, anxiety, and disruptive behavior disorders and
impairments in the cognitive, interpersonal and academic
functions.
a.
b.
c.
d.
7.
In obtaining the __________ history of the child suspected of
ADHD, the general health and well-being of both the child and
the parents need to be carefully assessed.
a.
b.
c.
d.
8.
More; higher
Less; lower
More; lower
Less; higher
Social
Family
Psychiatric
Medical
Information about the presence of other conditions that might
have triggered ADHD, and the use of medications and other
substances that can cause side effects or interact with ADHD
medications are obtained in the ______________.
a.
b.
c.
d.
9.
Medications list
Social history
Family history
Past medical history
The interview with teachers constitutes the _________ line of
the stepwise diagnostic process in identifying students with
ADHD.
a.
b.
c.
d.
First
Second
Third
Last
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10. The two versions of the Conners’ scale are long and short and
can be successfully administered to children between the ages of
___________years.
a.
b.
c.
d.
2
5
3
7
to
to
to
to
10
15
17
18
11. True or False. Apart from abnormalities within the dopamine
system, children with any type of ADHD have also been found to
exhibit abnormal levels of other neurotransmitters such as
serotonin, cholinesterase, adrenalin, and GABA.
a. True
b. False
12. The Continuous Performance Test (CPT) is an impressive test of
vigilance or sustained attention. It has been successfully
employed in the assessment of patients who sustained
a.
b.
c.
d.
traumatic brain injuries.
epileptics.
long-standing ADHD children.
All of the above.
13. Among other things, deterioration in executive function leads to
problems with
a.
b.
c.
d.
poor concentration
impaired working memory
prioritizing and planning complex sets of tasks
All of the above
14. The Woodcock Johnson III test was developed to determine
general intellectual ability, specific cognitive abilities, scholastic
aptitude, oral language skills and academic achievement. It is
applicable to individuals between the ages of ___________
years old.
a.
b.
c.
d.
2 to 90
18 to 60
2 to 18
30 to 40
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15. Children with predominantly ___________________ type of
ADHD face barriers when trying to form social relationships with
other children due to their tendency to be easily angered and
provoked.
a.
b.
c.
d.
Inattentive
Impulsivity
Autistic
Hyperactivity
16. True or False. It is not uncommon for children with ADHD who
are very bright to still score poorly in intelligence tests.
a. True
b. False
17. The ____________ lobe is responsible for the majority of
decision-making functions.
a.
b.
c.
d.
Cerebellar
temporal
frontal
parietal
18. Imaging studies have revealed that children diagnosed with
ADHD show a substantial ______________ of the brain volume.
a.
b.
c.
d.
enlargement
reduction
less gray matter
more gray matter
19. The diagnosis of ADHD in children, adolescents, and adults
usually occur in _______________ care settings.
a.
b.
c.
d.
secondary
tertiary
school
psychiatry
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20. True or False. States with improved health prevention and
screening practices have been reported to have lower reports of
prevalence rates.
a. True
b. False
21. Because of the complexity of ADHD, its therapy requires a
______________ approach.
a.
b.
c.
d.
Psychiatric
Therapeutic
Multimodal
None of the above.
22. The clinician must also pay close attention and focus on certain
dysmorphic features that may be present in children with ADHD,
EXCEPT for:
a.
b.
c.
d.
Fragile X Syndrome
Hydrocephalus
Klinefelter
Turner’s syndrome
23. The Delay Aversion Theory proposes a ________________
impairment in children with ADHD, which causes them to exhibit
intolerance to delays that in turn affects their cognitive
functioning and behavior in general.
a.
b.
c.
d.
Hearing and visual
Morally-learned
Biological-based
Family-learned
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24. The ______________________ test is a standardized test,
which consists of single letters presented on a computer screen
at varying rates: once per second, once every 2 seconds, and
once every 4 seconds. These are used to assess and evaluate the
three major symptoms of ADHD, of inattention, hyperactivity and
impulsivity.
a.
b.
c.
d.
continuous performance
mental status exam
memory/cognition
neurofeedback.
