Posted tagged ‘school problems’

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.