This is an intermediate level course. After completing this course, mental health professionals will be able to:
The materials in this course are based on the most accurate information available to the author at the time of writing. The scientific literature on ADHD grows daily, and new information may emerge that supersedes these course materials. This course will equip clinicians to have a basic understanding of the diagnosis and assessment of ADHD. The latest update of the content of this course was conducted in January of 2013.
Probably the four most important components to a comprehensive evaluation of the client with Attention-Deficit/Hyperactivity Disorder (ADHD) are the clinical interview, the medical examination, the completion and scoring of behavior rating scales, and the administration of certain psychological tests to rule in or out high-risk comorbid disorders, such as developmental/intellectual delay and learning disabilities. When it is feasible, clinicians may wish to supplement these components of the evaluation with objective assessments of the ADHD symptoms, such as psychological tests of attention or direct behavioral observations. These tests are not essential to reaching a diagnosis, however, or to treatment planning, but when abnormal findings are detected they may yield further information about the presence and severity of cognitive impairments that could be associated with some cases of ADHD. The problem is that the presence of normal scores are largely meaningless given the high proportion of ADHD cases that place in the normal range on such tests. In other words, abnormal scores may be meaningful in indicating the presence of a disorder (not necessarily ADHD) while normal scores should go uninterpreted given the high false negative rate of many ADHD tests. In this course, I describe the details of conducting clinical interviews with parents, teachers, and children/adolescents when it is the child or adolescent who is presenting for evaluation of ADHD. I also briefly discuss the essential features of the medical examination of ADHD children and issues that examination needs to address. This discussion is followed by an overview of some of the most useful behavior rating scales to incorporate in the clinical evaluation. A brief review of the role of psychological tests and direct observations in the evaluation is then presented. Readers wishing to have some of the clinical tools referenced here can find them in a convenient format with limited permission granted by the publisher for photocopying in the clinical manual accompanying my textbook on ADHD (see Barkley & Murphy, 2006). The information contained herein was initially drawn chiefly from my earlier chapters on assessment authored with the assistance of Gwenyth Edwards, Ph.D., and Michael Gordon, Ph.D. in my handbook for diagnosis and treatment (Barkley, 2006). This material was then updated for this course in January of 2013.
Clinicians should bear in mind several goals when evaluating children for ADHD. A major goal of such an assessment is the determination of the presence or absence of ADHD as well as the differential diagnosis of ADHD from other childhood psychiatric disorders. This differential diagnosis requires extensive clinical knowledge of these other psychiatric disorders, and readers are referred to the DSM-5 (American Psychiatric Association, 2013) for diagnostic criteria and to my earlier text on child psychopathology for a review of the major childhood disorders (see Mash & Barkley, 2014). In any child evaluation, it may be necessary to draw on measures that are normed for the individual’s ethnic background, if such instruments are available, to preclude the over diagnosis of minority children when diagnostic criteria developed on white American children are extrapolated to other ethnic groups. For further discussion on gender, socioeconomic status, and cross cultural issues related to diagnosis and prevalence of ADHD, please see the first course in this series titled ADHD: Nature, Course, Outcomes, and Comorbidity.
A second purpose of the evaluation is to begin delineating the types of interventions needed to address the psychiatric disorders and psychological, academic, and social impairments identified in the course of assessment. As noted later, these may include individual counseling, parent training in behavior management, family therapy, classroom behavior modification, psychiatric medications, and formal special educational services, to name just a few.
Another important purpose of the evaluation is to determine conditions that often coexist with ADHD and the manner in which these conditions may affect prognosis or treatment decision making. For instance, the presence of high levels of physically assaultive behavior by a child with ADHD may indicate that a parent training program is contraindicated, at least for the time being, because such training in limit setting and behavior modification could temporarily increase child violence toward parents when limits on noncompliance with parental commands are established. Or, consider the presence of high levels of anxiety specifically and internalizing symptoms more generally in children with ADHD. Research shows such symptoms may be a predictor of poorer responses to stimulant medication, although the point is arguable due to mixed results across studies on this issue. Similarly, the presence of high levels of irritable mood, severely hostile and defiant behavior, and periodic episodes of serious physical aggression and destructive behavior coupled with mania, grandiosity, and sleep or sexual disturbances may be early markers for later Bipolar Disorder (Manic-Depression) in children. Oppositional behavior is almost universal in juvenile-onset Bipolar Disorder (Giles, DelBello, Stanford, & Strakowski, 2007; Wozniak et al., 1995). Such a disorder is likely to require the use of several psychiatric medications in conjunction with a parent training program and occasionally even inpatient hospitalization.
A further objective of the evaluation is to identify the pattern of the child’s psychological strengths and weaknesses and to consider how these strengths and weaknesses may affect treatment planning. This identification may also include gaining some impression as to the parents’ own abilities to carry out the treatment program as well as the family’s social and economic circumstances and the treatment resources that may (or may not) be available within their community and cultural group. Some determination also must be made as to the child’s eligibility for special educational services within his or her school district if eligible disorders, such as developmental delay, learning disabilities, or speech and language problems, are present.
As the foregoing discussion illustrates, the evaluation of a child for the presence of diagnosable ADHD is but one of many purposes of the clinical evaluation. A brief discussion now follows regarding the different methods of assessment that may be used in the evaluation of ADHD children.
The initial phase of a diagnostic interview might not be conducted by the clinician but by a support staff member. The initial phone intake provides invaluable information when conducted by a well-trained individual; otherwise, it is a lost opportunity. When a parent calls to request an evaluation, it is useful to collect the following information: What is the reason for the parent’s request? Is it an open-ended question, such as “What’s wrong with my child?”, or a specific one, “Does my child have ADHD?” Who referred the family? Is the family self-referred because members recently read a newspaper article or saw a television program which raised their concerns? Is the family referred by the child’s school because of school-related rather than parental concerns? Is the family referred by a pediatrician or another health or mental health professional who questions ADHD but wants diagnostic confirmation? Has the child been previously evaluated or tested by someone else? Is the family looking for a second opinion, or for a reevaluation of ADHD that was diagnosed when the child was younger? Does the child have any other diagnosed conditions, such as mood disorders, substance abuse, or other developmental delays? Has the child been tested and diagnosed by the school system to have learning disabilities or cognitive delays? Is the child already on medication? Are the parents seeking an evaluation of their child’s response to medication rather than a diagnostic evaluation? If the child is on stimulant medication, would the parents consent to withhold the medication on the day of the evaluation or even starting the day before to allow observations of the child off their medication during the evaluation? The content of the diagnostic interview is influenced by all these factors, and important information can be collected and reviewed ahead of time when the reason for the referral is clear.
Thus, once the child is referred for services, the clinician must glean some important details from the telephone interview. This information also allows the clinician to set in motion some initial procedures. In particular, it is important at this point to do the following: (1) obtain any releases of information to permit reports of previous professional evaluations to be sought, (2) contact the child’s treating physician for further information on health status and medication treatment if any, (3) obtain the results of the most recent evaluation from the child’s school or have the parent initiate one immediately if school performance concerns are part of the referral complaints, (4) mail out the packet of parent and teacher behavior rating forms to be completed and returned before the initial appointment, being sure to include the written release of information permission form with the school forms, and (5) obtain any information from social service agencies that may be involved in providing services to this child.
