Posted tagged ‘attention deficit disoder’

What tests are available for ADHD?

May 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

I wrote last week about getting started with an evaluation for a child who’s not doing well in school. Don’t rush to just do ADHD testing—there are many reasons for attention problems, and it’s best to not just zero in on ADHD at the start.

Still, there’s a time when confirmation and testing for an ADHD diagnosis is appropriate. What kinds of tests are available?

A clinical history is, well, talking with someone who gets to know your child through an informal interview. This can be done by a physician, psychologist, therapist, counselor, or social worker. Though a clinical interview might not be considered a “test”, I think it’s still the single best way to both rule in and rule out an ADHD diagnosis. Especially when done by someone who’s known your child for years, like a pediatrician you’ve been working with.

There are also standardized forms that are a way of making sure the exact same questions are asked in the same way, so the answers can be compared to answers given by thousands of other children in clinical trials. These are the “forms” often suggested by schools, with names like the “Vanderbilt” or “Conners” forms. Usually more than one person fills them out, including both parents and a few teachers. Some of these forms only ask questions relevant to an ADHD or ADD diagnosis; others ask some questions to screen for anxiety or depression or other problems. Because they’re standardized and frequently used, many centers seem to rely on these forms to establish a diagnosis. I’m not sure that’s always wise, but I do agree that forms like these can help confirm or refute the impression from an interview and other sources. They’re certainly not the only way, or even the most important way, to establish a diagnosis.

Further testing along similar lines—using standardized questionnaires—can be done through a professional, who administers these tests and then compiles a report. This is often called “school testing” or “psychometric testing” or “neuropsych testing,” and it’s usually done by a psychologist. This kind of testing can be far more in-depth, and can include tests of intelligence, memory, and processing; these tests can also help establish if a learning disability is present. Good, thorough testing can teach parents a lot about their child’s strengths and weaknesses, and will go far beyond just answering if a child has or doesn’t have ADHD. But it can be expensive, and often health insurance does not cover this kind of testing.

There are some more high-tech tests available now, and this can be where we’ll get into some controversy. Many companies are selling computer-assisted testing apparatus. Some of these systems use video and motion sensors to evaluate how jiggly a child is, or how well they look at what they’re supposed to be looking at. Other systems claim to analyze brain waves. There’s very little independent research into these systems, though there’s a lot of anecdotes and testimonials and company-sponsored studies that say these systems are terrific. Not only do they objectively establish a diagnosis (so the claim goes), but medical providers can bill big bucks for the testing. I’ve had sales presentations for these things, and I’m not sure that this kind of testing helps patients quite as much as they say.

There are no blood tests or brain imaging studies that are routinely helpful in the evaluation for possible ADHD. However, if a careful history and physical exam suggest other possible diagnoses, sometimes these kinds of tests are needed not to establish the ADHD diagnosis, but to rule out other things.

It would be great if there were one quick and easy test for ADHD. Instead, we have to rely on the overall picture, starting with a thorough history and physical, including a detailed diagnostic interview. A whole lot of questions, and a whole lot of time to talk. To do it right may take multiple appointments, including time to get feedback from parents and teachers. It won’t be fast, and it won’t be cheap. But in the long run, it’s better to do it right.

Evaluating children for ADHD: Getting started

April 28, 2014

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.

Holding children back: Can it “prevent” ADHD?

December 19, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve been skeptical of the trend of “holding back” children with late birthdays. These are kids, usually born in the summer, who are just a few months short of the next grade cut-off. Some parents wonder whether it would be wise to hold them back a few months, so they end up one of the oldest (rather than youngest) kids in their class. This might seem to confer an advantage in terms of maturity, academic ability, and physical size, strength and coordination. Since children usually continue tracking up yearly, without later switching grades, kids “held back” in kindergarten will end up perhaps bigger and stronger and faster when trying out for teams in high school. A good idea?

Recent research has shown some stark differences in children who end up as the youngest versus the oldest kids in a classroom, which gives support to the idea of re-considering firm birthday-based rules for choosing when to start kids in school.

One good study was performed by researchers collaborating in Boston and Iceland. They looked at a nationwide cohort of Icelandic children, about 12000 kids, specifically grouping them by both birthdate and grade in school. Some findings from the study:

  • Mean test scores were lowest among the youngest children, especially in early grades. This gap lessened by middle school, but was still significant.
  • Children in the youngest third of a class were about 50% more likely to be prescribed medication for ADHD than kids in the oldest third of the class.

Similar findings have been reported by other researchers—this seems to be a real effect. Lumping children together by age creates a disparity in abilities within a classroom, with the youngest children being put at a relative disadvantage. That seems to create a greater likelihood of medical diagnoses and treatment for attention deficit disorder. It’s not known if holding back these younger kids with ADHD would allow them to become better students without fulfilling an ADHD diagnosis.

I’m not certain what the best approach is, here. Some kind of division between grades is inevitable, and some kids in any group are going to be the youngest. Perhaps smaller classes with a smaller age-range of children would help; or, perhaps an individualized approach to determining which kids will do best to start sooner versus later would address this disparity. In the held-back year, children who weren’t ready for school could get extra help with their attention abilities and other skills that will help them advance. However, this could lead to other problems later on, when kids of greatly varying age (and therefore physical and sexual maturity) are mixed together.

I don’t have a solution, but it seems like this is a genuine problem. We’d better figure out a way to work this out that doesn’t depend on more medications for the youngest kids in a grade.