Assessing Children With ADHD in Primary Care Settings
Assessing Children With ADHD in Primary Care Settings
Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been established that provides best practice diagnostic procedures for primary care physicians. These assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using Diagnostic and Statistical Manual of Mental Disorders IV criteria as the basis for making an ADHD diagnosis, and evaluating for comorbid conditions. The ADHD diagnostic process is complicated by several factors including the subjectivity of the ADHD diagnosis, differential diagnosis with comorbid conditions, and the inconsistent manifestation of ADHD symptomatology across development. The present article provides recommendations for addressing these complex diagnostic issues. ADHD assessment methods and tools, the process of assessing for comorbid conditions and making differential diagnosis, and when to make a referral to specialists are reviewed.
Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder usually diagnosed during childhood. ADHD is defined by three core behavioral domains: inattention, hyperactivity and impulsivity. However, based on results of factor analytic studies, current nosology combines the hyperactivity and impulsivity into a single domain termed hyperactivity/impulsivity. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV diagnostic criteria define three ADHD subtypes based on the presence of inattention and hyperactivity/impulsivity symptoms: predominantly inattentive type, predominantly hyperactive/impulsive type and combined type. In order to meet DSM-IV diagnostic criteria for one of these ADHD subtypes, a patient must have six of nine symptoms in either or both the inattention or hyperactivity/impulsivity symptoms domains, must have a history of symptoms starting in early childhood (i.e., prior to age 7 years), must demonstrate impairment in more than one setting, and must show clinically significant academic, social or occupational impairment. Finally, the patient's symptoms must not occur exclusively in the context of a pervasive developmental disorder (PDD), schizophrenia or psychosis, or be better explained by another medical or mental health condition. An ADHD diagnosis is associated with a broad range of impairments including academic underachievement, social and disciplinary problems, substance use and problems with driving (see [5] for a review of impairments across the lifespan).
Regarding prevalence, a recent US national epidemiological study of 8-15-year-old school children found an 8.7% prevalence of ADHD, with the predominantly inattentive type most prevalent (4.4%) among the ADHD subtypes (combined type: 2.2%; predominantly hyperactive/impulsive type: 2.0%). These subtype prevalence rates are likely to be different in clinic-referred samples than those reported in this epidemiological study since children with disruptive symptoms (e.g., hyperactive/impulsive symptoms) are more likely to be referred by parents and teachers for diagnosis and treatment.
A diagnosis of ADHD requires a thorough evaluation that optimally includes multiple methods and informants. Moreover, the diagnostic process requires a clinician who is well-versed in the ADHD diagnostic criteria, has experience with ADHD patients, and has the clinical acumen to make determinations about normal and abnormal patterns of behavior. Even with such a clinician, the ADHD diagnostic process can be complicated by several factors including the subjectivity of the ADHD diagnosis, presence of comorbid conditions and the differential manifestation of ADHD symptomatology across development.
Like all mental health disorders, the diagnostic criteria rely on a set of subjective criteria that require a clinical judgment about the presence or absence of symptoms. To date, no objective tests whether neuropsychological, neuroimaging or genetic have been established that can be used to reliably determine if a child has an ADHD diagnosis. Rather, ADHD symptom criteria require the clinician to determine whether each of 18 ADHD behavioral symptoms occurs 'often' or not. A working knowledge of normal development is critical as diagnosis requires documentation of deviance as compared to same-aged and same-gender peers. While knowledge of developmental norms and experience with ADHD patients may improve a clinician's ability to make such a determination, this determination is nonetheless subjective. Similar subjectivity is required to make clinical decisions about the rest of the ADHD diagnostic criteria including age of onset, pervasiveness and impairment. Fortunately, studies have shown that the ADHD diagnostic decision can be made reliably across clinicians.