Clinicians may want to send out a packet of questionnaires to parents and teachers following the parents’ call to their clinic but in advance of the scheduled appointment. In fact, the parents of children referred to our clinic are not given an appointment date until these packets of information are completed and returned to the clinic. This system ensures that the packets are completed reasonably promptly and that the information is available for review by the clinician prior to meeting with the family, making the evaluation process far more efficient in its collection of important information. In these days of increasing cost consciousness concerning mental health evaluations, particularly in managed care environments, efficiency of the evaluation is paramount and time spent directly with the family is often limited and at a premium. Besides a form cover letter from the professional asking the parents to complete the packet of information, and it also contains the General Instruction Sheet, a Child and Family Information Form, and a Developmental and Medical History Form, all of which can be obtained for limited photocopying purposes in my clinical manual (Barkley & Murphy, 2006). This packet also includes a reasonably comprehensive child behavior rating scale that covers the major dimensions of child psychopathology, such as the Child Behavior Checklist (CBCL; Achenbach, 2001) or the Behavior Assessment System for Children (BASC-2; Reynolds & Kamphaus, 2005). Also in this packet should be a copy of a rating scale that specifically assesses ADHD symptoms. Such a form can also be found in the clinical manual by Barkley and Murphy (2006). That scale permits the clinician to obtain information ahead of the appointment concerning the presence of symptoms of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), as well as ADHD symptoms and their severity. ODD and CD are quite common among children referred for ADHD, and it is useful to know of their presence in advance of the appointment. If desired, a more comprehensive rating scale of executive function deficits, nearly always associated with ADHD, can be obtained using either the Barkley Deficits in Executive Functioning Scale – Children and Adolescents (Barkley, 2012a) or the Behavior Rating Inventory of Executive Functioning (Gioia et al., 2000). Clinicians who wish to assess adaptive behavior via the use of a questionnaire might consider including the Normative Adaptive Behavior Checklist (NABC; Adams, 1984) in this packet or have parents complete this form on the day of the evaluation. Impairment in major domains of life activities is a required criterion for all Axis I psychiatric disorders in the DSM-5. Some information on impairment can be gleaned from the face pages of the CBCL or BASC-2. More recently, a normed rating scale of impairment has been created that can be included with this packet of other forms for obtaining information on 15 different domains of life activities in children (Barkley Functional Impairment Scale – Children and Adolescents; Barkley, 2012b). Finally, the Home Situations Questionnaire (HSQ) is included or saved for completion on the day of the appointment so that the clinician can gain a quick appreciation for the pervasiveness and severity of the child’s disruptive behavior across a variety of home and public situations (see Barkley & Murphy, 2006, for this form and its norms). Such information is of clinical interest not only for indications of pervasiveness and severity of behavior problems but also for focusing discussions around these situations during the evaluation and subsequent parent training program. These rating scales are discussed later.
It is useful to collect and review previous records before the interview. They might include any one or combination of the following: report cards, standardized testing results, medical records (including neurology, audiology, optometry, speech, and occupational therapy), individual educational plans, psychoeducational testing, psychological testing, and psychotherapy summaries.
A similar packet of information is sent to the teachers of this child, with parental written permission obtained beforehand, of course. This packet does not contain the Medical and Developmental History Form or any adaptive behavior survey that may have been included for parents. This packet could contain the teacher version of the CBCL or BASC, the School Situations Questionnaire (SSQ), and the same rating scale for assessing ADHD symptoms (see Barkley & Murphy, 2006, for the latter two scales and their norms). The Social Skills Rating System (Gresham & Elliott, 1990) might also be included if the clinician desires information about the child’s social problems in school as well as his or her academic competence. The clinician can quickly see, for example, if the teacher feels the child is functioning at grade level in various subject areas, how the child has performed on group-administered achievement or aptitude tests, or subjective impressions of the child’s general mood and behavioral functioning. If possible, it is quite useful to contact the child’s teachers for a brief telephone interview prior to meeting with the family. Otherwise, a meeting can take place following the family’s appointment.
Once the parent and teacher packets are returned, the family should be contacted by telephone and given their appointment date. It is our custom also to send out a letter confirming this appointment date with directions for driving to the clinic. With this letter, the clinician might send a short instruction sheet entitled “How to Prepare for Your Child’s Evaluation.” It is provided in my clinical manual (Barkley & Murphy, 2006). This instruction sheet gives the parents some information about what to expect on the day of the evaluation and what information to organize prior to this appointment. It also may set them at ease if having a mental health evaluation is disconcerting or anxiety inducing for them.
On the day of the appointment, the following still remains to be done: (1) parental and child interview, (2) completion of self-report rating scales by the parents, and (3) any psychological testing that may be indicated by the nature of the referral (intelligence and achievement testing, etc.).
The parent (often maternal) interview, although often criticized for its unreliability and subjectivity, is an indispensable part of the evaluation of children and adolescents presenting with concerns about ADHD. No adult is likely to have the wealth of knowledge about, history of interactions with, or sheer time spent with a child than the parents.
Whether wholly accurate or not, parent reports provide the most ecologically valid and important source of information concerning the child’s difficulties. It is the parents’ complaints that often lead to the referral of the child, will affect the parents’ perceptions of and reactions to the child, and will influence the parents’ adherence to the treatment recommendations to be made. Moreover, the reliability and accuracy of the parental interview have much to do with the manner in which it is conducted and the specificity of the questions offered by the examiner. An interview that uses highly specific questions about symptoms of psychopathology that have been empirically demonstrated to have a high degree of association with particular disorders greatly enhances diagnostic reliability.
The interview, particularly a semi-structured interview, allows the clinician in a sense to become another instrument in the assessment process. Although scorable data are obtained, the small details and nuances of parent and child report resonates with clinician-acquired knowledge (from previous interviews, research, readings, workshops, etc.) in such a way as to flesh out and support final diagnostic conclusions. In other words, the interview provides the phenomenological data that rating scales cannot capture. The interview must also, however, focus on the specific complaints about the child’s psychological adjustment and any functional parameters (eliciting events and their consequences) associated with those problems if psychosocial and educational treatment planning is to be based on the evaluation.
The parental interview often serves several purposes.
The suggestions that follow for interviewing parents of ADHD children are not intended as rigid guidelines, only as areas that clinicians should consider. Each interview clearly differs according to individual child and family circumstances. Generally, those areas of importance to an evaluation include demographic information, child-related information, school-related information, and details about the parents, other family members, and community resources that may be available to the family.
If not obtained in advance, the routine demographic data concerning the child and family (e.g., ages of child and family members; child’s date of birth; parents’ names, addresses, employers, and occupations; and the child’s school, teachers, and physician) should be obtained at the outset of the appointment. I also use this initial introductory period to review with the family any legal constraints on the confidentiality of information obtained during the interview, such as the clinician’s legal duty (as required by state law) to report to state authorities instances of suspected child abuse, threats the child (or parents) may make to cause physical harm to other specific individuals (the duty to inform), and threats the child (or parents) may make to harm themselves (e.g., suicide threats).
The interview then proceeds to the major referral concerns of the parents, and of the professional referring the child when appropriate. A parental interview form designed by Barkley and colleagues is available in my clinical manual (Barkley & Murphy, 2006). It can be very helpful in collecting the information discussed later. This form not only contains major sections for the important information discussed here but also contains the diagnostic criteria used for ADHD as well as the other childhood disorders most likely to be seen in conjunction with ADHD (ODD, CD, anxiety and mood disorders, Bipolar Disorder). Such a form allows clinicians to collect the essential information likely to be of greatest value to them in evaluating children using a convenient and standardized format across their client populations.
General descriptions of concerns by parents must be followed with specific questions by the examiner to elucidate the details of the problems and any apparent precipitants. Such an interview probes for the specific nature, frequency, age of onset, and chronicity of the problematic behaviors. It can also obtain information, as needed, on the situational and temporal variation in the behaviors and their consequences. If the problems are chronic, which they often are, determining what prompted the referral at this time reveals much about parental perceptions of the children’s problems, current family circumstances related to the problems’ severity, and parental motivation for treatment.
