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Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
ADHD Testing
Case: You are seeing Charlie, a 7 year old boy, along with his parents due to
concerns for hyperactivity and inattention. After reviewing the history and
completing a thorough physical exam, you think it is appropriate to begin testing for
ADHD.
Learning Objectives:
1. Review the current options for ADHD testing
2. Understand the benefits and downsides of the various forms of ADHD testing
________________________________________________________________________________________________
ADHD Basics
• Affects 6-7% of school-age children
• 3:1 male: female
• Coexisting conditions
o 35% oppositional defiant disorder
o 26% conduct disorder
o 25% anxiety
o 18% depressive disorders (often lasts into teenage years or
adulthood)
• When evaluating for ADHD, always evaluate for learning disabilities and
emotional problems that may be affecting behavior
• Diagnosis
o 6/9 behaviors in hyperactive/impulsive domain and/or in the
inattentive domain
 Hyperactive:
Fidgets with hands or feet or squirms
Leaves seat in classroom or other settings when
remaining seated is expected
Runs about or climbs excessively in inappropriate
situations
Has difficulty playing or engaging in leisure activities
quietly
“On the go” or often acts as if “driven by a motor”
Talks excessively
 Impulsivity
Blurts out answers before question has been completed
Difficulty awaiting turn
Interrupts or intrudes on others
 Inattention
Fails to give close attention to details or makes careless
mistakes
Difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly
Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
Does not follow through on instructions and fails to
finish schoolwork, chores or duties
Difficulty organizing tasks and activities
Avoids, dislikes or is reluctant to engage in tasks that
require sustained mental effort
Loses things necessary for tasks or activities
Easily distracted by extraneous stimuli
Forgetful in daily activities
o Presence of behaviors in 2 or more settings for at least 6 months
o Behaviors must occur prior to 7 yo
o Behaviors cause significant impairment in learning/social interactions
Clinical Evaluation
• AAP guideline states diagnosis requires evidence directly obtained from parents
or caregivers in various settings as well as from a school professional
• Use of ADHD specific scales to diagnose ADHD is not required, but can provide
important descriptions of patient behavior that can be helpful to clinicians
o Use of broad scales not recommended
• Should include evaluation for coexisting conditions
• No lab tests or other imaging techniques are necessary
Overview of Options for Screening Forms:
Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
From: AACAP Practice Parameters for Assessment and Treatment of Children and Adolescents with AttentionDeficit/Hyperactivity Disorder
Scale
Ages
Benefits
Limitations
Brown
3-18 yo
(multiple
forms)
Good for ADD and
attention only or
information
processing problems
Must be purchased;
long; mostly selfreported symptoms
Child Behavior
Checklist
2-3 yo
4-18 yo
Includes self-report
form for teens;
Less specific for
ADD/ADHD
**Conners -3
(commonly used)
6-18 yo
Adolescent selfreport available; Has
convenient carboncopy tear off sheets
for scoring
Multiple versions
available, may be
confusing; must
purchase
Conners- EC (early
childhood); Conners
(7,8)
2-6 yo
Only scale available
for preschool
children
Must purchase; very
difficult to diagnose
in this age range,
often used for
specialists
SNAP IV (Swanson,
Nolan and Pelham IV
Questionnaire)
5-11 yo
Electronic scoring
available on the
internet
Limited normative
data; no separate
parent and teacher
version
ADHD Rating Scale IV
(ADHD RS IV) (DuPaul
1998)
5-18 yo
**Vanderbilt ADHD
Rating Scale (VARS)
(Wolraich 2003)
(commonly used)
Elementary
School
ADHD Symptoms
Rating Scale (ADHD-
5-18 yo
Only asks about
DSM IV ADHD
Symptoms
Includes rating of
impairment; asks
about comorbid
conditions; available
free online
No normative data
on adolescents
Lengthy
Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
SRS) (Holland 2001)
Attention Deficit
Disorder Evaluation
Scale – 3rd edition
(ADDES-3_ (McCarney
2004)
4-18 yo
ACTeRS – 2nd edition
(Ullman 2000)
K-8th grade
Lengthy
Adolescent selfreport available
No normative data
on parent and
adolescent version
available
Adapted from: Peds in Review 2010 Wilms Floet et al 31 (2): 56 Table 2
Specific Screening Forms
• ADHD Rating Scale-IV
o http://elcaminopediatrics.com/forms_medrecords_adhdhome_pf.htm
o http://elcaminopediatrics.com/forms_medrecords_adhdschool_pf.ht
m
• Brown Rating Scales
