Download Evaluation and Assessment Issues in the Diagnosis

Evaluation and Assessment Issues in the
Diagnosis of Attention Deficit Hyperactivity Disorder
Ruth D. Nass, MD
This article discusses the availability and appropriateness of various assessment techniques for diagnosing ADHD. In terms of the interview/history, the necessity and viability
of using formal structured, semi structured, computerized and informal interviews for
making an ADHD diagnosis are critiqued. The pros and cons of the various questionnaires
frequently used to diagnose ADHD are addressed. The conundrum raised by multiple
informants who often disagree is discussed, as are the effects of age and gender. The
contributions of the medical and neurological examinations to the diagnosis of ADHD are
considered. The utility of a neuropsychological assessment and of continuous performance
testing to diagnosis is critiqued. Finally the lack of need for laboratory tests and the lack of
necessity of neurological workup, specifically EEG and imaging, are argued.
Semin Pediatr Neurol 12:200-216 © 2006 Elsevier Inc. All rights reserved.
T
he purpose of this review is to discuss the components of
the pediatric neurologist’s diagnostic evaluation of the
child with attention deficit hyperactivity disorder (ADHD).
In particular, evidence will be presented about which assessment procedures and tests are necessary for diagnosis and
whether any one test or any tests can be used in isolation or in
combination to diagnose ADHD.
The Interview/History
Are Formal Structured, Semistructured,
or Computerized Interviews Necessary
for Making an ADHD Diagnosis?
The history/intake interview is the cornerstone of the diagnostic assessment for ADHD. Formal structured and semistructured interviews like the Schedule for Affective Disorders and Schizophrenia for School-Age Children,1 the
National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children,2 the Diagnostic and Statistical
Manual of Mental Disorders (DSM)-based Diagnostic Interview For Children and Adolescents (DICA),3,4 and the Child
and Adolescent Psychiatric Assessment5 are used in research
studies to diagnose ADHD and thus would seem at first
glance to be the optimal, most reliable clinical assessment
Department of Neurology, New York University School of Medicine, New
York, NY.
Address reprint requests to Ruth D. Nass, MD, Department of Neurology,
New York University School of Medicine, NYU Medical Center, RR311,
550 First Ave, New York, NY 10016. E-mail: [email protected]
200
1071-9091/05/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.spen.2005.12.002
measure. However, such interviews are time consuming,
and, unlike pediatric psychiatrists, pediatric neurologists are
not trained to administer them. For example, the Child and
Adolescent Psychiatric Assessment basic interview covers an
age range from 9 to 17 years and takes about 1 hour to
administer. Similar comprehensive versions for use with
young adults and with preschool-aged children have also
been developed.5 Addressing the time issue, a shorter “gateway” version has been devised using the core symptoms of
the diagnostic category in question as screening items. Computerized interviews for parents to complete are available (eg,
a version of the DICA3,6), but they too are time consuming
both for the parent to fill out and for the clinician to score.
And again, the pediatric neurologist is not trained in their
interpretation. Theoretically, the availability of detailed glossaries and training manuals should make it possible to train
even “lay” interviewers, and certainly pediatric neurologists,
adequately for structured interviewing.4,7 Nonetheless, the
time constraints remain a practical issue.
Furthermore, the clear advantage of a structured, semistructured, or computerized interview compared with an informal history remains to be determined because the former
interview types are not immune to theoretical problems, in
addition to the practical problem of administration time. The
cross-reliability of many such interviews even in the hands of
those well trained in their administration has been questioned.8 Questions have been raised, for example, as to
whether the 2 versions (6-12 years, 13-18 years) of the highly
structured form of the DICA can be viewed as the same interview. This is a problem for any instrument assessing
Diagnosis of ADHD
youths of different ages because the same questions may be
understood differently by children and adolescents on account of their different developmental levels. The impact of
ethnic, cultural, and socioeconomic differences in youths’
understanding of interviews (and questionnaires, see later)
has not been sufficiently studied to determine whether and
which questions are perceived differently by different subgroups of interviewees. And there are interviewer as well as
interviewee issues. Even with highly structured instruments,
some interviewers are simply more skilled at interviewing
than others.4 Unless interviewers are carefully selected and
extremely well trained, even a highly structured instrument is
not always administered in the same way.4 This is an important issue even in the context of research use in which structured interviews are generally the gold standard.9-11
The weakness of highly structured interviews is highlighted by the controversy about the validity of such interviews in general and the degree of structure required for
maximal efficacy. A semistructured instrument (eg, versions
of the DICA)12 may actually provide a more accurate assessment of children, particularly younger ones, and adolescents
than a highly structured interview. With semistructured instruments, interviewers have the same basic script and provide the same basic probes. However, interviewers do not
have to use the exact same wording and probes. This allows
for more flexibility and individualization of the interview.
This may be particularly important for the younger child who
requires more concrete probes.4 Semistructured interviews
also require, however, that the interviewer know enough
about the disorder and its symptoms to be accurate as well as
flexible with their probes.4 Adding pictures to the interview,
which can be done in a semistructured situation, may enhance its validity particularly with younger children.13
Furthermore, validity studies based on a test-retest design4
comparing the structured interview with diagnoses in the
physician’s chart14 or behavioral questionnaires12 suggest
that even structured interviews vary in their reliability. This
factor would be a particular confound in an office practice.
Given time constraints and training issues as well, structured,
semistructured, and computerized interviews appear to be
more suited for research studies than clinical use.
Is an Informal Interview
Adequate for the Diagnosis of ADHD?
An informal interview/history focusing on the chief complaints about inattention, impulsivity, distractibility, and hyperactivity at school and at home, specifically addressing the
DSM IV criteria for ADHD, is the most practical way for the
pediatric neurologist to approach the diagnosis of ADHD. It
must be noted, however, that some research studies do not
support unstructured interviews as reliable means of making
DSM diagnoses.15 Even experienced clinicians do not always
agree about diagnosis after an informal interview. And their
diagnoses do not always coincide with structured interview
or computer-assisted interview results.16-20 On the other
hand, other validity studies show that informal interviews
agree with the diagnoses in the physician’s chart14 enhancing
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their credibility. From a practical vantage point, an informal
diagnostic interview, using a DSM-based template, coupled
with other ancillary measures (see later) seems the most reasonable and practical choice for diagnosing ADHD in the
pediatric neurologists’ office.
