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Section 16
Diagnostic Procedures for Children with ADHD

Question 16 | Test | Table of Contents

Clinical Interviews
The clinical interview is the most widely used method in the assessment process for ADHD (Batsche & Knoff). The well-conducted interview establishes the rapport that is necessary when implementing an intervention program and allows for coverage of a broad range of topics. Structured interviews such as the Diagnostic Interview Schedule for Children (Shaffer) and the Semistructured Clinical Interview for Children and Adolescents (McConaughy & Achenbach) are constructed around specific diagnostic criteria and have relatively high reliabilities (Edwards, Schultz, & Long). Although structured interviews are available and have certain advantages, most therapists rely on nonstandardized interviews.

Child interview. The clinical child interview is a recommended component in the assessment of children with ADHD (American Academy of Child and Adolescent Psychiatry; AACAP,). Children, particularly over age 10, can reliably report on their behavior, and the reliability of their report increases with age (Edwards et al.). How ever, children are more reliable in reporting on internalizing symptoms (such as anxiety and mood symptoms) than on externalizing symptoms such as aggressive behavior. The interview should include questions about behavioral problems and conflicts at home and school, peer relationships, and academic performance and experiences. The therapist should explore the child’s thought and speech, sensory and motor functions, emotional functioning, and insight and judgment (Sattler). Guidelines for child interviews and mental status evaluations can be found in Sattler. Shapiro provided a format for academically oriented child interviews.

Parent interviews. Parents can provide a reliable report of their child’s behavior, although the presence of parental or family stress may result in increased reporting of child behavior problems (Edwards et al.). The interviewer should obtain details of the child’s problems in the home setting, including the presence and frequency of behaviors characteristic of ADHD. A detailed developmental history and medical history are reviewed, along with any history of previous mental health treatment. The parent should also provide information about the history of mental health or learning problems in other members of the family. Finally, the therapist should gauge the reactions and levels of distress that are present in parents and other family members. The parent interviews found in Barkley and Murphy and Sattler are useful guidelines for therapists.

Teacher interviews. Teacher interviews provide important information about the child’s behavioral symptoms, social behavior, and academic performance (DuPaul & Stoner). Teachers should be asked to describe the difficulties that the child is experiencing with behavior, social relationships, and academic performance. They should identify when and in what situations behavioral difficulties occur most often, and what consequences result (McConaughy). The teacher is asked to describe the child’s curriculum, the instructional methods that are used in the classroom, and how well the child is performing compared with other students in the class. Examples of teacher interviews can be found in Sattler and Shapiro.

Behavior Rating Scales
Rating scales can provide more reliable and objective data than that provided by an interview (Merrill) and there are several well-standardized parent and teacher rating scales available (DuPaul). Behavior rating scales can be broad-band scales or narrow-band scales (Eckert & DuPaul). Broad-band rating scales measure a number of different behavior constructs and are useful in initial screening. Narrow-band scales are designed to measure a single, specific construct, such as hyperactivity, and are frequently used with one of the broad-band rating scales if ADHD is suspected. There are numerous broad-band scales available, and a comprehensive review of many of them may be found in Breen and Merrill. Two scales that are frequently used to assess children suspected of having ADHD are the Behavior Assessment System for Children (BASC, Reynolds & Kamphaus) and the Child Behavior Checklist (Achenbach) system. The BASC is an empirically based system that is suitable for children ages 4 through 18. It consists of parent-, teacher-, and self-completed rating scales along with a structured developmental history and observation form. The system provides measures of both problem and adaptive behaviors. The parent and teacher scales provide scores for over a dozen factors, including attention problems, hyperactivity, conduct problems, anxiety, and depression. They also provide an assessment of leadership, social skills, study skills, and learning problems. The child self-report provides ratings for a variety of factors such as attitudes toward school, anxiety and depression, self-esteem, and personal and school adjustment. Including items measuring adaptive behaviors and the similarity of the items used to measure ADHD to the DSM criteria (Kamphaus & Frick) make the BASC especially useful in assessing ADHD. The Child Behavior Checklist system includes parent rating forms for children from ages 4 to 18 (Achenbach), a Teacher’s Rating Form (Achenbach) and a Youth Self-Report (Achenbach). These integrated scales assess a number of behavioral constructs, including attention problems, aggressive behavior, social problems, and anxious/depressed. They have good reliability and validity, and have been used for many years in clinical and research settings. The narrow-band scales assess the symptoms of inattention, impulsivity, and hyperactivity. The ADHD Rating Scale (DuPaul) is a 14-item questionnaire that can be completed by parents and teachers. It has good reliability and validity and is sensitive to treatment effects. Became it has a small normative sample it is suggested for use as a screening or treatment outcome measure (Eckert & DuPaul). The Child Attention Profile (Barkley) is a relatively short questionnaire that has been found to discriminate between children with ADHD with and without hyperactivity and to be sensitive to treatment effects (Eckert & DuPaul). The ACTeRS Teacher Form (Ullmann, Sleator, & Sprague) and ACTeRS Parent Form (Ullmann, Sleator, & Sprague) were developed as diagnostic tools for ADHD. They provide a score for four dimensions: attention, hyperactivity, social problems, and oppositional behavior. Both forms are easy to complete and have good reliability. They can be particularly useful for differentiating children with ADHD-l and provide useful measures of social skills and oppositional behavior. Other narrow-band measures of ADHD include the Attention-Deficit Disorder Evaluation Scale (McCarney), the Brown Attention-Deficit Disorder Scales (Brown) and the Conners Rating Scales-Revised (Conners). The Disruptive Behavior Rating Scale (Barkley & Murphy) is available in a teacher and parent form. The items on this scale are derived from the DSM criteria for ADHD, oppositional-defiant disorder, and conduct disorder and are useful to gather information about behavioral problems of the child who may have ADHD. The School Situations Rating Scale (Barkley) documents problems with conduct in school, and the School Situations Rating Scale-Revised (Barkley) documents the number of attention-related difficulties present in school. These 12-item surveys are completed by teachers and provide ratings of the total number of situations in which attention problems occur and of their severity. The 16-item Home Situations Rating Scale (Barkley) and Home Situations Rating Scale-Revised (Barkley) provide similar measures for the home setting. These scales have proven useful in assessing the number, pervasiveness, and temporal variability of ADHD (DuPaul).