Following this part of the interview, the examiner should review with the parents potential problems that might exist in the developmental domains of motor, language, intellectual, academic, emotional, and social functioning. Such information greatly aids in the differential diagnosis of the child’s problems. To achieve this differential diagnosis requires that the examiner have an adequate knowledge of the diagnostic features of other childhood disorders, some of which may present as ADHD. For instance, many children with Autistic Spectrum Disorders or early Bipolar Disorder may be viewed by their parents as ADHD as the parents are more likely to have heard about the latter disorder than the former ones and will recognize some of the qualities in their children. Questioning about inappropriate thinking, affect, social relations, and motor peculiarities may reveal a more seriously and pervasively disturbed child. If such symptoms seem to be present, the clinician might consider employing the Children’s Atypical Development Scale (see Barkley, 1990) or the Child Bipolar Parent Questionnaire (Papolos, Hennen, Cockerham, Thode Jr., & Youngstrom , 2006) to obtain a more thorough review of these symptoms. Inquiry also must be made as to the presence or history of tics or Tourette’s Disorder in the child or the immediate biological family members. When noted, these disorders would result in a recommendation for the more cautious use of stimulant drugs in the treatment of ADHD or, perhaps, lower doses of such medicine than typical to preclude the exacerbation of the child’s tic disorder.
The examiner should also obtain information on the school and family histories. The family history must include a discussion of potential psychiatric difficulties in the parents and siblings, marital difficulties, and any family problems centered on chronic medical conditions, employment problems, or other potential stress events within the family. Of course, the examiner will want to obtain some information about prior treatments received by the child and his or her family for these presenting problems. When the history suggests potentially treatable medical or neurological conditions (allergies, seizures, Tourette’s Disorder, etc.), a referral to a physician is essential. Without evidence of such problems, however, referral to a physician for examination usually fails to reveal any further useful treatment information. But when the use of psychiatric medications is contemplated, a referral to a physician is clearly indicated.
Information about the child’s family is essential for two reasons. First, while ADHD is not caused by family stress or dysfunction, such adverse family factors can contribute to oppositional behavior or frank ODD (see Barkley, 2013 for more information on ODD). Therefore, the family history can help to clarify whether the child’s attentional or behavioral problems are developmental or actually a reaction to or product of stressful events that have taken place. Second, a history of certain psychiatric disorders in the extended family might influence diagnostic impressions or treatment recommendations. For example, because ADHD is hereditary, a strong family history of ADHD in biological relatives lends weight to the ADHD diagnosis, especially when other diagnostic factors are questionable. A family history of Bipolar Disorder in a child with severe behavioral problems might suggest that the child may be at higher risk for the disorder (8-fold increase in risk) and particular medication choices that otherwise might not be considered.
The interviewer can organize this section by first asking about the child’s siblings (whether there is anything significant about sibling relationships, whether siblings have any health or developmental problems). Then, questions about the parents may include how long they have been married, the overall stability of their marriage, whether each parent is in good physical health, whether either parent has ever been given a psychiatric diagnosis, and whether either parent has had a learning disability. The clinician should always be cautious of inquiring too much into the parents’ personal concerns. The purpose is to rule out family stress as a cause for the child’s difficulties and to determine what treatment recommendations may be appropriate.
In asking about extended family history, the interviewer should include maternal and paternal relatives (see clinical workbook by Barkley & Murphy, 2006).
Although it may seem tedious, it is extremely useful to go through the child’s school history year by year, starting with preschool. The examiner should ask parents open-ended questions: “What did his teachers have to say about him?”, “How did he do academically?”, or “How did he get along socially?” The examiner should avoid pointed, leading questions (e.g., “Did the teacher think he had ADHD?”). Examiners should allow parents to tell them their child’s story and listen for the red flags (e.g., the teacher thought he was immature, he had trouble with work completion, his organizational skills were terrible, he could not keep his hands to himself, or he would not do homework).
Gathering a reliable school history gives the clinician two crucial pieces of the diagnostic puzzle. First, is there evidence of symptoms or characteristics of ADHD in school previous to adolescence? Second, is there evidence of impairment in the child’s academic functioning as a result of these characteristics?
Examiners should ask parents what strategies teachers may have attempted to help the child in class. They should also inquire about tutoring services, school counselors, study skills classes, or peer helpers. The examiner should find out when and why teachers referred the child for psychoeducational testing. If the child is not doing well in school, the examiner should ask whether school personnel have ever offered an explanation. As always, the examiner should listen for clues about possible problems with behavioral regulation, impulse control, or sustained attention. If the child has a diagnosed learning disability, are there problems in school that cannot be explained by that learning disability?
As part of the general interview of the parent, the examiner must cover the symptoms of the major child psychiatric disorders likely to be seen in ADHD children. A review of the major childhood disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) in some semi-structured or structured way is imperative if any semblance of a reliable and differential approach to diagnosis and the documentation of comorbid disorders is to occur (see interview in Barkley & Murphy, 2006 based on earlier DSM-IV criteria). The examiner must exercise care in the evaluation of minority children to avoid over diagnosing psychiatric disorders simply by virtue of ignoring differing cultural standards for child behavior. Should the parent indicate that a symptom is present, one means of precluding over identification of psychopathology in minority children is to ask the following question: “Do you consider this to be a problem for your child compared to other children of the same ethnic or minority group?” Only if the parent answers “yes” is the symptom to be considered present for purposes of psychiatric diagnosis.
Before proceeding, an explanation is in order as to why ODD and CD are queried first. Many parents arrive at the diagnostic evaluation overwhelmed by emotional stress, frustrations with home behaviors, or endless criticisms about the child from the school; thus they may be inclined to say yes to anything. Starting with ODD and CD questions allows these parents to get some of this frustration out of their system. Thus, when they are asked questions about ADHD, the answers are potentially more reliable and accurate.
In addition, unfortunately some parents actually “shop” for the ADHD diagnosis. They may have an agenda that involves obtaining a diagnosis for their child that is not entirely objective. Beginning the clinical interview with the reason for referral and then the ODD questions may assist the clinician in gaining important clinical impressions about the parents’ agenda. This is also why it can be extremely useful for clinicians to completely eliminate the word “attention” from their vocabulary during the interview. When the clinician asks specific questions about ADHD symptoms, the questions should be phrased in such a way that they are concrete and descriptive.
As suggested in the first of these three CE courses on ADHD, adjustments have been made to the DSM-IV criteria for ADHD that now appear in the DSM-5:
The foregoing issues should be kept in mind when applying the DSM criteria to particular clinical cases. It helps to appreciate the fact that the DSM represents guidelines for diagnosis, not rules of law or dogmatic prescriptions. Some clinical judgment is always going to be needed in the application of such guidelines to individual cases in clinical practice.
To assist clinicians with the differential diagnosis of ADHD from other childhood mental disorders, I compiled a list of differential diagnostic tips (see Table 2.1). Under each disorder, I list those features that would distinguish this disorder, in its pure form, from ADHD. However, many ADHD children may have one or more of these disorders as comorbid conditions with their ADHD; thus the issue here is not which single or primary disorder the child has but what other disorders besides ADHD are present and how they affect treatment planning.
