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Jay J. Jones
Fresno, California
The objective diagnosis of ADHD is a difficult and time consuming task. Multiple measures must be used (Barkley, 1981), and formal diagnosis should only be done by practitioners who have great experience in diagnostic appraisal of children (Wender, 1987).
This description will concern itself only superficially with procedures and measures utilized to screen for, and confirm the diagnosis of ADHD. Detailed instructions or descriptions of evaluative procedures would be outside the scope of this paper.
Screening should be an important part of the educational and therapeutic process. In order for screening to be routinely done, the methods must be practical and time economic. Screening is most commonly accomplished by parent and teacher respondent rating scales. Scales such as these are generally considered more accurate when completed by teachers rather than parents. This may be explained by the fact that teachers are usually more objective than parents, and have a greater cross section of children from which to make comparisons (Barkley, 1981). Nonetheless, information obtained from these scales completed by both parents and teachers is invaluable. There is important information to be obtained by comparing the scoring of teachers vs. parents, and also comparing the ratings given by the two parents (Achenbach & Edelbrock, 1983).
Sattler's classic text on child assessment (1988) suggests that rating scales are popular because they are both time and cost economic, and they can be administered and scored easily. There are many rating scales available for this purpose, two of which will be identified here because of the frequency with which they are mentioned in the literature.
The Parent Symptom Questionnaire by C. Keith Connors (1990) is probably the most commonly used rating scale that is completed by parents. The parent scale is used along with the Connors Teacher Rating Scale (Barkley, 1981; Connors, 1990; Gueuremont, et al. 1990; Jastak & Wilkinson, 1984; Ross & Ross, 1976). Both versions of the Connors scale cover similar areas of child functioning, so that comparison between the teacher and parent version is simplified. Sattler (1988) reports that the Connors scales rate several areas of functioning including Hyperactivity, Conduct Problems, Emotional Overindulgence, Anxious-Passive, Asocial, and Daydream-Attendance Problems. Barkley (1981) states that both the teacher and the parent versions of the Connors can differentiate hyperactive from normal children. Ross and Ross (1976) suggest that the Connors scale is useful in the identification of ADHD, but the authors give emphasis to the scale's usefulness in the monitoring of pharmacological treatment. Halperin, et al. (1990) modified the Connors in an attempt to make the scale more sensitive in differentiating dimensions of the hyperactive / aggressive mixed diagnosis.
The second rating scale to be identified in this paper is the Child Behavior Checklist (CBCL). The CBCL was repeatedly referred to in the literature. Like the Connors, the CBCL has two forms for completion. One form to be completed by the teacher, and another by the parent(s). The CBCL is a far more comprehensive rating scale, but is also more difficult to score and administer than the Connors. A review of the manual for the CBCL (Achenbach & Edelbrock, 1983) reveals 26 dimensions along which a child can be evaluated. This compares to 6 dimensions covered by the Connors. The CBCL contains 116 items to respond to, compared to the Connors 93 item long version, and a 48 item abbreviated version (Connors, 1990; Sattler, 1988). Barkley (1981) recommends using both the Connors and the CBCL for comprehensive screening, but this may be excessive in terms of administration and scoring time. Guerumont, et al. (1990) suggest that the CBCL provides a thorough screening for childhood psychopathology in general, but recommends the Connors in the specific screening for ADHD.
Interviews are an important part of the diagnostic process. Ideally, there should be a face to face interview with both parents, and with the child. If possible, it is also very helpful to conduct an interview with the teacher (Barkley, 1981; Coker & Thyer, 1990; Gueuremont, et al. 1990).
All interviews are useful as a supplementary technique to the rating scales. Guidelines for such interviews vary according to the practitioner conducting the interview, and according to the purpose of the interview. The interview structure should be designed to suit the person(s) being interviewed. The content of the diagnostic sessions should be specifically suited to both the need for information and the subject being interviewed.
Parent interviews are predominantly designed to secure historical information about the child, to assess parenting styles and skills, and to develop a picture of the family dynamics. Developing positive rapport with the parent is important to later treatment, and so this should be considered in the parent interview strategy (Sattler, 1988).