The clinical history is in essence a medical document, and,
as such, it should include a detailed chief complaint, history
of present illness,21 psychiatric history, developmental history, medical history, family and social histories, review of
systems, and mental status examination. Familiarity with organizing such an evaluation gained from medical training
and use of the evaluation as a means of communication to
other care providers supports the use of the traditional medical history format as a diagnostic tool for ADHD.15
The informal diagnostic interview must be properly structured to be optimal. First, because parents and children often
do not agree on diagnosis,22,23 both need to be interviewed.
Both children, even young ones, and adolescents can give
important and valid information about themselves via interview. Joint and individual interviews (providing an opportunity to inquire about sensitive topics) are necessary.15 Evaluating the different respondents in person is particularly
important in view of the documented lack of agreement by
parents and children on questionnaires. But questionnaires
are necessary to corroborate and supplement the diagnostic
information obtained during the office history.
Are Questionnaire
Results Diagnostic of ADHD?
Questionnaires are an important and efficient part of the
diagnostic assessment but cannot be used in isolation to
make a diagnosis of ADHD.24-28 The correspondence between direct observation and rating scale diagnoses support
the validity of the latter for making the diagnosis, albeit not in
isolation.29,30 Teachers, parents, and older children can/
should all report on symptoms to assess for agreement/validity of diagnosis, to document that the ADHD symptoms occur in multiple settings, and to take advantage of the special
information that each can provide. Using different types of
questionnaires, narrow band tapping only ADHD issues, and
broad band tapping a wide range potential comorbid issues,
enhances the diagnostic and treatment options.
The Conundrum
of Multiple Informants
Multiple informants (parents, teachers, youths, and health
care professionals) do not necessarily agree on diagnosis.
Care must be taken to determine the best interpretation of the
data if disagreements occur.31-34
Parents
Parents are often the primary informant(s).35 But, parents,
like other informants, are susceptible to diagnostic biases,
social background effects,36-39 personal hidden agendas,
varying observational skills, different attitudes toward questionnaires, and the effects of setting on ADHD.40,41 In addi-
R.D. Nass
202
tion, varying parenting skills may affect the likelihood that
they make a diagnosis of ADHD in their own child. In view of
the hereditary nature42 of ADHD, the presence or absence of
ADHD in other family members, including the parent informant, may affect diagnostic acumen. However, at least 1
study suggests that parents with ADHD are no more or less
likely to diagnose ADHD in their children.43
Teachers
Teachers obviously provide the crucial information about
school behaviors.44 However, ADHD prevalence rates in
school-age children based on the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV)-referenced, teacher-completed behavior rating scales vary more
widely than one would like44-53 if one is depending on the
questionnaire results for diagnosis. Overall prevalence rates
range from 8% to 23%. A number of factors may underlie the
variability.
The age of the group being rated may affect teacher responses.49,51,52,54 Teachers of students of different ages may
differ in their reliability as informants for a variety of reasons.
Elementary school teachers spend the whole day with their
students and know them well,55 but high school teachers,
who only have a student for a single subject, may not know
the student as well. Indeed, high school teachers report the
lowest rates of adolescent psychopathology and show relatively low agreement with other sources.56 Furthermore, the
fact that ADHD subtype frequency differs at different ages
may further confound this. For example, based on DSM-IV–
referenced symptom inventories of about 3,000 school children aged between 3 and 18 years, teacher-reported prevalence rate of ADHD behaviors was 15.8%; rates for individual
subtypes were 9.9% for inattentive, 2.4% for hyperactive
impulsive, and 3.6% for combined. The inattentive type was
relatively uncommon in preschool children (3.9%), whereas
the hyperactive-impulsive type was least common in teenagers (0.8%).57-62
Teacher rating may be susceptible to a halo effect (1 behavior affects the perception of another). For example, child
actors with oppositional defiant disorder and ADHD were
more likely to be diagnosed ADHD than those with ADHD
alone.63,64 This may be another way of saying that comorbidities affect/bias the diagnosis of ADHD.49,65 Because different
ADHD subtypes show different comorbidities (eg, Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
symptoms are more common in the combined type than the
inattentive45,49,50,52), teachers may be even more likely to diagnose children with combined type and miss the inattentive
type. Social skills deficits may also differ by ADHD subtypes
with the combined type again tending to have the highest
frequency of social deficits.48,49,66
Every teacher has his/her biases about ADHD as a diagnosis.63,67 Knowledge about ADHD has been shown to affect
teacher-rating skills.68 A number of other factors have been
reported to affect teacher ratings. Ethnicity of the children
being rated may affect teacher ratings. In this same study,57-62
screening prevalence rates were higher for black (39.5%)
than white (14.2%) students. Prevalence of ADHD as reported by teachers is affected by geographic region in some
studies and not in others.49 Prevalence of ADHD is affected by
socioeconomic status in some studies and not in others.49
Despite all the variability, the reliability of teacher ratings is
attested to by the fact that teacher ratings predict peer ratings.69 Questionnaires do not necessarily replace a conversation with the teacher either for diagnosing or for assessing
treatment.70
Parents and Teachers: Degree of
Agreement, Causes of Disagreement,
and Whether to Make a Diagnosis
Parent-teacher agreement can be variable31,56,71-75 and may
depend on the particular questionnaire in use, age, gender,
presence of other comorbidities, and social class of the child
among other factors. Because ADHD behavior must be
present in 2 settings, parent-teacher disagreement31,33,34,76-78
can complicate making an ADHD diagnosis. In 1 recent
study, for example, teacher ratings of about 6,000 elementary
school children identified about 1,600 children as being at
high risk for ADHD. Follow-up parent interviews and further
information from teachers was collected on about 250 of the
“ADHD” children. The agreement between the parent and
teacher reports of ADHD symptoms according to a DSM-IV–
based questionnaire was relatively low. When the 2-setting
requirement was strictly enforced, poor interrater agreement
decreased diagnostic rates for all 3 types of ADHD in this
clinical sample: inattentive (fell from 15% [teachers] to 5%
[parents and teachers]), hyperactive/impulsive (fell from
11% [teachers] to 3% [parents and teachers]), and combined
(fell from 23% [teachers] to 7% [parents and teachers]). Using more lenient core symptom scores reduced parentteacher disagreement79 (Fig 1A and B). In another recent
study80 also using a DSM-IV– based questionnaire, 43.5% of
the students were diagnosed by both parent and teachers as
having ADHD; 11.5% had the inattentive type, and 32% had
ADHD combined type. In 41% of the cohort, only the parent
or the teacher diagnosed ADHD. In 16%, both parents and
teachers agreed that the child did not have ADHD.
