Observations indicating that a diagnosis of ADHD should be investigated...
Guidance officers, teachers, and allied health professionals frequently note behaviours which may be associated with ADHD and they comment on these in their reports. Sometimes, the report may also contain suggested management strategies to contain these problem behaviours. However, it happens all too often that a possible diagnosis of ADHD is not considered, and the child is left with an impediment to learning and to behaviour which is not being appropriately treated.
It is important that the flags indicating the possible involvement of ADHD be recognised in order to initiate appropriate action. In themselves, these flags do not justify a diagnosis of ADHD, since similar symptoms may be associated with other problems. However, they do indicate that such a diagnosis should be investigated further. Some of these flags are as follows:
Poor concentration
Short attention span
Very easily distracted
Spends a lot of time distracting others
Frequently off-task
Impulsive - doesn't consider consequences
Impulsive - started tasks before instructions finished
Very restless and difficult to keep on task
IQ may be an underestimate due to difficulty in staying on task.
Attentional difficulties prevented best performance
Has difficulty in putting words together to explain meaning
Needed encouragement to stay on task
Doesn't complete tasks in time
Considerable wriggling in his seat
Constantly in some kind of motion, drumming
Finds it impossible to sit without fidgeting
Consistent out of seat behaviour
Wanders around the classroom
Continually asked questions about the test materials
Interfered with the test materials, flipping through pages to see what was coming next
Talks excessively
Mouth always active- talking, singing, humming
Testing him was quite hard work - taking a long time. His speed was variable.
Seems to process information very slowly
fingers on the desk or fiddling with things.
Slow to commence tasks and rarely completes them
Sibling with ADD/ADHD
Long/Short Term Memory Problems
Very immature
Gives up easily
Motivation/Attitude
Off-task dreaming behaviour
May not be just dreaming in class - may be thinking
Poor listening skills
Difficulty following instructions
Asked for questions to be repeated a number of times
Needs individual instructions - step by step
Needed firm and clear directions
Slow to respond to directions
Impatient
Slow at processing information
Disruptive classroom behaviour
Uncooperative and disruptive
Takes no responsibility for his actions
Had difficulty in repeating sentences often forgetting the first word
Reached frustration point very quickly, especially on tasks that challenged him
Basically lazy at time
Endless questions about the work to do, etc
Drifts off into a world of his own
Often distracted by his own thoughts
Enjoyed talking all through the assessment
Often verbally cued himself with a memory task
Over-reacts
Poor short term memory
Can't handle a change in routine
Poor organization of self/resources
Extremely untidy - books etc everywhere
Lacks self-discipline
Children with the inattentive form of ADHD are frequently overlooked in the classroom since their behaviours are less irritating than the behaviours of the hyperactive/impulsive form. However, this does not mean that these children are any less disabled in their academic progress.
As noted above, the presence of any or even most of these symptoms does not prove that a diagnosis of ADHD is warranted. However, these symptoms do indicate that further investigation is necessary.
Copyright Dr Stephen Dossel, and the ADD Association Queensland. This article may be reprinted but should not be modified in any way. Any such use should be acknowledged in the normal manner and must include the author's name and the source of the article.
Misdiagnosis or Overdiagnosis
There are a number of sources of mis-diagnosis.
1. Children who should have been diagnosed as ADD or ADHD but who were not. This happens most often with the ADD children since their behaviours are only mildly annoying if at all. Children whose academic performance is average are often assumed not to have ADD or ADHD. In actual fact, they may be underachieving to a considerable extent.
2. Behaviour problems. The behaviours observed may be similar to those in ADD/ADHD. Parents would often prefer a diagnosis of ADHD since they feel that this absolves them of blame.
3. Children diagnosed as Speech and Language Impaired when ADD/ADHD is the primary disorder. ADHD children typically have specific deficits in language development. Sometimes children are diagnosed as in need of occupational therapy because of their excess activity.
Reputable estimates of the incidence of ADD/ADHD suggest that 5%-7% of the whole population suffers from this disorder. However, guidance officers are involved with a narrow spectrum of the total population, i.e., those having problems fitting into the education system. Hence the incidence of ADD/ADHD in the population with which guidance officers are involved will be much higher, possibly as high as 25%-30%.
The Diagnosis of Attention Deficit Hyperactivity Disorder
Before considering a number of issues pertinent to the diagnosis of ADHD, it is useful to note some of the requirements laid down by DSM-IV, since these are frequently overlooked. The behaviours characteristic of ADHD are not pathological or abnormal. They are normal behaviours which are maladaptive in that they occur with greater frequency, or with greater intensity in situations where such behaviour is inappropriate. Hence one of the criteria specified by DSM-IV is that the designated behaviours occur to a degree which is maladaptive. Unfortunately, this is a subjective interpretation very much in the mind of the observer.