Whenever possible the practitioner should seek to get information from the parent related to 1) demographics, 2) specific information about the child, 3) information about the parents history, and 4) other important family events (Barkley, 1981). Gueurmont et al. (1990) emphasize the importance of acquiring information about developmental milestones, pregnancy and delivery information, and other developmental information. Coker & Thyer (1990) particularly stress the appropriateness of separate interviewers for the parents and for the child individually. They suggest that it would be ideal for a psychologist to interview the child, and perhaps a social worker to interview the parents. If this splitting of the interviewing is practiced, close collaboration in treatment planning and treatment delivery is necessary.
Interview of the child should cover standard mental status protocol, with specialized procedures unique to focusing on ADHD symptoms (Barkley, 1981). Examiners should be aware that symptoms of ADHD are not necessarily seen across all situations. Therefore it is common that few--if any--directly observable data may be demonstrated in the face-to-face interview. Sattler is explicit about the need for the interview techniques to be suited to the developmental level of the child and he recommends focus on the goals of 1) obtaining accurate information, 2) describing the various assessment procedures to the child, and 3) forming a professional opinion about the child (Sattler, 1988). Gueuremont et al. (1990) stress the usefulness of noting any motoric evidence of hyperactivity, such as fidgeting, restlessness, eye focus, and general ability to follow the interview format.
Teacher interviews may prove the most useful of the face-to-face information gathering efforts. Gueuremont et al. (1990) believe it is especially important to learn how long the teacher has known the child, and to get the teacher's assessment of the child's level of organization, motivation, orderliness of work, approach to tasks, and relationship with other students. Barkley (1981) suggests that if a face-to-face interview is not possible, a telephone interview can also be most helpful. He points out that the teacher may be the best source for opinions about whether the child is affected by other forms of learning disability. Sattler (1988) emphasizes the importance of discovering what educational strategies have been attempted, and the result of these strategies.
Direct observation in the naturalistic setting is, perhaps, the most accurate indicator of the child's performance capabilities. In this context, direct observation can either mean observations made directly by the examiner, or observations made by teachers or parents. These observations should be recorded according to some prescribed format.
The CBCL (Achenbach & Edelbrock, 1983) has a form that can be used for the direct observation of children for diagnostic purposes. When the practitioner is making the observations directly, it is desirable for some standardized guideline to be used to preserve objectivity. This is also important when a teacher makes the direct observation. However, teachers and other child practitioners can provide useful information by observing with or without specifically structured guidelines. When parents are gathering the observational data, specific guidelines and techniques should be used.
Barkley (1981) identifies four types of recording methods for behavioral scientists, 1) behavioral products recording, 2) event recording, 3) duration recording, and 4) interval recording or sampling.
Psychoeducational testing is yet another dimension used in the ADHD assessment process. This is one dimension of the ADHD assessment process that will ideally be accomplished a professional with extremely specialized expertise. Most practitioners will seek the services of a professional educational, school, or clinical psychologist to perform testing services. Such testing should offer information regarding both intelligence and achievement. Although many excellent tests are available to the psychologist, two tests will be mentioned here. These two tests are presented because they can yield significant information, yet can be administered and scored by non-psychologist practitioners such as teachers, counselors or social workers.
The Wide Range Achievement Test (WRAT) can be administered by experienced professionals such as teachers, counselors and social workers. The WRAT can provide important information that relates to academic achievement level and learning disability (Jastak & Wilkinson, 1984). Sattler (1988) points out that ADHD children perform more poorly than normals on some, but not all, tests (Sattler, 1988).
In the case of achievement tests, the test taking deficiency that often reveals inadequacy is the child's inability to attend. This--along with impulsive responding--may give the appearance on an achievement test that under represents the child's true abilities. Nonetheless, some baseline of academic achievement must be established as an aid to planning the remedial educational effort. This is true no matter whether the academic deficit is explained by intelligence or ADHD disability.
Barkley (1981) believes that tests like the WRAT can be used most effectively, even if only used as a screening instrument. If an area of deficiency appears on the WRAT, that area can be evaluated on closer analysis by some more sophisticated test.