Another study found substantial variance in the description of ADHD subtypes depending on the source (parents
versus teachers) and measure, 2 commonly used broadband
scales: Child Behavior Checklist56,71 or Behavioral Assessment System for Children (BASC).81 For example, parents
saw the combined type ADHD child as having more conduct
and hyperactivity issues than the inattentive type, whereas
teachers did not. Parents gave higher inattentive rating to
children with the combined subtype on the Child Behavior
Checklist but not on the BASC. Given this variation within
the same population, even greater differences would be expected and have been found with different populations and
different diagnostic and reporter sources.82
Parents and Youths
Parents and youths agree about diagnosis anywhere from
20% to 80% of the time. In some studies, rates of reported
Diagnosis of ADHD
203
Table 1 Frequency of Comorbid Disorders in Children
With ADHD
(%)
Oppositional defiant disorder
Conduct disorder
Major depressive disorder
Bipolar disorder
Anxiety disorder
Tics/Tourette syndrome
Learning disabilities
40-65
25-35
30
10
25
>10
About 20
ADHD symptoms are almost twice as high in parents’ reports
as those made by children and adolescents.83 In other words,
they often disagree about diagnosis. Initial studies suggested
and recent studies confirm that parents report more symptoms overall than children do about themselves.14,84 Even
more specifically, parents tend to note the core externalizing
symptoms of ADHD (impulsivity, hyperactivity, and inattention) and behavioral issues (oppositional defiant disorder
and conduct disorder),33 whereas children and adolescents
often deny them.11,83,85,86
By contrast, children and adolescents can report on internalizing symptoms (anxiety, mood, and obsessiveness) and
substance abuse about which parents may be unaware. A
gender bias may exist in this differential reporting with girls
in particular reporting more internalizing symptoms than
their parents.84 Some researchers have suggested that diagnosing ADHD based on either parents’ or youths’ positive
responses,23 as well as on a positive response from both, may
be acceptable.
Health Care Professionals
and Teachers or Parents
Health care professionals do not really have an opportunity to
assess for ADHD in a naturalistic environment.87 The office is
obviously an artificial setting, and the demands are out of the
ordinary. The observation period for the health care professional is also quite brief. In 1 study, health care professionals
diagnosed ADHD in only 40% of those identified by their
teachers.79 Another study40 comparing the frequency of parent, teacher, and physician ADHD diagnosis found a rather
poor agreement rate as well. In 9%, parents, teachers, and the
primary care physician agreed that the diagnosis was ADHD,
Table 2 Frequency of ADHD in Children With Other Disorders
(%)
Figure 1 (A) Parent-teacher combinations: hyperactive impulsive
ADHD subtype. Percent diagnosed with ADHD depending on
whether the source is parent, teacher, parent and teacher, or parent
or teacher. (B) Parent-teacher combinations: inattentive ADHD subtype. Percent based on parent, teacher, parent and teacher, and
parent or teacher report.
Conduct disorder or oppositional defiant
disorder (under 12 years)
Conduct disorder (adolescent)
Major depressive disorder
Bipolar disorder
Anxiety disorder
Tourette syndrome
Learning disability
About 100
30
10-30
About 100
25
>50
About 20
R.D. Nass
204
Table 3 ADHD Diagnostic Questionnaires
Ages
Parent
and
Teacher
SelfReport
Normative
Data
Discriminant
Validity
ACTeRS
5-13
Yes
Yes
ADHD v nonclinical v
LD
CRS-R
3-17
Yes
Yes
Limited T scores
and
percentiles
Yes
DSM-based symptom
inventories, ECI,
CSI, ASI
SNAP-IV
3-17
Yes
Yes
5-11
Yes
No
Yes, categorical
and severity
cutoff
Limited
VADTRS, VADPRS
6-12
Yes
No
Limited
ADDES-2
4-18
Yes
No
Yes
ADHD v nonclinical,
93rd-98th percentile
ADHD-SRS
5-18
Yes
No
Yes
ADHD v nonclinical
85th-95th percentile
ADHD RS-IV
5-18
Yes
Yes
Yes, 80th-93rd
percentile
ADHD v nonclinical,
ADHD subtypes
ADHD v nonclinical
93rd percentile
ADHD v nonclinical
None
95%
85th-97th percentile
(teachers only)
Other
Takes 5-10 min
Spanish version
Computerized
Takes 20-30 mins,
short and long
forms, quick score
forms, French
Canadian version
Takes 10-15 min
5-10 min short form,
20-30 long form
Takes 10-15 min
Spanish and German
versions
Takes 10-15 min
Computer scoring
Spanish version
Takes 15-20 min
Computer scoring
Spanish version
Takes 5-10 min
Spanish version
NOTE. ACTeRS (Attention Rating Scale).276,165
ADDES-2 (Attention Deficit Disorder Evaluation Scale-Second Edition).117,118
ADHD RS-IV (ADHD Rating Scale-IV).135
ADHD SRS (ADHD Symptoms Rating Scale).121
ASI (Adolescent Symptom Inventory).57
CSI (Child Symptom Inventory).58
CRS-R (Connors Rating Scale Revised).109
DSM-Based Symptom Inventories.35,57,276
ECI (Early Child Symptom Inventory).59
SNAP-IV (Swanson, Nolan, and Pelham-IV Questionnaire).95
VADTRS, VADPRS (Vanderbilt ADHD Diagnostic Parent Rating Scale; Vanderbilt ADHD Diagnostic Teacher Rating Scale).53,97,125
in 30% they agreed that the diagnosis was not ADHD, and in
61% the 3 groups could not agree on diagnosis.