25. Interview of the child involves a:
a. duration of approximately 2 to 3 hours arranged over two sessions.
b. session with parents and teachers to facilitate the gathering of
relevant information
c. session with the patient alone
d. All of the above.
26. True or False. IQ tests administered to young people are
intended to observe patterns of behavior, which may be
consistent with the symptoms of ADHD.
a. True
b. False
27. The NEBA device is an ________________ aid and used as part
of a complete medical or psychological examination to confirm
the diagnosis of ADHD or evaluate the need for further
diagnostic tests.
a.
b.
c.
d.
Neurofeedback
EEG-based assessment
XRAY
Both a and b above.
28. Impaired executive function can lead to problems with
a.
b.
c.
d.
organization
achieving and maintaining concentration
regulation of emotions
All of the above.
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29. The Home Situations Questionnaire (HSQ) may allow the
clinician a quick understanding of
a. the frequency and severity of the child’s disruptive behavior in
several home settings.
b. marital discord in the home
c. incidence of child abuse in the home
d. Both a and c above.
30. The IVA-CPT test comprises four categories, EXCEPT
a.
b.
c.
d.
Attention
Response control
Expansive mood
Validity
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Correct Answers:
1)
_____________________ are the primary neurotransmitters
that mediate frontal-lobe function.
b. Catecholamines
“Catecholamines are the primary neurotransmitters that mediate
frontal-lobe function”.
2)
The predominantly hyperactive/impulsive type of ADHD is
usually characterized by high energy and constant movement.
The classic manifestation(s) of this type of ADHD is/are
__________________.
a.
b.
c.
d.
restlessness
exhaustion
failed attempts at building social relationships
All of the above [Correct Answer]
“Those who manifest hyperactive behaviors are usually seen exhibiting
a sense of restlessness, being fidgety or unable to stay still, and
frequently fiddle with things when not on the move… these children
can also endlessly move about unless exhaustion causes them to stop
or slow down… Impulsive behaviors manifested by children with
predominantly hyperactive-impulsive type of ADHD are the reason
behind failed attempts at building and maintaining social relationships”.
3)
A comprehensive neurologic examination needs to be
performed in children with ADHD to rule out the possibility of
neurodegenerative disorders such as _______________.
c. Adrenal leukodystrophy
“A comprehensive neurologic examination needs to be performed in
children with ADHD to rule out the possibility of neurodegenerative
disorders such as neuronal ceroid lipofuscinosis and adrenal
leukodystrophy.”
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4)
What is a comorbidity of ADHD when children engage
themselves in ongoing destructive patterns that is defined by
persistence of disobedience and triggered by anger and hostility.
c. Oppositional defiant disorder
“Oppositional defiant disorder, on the other hand, is seen when
children engage themselves in ongoing destructive patterns that is
defined by persistence of disobedience and triggered by anger and
hostility. Also, these children exude defiance against authoritative
figures that are not typical of children their age. It may be
accompanied by extreme anger and stubbornness that is also not
exhibited by most children of the same age.”
5)
True or False. ADHD is considered a condition of childhood,
which requires less caution when giving future prognosis.
b. False
“ADHD is considered a lifelong condition, which requires greater
caution when giving future prognosis and careful preparation of the
family for coping with problems that may be encountered in later life.”
6)
Children with attention deficit hyperactivity disorder are
_______ likely to have ________ levels of comorbidities related
to mood, anxiety, and disruptive behavior disorders and
impairments in the cognitive, interpersonal and academic
functions.
a. More; higher
“It has also been studied that children with ADHD are more likely to
exhibit the prototypical symptoms of the disorder; they have higher
levels of comorbidities related to mood, anxiety, and disruptive
behavior and impairments in their cognitive, interpersonal and
academic functions.”