The Slosson intelligence test, while not as comprehensive as other intelligence tests (eg. the Weschler), also can be administered as a screening instrument by non-psychologist practitioners (Slosson, 1983, 1985).
There are correlations between achievement tests and intelligence tests that provide information that can be useful in the diagnosis of ADHD, but we must observe Sattler's caution (1988) that suggests that no specific test pattern--neither in psychoeducational, psychometric, nor projective--is definitively indicative of ADHD. Testing such as this can only serve as an adjunct to the other appropriate diagnostic methods.
Informal measures are another important possibility in the ADHD diagnostic process. Guerin and Maier (1983) offer a great array of informal assessment techniques that can be used in the educational or other professional setting. These techniques include 1) interaction recording, 2) observational techniques, 3) interview/conference techniques, 4) questionnaires, 5) developmental assessments, and 6) assessments of thinking, language, spelling, handwriting, reading and arithmetic. Sattler also echoes this notion recommending informal techniques for evaluating skills in reading, written expression and spelling (Sattler, 1988).
A considerable problem related to ADHD is diagnostic confusion. ADHD is often difficult to differentiate from other associated disorders such as learning disability (Barkley, 1981; Garfinkel & Wender, 1989; Grande, 1988; Gueremont, et al. 1990; Halperin, et al. 1989) conduct disorder (Draeger et al. 1986; Lambert, 1988; Reeves, Werry, Elkend, & Zametkin, 1987; Satterfield, et al. 1987; Wallander, 1988; Werry, Reeves, & Elkind, 1987), and oppositional defiant disorder (APA, 1987, 1980; Coker & Thyer, 1990; Garfinkel & Wender, 1989; Gueuremont, et al. 1990; Henker & Whalen, 1989; Werry, et al. 1987). Garfinkel and Wender (1989) identify a major problem in making the differential diagnosis between ADHD and CD, pointing out that the two often overlap. Gittelman, Manuzza, Shenker, and Bonagura (1985) report that there is such a high rate of children with ADHD/CD combination that diagnostic confusion is significant. Quay and Werry (1986) point out that ADHD features such as restlessness and overactivity are also seen in CD children who do not otherwise fit the diagnosis of ADHD. There seems less controversy about "construct validity" between ADHD and ODD, but there is strong opinion that ODD and CD may not be separate disorders, but may only depict degrees of disorder along a common continuum (Reeves, et al. 1987; Werry, et al. 1987).
Various researchers argue against the position that ADHD is an isolated disorder at all. Werry, et al. (1987) question the validity of ADHD as a disorder that is separate from CD, and Gittelman et al. (1985) speculate that ADHD may not be a discreet syndrome, but a variant of CD. The argument in this regard is that ADHD and CD are a combined disorder, and that there are rarely examples of children who do not manifest characteristics of both. This is obviously not supported by American Psychiatric Association (1980), since variations of each of these disorders were included in the DSM III, since the authors felt that both clinical and research evidence supported the strength of the individual diagnoses. Consequently, both diagnoses were subsequently included in DSM III-R (1987).
On the other hand Mannuzza et al. (1988) report what they consider to be strong evidence to support the construct validity of both ADHD and CD as separate disorders. They agree that both often coexist in the same child.
Perhaps the most remarkable finding by this writer in the whole researching of this paper has been the preponderance of material that addresses the diagnostic confusion and associated problems with the ADHD/CD mixed diagnosis. Although this dimension of the ADHD problem has proven too much to report on in the scope of this paper, it is certainly an interesting finding, with broad implications for both education and treatment. It should still be pointed out here that by almost all who address the issue of mixed diagnosis (ADHD/CD), the prognosis for long term adjustment is extremely poor (Cantwell, 1989; Garfinkel & Wender, 1989; Gittelman, et al. 1985; Hamden, et al. 1989; Kaplan, et al. 1990; Mannuzza, et al. 1988; Nichamin & Windell, 1984; Roberts, 1990).
Last Modified: Tuesday, November 11, 1997 8:42:35 PM
Steven J. Foust, peregrin@enteract.com