What Types and
Which Questionnaires
Should Be Used?
Broadband Versus Narrowband
Questionnaires
Broadband questionnaires evaluate not only for the ADHD
diagnosis but also for common comorbidities (Tables 1 and
2) of ADHD (that occur in both clinical and community
samples), which may affect both diagnostic accuracy and
treatment.7,70,88-96 For example, the MTA study showed that
children with co-occurring ADHD and anxiety disorders (but
who had no oppositional defiant disorder or conduct disorder) were likely to respond equally well to the MTA behavioral and medication treatments. Children with ADHD only
or ADHD with oppositional defiant disorder or conduct dis-
order (but without anxiety disorders) responded best to the
MTA medication treatment regimen (with or without behavioral treatments). Children with multiple comorbid disorders
(anxiety and oppositional defiant disorder and/ or conduct
disorder) responded optimally to combined (medication and
behavioral) treatments.93 In addition to posing questions
about other non-ADHD problems, broadband questionnaires generally leave space for comments. Sometimes finding a discrepancy between comments of parents, teachers, or
youths and their ratings on the Likert scale items (where one
is forced to choose 0, 1, or 2) prompts questions from the
physician that enhance the accuracy of diagnosis.
On the negative side, broadband questionnaires are longer
because they are more comprehensive than narrowband
questionnaires. This makes them less useful for repeated use.
Also, they have fewer questions about ADHD because other
diagnostic entities must be covered as well.
By contrast, narrowband questionnaires focus on the
core ADHD symptoms and are useful both for making the
specific diagnosis and for monitoring treatment. Informa-
Diagnosis of ADHD
tion from both types of questionnaires maximizes the
breadth of the assessment and treatment options. Each
physician should choose questionnaire(s) with which he/
she is comfortable.
Specific Broadband Questionnaires.
Several broadband questionnaires are available. The Preschool and School-Age Checklist measures of Achenbach and
Rescorla56,71 and the BASC81 (with forms for teachers, parents, and adolescents) are the most commonly used. The
Vanderbilt questionnaires53,97 and the long form of the Swanson, Nolan, and Pelham Questionnaire98 (see later) (with
forms for teachers and parents), designed primarily for
ADHD diagnosis, include some questions relating to common comorbidities.
Specific Narrowband Questionnaires
A number of narrowband questionnaires, some DSM-based
and others not, are available24,25 Each has its pros and cons
(Table 3). Differences among the questionnaires reflect variations in degree of standardization,99,100 norms, age span,
range of informants, and potential for gender biases.101 Some
questionnaires may be more appropriate for diagnosis and
others for medication monitoring. Economics may also be a
consideration; some questionnaires are available on the Internet and may be repeatedly used, whereas others must be
purchased for single use. Some questionnaires require computer scoring systems to be practical time wise.
The narrowband scales that are based on DSM-IV have
good face validity because their items are derived from the
standard diagnostic construct for ADHD, although clinically
relevant validation is wanting for most of the scales generally
used for ADHD.102 For example, the same ADHD sample was
used in both the development and validation of the discriminant analysis of the Connors Rating Scales–Revised (CRS-R).
However, if the questionnaire is seen as a part of an array of
data used to make a diagnosis, this shortcoming is mitigated.103,104 Most questionnaires yield the same core subscales of inattention and hyperactivity/impulsivity subtypes,
are similar in format, and rely on adults’ reports of youths’
behavior. Thus, it is difficult to find advantages for one scale
over another, and “head-to-head” comparisons of these scales
are not available. Therefore, choosing a scale largely hinges
on the need for additional items to screen for comorbidities,
other measures included in the assessment battery, the intended adult reporter, the need for adolescent self-report,
and then matching the planned application to a scale’s format
and psychometric properties.99
Guidelines:
Prioritizing Scale Selection
to Specific Applications
A thorough assessment of ADHD symptoms requires a scale
that taps both the broad context and nuances of ADHD. The
CRS-R39,105-112; the Swanson, Nolan, and Pelham-IV Questionnaire (SNAP-IV)98,113,114; the Attention Deficit Disorder
Evaluation Scale-Second Edition (ADDES-2)115-118; and the
205
ADHD Symptoms Rating Scale (ADHD-SRS)119-121 are most
likely to provide such thorough assessments.99 Among these,
the SNAP-IV, although it has been used frequently in research studies,122,123 has the least published technical properties including age norms. However, it does have the advantage of an Internet-accessible scorer with graphics that
provides preliminary cutoff criteria for diagnosis. The CRS-R
has the strongest research base with data on both community
and clinical populations. The normative samples of both the
CRS-R and ADDES-2 have multiple demographic strata,
which allows for optimal interpretation of an individual’s
scores. By contrast, the ADHD-SRS scores can only be compared with broad ranges of other children (5-12 years of age)
and adolescents (13-18 years of age), although this is probably adequate for most clinical applications. Of the 4, only the
CRS-R provides normative data for preschoolers. Furthermore, the CRS-R’s abbreviated versions and brief ADHDspecific forms facilitate repeated administration of the scale
for treatment monitoring. The adolescent self-report of the
CRS-R (Connor-Wells Adolescent Self-Report Scale)108,109 allows for comparison of youths’ perceptions with those of
parents and/or teachers. Finally, the Connors’ questionnaire
subscales screening for at least some comorbidities may be
helpful in situations in which additional broadband scales
cannot be administered.99 The ADDES-2 and ADHD-SRS are
comparable scales and have multiple items to tap each
DSM-IV symptom of ADHD. Therefore, either could be useful in assessing the nuances of ADHD. Both the ADDES and
ADHD-SRS would be complimented by a broadband measure. The ADDES-2 has the advantage of having both parent
and teacher versions. Both of these scales need to be researched further with clinical populations to more comprehensively evaluate their utility, sensitivity, and specificity and
to enhance the breadth of published experience. Furthermore, neither has an adolescent self-report form.99
Screening for ADHD requires a brief scale with good sensitivity to rapidly identify as many true cases as possible. The
CRS-R,124 ADHD Rating Scale-IV (ADHD RS-IV),33,41,44
Vanderbilt ADHD Teacher Rating Scale (VADTRS),53,97 and
Vanderbilt ADHD Parent Rating Scale (VADPRS)125 all meet
the bill on this count. The American Academy of Pediatrics
has endorsed this scale and provides a complete tool kit on
the Internet (www.nichq.org) that even includes a cover letter to teachers. The CRS-R and ADHD RS-IV have been used
most often with clinical samples. The CRS-R shows excellent
sensitivity; but it is a bit long for screening purposes. The
abbreviated version might be a good screen; however, its
diagnostic sensitivity and specificity are not established. The
ADHD RS-IV is the briefest, and it has shown discriminant
validity. However, the suboptimal sensitivity of the teacher
form raises questions about its usefulness in the school setting. The VADTRS and VADPRS are also quick screens, but
more data on their sensitivity and general utility are needed.99
Other scales are available. The pros and cons of many of
these are listed in Table 3. Ultimately, the clinician must
choose the one(s) with which he/she is comfortable. Having
the questionnaires at the time of the initial visit can streamline the assessment. Providing teachers with an addressed
R.D. Nass
206
stamped envelope for the rating scales increases the return
rate.