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7)
In obtaining the __________ history of the child suspected of
ADHD, the general health and well-being of both the child and
the parents need to be carefully assessed.
b. Family
“The family history of the child should also be assessed. Specifically,
the general health and wellbeing of the child and the parents need to
be carefully assessed,…”
8)
Information about the presence of other conditions that might
have triggered ADHD, and the use of medications and other
substances that can cause side effects or interact with ADHD
medications are obtained in the ______________.
d. Past medical history
“The past medical history is important in providing clues as to the
possible triggers that precipitated the behavioral symptoms, other
than ADHD itself. The presence of other conditions that might have
triggered the condition is explored as well as the use of medications
and other substances that can cause side effects or interacted with
ADHD medications.”
9)
The interview with teachers constitutes the _________ line of
the stepwise diagnostic process in identifying students with
ADHD.
a. First
“The interview with teachers constitutes the first line of the stepwise
diagnostic process in identifying students with ADHD.”
10) The two versions of the Conners’ scale are long and short and
can be successfully administered to children between the ages
of ___________years.
c. 3 to 17
“The two versions of the Conners’ scale are long and short and can be
successfully administered to children between the ages of 3 to 17
years.”
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11) True or False. Apart from abnormalities within the dopamine
system, children with any type of ADHD have also been found to
exhibit abnormal levels of other neurotransmitters such as
serotonin, cholinesterase, adrenalin, and GABA.
a. True
“Apart from abnormalities within the dopamine system, children with
any type of ADHD have also been found to exhibit abnormal levels
of other neurotransmitters such as serotonin, cholinesterase,
adrenalin, and GABA. These neurotransmitters and their pathways,
as a result of ADHD, have been found by researchers to be altered.”
12) The Continuous Performance Test (CPT) is an impressive test of
vigilance or sustained attention. It has been successfully
employed in the assessment of patients who sustained
a.
b.
c.
d.
traumatic brain injuries.
epileptics.
long-standing ADHD children.
All of the above. [Correct Answer]
“Another widely used diagnostic tool in the assessment of ADHD is
the Continuous Performance Test (CPT)… The Continuous
Performance Test is an impressive test of vigilance or sustained
attention. It has been successfully employed in the assessment of
patients who sustained a traumatic brain injury (TBI) as well as
those who are epileptics. It has also been successful in the
assessment of long-standing ADHD children.”
13) Among other things, deterioration in executive function leads to
problems with
a.
b.
c.
d.
poor concentration
impaired working memory
prioritizing and planning complex sets of tasks
All of the above [Correct Answer]
“The deterioration in executive function which occurs in ADHD is
cited as one of the most compelling reasons for the manifestation of
behavioral symptoms such as poor concentration, impaired working
memory, problems related to shifting among tasks, and prioritizing
and planning complex sets of tasks or completing long term
projects at work or school.”
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14) The Woodcock Johnson III test was developed to determine
general intellectual ability, specific cognitive abilities, scholastic
aptitude, oral language skills and academic achievement. It is
applicable to individuals between the ages of ___________
years old.
a. 2 to 90
“The Woodcock Johnson III test was developed to determine general
intellectual ability, specific cognitive abilities, scholastic aptitude, oral
language skills and academic achievement. It is applicable to
individuals between the ages of 2 to 90 years old.”
15) Children with predominantly ___________________ type of
ADHD face barriers when trying to form social relationships
with other children due to their tendency to be easily angered
and provoked.
b. Impulsivity
“Impulsive behaviors manifested by children with predominantly
hyperactive-impulsive type of ADHD are the reason behind failed
attempts at building and maintaining social relationships.”
16) True or False. It is not uncommon for children with ADHD who
are very bright to still score poorly in intelligence tests.
a. True
“It is not uncommon for children with ADHD who are very bright to still
score poorly in intelligence tests.”
17) The ____________ lobe is responsible for the majority of
decision-making functions.
c. frontal
“The ____________ lobe is responsible for the majority of decisionmaking functions.”