For years, some clinicians eschewed diagnosing children, viewing it as a mechanistic and dehumanizing practice that merely results in unnecessary labeling. Moreover, they felt that it got in the way of appreciating the clinical uniqueness of each case, unnecessarily homogenizing the heterogeneity of clinical cases. Some believed that labeling a child’s condition with a diagnosis is unnecessary as it is far more important to articulate the child’s pattern of behavioral and developmental excesses and deficits in planning behavioral treatments. Although there may have been some justification for these views in the past, particularly prior to the development of more empirically based diagnostic criteria, this is no longer the case in view of the wealth of research that went into creating the DSM-5 childhood disorders and their criteria. This is not to say that clinicians should not document patterns of behavioral deficits and excesses, as such documentation is important for treatment planning; only that this documentation should not be used as an excuse not to diagnose at all. Furthermore, given that the protection of civil rights and entitlements such as access to educational and other services may actually hinge on awarding or withholding the diagnosis of ADHD, dispensing with diagnosis altogether could well be considered professional negligence. Moreover, billing insurance companies or government agencies for professional services requires the specification of a DSM diagnosis. For these reasons and others, clinicians, along with the parent of each child referred to them, must review in some systematic way the symptom lists and other diagnostic criteria for various childhood mental disorders.
The parental interview may also reveal that one parent, usually the mother, has more difficulty managing the ADHD child than does the other. Care should be taken to discuss differences in the parents’ approaches to management and any marital problems these differences may have spawned. Such difficulties in child management can often lead to reduced leisure and recreational time for the parents and increased conflict within the marriage and often within the extended family should relatives live nearby. It is often helpful to inquire as to what the parents attribute the causes or origins of their child’s behavioral difficulties, because such exploration may unveil areas of ignorance or misinformation that will require attention during the initial counseling of the family about the child’s disorder(s) and their likely causes. The examiner also should briefly inquire about the nature of parental and family social activities to determine how isolated, or insular, the parents are from the usual social support networks in which many parents are involved. Research by Wahler (1980) shows that the degree of maternal insularity is significantly associated with failure in subsequent parent training programs. When present to a significant degree, such a finding might support addressing the isolation as an initial goal of treatment rather than progressing directly to child behavior management training with that family.
The first topic in this portion of the interview involves peer relationships and recreational activities. A clinical diagnosis of ADHD requires impairment in the child’s functioning in at least two important areas. This area could certainly be one of them. In addition, evidence of impaired peer relationships may lead to important treatment recommendations such as participation in a peer social skills training group or a peer support group.
Parents are asked if the child has trouble making or keeping friends, how the child behaves around other children, and how well the child fits in at school. Parents are also asked if they have concerns about the friends with whom their child spends time (e.g., do parents view them as “troublemakers”). Finally, they are asked about recreational activities in which the child participates outside school and any problems that occurred during those activities.
Compliance with parental requests and parental use of compensatory or motivational strategies also can be explored, especially if the clinician anticipates conducting parent training in child management skills with this family. These questions also substantiate evidence of impairment in family functioning as well as possible treatment recommendations for parent management training. If the interview on parent-child interactions discussed later is not to be used, parents are asked to describe how quickly their child complies with parental requests, if there are discrepancies in the child’s behavior with mother and father, and if parents generally agree on how to manage their child. They are also asked to describe the types of disciplinary strategies they use and whether or not they have tried incentive systems to encourage more appropriate behavior.
At a later appointment, perhaps even during the initial session of parent training, the examiner may wish to pursue more details about the nature of the parent-child interactions surrounding the following of rules by the child. If so, parents should be questioned about the child’s ability to accomplish commands and requests in a satisfactory manner in various settings, to adhere to rules of conduct governing behavior in various situations, and to demonstrate self-control (rule following) appropriate to the child’s age in the absence of adult supervision. I have found it useful to follow the format set forth in Table 2.2 in which parents are questioned about their interactions with their children in a variety of home and public situations. When problems are said to occur, the examiner follows up with the list of questions in Table 2.2. When time constraints are problematic, the HSQ rating scale can be used to provide similar types of information. After parents complete the scale, they can be questioned about one or two of the problem situations using the same follow-up questions as in Table 2.2. The HSQ scale is discussed later.
Table 2.2. Parental Interview Format for Assessing Child Behavior Problems at Home and in Public
Situation to be discussed
If a problem, follow-up questions to ask
Overall parent-child interactions
Playing with other children
Washing and bathing
When parent is on telephone
Child is watching television
When visitors are in your home
When you are visiting someone else’s home
In public places (stores, restaurants, church, etc.)
When father is in the home
When child is asked to do chores
When child is asked to do school homework
When child is riding in the car
When child is left with a baby-sitter
Any other problem situations
1. Is this a problem area? If so, then proceed with questions 2-9.
2. What does the child do in this situation that bothers you?
3. What is your response likely to be?
4. What will the child do in response to you?
5. If the problem continues, what will you do next?
6. What is usually the outcome of this situation?
7. How often do these problems occur in this situation?
8. How do you feel about these problems?
9. On a scale of 1 (no problem) to 9 (severe), how severe is this problem for you?
Such an approach yields a wealth of information on the nature of parent-child interactions across settings, the type of noncompliance shown by the child (stalling, starting the task but failing to finish it, outright opposition and defiance, etc.), the particular management style employed by parents to deal with noncompliance, and the particular types of coercive behaviors used by the child as part of the noncompliance.
The parental interview can then conclude with a discussion of the children’s positive characteristics and attributes as well as potential rewards and reinforcers desired by the children that will prove useful in later parent training on contingency management methods. Some parents of ADHD children have had such chronic and pervasive management problems that upon initial questioning they may find it hard to report anything positive about their children. Getting them to begin thinking of such attributes is actually an initial step toward treatment as the early phases of parent training will teach parents to focus on and attend to desirable child behaviors (see Barkley, 2013).
Some time should always be spent directly interacting with the referred child. The length of this interview depends on the age, intellectual level, and language abilities of the children. For preschool children, the interview may serve merely as a time to become acquainted with the child, noting his or her appearance, behavior, developmental characteristics, and general demeanor. For older children and adolescents, this time can be fruitfully spent inquiring about the children’s views of the reasons for the referral and evaluation, how they see the family functioning, any additional problems they feel they may have, how well they are performing at school, their degree of acceptance by peers and classmates, and what changes in the family they believe might make life for them happier at home. As with the parents, the children can be queried as to potential rewards and reinforcers they find desirable which will prove useful in later contingency management programs.
Children below the age of 9 to 12-years-old are not especially reliable in their reports of their own disruptive behavior. The problem is compounded by the frequently diminished self-awareness and impulse control typical of defiant children with ADHD (Hinshaw, 1994). Such ODD/ADHD children often show little reflection about the examiner’s questions and may lie or distort information in a more socially pleasing direction. Some report that they have many friends, have no interaction problems at home with their parents, and are doing well at school, in direct contrast with the extensive parental and teacher complaints of inappropriate behavior by these children. Because of this tendency of ADHD children to underreport the seriousness of their behavior, particularly in the realm of disruptive or externalizing behaviors (Barkley, Fischer, Edelbrock, & Smallish, 1991; Fischer, Barkley, Fletcher, & Smallish, 1993), the diagnosis of ODD or ADHD is never based on the reports of the child. Nevertheless, children’s reports of their internalizing symptoms, such as anxiety and depression, may be more reliable and thus should play some role in the diagnosis of comorbid anxiety or mood disorders in children with ADHD (Hinshaw, 1994).
Although notation of children’s behavior, compliance, attention span, activity level, and impulse control in the clinic is useful, clinicians must guard against drawing any diagnostic conclusions when the children are not problematic in the clinic or office. Many ODD and ADHD children do not misbehave in the clinician’s office; thus reliance on such observations would clearly lead to false negatives in the diagnosis (Sleator & Ullmann, 1981). In some instances, the behavior of the children with their parents in the waiting area prior to the appointment may be a better indication of the children’s management problems at home than is the children’s behavior toward the clinician, particularly when the interaction between child and examiner is one to one.
