Evaluating children for ADHD: Getting started

The Pediatric Insider

© 2014 Roy Benaroch, MD

We frequently get this call at the office, something like this: “Brian’s teacher says he isn’t paying attention in class. The school wants us to get forms from his doctor to fill out to see if he has ADHD. Do I get those forms from you?”

I honestly don’t know how most pediatricians handle these calls, but I’ll tell you what I think parents faced with this situation ought to do.

I think it’s a mistake to assume children who aren’t doing well in school or aren’t paying attention in class should immediately be tested for ADHD. I can’t think of a single other medical symptom that’s evaluated like that—to start with one symptom, and immediately do one specific test to diagnose one specific diagnosis, over the phone, with no additional information or a physical exam or any consideration that there could be more than one possible diagnosis.

In medicine, what we’re supposed to do is start with a complaint or a symptom, get more information from a history and physical exam, and then develop what’s called a “differential diagnosis.” That’s a list of possibilities. Could be X, could be Y, could be Z. Then, if necessary, we use tests to narrow down the list, and then talk about treatment options for the diagnosis that’s either the most likely, or the most dangerous, or both. Let me give you an example:

Someone comes to see me with a pain in their foot. I don’t immediately assume it’s a broken toe and do an x-ray—I first ask when and how it happened. Maybe it started to hurt after you stepped on a bee, maybe it began after you swam in the Amazon river, maybe it began after you got a new pair of shoes. I then examine the foot. Maybe there’s a splinter or a swollen joint. Or maybe a piranha bite. I don’t know until I’ve asked the questions and done my exam. Only after that part do I consider whether I need an x-ray, or a blood test, or an Acme Piranha Repair Kit.

Yet, when kids aren’t paying attention in class, I often get calls to just do the ADHD testing. What if Junior isn’t paying attention because he’s not getting enough sleep? Or he has a hearing problem? Or a learning disability, or depression, or substance abuse? What if he’s being bullied, or has a vision deficit, or hypothyroidism? What if he doesn’t understand English well? What if his allergy medicine is making him dopey?

If the only thing we do is test for ADHD, we won’t even consider the possibility that something else might be going on. That’s a shame, and a disservice to the child and family.

Don’t start with testing. Start with a broad medical evaluation: a visit to the doctor for a complete history and physical. Then we’ll decide what ought to be done next.

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7 Comments on “Evaluating children for ADHD: Getting started”

  1. Salbert Says:

    Or, maybe we could investigate the possibility that Junior is 6 and is forced to sit still in a chair all day long doing paper and pencil tasks. I would always suggest modifying instructional strategies before modifying the child or trying medication.


  2. Dr. Roy Says:

    Salbert, I would certainly include “unreasonable expectations” among a list of “ADD mimics”.


  3. Rob Lindeman Says:

    I wish we would dispense with the word ‘test’ when we refer to attention deficits. There is no ‘test’ per se. There is a questionnaire comprising questions about another person’s behavior. To refer to a questionnaire as a test does violence to the language, not to mention what it does to the kids!


  4. Dr. Roy Says:

    Rob makes a valid point. “Tests” in the realm of psychiatry and psychology are almost entirely questionnaires and observational scales, which may be fundamentally different from the “tests” used in other areas of medicine (xrays, blood tests, EKGs, etc.)


  5. Stephanie Says:

    Thank you for referencing the issue of sleep. The effect of sleep deprivation can be inattentiveness or impulse control issues. I find that sleep is one of the last things that parents – and even professionals – consider when addressing these kinds of problems.


  6. Dr. Roy Says:

    Stephanie, you’re right. Both inadequate quantity of sleep and inadequate quality of sleep can masquerade as “ADHD.” A sleep history is an essential part of an eval for school problems.


  7. Anna Says:

    What do you think about neurofeedback for adhd? Becca was evaluated this way and the results indicated that she has adhd. She has had one session since that where she plays pac-man by focusing on the screen to move him.


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