o http://www.drthomasebrown.com/assess_tools/index.html
• Child Behavior Checklist
o Categorizes data into 6 categories: withdrawn, somatic complaints,
anxious/depressed, social problems, though problems, attention
problems, delinquent behavior, and aggressive behavior and
compares to normative values
o http://www.aseba.org/forms/schoolagecbcl.pdf
• Connors Scales
o Forms for parents, teachers, and for adolescents to self-evaluate
o Short (<30 questions, 4 point Likert scale) and long (60-90 questions,
3 point Likert scale) version forms available
o One of the most popular, has been around for 30+ years
o Appropriate for children ages 3-17
o IOWA (Inattention/Overactivity with Aggression) version for teachers
o Proven reliability and clinical utility
• SNAP-IV-C Rating Scale
o One form, can be completed by parents, teachers or other caregivers
o 80 questions
 Shorter, 18 question form: http://www.adhd.net
o Includes questions that may assess for oppositional defiant disorder,
conduct disorder, intermittent explosive disorder, tourette’s disorder,
stereotypic movement disorder, OCD, generalized anxiety disorder,
narcolepsy, manic episodes, major depressive episodes, and
dysthymic disorder
•
Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
o Contains 10 questions from the SKAMP to assess or classroom
manifestations of inattention, hyperactivity and impulsivity
(estimates severity of impairment in classroom)
o Not as recommended by AAP because is a more general assessment,
not as specific to ADHD
o http://www.chironeuroindy.com/PDF/assesstools_snap-iv-C-6160C80tems.pdf
Vanderbilt Assessment Scale
o Separate parent and teacher assessment forms, 43-55 questions each
o Two parts per form: symptom assessment and impairment of
performance at home/school/social settings
o Can also screen for oppositional defiant disorder, conduct disorder,
anxiety and depression
o Proven reliability and clinical utility
o http://www.brightfutures.org/mentalhealth/pdf/professionals/bridg
es/adhd.pdf
o Parent form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/03VanAssesScaleParentInfor.pdf
o Teacher form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/04VanAssesScaleTeachInfor.pdf
o Parent follow up form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/05VanFollowUpParentInfor.pdf
o Teacher follow up form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/06VanAssessFollowUpTeachInfor.pdf
o Provider scoring instructions:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/07ScoringInstructions.pdf
General Problems with Scales
• May be gender biased (boys diagnosed more often than girls)
• Not created for children under age 4 or for adults
• May be culturally biased
• May not be good measures of developmental variations in expression of ADHD
• Diagnosis may be missed when child’s behaviors do not conform to DSM IV
criteria
• Scales differ in normative data (ie age ranges) – make sure scale range correlates
to patient age/race/sex if possible
• Limited data to evaluate whether scales can be repeated to be used to monitor
medication effectiveness
• Validity of scales for screening for comorbid conditions not as well established
•
Continuity Clinic Curriculum
Lucile Packard Children’s Hospital
ADHD Testing
Scales alone do not confirm a diagnosis – must use clinical judgment to integrate
scales into entire clinical assessment
Peer Reviewed by David Bergman, MD 2011
References/Resources
• Peds in Review 2003:
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
ll/24/3/92?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=ADHD+testing&
searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
• Peds in Review 2010:
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
ll/31/2/56?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=adhd&searchid
=1&FIRSTINDEX=10&sortspec=relevance&resourcetype=HWCIT
• Connors, CK. Clinical use of Rating Scales in diagnosis and treatment of ADHD.
Pediatric Clinics of North America. Oct 1999.
http://www.mdconsult.com.laneproxy.stanford.edu/das/article/body/2257920
514/jorg=journal&source=MI&sp=10952538&sid=1080298365/N/153917/1.htm
l?issn=0031-3955
• AACAP Practice Parameters:
http://dbptraining.stanford.edu/4_readings/readingdocs/Practice%20paramet
er%20for%20the%20assessment%20and%20treatment%20of%20children%2
0adoles%20ADD.pdf
• Cordes M, McLaughlin, TF. Attention Deficit Hyperactivity Disorder and Rating
Scales with a Brief Review of the Connors Teacher Rating Scale (1998).
International Journal of Special Education, 2004. Vol 19 (2).
• Auerbach article on the Child Behavior Checklist:
http://ch.missouri.edu/Education/STUDENTSYLLABUS/Articles/behavioral%2
0checklist.pdf