The high incidence of comorbid conditions in children with ADHD also complicates the diagnostic process. It is estimated that between 44 and 80% of children diagnosed with ADHD have at least one comorbid mental health disorder in combination with ADHD. The most prevalent comorbid diagnosis is oppositional defiant disorder (ODD) with comorbidity rates over 50%. Other common comorbid diagnoses are learning disorders (LDs), conduct disorder (CD), anxiety disorders and mood disorders (see [11] for review). The fact that these other mental disorders often co-occur with ADHD can make the diagnosis of ADHD complicated as the clinician must make the determination whether such diagnoses signify a comorbid condition or instead, represent a differential diagnosis causing the presentation of ADHD symptomatology.
The differential presentation of ADHD across development can also pose a challenge to the clinician. In very young children (e.g., preschoolers), symptoms of inattention may not manifest due to the lack of environmental demands that require attention control. Furthermore, hyperactivity and impulsivity can be quite normative among preschool-aged children. As children develop through adolescence, there is a waning of hyperactive/impulsive symptoms, although inattention symptoms and attention-related impairments seem to persist.
A diagnostic evaluation for ADHD can be conducted by a number of specialists including but not limited to psychologists, psychiatrists, educational specialists, neurologists and pediatricians (both generalists and developmental and behavioral specialists). Owing to the high prevalence of ADHD, the limited number of specialists (e.g., developmental-behavioral pediatricians, child psychiatrists) and common insurance reimbursement restrictions on ADHD diagnostic evaluations, many children present to and are evaluated by primary care providers.
In response to this demand, the American Academy of Pediatrics (AAP) issued a set of consensus guidelines related to ADHD assessment and treatment. The guidelines summarize the empirical literature and make recommendations to community-based physicians regarding best practice procedures. Assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using DSM-IV criteria as the basis for making an ADHD diagnosis and evaluating for comorbid conditions. The present article focuses on recommended diagnostic procedures in primary care settings. We examine ADHD assessment methods and tools, discuss the process of assessing for comorbid conditions and making differential diagnosis, and discuss when to make a referral to specialists. For information on the evidence-based treatment of ADHD in primary care settings readers are referred to the AAP treatment guidelines. Also see Madaan et al. and Chronis et al. for more comprehensive reviews of pharmacotherapy and psychosocial treatment options for children with ADHD.
Abstract and Introduction
Asbtract
Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been established that provides best practice diagnostic procedures for primary care physicians. These assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using Diagnostic and Statistical Manual of Mental Disorders IV criteria as the basis for making an ADHD diagnosis, and evaluating for comorbid conditions. The ADHD diagnostic process is complicated by several factors including the subjectivity of the ADHD diagnosis, differential diagnosis with comorbid conditions, and the inconsistent manifestation of ADHD symptomatology across development. The present article provides recommendations for addressing these complex diagnostic issues. ADHD assessment methods and tools, the process of assessing for comorbid conditions and making differential diagnosis, and when to make a referral to specialists are reviewed.
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder usually diagnosed during childhood. ADHD is defined by three core behavioral domains: inattention, hyperactivity and impulsivity. However, based on results of factor analytic studies, current nosology combines the hyperactivity and impulsivity into a single domain termed hyperactivity/impulsivity. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV diagnostic criteria define three ADHD subtypes based on the presence of inattention and hyperactivity/impulsivity symptoms: predominantly inattentive type, predominantly hyperactive/impulsive type and combined type. In order to meet DSM-IV diagnostic criteria for one of these ADHD subtypes, a patient must have six of nine symptoms in either or both the inattention or hyperactivity/impulsivity symptoms domains, must have a history of symptoms starting in early childhood (i.e., prior to age 7 years), must demonstrate impairment in more than one setting, and must show clinically significant academic, social or occupational impairment. Finally, the patient's symptoms must not occur exclusively in the context of a pervasive developmental disorder (PDD), schizophrenia or psychosis, or be better explained by another medical or mental health condition. An ADHD diagnosis is associated with a broad range of impairments including academic underachievement, social and disciplinary problems, substance use and problems with driving (see [5] for a review of impairments across the lifespan).