This is not to say that the office behavior of a child is entirely meaningless. When it is grossly inappropriate or extreme, it may well signal the likelihood of problems in the child’s natural settings, particularly school. It is the presence of relatively normal conduct by the child that may be an unreliable indicator of the child’s normalcy elsewhere. For instance, in a study of 205 4- to 6-year-old children, I have examined the relationship of office behavior to parent and teacher ratings. Of these children, 158 were identified at kindergarten registration as being 1.5 standard deviations above the mean (93rd percentile) on parent ratings of ADHD and ODD (aggressive) symptoms. These children were subsequently evaluated for nearly 4 hours in a clinic setting, after which the examiner completed a rating scale of the child’s behavior in the clinic. I then classified the children as falling below or above the 93rd percentile on these clinic ratings using data from a normal control group. The children were also classified as falling above or below this threshold on parent ratings of home behavior and teacher ratings of school behavior using the CBCL. I have found that no significant relationship exists between the children’s clinic behavior (normal or abnormal) and the ratings by their parents. However, a significant relationship exists between abnormal ratings in the clinic and abnormal ratings by the teacher: 70% of the children classified as abnormal in their clinic behavior were also classified as such by the teacher ratings of class behavior, particularly on the externalizing behavior dimension. Normal behavior, however, was not necessarily predictive of normal behavior in either parent or teacher ratings. This finding suggests that abnormal or significantly disruptive behavior during a lengthy clinical evaluation may be a marker for similar behavioral difficulties in a school setting. Nevertheless, the wise clinician will contact the child’s teacher directly to learn about the child’s school adjustment rather than relying entirely on such inferences about school behavior from clinic office behavior. Since this study was completed, standard observation forms for recording child behavior during testing and in school settings have been developed and made commercially available: the Test Observation Form (TOF; McConaughy & Achenbach, 2004; McConaughy, Ivanova, Antshel, & Eiraldi, 2009; McConaughy, Invanova, Antshel, Eiraldi, and Dumenci, 2009; McConaughy, et al., 2010).
At some point before or soon after the initial evaluation session with the family, contact with the children’s teachers may be helpful to further clarify the nature of the children’s problems. This contact will most likely occur by telephone unless the clinician works within the child’s school system. Interviews with teachers have all of the same merits as interviews with parents, providing a second ecologically valid source of indispensable information about the child’s psychological adjustment, in this case in the school setting. Like parent reports, teacher reports are also subject to bias, and the integrity of the informant, whether it be the parent or teacher, must always be weighed by judging the validity of the information itself.
Many ADHD children have problems with academic performance and classroom behavior and the details of these difficulties need to be obtained. Initially this information may be obtained by telephone; however, when time and resources permit, a visit to the classroom and direct observation and recording of the children’s behavior can prove quite useful if further documentation of ADHD behaviors is necessary for planning later contingency management programs for the classroom. Although this scenario is unlikely to prove feasible for clinicians working outside school systems, particularly in the climate of increasing managed health care plans, which severely restrict the evaluation time that will be compensated, for those professionals working within school systems, direct behavioral observations can prove very fruitful for diagnosis, and especially for treatment planning (Atkins & Pelham, 1992; DuPaul & Stoner, 2003). As noted above, standardized behavioral observation forms have been recently published to permit recording such behavior: The Direct Observation Form (DOF; McConaughy & Achenbach, 2009; McConaughy et al., 2009).
Teachers should also be sent the rating scales mentioned earlier. They can be sent as a packet prior to the actual evaluation so that the results are available for discussion with the parents during the interview, as well as with the teacher during the subsequent telephone contact or school visit.
The teacher interview also should focus on the specific nature of the children’s problems in the school environment, again following a behavioral format. The settings, nature, frequency, consequences, and eliciting events for the major behavioral problems also can be explored. The follow-up questions used in the parental interview on parent-child interactions (shown in Table 2.1) may prove useful here as well. Given the greater likelihood of the occurrence of learning disabilities in this population, teachers should be questioned about such potential disorders. When evidence suggests their existence, the evaluation of the children should be expanded to explore the nature and degree of such deficits as viewed by the teacher. Even when learning disabilities do not exist, children who have ADHD are more likely to have problems with sloppy handwriting, careless approaches to tasks, poor organization of their work materials, and academic underachievement relative to their tested abilities. Time should be taken with the teachers to explore the possibility of these problems.
Child behavior checklists and rating scales have become an essential element in the evaluation and diagnosis of children with behavior problems. The availability of several scales with excellent reliable and valid normative data across a wide age range of children makes their incorporation into the assessment protocol quite convenient and extremely useful. Such information is invaluable in determining the statistical deviance of the children’s problem behaviors and the degree to which other problems may be present. As a result, it is useful to mail out a packet of these scales to parents prior to the initial appointment asking that they be returned on or before the day of the evaluation, as described earlier. Thus the examiner can review and score the scales before interviewing the parents, allowing vague or significant answers to be elucidated in the subsequent interview and focusing the interview on those areas of abnormality highlighted in the responses to scale items.
Numerous child behavior rating scales exist, and readers are referred to other reviews (Barkley, 1988a, 1990, 2012a) for greater details on the requirements and underlying assumptions of behavior rating scales – assumptions all too easily overlooked in the clinical use of these instruments. Despite their limitations, behavior rating scales offer a means of gathering information from informants who may have spent months or years with the child. Apart from interviews, there is no other means of obtaining such a wealth of information with so little investment of time. The fact that such scales provide a means to quantify the opinions of others, often along qualitative dimensions, and to compare these scores to norms collected on large groups of children is further affirmation of the merits of these instruments. Nevertheless, behavior rating scales are opinions and are subject to the oversights, prejudices, and limitations on reliability and validity that such opinions may have.
Initially, it is advisable to utilize a “broad band” rating scale that provides coverage of the major dimensions of child psychopathology known to exist, such as depression, anxiety, withdrawal, aggression, delinquent conduct, and, of course, inattentive and hyperactive-impulsive behavior. These scales should be completed by parents and teachers. Such scales would be the BASC-2 (Reynolds & Kamphaus, 2005) and the CBCL (Achenbach, 2001), both of which have versions for parents and teachers and satisfactory normative information.
Narrow-band scales should be employed in the initial screening of children that focus specifically on the assessment of symptoms of ADHD. For this purpose, parent and teacher versions of a Disruptive Behavior Rating Scale can be found in my clinical workbook (Barkley & Murphy, 2006). Those scales obtain ratings of the DSM-IV symptoms of ODD, ADHD, and CD (parent-form only), as described earlier. Since the symptom lists for these disorders in the DSM-5 are unlikely to be changed, this rating scale can still prove informative. DuPaul and colleagues collected U.S. norms for another version of an ADHD rating scale, the ADHD-IV Rating Scale (DuPaul et al., 1998).
The clinician should also examine the pervasiveness of the child’s behavior problems within the home and school settings as such measures of situational pervasiveness appear to have as much or more stability over time than do the aforementioned scales (Fischer et al., 1993). The HSQ (Barkley, 1987, 1990; Barkley & Murphy, 2006) provides a means for doing so, and normative information for these scales is available (Altepeter & Breen, 1992; Barkley, 1990; Barkley & Edelbrock, 1987; Barkley & Murphy, 2006; DuPaul & Barkley, 1992). The HSQ requires parents to rate their child’s behavioral problems across 16 different home and public situations. The SSQ similarly obtains teacher reports of problems in 12 different school situations.
