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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.


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.


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.


1. _________________ are the primary neurotransmitters that mediate frontal-lobe function.

a. Amino acids b. Catecholamines c. Gaba peptides d. 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. Inattentiveness or lack of attention b. Disorganization c. Forgetfulness d. 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. Inattentive b. Impulsivity c. Autistic d. 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. Alzheimer’s Disease b. Parksinson’s Disease c. Adrenal leukodystrophy d. Mad Cow disease

5. The formal diagnosis of ADHD in children, adolescents, and

adults usually occur in __________________.

a. School b. Primary care settings c. Secondary care settings d. Home


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


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


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,


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


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 lesser-

resourced 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,


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


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 3-

4% 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


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.


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


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


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


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.


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


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 hyperactive-

impulsive 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


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 self-

mutilating 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


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 hyperactive-

impulsive 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


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 hyperactivity-

impulsiveness. 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


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


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 self-

esteem, 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


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


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


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, side-

tracked).

• 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).


• 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


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


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


• 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


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


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,


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


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


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


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


• 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.


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


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.


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


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 hyperactive-

impulsive. 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


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,


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.


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.


• 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.


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


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


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?


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.


• 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.


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.


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


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


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.


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


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


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.


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.


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


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


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


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 WAIS-

III, 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.


• 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


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


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


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.


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


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


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


• 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 ADHD-

focused 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.


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, ADHD-

predominantly 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.


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


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.


• 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.


• 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


• 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


• 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.


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


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, non-

verbal 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


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.


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:


• 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.


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.


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.


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.


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

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.


1. _______________________ are the primary neurotransmitters that mediate frontal lobe function.

a. Amino acids b. Catecholamines c. Gaba peptides d. 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. Inattentiveness or lack of attention b. Disorganization c. Forgetfulness d. All of the above

3. A comprehensive neurologic examination needs to be performed

in children with ADHD to rule out the possibility of neurodegenerative disorders such as _______________.

a. Alzheimer’s Disease b. Parksinson’s Disease c. Adrenal leukodystrophy d. Mad Cow disease

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.

a. Autism b. Antisocial Disorder c. Oppositional defiant disorder d. Asperger’s Syndrome

5. True or False. ADHD is considered a condition of childhood,

which requires less caution when giving future prognosis.

a. True b. False


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 b. Less; lower c. More; lower d. Less; higher

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. Social b. Family c. Psychiatric d. Medical

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 ______________.

a. Medications list b. Social history c. Family history d. Past medical history

9. The interview with teachers constitutes the _________ line of

the stepwise diagnostic process in identifying students with ADHD.

a. First b. Second c. Third d. Last


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. 2 to 10 b. 5 to 15 c. 3 to 17 d. 7 to 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. traumatic brain injuries. b. epileptics. c. long-standing ADHD children. d. All of the above.

13. Among other things, deterioration in executive function leads to

problems with

a. poor concentration b. impaired working memory c. prioritizing and planning complex sets of tasks d. 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. 2 to 90 b. 18 to 60 c. 2 to 18 d. 30 to 40


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. Inattentive b. Impulsivity c. Autistic d. 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. Cerebellar b. temporal c. frontal d. parietal

18. Imaging studies have revealed that children diagnosed with ADHD show a substantial ______________ of the brain volume.

a. enlargement b. reduction c. less gray matter d. more gray matter

19. The diagnosis of ADHD in children, adolescents, and adults usually occur in _______________ care settings.

a. secondary b. tertiary c. school d. psychiatry


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. Psychiatric b. Therapeutic c. Multimodal d. 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. Fragile X Syndrome b. Hydrocephalus c. Klinefelter d. 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. Hearing and visual b. Morally-learned c. Biological-based d. Family-learned


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 b. mental status exam c. memory/cognition d. 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. Neurofeedback b. EEG-based assessment c. XRAY d. Both a and b above.

28. Impaired executive function can lead to problems with

a. organization b. achieving and maintaining concentration c. regulation of emotions d. All of the above.


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. Attention b. Response control c. Expansive mood d. Validity


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. restlessness b. exhaustion c. failed attempts at building social relationships d. 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.”


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.”


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.”


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. traumatic brain injuries. b. epileptics. c. long-standing ADHD children. d. 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. poor concentration b. impaired working memory c. prioritizing and planning complex sets of tasks d. 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.”


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 decision-making functions.”


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.”


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.”


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.”


28) Impaired executive function can lead to problems with

a. organization b. achieving and maintaining concentration c. regulation of emotions d. 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


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. National Institute of Mental Health. Attention Deficit Hyperactivity Disorder. Retrieved from http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml

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3. 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-hyperactivity-disorder-in-adults-epidemiology-pathogenesis-clinical-features-course-assessment-and-diagnosis?source=search_result&search=adhd&selectedTitle=2~150

4. Diagnostic and statistical manual of mental disorders (DSM-II), 4th edn Text revision. Washington DC: American Psychiatric Association; 2000.

5. Still, G.F. (1902). Some abnormal psychical conditions in children: the Goulstonian lectures. Lancet, 1:1008–1012.

6. Brown, W.A., Bradley, Charles, M.D. (1998). American Journal of Psychiatry, 155:968.

7. Gross, M.D. (1995). Origin of stimulant use for treatment of attention deficit disorder. American Journal of Psychiatry, 152:298–299.

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9. 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-to-treat-attention-deficit-hyperactivity-disorder-in-children-and-adolescents?source=search_result&search=adhd%20and%20catecholamines&selectedTitle=4~150

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11. 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.

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