Regarding prevalence, a recent US national epidemiological study of 8-15-year-old school children found an 8.7% prevalence of ADHD, with the predominantly inattentive type most prevalent (4.4%) among the ADHD subtypes (combined type: 2.2%; predominantly hyperactive/impulsive type: 2.0%). These subtype prevalence rates are likely to be different in clinic-referred samples than those reported in this epidemiological study since children with disruptive symptoms (e.g., hyperactive/impulsive symptoms) are more likely to be referred by parents and teachers for diagnosis and treatment.
A diagnosis of ADHD requires a thorough evaluation that optimally includes multiple methods and informants. Moreover, the diagnostic process requires a clinician who is well-versed in the ADHD diagnostic criteria, has experience with ADHD patients, and has the clinical acumen to make determinations about normal and abnormal patterns of behavior. Even with such a clinician, the ADHD diagnostic process can be complicated by several factors including the subjectivity of the ADHD diagnosis, presence of comorbid conditions and the differential manifestation of ADHD symptomatology across development.
Like all mental health disorders, the diagnostic criteria rely on a set of subjective criteria that require a clinical judgment about the presence or absence of symptoms. To date, no objective tests whether neuropsychological, neuroimaging or genetic have been established that can be used to reliably determine if a child has an ADHD diagnosis. Rather, ADHD symptom criteria require the clinician to determine whether each of 18 ADHD behavioral symptoms occurs 'often' or not. A working knowledge of normal development is critical as diagnosis requires documentation of deviance as compared to same-aged and same-gender peers. While knowledge of developmental norms and experience with ADHD patients may improve a clinician's ability to make such a determination, this determination is nonetheless subjective. Similar subjectivity is required to make clinical decisions about the rest of the ADHD diagnostic criteria including age of onset, pervasiveness and impairment. Fortunately, studies have shown that the ADHD diagnostic decision can be made reliably across clinicians.
The high incidence of comorbid conditions in children with ADHD also complicates the diagnostic process. It is estimated that between 44 and 80% of children diagnosed with ADHD have at least one comorbid mental health disorder in combination with ADHD. The most prevalent comorbid diagnosis is oppositional defiant disorder (ODD) with comorbidity rates over 50%. Other common comorbid diagnoses are learning disorders (LDs), conduct disorder (CD), anxiety disorders and mood disorders (see [11] for review). The fact that these other mental disorders often co-occur with ADHD can make the diagnosis of ADHD complicated as the clinician must make the determination whether such diagnoses signify a comorbid condition or instead, represent a differential diagnosis causing the presentation of ADHD symptomatology.
The differential presentation of ADHD across development can also pose a challenge to the clinician. In very young children (e.g., preschoolers), symptoms of inattention may not manifest due to the lack of environmental demands that require attention control. Furthermore, hyperactivity and impulsivity can be quite normative among preschool-aged children. As children develop through adolescence, there is a waning of hyperactive/impulsive symptoms, although inattention symptoms and attention-related impairments seem to persist.
A diagnostic evaluation for ADHD can be conducted by a number of specialists including but not limited to psychologists, psychiatrists, educational specialists, neurologists and pediatricians (both generalists and developmental and behavioral specialists). Owing to the high prevalence of ADHD, the limited number of specialists (e.g., developmental-behavioral pediatricians, child psychiatrists) and common insurance reimbursement restrictions on ADHD diagnostic evaluations, many children present to and are evaluated by primary care providers.
In response to this demand, the American Academy of Pediatrics (AAP) issued a set of consensus guidelines related to ADHD assessment and treatment. The guidelines summarize the empirical literature and make recommendations to community-based physicians regarding best practice procedures. Assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using DSM-IV criteria as the basis for making an ADHD diagnosis and evaluating for comorbid conditions. The present article focuses on recommended diagnostic procedures in primary care settings. We examine ADHD assessment methods and tools, discuss the process of assessing for comorbid conditions and making differential diagnosis, and discuss when to make a referral to specialists. For information on the evidence-based treatment of ADHD in primary care settings readers are referred to the AAP treatment guidelines. Also see Madaan et al. and Chronis et al. for more comprehensive reviews of pharmacotherapy and psychosocial treatment options for children with ADHD.
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