Written by Cesar Soutullo, MD, PhD; Director, Child & Adolescent Psychiatry Unit, University of Navarra Clinic, Pamplona, Spain
Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder, which often starts early in childhood.1 The aetiology of ADHD is complex, and there is evidence that multiple genetic factors,2 environmental risk factors3-9 and gene–environment interactions influence its presentation, the age of onset, course and response to treatment.10-16 The chronic nature of ADHD means that in children and adolescents, symptoms may impact on life at school, daily life and activities, social life and family relationships; in adults, ADHD may be associated with relationship problems and workplace impairment.1,17-21
The importance of accurate assessment and diagnosis
The presentation of ADHD can differ depending on the patient’s personal, familial, academic and societal characteristics. Therefore, although a treatment plan should follow the recommendations of clinical guidelines, it is important to adopt a patient-centred management approach to identify the unique needs of the patient and family.22-26 This approach will help clinicians to reach an individualised and multimodal treatment/management plan, from a bio-psycho-social perspective.
The initial assessment of a child or adolescent with possible ADHD should include most of the following:
- Parent and child interview
- This includes a thorough medical history to rule out medical causes of hyperactivity, inattention or impulsivity.
- Information from teachers is also gathered, including results from teacher questionnaires.
- A detailed developmental and social history is taken, which includes assessment of family, psychosocial and cross-cultural factors, such as family and school demands and expectations, and current stressors.
“Why now?” What caused the parents to seek help at this particular moment?
- Mental status and complementary testing
- This part of the evaluation will help rule out other psychiatric disorders that may look like ADHD, or that may co-occur with ADHD. The presence of a comorbidity may influence treatment response, patterns of tolerability and adverse events, and other factors such as treatment adherence.
- At this point, the involvement of a clinical psychologist is needed to assess intelligence (IQ) and to perform some neuropsychological evaluations. These tests are not diagnostic, but may help to assess the degree of neuropsychological function impairment present in the child. For example, a continuous performance test may help to assess some aspects of executive function, such as inattention, impulsivity, vigilance, reaction time and variability over time.27 A Wechsler Intelligence Scale for Children (WISC) IQ test will assess general intelligence and verbal and non-verbal reasoning, working memory and other skills.28
- Physical examination. Evaluation of sight, hearing, weight, height, pulse, blood pressure, haemoglobin, ionogram, hepatic or thyroid function, along with a urine toxic screen may be performed at the initial stage of the evaluation, either by a child and adolescent psychiatrist or a paediatrician. Other tests such as further blood testing, electroencephalogram and brain imaging may be carried out to exclude other disorders.
- Patient interactions. We also observe the interaction of the child or adolescent with parents and with other adults. A child that is still and quiet during the evaluation does not rule out ADHD; many children are able to hold their behaviour for a while, especially in unfamiliar situations outside of the home or classroom/workplace.
Any medical problem that may impact the child´s energy, concentration, attention, impulse control or activity level should be carefully considered, during both the medical history taking and the physical examination.
Assessment tools and rating scales
In addition to the general child and adolescent psychiatry interview, clinicians may use rating scales to evaluate ADHD symptoms and other psychopathology. Generally, questionnaires are preferred to rating scales which require clinician involvement, although sometimes a rating scale scored by the clinician may be necessary.
- General psychopathology questionnaires
- A good general psychopathology scale is the Strengths and Difficulties Questionnaire (SDQ),29,30 which is validated, freely available online and translated into many languages. As well as having a prosocial scale, the sensitivity of this scale means a negative result almost rules out the particular problem being studied (for example, emotional symptoms such as anxiety and depression, conduct problems, hyperactivity or problems with peers).
- Another very good, simple and validated instrument for screening is the Child´s Behaviour Checklist (CBCL).31,32 This is not free, but for a clinic is worth the investment.
- Specific disorder questionnaires
- Questionnaires to explore depression and anxiety symptoms include the Child Depression Inventory (CDI),33 and the Multidimensional Anxiety Scale for Children (MASC).34 The MASC has subscales which provide hints on social, harm-avoidant, somatisation and separation anxiety.
- Some questionnaires used to explore autism spectrum disorder (ASD) symptoms include the Children Communication Checklist (CCC),35 the Early Screening for Autism Traits (ESAT)36 and the Child Asperger Screening Test (CAST).37 If in doubt, a complete language evaluation is needed for differential diagnosis between ASD and specific language developmental delay.
- The Sleep Disturbance Scale for Children (SDSC)38 developed by the European Sleep Research Society, is used to screen for sleep problems at baseline. This is important in ensuring that sleep problems are not wrongly attributed to a medication-related adverse event.
Lack or poor quality of sleep is a frequently overlooked problem that may impact mood and attention
- ADHD questionnaires
- To assess ADHD symptoms and behaviour, we use the ADHD Rating Scale-IV (ADHD-RS-IV)39 and Swanson, Nolan and Pelham-IV (SNAP-IV) rating scale,40 which also includes items for oppositional defiant disorder. The updated SNAP-IV contains all of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5TM) ADHD symptoms and can be completed by parents, teachers and clinicians. Clinician-rated SNAP-IV questionnaires are more reliable than those completed by parents and teachers, as they incorporate information from all sources (parents, child and teachers).
- However, this is not a diagnostic instrument, and it should be used as a rating scale or questionnaire to explore both baseline symptoms and follow-up symptoms that remain active. Furthermore, we have found there is a tendency of parents and teachers to gradually score lower and lower over time, even if the symptoms remain active.
- Functional impairment and quality of life (QoL) questionnaires
- It is also key to evaluate not only the presence of ADHD symptoms, but also the impact of these on QoL and the impairment they cause. The Weiss Functional Impairment Rating Scale (WFIRS-P),22 and the Child Health and Illness Profile-Child Edition: Parent Report Form (CHIP-CE:PRF)41 are useful resources.
- After gathering this information to rule out other disorders, the team will reach a bio-psycho-social formulation. Ideally, the diagnosis of ADHD should come with the confirmation of any comorbidities or cognitive/neuropsychological problems and information regarding the patient’s social, academic and family situation, impairment and impact on QoL.
Once a complete diagnosis has been reached, an individualised, patient-centred treatment plan can be designed, which includes interventions at home with the parents (mostly behavioural) and at school (behavioural and academic), and also determines whether there is a need for pharmacological intervention.
Disclaimer: The views expressed here are the views of the physician and based upon his own personal clinical experience. They are not those of Takeda.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
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