As noted earlier, abundant research shows that ADHD is associated with substantial and pervasive deficits in executive functioning (EF) in daily life, even if those deficits are not always evident on neuropsychological tests used with either children or adults (Barkley, 2012a; Barkley & Murphy, 2010, 2011; Barkley & Fischer, 2011). It is therefore recommended that clinicians wishing to evaluate EF in children having ADHD use rating scales of EF in daily life that provide a better (more ecologically valid) means of doing so than do tests. One recent scale developed to do so is that by myself (Barkley, 2012a) but clinicians may find the earlier BRIEF (Gioia et al., 2000) to be useful for this purpose as well, although its norms are not a nationally representative sample of U.S. children as are those in the former scale.Clinicians should also formally evaluate impairment in major life activities in some standardized way. To that end, the new rating scale by myself (Barkley, 2012b) can help assess a child’s impairment in 15 major life activities relative to norms collected on a U.S. representative sample of children ages 6 to 18-years-old.
The more specialized or narrow-band scales focusing on symptoms of ODD and ADHD as well as the HSQ and SSQ can be used to monitor treatment response when given prior to, throughout, and at the end of parent training. They can also be used to monitor the behavioral effects of medication on children with ADHD. In that case, use of the Side Effects Rating Scale is encouraged (see Barkley & Murphy, 2006)and should be given both before and after the medication trial has been initiated in order to determine which specific problems are the result of starting medication and which ones were pre-existing difficulties that should not be attributed to the medication trial.
One of the most common problem areas for ADHD children is their academic productivity. The amount of work that ADHD children typically accomplish at school is often substantially less than that done by their peers within the same period. Demonstrating such an impact on school functioning is often critical for ADHD children to be eligible for special educational services (DuPaul & Stoner, 2003). The Academic Performance Rating Scale (see Barkley, 1990) was developed to provide a means of screening quickly for this domain of school functioning. It is a teacher rating scale of academic productivity and accuracy in major subject areas with norms based on a sample of children from central Massachusetts (DuPaul, Rapport, & Perriello, 1991).
Achenbach and Edelbrock (1986) developed a rating scale quite similar to the CBCL which is completed by children ages 11 to 18-years-old (Youth Self-Report Form). Most items are similar to those on the parent and teacher forms of the CBCL except that they are worded in the first person. A later revision of this scale (Cross-Informant Version; Achenbach, 2001) now permits direct comparisons of results among the parent, teacher, and youth self-report forms of this popular rating scale. Research suggests that although such self-reports of ADHD children and teens are more deviant than the self-reports of youth without ADHD, the self-reports of problems by the ADHD youth, whether by interview or the CBCL Self-Report Form, are often less severe than the reports provided by parents and teachers (Fischer et al., 1993; Loeber, Green, Lahey, & Stouthamer-Loeber, 1991). The BASC-2, noted earlier, also has a self-report form that may serve much the same purpose as that for the CBCL.
The reports of children about internalizing symptoms, such as anxiety and depression, are more reliable and likely to be more valid than the reports of parents and teachers about these symptoms in their children (Achenbach et al., 1987; Hinshaw, Han, Erhardt, & Huber, 1992). For this reason, the self-reports of defiant children and youth should still be collected as they may have more pertinence to the diagnosis of comorbid internalizing disorders in children than to the defiant behavior itself.
Research shows that a major area of life functioning affected by ADHD is the realm of general adaptive behavior (Barkley, 2006; Barkley, DuPaul & McMurray, 1990; Roizen, Blondis, Irwin, & Stein, 1994). Adaptive behavior often refers to the child’s development of skills and abilities that will assist them in becoming more independent, responsible, and self-caring individuals. This domain often includes (1) self-help skills, such as dressing, bathing, feeding, and toileting requirements, as well as telling and using time and understanding and using money; (2) interpersonal skills, such as sharing, cooperation, and trust; (3) motor skills, such as fine motor (zipping, buttoning, drawing, printing, use of scissors, etc.) and gross motor abilities (walking, hopping, negotiating stairs, bike riding, etc.); (4) communication skills; and (5) social responsibility, such as degree of freedom permitted within and outside the home, running errands, performing chores, and so on. So substantial and prevalent is this area of impairment among children with ADHD that Roizen et al. (1994) have even argued that a significant discrepancy between IQ and adaptive behavior scores (expressed as standard scores) may be a hallmark of ADHD.
Several instruments are available for the assessment of this domain of functioning. The Vineland Adaptive Behavior Inventory II (Sparrow, Cicchetti & Balla 2005) is probably the most commonly used measure for assessing adaptive functioning. It is an interview, however, and takes considerable time to administer. For other scales assessing adaptive behavior, see the review by Evans & Bradley-Johnson (2007). The CBCL and the BASC completed by parents also contains several short scales that provide a cursory screening of several areas of adaptive functioning (Activities, Social, and School) in children, but it is no substitute for the in-depth coverage provided by the Vineland or NABC scales.
As noted earlier, children with ADHD often demonstrate significant difficulties in their interactions with peers, and such difficulties are associated with an increased likelihood of persistence of their disorder. A number of different methods for assessing peer relations have been employed in research with behavior problem children, such as direct observation and recording of social interactions, peer and subject completed sociometric ratings, and parent and teacher rating scales of children’s social behavior. Most of these assessment methods have no norms and thus would not be appropriate for use in the clinical evaluation of children with ADHD. Reviews of the methods for obtaining peer sociometric ratings can be found elsewhere (Newcomb, Bukowski, & Pattee, 1993). For clinical purposes, rating scales may offer the most convenient and cost-effective means for evaluating this important domain of childhood functioning. The CBCL and BASC-2 rating forms described earlier contain scales that evaluate children’s social behavior. As discussed earlier, norms are available for these scales, permitting their use in clinical settings. The more recently developed Barkley Functional Impairment Scale – Children and Adolescents also covers various domains of social life and has U.S. representative norms (Barkley, 2012b). Three other scales that focus specifically on social skills are the Matson Evaluation of Social Skills with Youngsters (MESSY; Matson, Rotatori, & Helsel, 1983), the Taxonomy of Problem Social Situations for Children (TOPS; Dodge, McClaskey, & Fledman, 1985), and the Social Skills Rating System (Gresham & Elliott, 1990). The latter also has norms and a software scoring system, making it useful in clinical contexts. I have used it extensively in our research and clinical evaluations.
It has become increasingly apparent that child behavioral disorders, their level of severity, and their response to interventions are, in part, a function of factors affecting parents and the family at large. Several types of psychiatric disorders are likely to occur more often among family members of a child with ADHD than in matched groups of control children. Numerous studies over the past 30 years have demonstrated the further influence of these disorders on the frequency and severity of behavioral problems in ADHD children. As discussed earlier, the extent of social isolation in mothers of behaviorally disturbed children influences the severity of the children’s behavioral disorders as well as the outcomes of parent training. Separate and interactive contributions of parental psychopathology and marital discord affect the decision to refer children for clinical assistance, the degree of conflict in parent-child interactions, and child antisocial behavior. The degree of parental resistance to training also depends on such factors. Assessing the psychological integrity of parents, therefore, is an essential part of the clinical evaluation of defiant children, the differential diagnosis of their prevailing disorders, and the planning of treatments stemming from such assessments. Thus, the evaluation of children for ADHD is often a family assessment rather than one of the child alone. Although space does not permit a thorough discussion of the clinical assessment of adults and their disorders, this section provides a brief mention of some assessment methods clinicians may find useful as a preliminary screening for certain variables of import to treatment in ADHD children.