Behavioral Observation
Behavioral observation involves observing the child in the classroom or during simulated academic or social tasks while in the office or clinic (Shelton & Barkley). Several systems of direct behavior observation have been developed, including methods that involve simulated academic or parent--child interaction (Barkley) and systems that are used in sampling behavior in the natural environment (Achenbach; Goldstein & Goldstein). Observational data are useful in designing and evaluating interventions (Burcham & DeMers).The major drawbacks of direct observation include the cost in time and professional resources in conducting the observation and the potential of invalid samples of behavior because the presence of the observer may alter the behavior of the child and others present in the setting (Batsche & Knoff; Burcham & DeMers). Time-sampling, the major method of collecting observational data, is also not sensitive to low-rate behaviors, such as aggression (Atkins & Pelham).

Psychological and Psychoeducational Assessment
Most traditional psychological and psychoeducational assessment techniques have not proven useful in diagnosing ADHD (DuPaul & Stoner). Although some researchers believe that standardized measures of attention and impulsivity, such as continuous performance tests, are useful in assessing distractibility and inattention (Kronenberger & Meyer), others have concluded that they do not reliably discriminate children with ADHD (DuPaul, Anastopoulos, Shelton, Guevremont, & Metavia; Shelton & Barkley). From the perspective of the DSM (APA) diagnostic system, these tests are not necessary for making the diagnosis of ADHD (Goldstein). Although not a traditional psychoeducational assessment instrument, the Academic Performance Rating Scale (DuPaul, Rapport, & Perriello) collects information on the child’s academic and learning skills and performance. The scale has good reliability and can differentiate between students with and without classroom behavior problem. The scale taps academic competencies rather than behavioral deficits and provides information that is not obtained through other rating scales or direct observation, It is a useful supplement to a teacher interview and inspection of the child’s schoolwork. Curriculum-based measurement of the child’s academic skills may be useful in determining the child’s academic level and the appropriateness of the current academic placement.

The Diagnostic Process
The diagnosis of ADHD is not made by single objective measures such as laboratory or performance tests, psychological tests, or patterns of performance on psychoeducational tests but by the number of symptoms present, no single one of which is diagnostic of ADHD (McBurnett, Lahey, & Pfiffner). History and observation provide the primary basis for making the diagnosis (Culbertson). Diagnosis is complicated in that behaviors that are symptomatic of ADHD are also likely to occur in normal children during the course of development and may also occur as symptoms of problems other than ADHD (McBurnett et al.). The likelihood of comorbid disorders being present is relatively high, and the assessment should also address the identification of other disorders (Schaughency & Rothlind). Finally, the therapist must assess how the symptoms of ADHD impair the child’s functioning in school, in social relations, or in the home.

Identifying Core Symptoms
History and observation are the basic methods for identifying core symptoms of ADHD. The therapist should interview the parent and, whenever possible, the child’s teacher to ascertain the presence of specific symptoms of ADHD. Rating scales can be useful in gathering information about specific behaviors that the child might exhibit, particularly the narrow-band scales that provide for a rating of the symptoms that are most relevant to ADHD. Behavioral observation is also helpful in identifying the behaviors that characterize ADHD. It is important to make observations in the child’s natural environment (such as in the classroom or in the cafeteria) because all but the most seriously hyperactive and impulsive children can suppress their hyperactive and impulsive behavior temporarily when in the therapist’s office (Culbertson). Behavioral observation can also establish whether similar behavior is present in other children the client’s age and whether the symptomatic behavior is exhibited at a level greater than that in other children. A detailed developmental history is necessary to determine the age of onset and course of ADHD symptoms. The use of multiple informants is required to identify the situational pervasiveness of the symptoms of ADHD. However, the level of agreement on symptoms between teachers and parents is often relatively low and may represent differences other than the presence of core symptoms (Barkley). When evaluating the situational pervasiveness of ADHD symptoms the symptoms should be present in two or more settings in which the environmental demands on the child are equivalent (Kamphaus & Frick). Narrow-band rating scales are useful for documenting the situational pervasiveness of ADHD symptoms and conveniently provide information that may not be quantifiable in other ways.

