Pay Attention: Neurology and ADHD, Part 1

How IS an ADHD diagnosis made in
children? What is a neurologist¹s role?

Janine Rosenberg, PhD: No single test can diagnose a child as having ADHD. Ideally, a licensed health professional needs to gather information about the child and his/her behavior in multiple settings. A family may first seek guidance from their pediatrician, who can screen ADHD symptoms but should then refer the family to a mental health specialist with experience in ADHD. Prior to referral, however, some medical rule-out diagnoses can be made, such as seizures, ear infections, hearing or vision problems, thyroid problems, sleep issues, medical conditions, and significant stressors and major changes. A neurologist can assist with rule-out diagnosis, especially a seizure disorder. Neurology testing is not needed to diagnose or treat ADHD.

Comprehensive psychological testing assesses various areas of functioning, including: cognitive functioning (intelligence), academic functioning (school performance), mood (anxiety, depression), behavior (opposition, conduct), social functioning, and attentional functioning (inattention, hyperactivity, and impulsivity). Information is gathered through parent and child interviews; parent, child and teacher questionnaires, behavior observations; and individual one-on-one testing measures. The key to diagnosing ADHD is not just that there are attention and hyperactivity symptoms, but that they are impairing, are excessive (i.e., affecting all aspects of the child's life), are more frequent than with peers, and occur in multiple settings. In other words, the degree of impairment is more important than the number of symptoms. This answer is best answered through testing and evaluation described above.

What is the role of learning disabilities and when do you screen for those?

With every psychological testing case, I always test for possible learning disorders. It is unadvisable to test for ADHD without first ruling in or out ADHD. The reasons for this is that a learning disorder might coexist with ADHD, or it might appear that ADHD exists but in actuality the learning disorder explains the ADHD-like symptoms (i.e., attention difficulties in but not outside the classroom).

When Do you initiate evaluation for a comorbid learning disability?

Similar to what I described above, I would always evaluate for a possible comorbid learning disorder at the same time that I evaluate for ADHD. In addition, even if both diagnoses exist, I typically recommend that both symptoms related to the learning disorder and ADHD be addressed at the same time. Learning disorders are treated through increasing intensive services and one-on-one extra help through school, as well as repetition and reinforcement of skills outside of the school (e.g., summer school, educational websites/programs, tutoring). ADHD is treated through behavior modifications at school (accommodations such as sitting at the front of the class and extended time on tasks and tests) and at home (with the help of parent management training sessions). In most cases, only after these interventions have been implemented do you consider additional support (stimulant medication).

What may alert you TO a
learning disability?

Learning disorder used to be diagnosed if there was a significant discrepancy in standard scores between cognitive functioning (i.e., intelligence) and academic functioning. However, this did not allow all children who were struggling with academic learning but did not have a large enough discrepancy (e.g., a child who has borderline intelligence (Standard Score = 75) and borderline academic functioning (SS=75)). Therefore, the new way of thinking is that the child's academic performance is well below grade and age level and is causing impairment in academic or other settings. I come to this conclusion by analyzing data that I collect through history with parent (and child), parent and teacher questionnaires, and standardized cognitive and academic testing. However, regardless of the actual diagnosis, what matters most is the specific recommendations and treatment plan that would be most helpful to the child to have less impairing symptoms and succeed.

What about DSM-V changes for ADHD?

The changes made on ADHD in DSM-V allowed for more clarification. I think changing it from 7 years to 12 years might be viewed as dangerous, because more people with ADHD will be diagnosed with ADHD. However, taken from a different perspective, there are many children who did not demonstrate symptoms early on (for reasons such as they were extremely bright and able to “mask” their symptoms at school because they were still getting good grades; they are female and research has shown that they tend to be under-diagnosed; and/or they have inattentive presentation and are well-behaved and quiet at school and therefore do not stand out any “problems.”); therefore, the older children will be able to justifiably meet criteria for ADHD and receive proper treatment. The DSM-V's clarification of ADHD symptoms in adults is beneficial, as they do present differently and more often appear associated with executive functioning.

One issue that occasionally comes up in testing is that a child (for example) has a slow processing speed, which impacts their ability to sustain attention and complete tasks as compared to other children with average processing speed. However, they do not meet criteria for ADHD. Therefore, where do these children fit? I would have liked to see a sub-category of ADHD that can describe those people who have slower processing speeds and may benefit from similar accommodations and behavior strategies.

Furthermore, another thing that would be beneficial to add to the criteria is the requirement of thorough evaluation of the patient. For example, gathering history, multiple informants report, psychological testing, etc. This might help decrease the number of children being diagnosed with ADHD based on a 10 minute doctor's visit. n

Janine Rosenberg, PhD, is an Assistant Professor of Clinical Psychology and Director of Hyperactivity, Attention, and Learning Problems Clinic at the University of Illinois at Chicago.