The parents can complete these instruments in the waiting room, during the time their child is being interviewed. (To save time, some professionals may prefer to send these self-report scales out to parents in advance of their appointment, at the same time they send the child behavior questionnaires to the parents. If so, the clinician needs to prepare a cover letter sensitively explaining to parents the need for obtaining such information.) On the day of the interview, the clinician can indicate to parents that having a complete understanding of a child’s behavior problems requires learning more about both the children and their parents. This process includes gaining more information about the parents’ own psychological adjustment and how they view themselves as succeeding in their role as parents. The rating scales can then be introduced as one means of gaining such information. Few parents refuse to complete these scales after an introduction of this type.
Family studies of the aggregation of psychiatric disorders among the biological relatives of children with ADHD and ODD clearly demonstrate an increased prevalence of ADHD and ODD among the parents of these children (Barkley, 2006; Nigg, 2006). In general, there seems to be at least a 40–50% chance that one of the two parents of the child with ADHD will also have adult ADHD (15–20% of mothers and 25–30% of fathers). The manner in which ADHD in a parent might influence the behavior of an ADHD child specifically and the family environment more generally has now been studied. It indicates that such parents are less attentive and responsive to their children, monitor their activities less often, and may be less rewarding of their children’s positive behavior (Chronis-Toscano et al., 2008; Johnston & Mash, 2001; Johnston, Mash, Miller, & Ninowski, 2012). Adults with ADHD also have been shown to be more likely to have problems with anxiety, depression, personality disorders, alcohol use and abuse, and marital difficulties; to change their employment and residence more often; and to have less education and socioeconomic status than adults without ADHD (Barkley et al., 2008) all of which can have an impact of the functioning of an ADHD child within such a family. Greater diversity and severity of psychopathology among parents is particularly apparent among the subgroup of ADHD children with comorbid ODD or CD. More severe ADHD seems to also be associated with younger age of parents (Murphy & Barkley, 1996), suggesting that pregnancy during their own teenage or young adult years is more characteristic of parents of ADHD than non-ADHD children. It is not difficult to see that these factors, as well as the primary symptoms of ADHD as well, could influence the manner in which child behavior is managed within the family as well as the quality of home life for such children more generally. Some research in our clinic suggests that when the parent has ADHD, the probability that the child with ADHD will also have ODD increases markedly. Studies (Evans, Vallano, & Pelham, 1994; Sonuga-Barke et al., 2002) suggest that ADHD in a parent may interfere with the ability of that parent to benefit from a typical behavioral parent training program. Treatment of the parent’s ADHD (with medication) may result in greater success in subsequent retraining of the parent (Chronis-Tuscano et al., 2008). These preliminary findings suggest the importance of determining the presence of ADHD in the parents of children undergoing evaluation for the disorder.The DSM-5 symptom list for ADHD has been cast in the form of two behavior rating scales for use in screening adults for ADHD, one for current behavior and the other for recall of behavior during childhood (Barkley, 2011). Norms are available for a representative sample of the U.S. adult population and the scale has excellent psychometric properties. Again, clinically significant scores on these scales do not, by themselves, grant the diagnosis of ADHD to a parent, but they should raise suspicion in the clinician’s mind about such a possibility. If so, consideration should be given to referral of the parent for further evaluation and, possibly, treatment of adult ADHD.
The use of such scales in screening parents of ADHD children would be a helpful first step in determining whether the parents have ADHD. If the child meets diagnostic criteria for ADHD and these screening scales for ADHD in the parents prove positive (clinically significant), referral of the parents for a more thorough evaluation and differential diagnosis might be in order. At the very least, positive findings from the screening would suggest the need to take them into account in treatment planning and parent training.
Many instruments exist for evaluating marital discord in parents. The one most often used in research on childhood disorders has been the Locke-Wallace Marital Adjustment Scale (Locke & Wallace, 1959). Marital discord, parental separation, and parental divorce are more common in parents of ADHD children. (Johnston & Mash, 2001; Johnston et al., 2012). Parents with such marital difficulties may have children with more severe defiant and aggressive behavior and such parents may also be less successful in parent training programs. Screening parents for marital problems, therefore, provides important clinical information to therapists contemplating a parent training program for such parents. Clinicians are encouraged to incorporate a screening instrument for marital discord into their assessment battery for parents of children with defiant behavior.
Parents of ADHD children, especially those with comorbid ODD or CD, are frequently more depressed than those of normal children, which may affect their responsiveness to behavioral parent training programs. The Beck Depression Inventory (Beck, Steer, & Brown, 1996; Beck, Steer, & Garbin, 1988) is often used to provide a quick assessment of parental depression. Greater levels of psychopathology generally and psychiatric disorders specifically also have been found in parents of children with ADHD, many of whom also have ADHD (Barkley, 2006; Breen & Barkley, 1988; Lahey et al., 1988). One means of assessing this area of parental difficulties is through the use of the Symptom Checklist 90 – Revised (Derogatis, 1986). This instrument not only has a scale assessing depression in adults but also has scales measuring other dimensions of adult psychopathology and psychological distress. Whether clinicians use this or some other scale, the assessment of parental psychological distress generally and psychiatric disorders particularly makes sense in view of their likely impact on the child’s course and the implementation of the child’s treatments typically delivered via the parents.
Research over the past 15 years suggests that parents of children with behavior problems, especially those children with comorbid ODD and ADHD, report more stress in their families and their parental role than those of normal or clinic-referred non-ADHD children (Johnston & Mash, 2001). One measure frequently used in such research to evaluate this construct has been the Parenting Stress Index (PSI; Abidin, 1995). The original PSI is a 150-item multiple-choice questionnaire which can yield six scores pertaining to child behavioral characteristics (distractibility, mood, etc.), eight scores pertaining to maternal characteristics (e.g. depression, sense of competence as a parent, etc.), and two scores pertaining to situational and life stress events. These scores can be summed to yield three domain or summary scores: Child Domain, Mother Domain, and Total Stress. A shorter version of this scale is available (Abidin, 1995) and clinicians are encouraged to utilize it in evaluating parents of defiant children.
This section was originally taken from my chapter with Michael Gordon (see Barkley, 2006) for the initial edition of this course but has been updated in January 2013. Even so, that earlier chapter can be consulted for further details on the use of psychological tests for assessment of children with ADHD. Despite advances in our knowledge about psychological testing and the allure of numbers over perception, the search for accurate and reliable measures of ADHD symptoms has not yielded a litmus test. The absence of a gold standard for the diagnosis as well as the heterogeneity of the disorder itself precludes any one test (and, for that matter, rating scale or interview format) from claiming pinpoint accuracy. At best, research in this arena has produced techniques that can have some clinical utility but cannot supplant other sources of information. That is because at this time no psychological tests have been shown to be sufficiently accurate in detecting the diagnosis of ADHD or in ruling out those who do not have the disorder (positive and negative predictive power) so as to warrant their adoption in clinical practice for diagnosing ADHD. Perhaps their strongest contributions are in identifying comorbid conditions.
If psychological testing is to be done, the following points should be kept in mind:
Reliability of administration
Evidence that it can discriminate among diagnostic groups (ADHD vs. normal, ADHD vs. other clinical entities, or other clinical entities from normal or other clinical entities)
Proof that it enhances diagnostic accuracy and treatment planning (even if it does not have high predictive value)
The last two points on our list warrant some elaboration. Much of the scientific focus on psychological testing falls, appropriately, on the capacity of a test to predict group status. Most studies explore the degree of agreement among various clinical measures, often with a selected combination established as the benchmark. However, a psychological test can be of significant value even if it does not wholly agree with other measures. For example, a test may provide unique information regarding the severity of pathology or the amenability of a child to certain treatments. A test might also have value in predicting outcome or confirming a diagnosis in unique populations or age groups. Therefore, a single-minded focus on discriminative power may overlook other possible contributions of testing. Nevertheless, when test developers argue for the value of their tests in making diagnostic classifications, data must be provided from peer-reviewed scientific studies that the test, in fact, achieves those aims. Many developers report the sensitivity and specificity of their measures, but these indices are not relevant to how the tests are actually used by clinicians. They merely indicate what percentage of cases with and without ADHD do poorly or well on the tests. This sequence is the reverse of what happens in clinical practice where the clinician knows the test score first and then wants to predict the diagnosis, in which case statistics pertaining to positive and negative predictive power are the relevant ones. When such data are provided, which is rare in my experience, they indicate marginally acceptable positive predictive power but unacceptable negative predictive power due to the large minority of cases with ADHD that can pass such tests. As a result, there are no psychological tests that can be recommended at this time to diagnose ADHD.