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18) Imaging studies have revealed that children diagnosed with
ADHD show a substantial ______________ of the brain volume.
b. reduction
“… imaging studies have revealed that children diagnosed with ADHD
show a substantial reduction of the brain volume,…”
19) The diagnosis of ADHD in children, adolescents, and adults
usually occur in _______________ care settings.
a. secondary
“The diagnosis of ADHD in children, adolescents, and adults usually
occur in secondary care settings.”
20) True or False. States with improved health prevention and
screening practices have been reported to have lower reports of
prevalence rates.
b. False
“States with improved health prevention and screening practices have
been reported to have higher reports of prevalence rates. The more
rigorous the screening process, the greater the likelihood of finding
more symptoms related to a diagnosis of ADHD.”
21) Because of the complexity of ADHD, its therapy requires a
______________ approach.
c. Multimodal
“Because of the complexity of ADHD, its therapy requires a multimodal
approach.”
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22) The clinician must also pay close attention and focus on certain
dysmorphic features that may be present in children with ADHD,
EXCEPT for:
b. Hydrocephalus
“The clinician must also pay close attention and focus on certain
dysmorphic features that may be present in children with ADHD. These
might indicate a deeper problem, which may be genetic in nature.
Examples of these genetic problems may include, but are not limited
to:
• Fragile X Syndrome (higher rates are prevalent in female
patients than in males)
• Klinefelter
• Turner’s syndrome”
23) The Delay Aversion Theory proposes a ________________
impairment in children with ADHD, which causes them to
exhibit intolerance to delays that in turn affects their cognitive
functioning and behavior in general.
c. Biological-based
“The Delay Aversion Theory proposes a biological-based impairment in
children with ADHD, which causes them to exhibit intolerance to delays
that in turn affects their cognitive functioning and behavior in general.”
24) The ______________________ test is a standardized test,
which consists of single letters presented on a computer screen
at varying rates: once per second, once every 2 seconds, and
once every 4 seconds. These are used to assess and evaluate
the three major symptoms of ADHD, of inattention,
hyperactivity and impulsivity.
a. continuous performance
“The continuous performance test is a standardized test, which ….
consists of single letters presented on a computer screen at varying
rates: once per second, once every 2 seconds, and once every 4
seconds … used to assess and evaluate the three major symptoms of
ADHD, of inattention, hyperactivity and impulsivity.”
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25) Interview of the child involves a:
a. duration of approximately 2 to 3 hours arranged over two sessions.
b. session with parents and teachers to facilitate the gathering of
relevant information
c. session with the patient alone
d. All of the above. [Correct Answer]
“Interview of the child involves the following:
• A duration of approximately 2 to 3 hours arranged over two
sessions
• A session with parents and teachers to facilitate the gathering of
relevant information
• A session with the patient alone”
26) True or False. IQ tests administered to young people are
intended to observe patterns of behavior, which may be
consistent with the symptoms of ADHD.
a. True
“IQ tests administered to young people are intended to observe
patterns of behavior, which may be consistent with the symptoms of
ADHD.”
27) The NEBA device is an ________________ aid and used as part
of a complete medical or psychological examination to confirm
the diagnosis of ADHD or evaluate the need for further
diagnostic tests.
b. EEG-based assessment
“The NEBA device is an EEG-based assessment aid and used as part of
a complete medical or psychological examination to confirm the
diagnosis of ADHD or evaluate the need for further diagnostic tests.”
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28) Impaired executive function can lead to problems with
a.
b.
c.
d.
organization
achieving and maintaining concentration
regulation of emotions
All of the above. [Correct Answer]
“The executive functions include mental processes that are necessary
to carry out and regulate daily tasks and to control and perform the
management of daily tasks. Impaired executive function leads to
problems with keeping track of time, organizing things, the habit of
procrastinating things excessively, problems with achieving and
maintaining concentration, speed in processing impulses and
information, regulation of emotions, the use of working memory and
problems with an individual’s short term memory.”