Differential Diagnosis of Alternative Causes of Core Symptoms
There are several disorders that have symptoms similar to those of the core symptoms of ADHD. Anxiety may have prominent symptoms of restlessness and inattention. Depression in childhood may produce inattention and psychomotor agitation, which may be confused with symptoms of ADHD. Medical or neurological disorders can also be manifested in problems with attention, impulsivity, or overactivity. The best way to rule out other disorders as the sole cause of the child’s symptoms is to adequately determine that the symptoms are of sufficient number, duration, and intensity to meet the criteria for ADHD, because many disorders producing similar symptoms result in symptoms of lower intensity or shorter duration (Kamphaus & Frick). A thorough developmental and medical history may signal potential medical concerns that need additional investigation by a physician. A detailed history of the onset and duration of symptoms will often point to an alternative explanation of the child’s behavior. A family history of ADHD, learning disorder, or internalizing disorder (depression or anxiety) will also help the clinician in considering whether other disorders may better account for the child’s symptoms. Direct observations may be helpful in discriminating ADHD from other related psychiatric or developmental disorders (Platzman et al.). Broad-band rating scales are also useful for differential diagnosis.

Identification of Cormorbid Disorders
Children with ADHD are very likely to have coexisting psychiatric disorders (Kronenberger & Meyer). As many as 60% of children with ADHD-C will meet the criteria for oppositional-defiant disorder, and up to 50% will eventually meet the criteria for conduct disorder (Barkley). As many as 50% of children with ADHD may develop a mood disorder, and anxiety disorders are commonly reported, especially in children with ADHD-I (Barkley). The incidence of comorbid disorders is more likely for children whose parents have a history of psychopathology or whose families are disorganized or dysfunctional (Julien). Children with Tourette’s syndrome frequently have ADHD (Power & Mercugliano), and learning disabilities also commonly occur with ADHD (Culbertson). Broad-band rating scales, which measure different behavior constructs including depression and anxiety, are useful for identifying comorbid disorders. Careful mental status evaluation will help identify behaviors that are symptomatic of comorbid disorders. A family history of psychopathology or family dysfunction, which can be identified through clinical history and interviewing, raise the level of suspicion of additional internalizing disorders. Tests of cognitive and academic functioning help assess children experiencing academic skills problems who may have comorbid learning disabilities. They are also useful in evaluating the level of impairment in academic functioning resulting from ADHD.
--Brown, Michael B; Diagnosis and Treatment of Children and Adolescents with Attention-Deficit Hyperactivity Disorder; Journal of Counseling & Development; Spring 2000, Vol. 78 Issue 2, p195

Personal Reflection Exercise #2
The preceding section contained information about diagnostic procedures for children with ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Diagnosis of children with attention-deficit/hyperactivity disorder (ADHD)
comorbid autistic traits (ATs) by applying quantitative magnetic
resonance imaging techniques

- Tang, S., Liu, X., Nie, L., Chen, Z., Ran, Q., & He, L. (2022). Diagnosis of children with attention-deficit/hyperactivity disorder (ADHD) comorbid autistic traits (ATs) by applying quantitative magnetic resonance imaging techniques. Frontiers in psychiatry, 13, 1038471. https://doi.org/10.3389/fpsyt.2022.1038471


Peer-Reviewed Journal Article References:
Granziera, H., Collie, R. J., Martin, A. J., & Nassar, N. (2021). Behavioral self-regulation among children with hyperactivity and inattention in the first year of school: A population-based latent profile analysis and links with later ADHD diagnosis. Journal of Educational Psychology.

Shahidullah, J. D., Carlson, J. S., Haggerty, D., & Lancaster, B. M. (2018). Integrated care models for ADHD in children and adolescents: A systematic review. Families, Systems, & Health, 36(2), 233–247.

Smith, Z. R., Eadeh, H.-M., Breaux, R. P., & Langberg, J. M. (2019). Sleepy, sluggish, worried, or down? The distinction between self-reported sluggish cognitive tempo, daytime sleepiness, and internalizing symptoms in youth with attention-deficit/hyperactivity disorder. Psychological Assessment, 31(3), 365–375.

Weyers, L., Zemp, M., & Alpers, G. W. (2019). Impaired interparental relationships in families of children with attention-deficit/hyperactivity disorder (ADHD): A meta-analysis. Zeitschrift für Psychologie, 227(1), 31–41.

QUESTION 16
According to Brown, what are the four most commonly occurring comorbid disorders in children with ADHD? To select and enter your answer go to Test.

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