Likewise, DSM-IV specifies that the designated behaviours must occur with a frequency or intensity which is inconsistent with developmental level. Developmental level is not merely dependent on chronological age. It is also dependent on the intellectual ability of the child. A child of below average intelligence cannot be expected to act with the same degree of maturity as other children of the same age.
The symptoms of ADHD as designated in DSM-IV are not unique to ADHD. Many of these symptoms may be indicative of Conduct Disorder, Anxiety Disorder, Childhood Depression, and Learning Disability. To further confound the issue, the above disorders may be co-morbid with ADHD in the same individual. Hence, the clinician not only has to differentiate the various disorders, but has to identify which of these disorders are coexistent, and to develop treatment strategies appropriate to the needs of the particular person.
The diagnosis of ADHD is a clinical diagnosis based on the careful consideration of all the available data. It sometimes happens that parents are asked a set of eighteen questions which match the diagnostic criteria in DSM-IV. This is sampling a restricted range of behaviours and relies heavily on one source of information. Further, the DSM-IV diagnostic criteria requires the behaviours to be observable in two or more situations.
While DSM-IV attempts to make the diagnosis of ADHD as objective as possible, subjectivity has not been eliminated. The degree to which a behaviour is seen as maladaptive is a matter of opinion. Each of the DSM-IV diagnostic criteria contains the word "often". The question arises, "How many instances makes an often?" The most effective way to manage the subjectivity inherent in the diagnostic process is to gather as much relevant information about the client from as many sources as possible, and to be alert to the feelings and attitudes of those providing the information.
Information Gathering
As noted above, a number of sources of information are available to the clinician to assist in the diagnosis of ADHD. Each of these sources of information is potentially useful, but not one of them may be regarded as infallible by itself. These sources of information will be briefly reviewed below.
Intelligence tests indicate the developmental level of the child. This is important for a diagnosis under DSM-IV criteria. In addition, intelligence tests facilitate the observation of the child in a structured standardised assessment situation. Frequently, behaviours characteristic of ADHD may be observed during the assessment. It sometimes happens that the results of the intelligence test are adversely affected by such ADHD characteristics as impulsivity, and difficulty in following instructions. In such a case, the validity of the obtained I.Q. score as a true indication of the child's intellectual ability needs to be considered.
Psychological tests may provide useful information since they allow the observation of the child in a structured standardised situation. However, despite the claims sometimes made for their validity, no psychological test has proven to be sufficiently reliable in the clinical situation to warrant its use as the only diagnostic instrument. Continuous performance tests frequently indicate difficulties with attention and/or impulsivity. However the presence or absence of such indications is not sufficient in itself to enable a reliable diagnosis. One of the problems in assessing children for ADHD is that many of them can put in additional effort to control the behaviours characteristic of ADHD for a short time if they are sufficiently motivated. Working with a stranger in a strange environment, with the natural desire to please and impress the clinician may provide sufficient motivation to enable the child to present as being normal.
Behaviour Rating Scales may provide very useful information which loads on a number of factors which assist the clinician to differentiating the variety of disorders. However, behaviour rating scales usually have relatively few items loading on each of the factors, and the rater's current feelings towards the child may distort the ratings provided. Hence, behaviour rating scales need to be evaluated with due caution.
Anecdotal information obtained from parents or teachers may provide a great deal of useful information. The clinician may ask further questions to clarify any issues and to gain the maximum of relevant information. Diagnostic interviews also allow the clinician to assess the attitudes of parents and teachers towards the child. This may be relevant to a diagnosis as well as being relevant to treatment strategies.
Observations made by the clinician during the assessment may provide corroborative evidence which helps to improve the reliability of the diagnosis. Certainly, such observations may help to clarify the severity of the behaviours. However, it is possible for severe ADD/ADHD'S to appear normal in the assessment situation.
The diagnosis of Attention Deficit Disorder cannot be carried out in a short interview. Information needs to be gathered systematically from parents and teachers as well as observations during the assessment. Intelligence must be considered as a possible explanation for the symptomatic behaviours. Other possible diagnoses must be considered either as alternative diagnoses or as comorbid conditions. The diagnosis of Attention Deficit Disorder is a clinical decision based on careful consideration of the all of the relevant information, considered within the framework of DSM-IV.
Guidance Officers must determine whether the indications of a possible diagnosis of ADD/ADHD warrant further investigation. They must decide whether they have the necessary expertise or whether is necessary to refer on to another professional with appropriate expertise.
Copyright Dr Stephen Dossel, and the ADD Association Queensland. This article may be reprinted but should not be modified in any way. Any such use should be acknowledged in the normal manner and must include the author's name and the source of the article.