29) The Home Situations Questionnaire (HSQ) may allow the
clinician a quick understanding of
a. the frequency and severity of the child’s disruptive behavior in
several home settings.
“… the Home Situations Questionnaire (HSQ) may also be sent out
along with the other contents of the packet or administered on the day
of the scheduled patient evaluation to allow the clinician a quick
understanding of the frequency and severity of the child’s disruptive
behavior in several home settings.”
30) The IVA-CPT test comprises four categories, EXCEPT
c. Expansive mood
“The IVA-CPT test comprises of four categories:
• Attention
• Response control
• Attribute
• Validity”
References Section
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The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading. [This is Part 1 of a 2 Part series on Pediatric ADHD].
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
National Institute of Mental Health. Attention Deficit Hyperactivity
Disorder. Retrieved from
http://www.nimh.nih.gov/health/publications/attention-deficithyperactivity-disorder/index.shtml
Crichton, A. (1798). An inquiry into the nature and origin of mental
derangement: comprehending a concise system of the physiology and
pathology of the human mind and a history of the passions and their
effects. Cadell, T. Jr, Davies, W., London [Reprint: Crichton, A. (2008).
An inquiry into the nature and origin of mental derangement. On
attention and its diseases. Journal of Attention Disorder 12:200–204.
Bukstein, O. (2016). Attention deficit hyperactivity disorder in adults:
Epidemiology, pathogenesis, clinical features, course, assessment, and
diagnosis. Up To Date. Retrieved online at
https://www.uptodate.com/contents/attention-deficit-hyperactivitydisorder-in-adults-epidemiology-pathogenesis-clinical-features-courseassessment-anddiagnosis?source=search_result&search=adhd&selectedTitle=2~150
Diagnostic and statistical manual of mental disorders (DSM-II), 4th
edn Text revision. Washington DC: American Psychiatric Association;
2000.
Still, G.F. (1902). Some abnormal psychical conditions in children: the
Goulstonian lectures. Lancet, 1:1008–1012.
Brown, W.A., Bradley, Charles, M.D. (1998). American Journal of
Psychiatry, 155:968.
Gross, M.D. (1995). Origin of stimulant use for treatment of attention
deficit disorder. American Journal of Psychiatry, 152:298–299.
Centers for Disease Control and Prevention. (2010). Increasing
Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder
Among Children --- United States, 2003 and 2007. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm
Krull, K.R. (2016). Pharmacology of drugs used to treat attention
deficit hyperactivity disorder in children and adolescents. Up To Date.
Retrieved online at
https://www.uptodate.com/contents/pharmacology-of-drugs-used-totreat-attention-deficit-hyperactivity-disorder-in-children-andadolescents?source=search_result&search=adhd%20and%20catechola
mines&selectedTitle=4~150
Spinelli, S., Joel, S., Nelson, T.E., Vasa, R.A., Pekar, J.J., Mostofsky,
S.H. (2011). Different neural patterns are associated with trials
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11.
12.
13.
14.
15.
16.
17.
18.
19.
preceding inhibitory errors in children with and without attentiondeficit/hyperactivity disorder. Journal of American Academy of Child
and Adolescent Psychiatry, 50(7):705-715.e3.
Ducharme, S., Hudziak, J.J., Botteron, K.N., Albaugh, M.D., Nguyen,
T.V., Karama, S. (2012). Decreased regional cortical thickness and
thinning rate are associated with inattention symptoms in healthy
children. Journal of American Academy of Child and Adolescent
Psychiatry, 51(1):18-27.e2.
Krull, K. (2016). Attention deficit hyperactivity disorder in children and
adolescents: Epidemiology and pathogenesis. Up To Date. Retrieved
online at https://www.uptodate.com/contents/attention-deficithyperactivity-disorder-in-children-and-adolescents-epidemiology-andpathogenesis?source=search_result&search=adhd%20and%20twins&s
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