Is Gender a Factor That Requires
a Change in Diagnostic Assessment?
Gender must be considered at all levels of the assessment
(office interview, questionnaires, and neuropsychological
testing) of the potential ADHD child.46,65,126-132 Girls with
ADHD are more likely than boys to have the predominantly
inattentive type of ADHD, less likely to have a learning disability, and less likely to manifest dramatic problems in
school or in their spare time. In addition, girls with ADHD are
at less risk for comorbid major depression, conduct disorder,
and oppositional defiant disorder than boys with ADHD. The
lower frequency of psychiatric, cognitive, and apparent functional impairment in girls may increase the rate of failed/
misdiagnosis.133 Thus, they are less likely to get to the office
for assessment. And their problems may be less apparent
during the interview and on questionnaire reports.
Parents underreport girls’ symptoms.134 Teacher rating
scales, especially those that are brief, may also fail to pick up
girls with ADHD. Most, but not all,135 teacher rating studies
report a preponderance of males for all 3 ADHD subtypes. In
Nolan et al’s study49 study based on questionnaire reports,
gender differences varied both according to the age of the
child and ADHD subtype. Males outnumbered females for all
subtypes, except the Inattentive type in preschool children.
Formal neuropsychological testing may be particularly useful
when diagnosing ADHD in girls, but the relative infrequency
of learning issues may mitigate against doing the assessment
in the first place. Therefore, when the question of ADHD is
raised about a girl the assessment needs to be unusually thorough.
Is Age a Factor in the
Diagnostic Assessment?
persistent enough symptoms to be diagnosed with ADHD,
only one half still met criteria for the diagnosis in elementary
school.148 Therefore, symptom duration of 12 months (rather
than the 6 months suggested for school-age children) has
been proposed as a more appropriate criterion for the diagnosis of ADHD in preschoolers.25 On the other hand, many
studies document a strong correlation between a diagnosis
of ADHD during the preschool period and at school
age.147,149-151
The specific diagnostic criteria for the preschooler are less
clear cut than in the older child. Preschool children with
ADHD are characteristically extremely hyperactive.137,152
Clinical observations of preschool children in naturalistic settings are often particularly useful; in one such study, only 6%
of preschool children with ADHD had no problems during
the clinical observation.152 Behavioral comorbidities are particularly common in preschoolers with ADHD.153,154 Young
children with ADHD also tend to have high rates of language
problems155 and developmental coordination disorder.156
Parent and teacher/caregiver rating scales are useful in the
diagnosis of ADHD during the preschool years.56,105,157-161
However, if the child is not in school, a second reporter may
not be available to confirm parents’ impressions. The crucial
symptoms may differ from that of the school age child. In 1
study, 6 DSM-based ADHD symptoms discriminated preschool children with ADHD from controls better than the
remaining 12 items. These were (1) difficulty sustaining attention, (2) easily distracted, (3) often “on the go,” (4) runs/
climbs about excessively, (5) does not follow through on
instructions, and (6) difficulty remaining seated.146 Impulsivity symptoms were infrequently endorsed, possibly because
the examples and wording in the DSM apply more clearly to
older children. Scales designed specifically for preschoolers
may be better choices than DSM-based scales.59,71,157 Questions more relevant to diagnosing ADHD in the preschooler
are shown in Table 4.
Both preschool children and adolescents present particular
problems for diagnosis.
Diagnosing ADHD
in the Preschooler
In about half the children with ADHD, onset is said to occur/be apparent before 4 years of age.136,127 But the estimated
frequency of ADHD in children between 2 and 5 years varies
widely from approximately 2% to 5%138-141 to 10%45 to
18%.142 Diagnosing ADHD in preschoolers can be complex
because the range of behaviors acceptable in the preschooler
is so broad.137,143-146 Furthermore, ADHD symptoms may be
transient, lasting only 3 to 6 months.25,147 In 1 prospective
study of over 200 children followed from birth to kindergarten school entry, 41% of the preschoolers were found by
parents, teachers, or the researchers to have some attention
difficulties.137 In 5%, the attention issues were significant and
persisted at least into elementary school, but an additional
8% had significant problems that abated before school age.
Another study found that even among those with severe and
Diagnosing ADHD
in the Adolescent
Adolescents110,162-164 often underreport their ADHD symptoms in comparison to parent reports. Nonetheless, an adolescent self-report is useful for corroborating parents and
teachers (Connor Wells Adolescent Self-Report,109 Youth Self
Report,56 Youth Self-Report,81 Adolescent Symptom Inventory 4,61 and ACTeRS.165 As discussed previously, junior high
and high school teachers who see students only for single
subjects and see larger numbers of students may be less able
to accurately complete ADHD questionnaires. Finally, the
questionnaires that are DSM-based were by and large developed for elementary school age children and may not focus in
on issues more relevant to adolescent manifestations of
ADHD. Organizational and executive functioning issues may
be the primary problems of the adolescent with ADHD. As
with girls, neuropsychological testing may be particularly
helpful for corroborating suspected ADHD diagnoses. Ques-
Diagnosis of ADHD
Table 4 Characteristics of the Preschool Child With ADHD
Rushes through tasks paying little attention to details
Has difficulty paying attention to tasks or play activities
Does not seem to listen
Shifts from 1 activity to another
Has difficulties organizing activities
Avoids doing tasks that require mental effort
Loses things
Is easily distracted
Is forgetful
Fidgets or squirms
Has difficulty remaining seated
Runs about or climbs on things when asked not to
Has difficulty playing quietly
In always on the go
Talks excessively
Blurts out answers before the question is complete
Has difficulty awaiting his turn
Interrupts people or disrupts group activities
NOTE. 0-3 scale from Gadow KD, Sprafkin J: Early Childhood Inventory-4 Screening Manual. Stony Brook, NY; Checkmate Plus,
2000.
tionnaires tapping executive function (see later) may also be
useful.
Is Medical History Relevant to Diagnosis?
A thorough medical history is part of the initial evaluation.166
Prematurity and frequent episodes of otitis with hearing loss,
for example, may be risk factors of ADHD (Table 5).
Is Family History Relevant to Diagnosis?
A complete family history for ADHD and its common comorbidities should be taken. ADHD is a highly heritable disorder,167-169 and, although a positive family history does not
confirm the diagnosis, it can be supportive.
Is the Psychosocial History
Relevant to Diagnosis?
Again, a psychosocial history, although not diagnostic, provides important information that may play a major role in
management decisions.122 For example, in families on public
assistance, medication management resulted in decreased
closeness in parent-child interactions, and combined treatment yielded relatively greater benefits for teacher-reported
social skills. In families with high treatment acceptance/attendance, intent-to-treat results were upheld. Acceptance/
attendance was particularly important for medication treatments. In view of the heritability of ADHD and its
comorbidities, psychosocial issues are likely to be present
and require attention.170
Do the Medical and Neurologic Examination
Contribute to the Diagnosis of ADHD?
Medical problems that can be associated with ADHD have
been discussed previously (Table 5). The general medical
examination may be used to corroborate some of these con-
207
ditions. Minor physical anomalies (eg, electric hair, hypertelorism, highly arched palate, and low-set ears) may occur at a
higher rate in preschoolers with ADHD than in the general
population,171 particularly when the ADHD is transmitted via
the paternal line.
The neurologic examination is part of any complete diagnostic evaluation. In addition to the traditional neurologic
examination, a number of standardized office examinations
that tap developmental neurologic functions are available.172-178 Many, but by no means all studies, suggest a high
frequency of soft signs in ADHD children; some even suggest
that certain neurologic findings may be diagnostic of ADHD.
Denckla179 distinguishes 2 types of soft signs: developmental
ones, findings that would be normal if the child were
younger, and classic pastel soft signs, findings that could be
seen on the traditional neurologic examination but are subtle
in their presentation and not necessarily reproducible [eg,
minor reflex asymmetry].) Age-inappropriate overflow movements (eg, mirror movements) are motor signs thought to reflect
immaturity in cortical systems involved in automatically (unconsciously, without explicit effort) inhibiting extraneous
movement.180 Overflow movements have often been reported
to be increased in children with ADHD.156,170,177,181-187 In 1 recent study, children with ADHD made more errors on the conflicting and contralateral motor response tests (ie, showed impaired response inhibition compared with controls).188 In the
National Collaborative Perinatal Project, severe hyperactive impulsive behavior was not associated with soft signs at age 7 years,
although severe soft signs did correlate with hyperactivity at age
4 years.170
In view of the basal ganglia dysfunction documented in
ADHD, the Prechtl sign, which requires the child to close his
eyes, extend his arms, and stick out his tongue and which
thereby elicits choreiform movements,178 might be expected
to be a marker of ADHD. However, the significance the Prechtl sign remains debated.189 Its frequency in the general
population versus ADHD children versus other clinical populations is not known nor is the age range when it might be
particularly revealing documented.
Much can be learned from the child’s attitude toward the
examination, as well potentially as from the examination it-
Table 5 Medical Problems Associated With ADHD
Thyrotoxicosis, hypothyroidism, generalized resistance to
thyroid hormone
Epilepsy
Allergy
Asthma
Otitis media
Chronic illness
Lead poisoning
Concussion, closed head injury
Tics/Tourette syndrome
Prematurity
Inborn errors of metabolism
Chromosomal disorders (eg, Turner syndrome, fragile X
syndrome)
208
Table 6 Neuropsychological Measures Useful in Assessing
Children With ADHD
Wechsler IQ subtests
Freedom from distractibility factor (coding, digit span,
arithmetic)
Working memory factor (coding, digit span)
Processing speed factor (symbol search, arithmetic)
Executive functions
Initiation—Reitan Trails A
Inhibition—Stroop Interference task, go no go task, stop
signal tasks
Sustained attention—Reitan Trials A, MFF
Shift—Stroop Interference task, Wisconsin card sort,
Reitan Trials B
Working memory—paced auditory serial addition task,
California Verbal Learning test
Naturalistic measures of attention
Six elements test
Hayling sentence
Questionnaires
Behavior Rating Inventory of Executive Function (BRIEF)
Brown Attention-Deficit Disorder Scales for Children and
Adolescents
self. Although the agreement between physician and parent
and teacher about the diagnosis of ADHD is often low,40
behavioral assessment during the neurologic examination
gives the pediatric neurologist a better opportunity to make
observations and weigh in thoughtfully on the likelihood of
ADHD and possible other comorbid behavioral disorders
(oppositional defiant disorder and conduct disorder).
Furthermore, the neurologic examination, whether diagnostic of ADHD in and of itself, provides an opportunity to
evaluate for commonly comorbid neurologic problems of coordination like tic disorders, dyspraxia, and dysgraphia.190
The office mental status examination allows for an assessment for learning disabilities170 that co-occur not infrequently with ADHD including dyslexia, dysgraphia, nonverbal learning disabilities, visuospatial difficulties, dyscalculia,
and social emotional difficulties.
Can Neuropsychological Testing
Be Used to Diagnose ADHD?
Neuropsychological testing191,192 is not a necessary part of the
diagnostic assessment of ADHD, unless specific comorbid or
associated learning issues need to be evaluated. Results of
neuropsychological testing, however, may lend support to
the diagnosis (Table 6).193 Although neuropsychological testing may be supportive of the ADHD diagnosis, it cannot be
used in isolation to diagnose ADHD.
Executive dysfunction is common in the ADHD
child.194-196 Thus, the ability to initiate, inhibit, sustain,
and/or shift attention is often problematic for the child with
ADHD. On the traditional Wechsler IQ test,197,198 the
subtests that tend to be rote, repetitive, and require attention
and memory are difficult for the ADHD child including coding (associating symbols with numbers), digit span (repeating number series forward and backward), symbol search
R.D. Nass
(matching patterns), and arithmetic (mental calculations).199
The ADHD child may perform slowly and/or inaccurately.
Memory tasks that have less content are more difficult than
those that are more engaging. For example, memory for stories is easier than memory for words. Tasks requiring active
working memory tend to be hard for the ADHD child.200
Several questionnaires for parents and/or the youths themselves address executive function rather than DSM-based
characteristics of ADHD. The Brown Attention-Deficit Disorder Scales for Children and Adolescents201 for parents and
youths evaluates 6 facets of executive functioning: organizing, prioritizing, and activating to work; focusing, sustaining,
and shifting attention to tasks; regulating alertness, sustaining effort, and processing speed; managing frustration and
modulating emotions; using working memory and accessing
recall; and monitoring and self-regulating action. The Behavior Rating Inventory of Executive Function.202 for parents
and teachers also looks at executive functions in a questionnaire format that assesses the ability to inhibit, shift, control
emotions, initiate, working memory, plan/organize, organize
materials, and monitor behavior.
Deficits in executive functioning are by no means always
present194,203 in ADHD children nor are they unique to
ADHD. For example, executive dysfunction is seen in patients with oppositional defiant disorder and conduct disorder.204-206 Age may be a factor. Cognitive test performance on
structured measures that are very useful for corroborating the
diagnosis in the older child may be less helpful in discriminating between ADHD and normal preschool children. For
example, preschoolers do not always differ from controls on
preschooler oriented tests of attention and impulse control207
such as matching familiar figures (picking out a matching
figure from among several choices), embedded figures (finding a simple pattern within a complex one),208 and draw a
line slowly (drawing within the lines).209 Some data indicate
that comorbid learning disabilities, especially arithmetic disability, significantly increases the severity of executive function impairment in ADHD.210 Intelligence also plays a role.
Higher IQ ADHD children may compensate for their attention difficulties sufficiently to mask executive dysfunction on
traditional measures.211 Executive measures, which are open
ended and tap everyday real-life–like problem-solving skills
(eg, Six Elements Test, Hayling Sentence Completion Test212)
may better distinguish children with ADHD from community
controls213 than traditional structured measures of executive
function. However, these measures are less well normed and
generally not available to most clinicians. Enhanced understanding of the endophenotype of ADHD214 will improve the
choice of corroborating neuropsychological tests.
Many children with ADHD have learning disabilities, and
many children with learning disabilities have ADHD (Tables
1 and 2). Not surprisingly, children with ADHD and learning
disabilities are likely to be more impaired on both executive
and nonexecutive functions than ADHD children without
learning disabilities. In 1 study, neuropsychological performance was most impaired in ADHD with combined arithmetic and reading disability.210 Complete neuropsychological assessment of dyslexia, dysgraphia, nonverbal learning
Diagnosis of ADHD
disabilities, visuospatial difficulties, dyscalculia, and social
emotional difficulties is warranted but not diagnostic in the
ADHD child who is having academic difficulties.
What Is a Continuous Performance
Test? Can a Continuous Performance
Test Be Used to Diagnose ADHD?
Continuous performance tasks (CPTs), which should theoretically prove difficult for inattentive and impulsive ADHD
children, are frequently used as a standardized corroborative
test for ADHD (as well as a way to monitor medication effect)
and are tauted by some as an acceptable diagnostic measure
in and of themselves. Several scores can be derived from CPT
performance including errors of omission and commission,
mean hit reaction time, and mean hit reaction time standard
error. Children diagnosed with ADHD often have more variable reaction times and make more errors of commission and
omission than control children.215 However, what each CPT
parameter actually measures has largely been based on clinical assumptions (eg, omission errors measure inattention,
commission errors measure impulsivity) rather than biological validity.
Most CPTs require a response when an infrequent target is
presented either in isolation or after a cue (eg, an “x” followed
by an “a”). Here the main requirement is vigilance, watching
for the appearance of an infrequent target. Theoretically,
omission errors (failing to respond when the target is there)
would be expected more often than commission errors (responding when the target is not there). Emphasizing inhibition, one of the newer CPTs, the Connors II,216 differs from
most other CPTs by requiring frequent responding when the
often seen target is presented and an infrequent non response
when a nontarget item appears on the screen. Hence, more
commission than omission errors are expected, and performance variability is likely in ADHD subjects. The Connors II
CPT has the format of a stop signal task, which has been used
to test for disinhibition in a variety of cognitive disorders.
Disinhibition has been considered one of several possible
seminal underlying cognitive deficits in ADHD217 (ie, an endophenotype).214 Thus, the Connors II CPT may be a better
test for ADHD, but this has yet to be documented in clinical
studies. But, more to the point, until and if any CPT is proven
to measure the/an endophenotype of ADHD, it cannot be
used to make an ADHD diagnosis in isolation.
Because CPTs likely tap/tax attention and impulsivity,
core, but not necessarily critical, components of ADHD,215
they are appropriate tasks to help corroborate a diagnosis of
ADHD.218-220 However, the data on the various CPTs are
variable in terms of their sensitivity and specificity and their
false-positive and -negative rate in both community and clinical samples221 (Table 7). Indeed, CPTs have a failure rate of
about 50% in children diagnosed with ADHD by other
means.220,222,223 Furthermore, although continuous performance tests have generally differentiated ADHD children
from normal/community control groups,216,224 their track
record for clinical control groups is more controversial.225-228
Skill gaps are conflated in the former context.221 McGee and
209
Table 7 Continuous Performance Tasks
False negative/sensitivity
27%-85% Gordon
26% Connors 3
10%-15% Test of Visual Attention (TOVA)
11% ⴙ Connors II (minimizes false-negative
option)
False positive/specificity
14% Gordon
14% Connors 3
13-30% TOVA
12% ⴙ Connors II (minimizes false-positive option)
coworkers,222 for example, found that despite the fact that
CPT performance was not influenced by age, gender, socioeconomic status, fatigue effects (order of tests), visuomotor
integration ability, fine motor speed, or confounded by anxiety or conduct disorders, CPT performance did not distinguish ADHD children from clinical controls, only from community controls.
A number of factors may affect the reliability of the CPT as
a diagnostic instrument. Comorbid psychiatric disorders,
gender, and even age have been shown to affect performance.
In addition, a number of cognitive comorbidities can affect
performance. Although a number of the CPT instruments
have been thoughtfully modified to minimize extraneous effects on results (eg, language and reading, see later) and to
maximize the attentional component of the task, CPTs are
not reliable as isolated diagnostic measures for ADHD.
Confounding Factors
Comorbid Psychiatric Disorders
Results of continuous performance tests (CPTs) used in a
number of studies of children who carry the diagnosis of
ADHD highlight the effects of confounding psychiatric factors for interpreting CPT results.229 For example, CPT inattention, impulsivity, and dyscontrol errors were high in all
MTA ADHD groups.130 But different comorbidities modified
CPT performance. Children with ADHD and oppositional
defiant or conduct disorder were rated as more impulsive
than inattentive, whereas children with ADHD and anxiety
disorders were relatively more inattentive than impulsive.130
Another study documented that anxiety disorder both in isolation and synergistically with ADHD affects performance on
CPTs,230 thus potentially increasing the false-positive and
false-negative rate of the CPT. The effects of psychiatric comorbidity on CPT performance may explain the poor track
records of CPTs in distinguishing ADHD children from clinical controls.
Cognitive Confounds
A number of different CPTs are available, and design differences are aimed at minimizing potential cognitive confounds.
Reading is a confound in CPT performance, and reading difficulties can produce a high false-positive rate. Because the
comorbidity of ADHD and dyslexia is reported to be as high
as 25%,231 the basis of poor CPT performance in children
R.D. Nass
210
with both disorders may be difficult to determine. Most CPTs
require rapid letter identification, and CPT performance has
been correlated with phonologic awareness scores. Thus,
dyslexic children may do poorly on some CPTs for nonADHD reasons.222,232 Hence, some CPTs, like the Test of
Variables of Attention, have been designed to minimize reading in an effort to mitigate any confound of reading disabilities. The Test of Variables of Attention uses shapes instead of
letters. Memory demands can also be a confounding factor.
Thus, cued versus uncued CPTs could produce different results in the same subject because of the memory load rather
than the ADHD itself. Similarly, both the duration of a CPT
and the interstimulus interval alter the difficulty/memory
load of the task.
Other Confounds
A number of other confounding factors are reported. Gender
also appears to have an effect on CPT performance. For example, girls in the MTA study were less impaired than boys
on most CPT indices, particularly impulsivity. Girls with
ADHD and anxiety made fewer CPT impulsivity errors than
girls with ADHD alone.130 Thus, gender alone as well as in
conjunction with psychiatric comorbidities infringe on the
accuracy of a CPT in the diagnosis of ADHD. Examiner presence233 has been shown to impact CPT performance (perhaps
enhanced anxiety plays a role). Social class has been reported
to affect CPT performance.229,234 Age may also be a factor that
affects performance, regardless of ADHD status.229 Some
studies suggest that specific subgroups of ADHD children do
not show deficits on CPTs.223,229 In 1 study, ADHD children
who performed well (false negatives) on the CPT task were
older, of lower socioeconomic status, had more conduct
problems, and had less inattention.229 Although some studies
suggest correlations between particular error types and specific ADHD symptoms216 or ADHD severity,222 others do
not.229,235 This suggests that CPTs do not measure the critical
feature of ADHD.
What Laboratory Tests,
if Any, Are Appropriate in
the Evaluation of the ADHD Child?
Laboratory tests including magnetic resonance imaging, electroencephalography, and blood studies have no place in the
diagnostic workup, except under special circumstances.
such studies do not support the use of these measures for
diagnostic purposes.
Neuroimaging Assessment
Although research studies have documented specific structural abnormalities in ADHD, these findings cannot yet be
extrapolated to the general population for diagnostic purposes nor are they apparent on routine imaging. Research
structural imaging studies242,243 document reductions in
both the gray and white matter of the prefrontal cortex,244-248
small corpus callosum,231,249-252 small cerebellum,253,254
small basal ganglia,217,255-258 particularly the caudate,259-263
and absence of typical basal ganglia asymmetries.262 These
smaller structures are stable over time.261 Gender effects on
structure are also reported.264 In a recent study sampling 27
nonreferred children (one of whom had ADHD based on the
broadband questionnaire score), a greater degree of right-toleft caudate volume asymmetry predicted subclinical inattentive behaviors.265
Metabolic studies using single photon emission computed
tomography (SPECT) and position emission tomography
(PET) have shown decreased cerebral blood flow in right
lateral prefrontal cortex, right middle temporal cortex, both
orbital prefrontal cortex and both cerebellar cortices,266-272 as
well as atypical dopamine metabolism273 in children and
adults with ADHD compared with the controls. Functional
imaging studies suggest abnormalities in the frontal circuitry
including the anterior cingulate during a Stroop interference
task274 as well as right frontostriatal circuitry217 and basal
ganglia275 abnormalities during tasks measuring attention.
Despite the promise of such studies, the current state of
knowledge does not warrant structural or functional imaging
as a diagnostic or evaluative measure in ADHD.
In summary, overall the diagnostic assessment begins with
the history and requires the clinician to choose a battery of
measures that satisfies what is, to some degree, an individually determined level of diagnostic certainty. It is, however,
clear that no single test can be used to make the diagnosis and
that measures that may look promising from a research vantage are not as yet an appropriate part of the diagnostic evaluation.
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