The requirement that tests should be practical to administer and interpret reflects the realities of modern clinical practice. As demands for cost efficiency mount, practitioners cannot afford to use measures that are unwieldy, time-consuming, or complicated. The ever-increasing focus on practicality has influenced our recommendations for psychological testing and observational techniques. Simply put, it makes little sense to consider approaches that are impractical, even if they might offer meaningful information.
The value of psychological testing may therefore be greatest for ruling in or out the presence of intellectual delay or learning disorders as associated conditions in cases of ADHD. In those instances, brief screening tests of IQ and academic achievement can be given. While only a small percentage of cases of ADHD have intellectual delay, slightly higher than the national average, up to half of them may have learning disabilities (DuPaul et al., 2012). Given this high prevalence of LD in ADHD, all cases of ADHD should receive screening on academic achievement tests.
Apart from the legal and ethical issues involved in the general practice of providing mental health services to children, several such issues may be somewhat more likely to occur in the evaluation of ADHD children. The first involves the issue of custody or guardianship of the child as it pertains to who can request the evaluation of the child who may have ADHD. Children with ODD, ADHD, or CD are more likely than average to come from families in which the parents have separated or divorced or in which significant marital discord may exist between the biological parents. As a result, the clinician must take care at the point of contact between the family and the clinic or professional to determine who has legal custody of the child and particularly the right to request mental health services on behalf of the minor. It must also be determined in cases of joint custody, an increasingly common status in divorce/custody situations, whether the nonresident parent has the right to dispute the referral for the evaluation, to consent to the evaluation, to attend on the day of appointment, and/or to have access to the final report. This right to review or dispute mental health services may also extend to the provision of treatment to the child. Failing to attend to these issues before the evaluation can lead to contentiousness, frustration, and even legal action among the parties to the evaluation that could have been avoided had greater care been taken to iron out these issues beforehand. Although these issues apply to all evaluations of children, they may be more likely to arise in families seeking assistance for ADHD children.
A second issue that also arises in all evaluations but may be more likely in cases involving ADHD is the duty of the clinician to disclose to state agencies any suspected physical or sexual abuse or neglect of the child. Clinicians should routinely forewarn parents of this duty to report when it applies in a particular state before starting the formal evaluation procedures. In view of the greater stress that ADHD or ODD children appear to pose for their parents, as well as the greater psychological distress their parents are likely to report, the risk for abuse of defiant children may be higher than average. The greater likelihood of parental ADHD or other psychiatric disorders may further contribute to this risk, resulting in a greater likelihood that evaluations of children with disruptive behavior disorders will involve suspicions of abuse. Understanding such legal duties as they apply in a given state or region and taking care to exercise them properly yet with sensitivity to the larger clinical issues are the responsibility of any clinician involved in providing mental health services to children.
Over the past 20 years, ADHD children have been gaining access to government entitlements, sometimes thought of as legal rights, which makes it necessary for clinicians to be well informed about the legal issues if they are to properly and correctly advise the parents and school staff. For instance, children with ADHD in the United States are now entitled to formal special educational services under the Other Health Impaired Category of the Individuals with Disabilities in Education Act, provided of course that their ADHD is sufficiently serious to interfere significantly with school performance. In addition, such children also have legal protections and entitlements under Section 504 of the Disability Rights Act or the more recent Americans with Disabilities Act as it applies to the provision of an appropriate education for children with disabilities (see DuPaul & Stoner, 2003; Latham & Latham, 1992, for discussions of these entitlements). And should ADHD children have a sufficiently severe disorder and reside in a family of low economic means, they may also be eligible for financial assistance under the Social Security Act. Space precludes a more complete explication of these legal entitlements here. Readers are referred to the excellent text by attorneys Latham and Latham (1992) for a fuller account of these matters. Suffice it to say here that clinicians working with ADHD children need to familiarize themselves with these various rights and entitlements if they are to be effective advocates for the children they serve.
A final legal issue related to ADHD children is that of legal accountability for their actions in view of the argument made elsewhere (Barkley, 1997, 2006) that their ADHD is a developmental disorder of self-control. Should children with ADHD be held legally responsible for the damage they may cause to property, the injury they may inflict on others, or the crimes they may commit? In short, is ADHD an excuse to behave irresponsibly without being held accountable for the consequences? The answer is unclear and deserves the attention of sharper legal minds than ours. It is my opinion, however, that ADHD explains why certain impulsive acts may have been committed but does not sufficiently disturb mental faculties to excuse legal accountability, as might occur, for example, under the insanity defense (Barkley, 1997). Nor should ADHD be permitted to serve as an extenuating factor in the determination of guilt or the sentencing of an individual involved in criminal activities, particularly those involving violent crime. This opinion is predicated on the fact that the vast majority of children with ADHD, even those with comorbid ODD, do not become involved in violent crime as they grow up. Moreover, studies attempting to predict criminal conduct within samples of ADHD children followed to adulthood either have not been able to find adequate predictors of such outcomes or have found them to be so weak as to account for a paltry amount of variance in such outcomes. Moreover, those variables that may make a significant contribution to the prediction of criminal or delinquent behavior more often involve measures of parental and family dysfunction as well as social disadvantage and much less so, if at all, measures of ADHD symptoms. Until this matter receives greater legal scrutiny, it seems wise to view ADHD as one of several explanations for impulsive conduct but not a direct, primary, or immediate cause of criminal conduct for which the individual should not be held accountable.
It is essential that children being considered for a diagnosis of ADHD have a complete pediatric physical examination. However, traditionally such examinations are brief, relatively superficial, and as a result often unreliable and invalid for achieving a diagnosis of ADHD or identifying other comorbid behavioral, psychiatric, and educational conditions (Costello et al., 1988; Sleator & Ullmann, 1981). This is often the result of ignoring the other two essential features of the evaluation of ADHD children: a thorough clinical interview, reviewed earlier, and the use of behavior rating scales. To properly diagnose and treat these children and adolescents, it is imperative that adequate time be committed to the evaluation to complete these components. If this is not possible, the physician is compelled to conduct the appropriate medical examination but withhold the diagnosis until the other components can be accomplished by referral to another mental health professional.
The features of the pediatric examination and the issues that must be entertained therein are described next.
Most of the contents of an adequate medical interview are identical to those described previously for the parental interview. However, greater time will clearly be devoted to a more thorough review of the child’s genetic background, pre- and peri- natal events, and developmental and medical history as well as the child’s current health, nutritional status, and gross sensory-motor development. The time to listen to the parents’ story and the child’s feelings and to explain the nature of the disorder is one of the most important things a physician can offer a family. In this way, the evaluation process itself can often be therapeutic.
One major purpose of the medical interview that distinguishes it from the psychological interview noted previously is its focus on differential diagnosis of ADHD from other medical conditions, particularly those that may be treatable. In rare cases, the ADHD may have arisen secondary to a clear biologically compromising event, such as recovery from severe Reye’s syndrome, surviving an hypoxic-anoxic event such as near drowning or severe smoke inhalation, significant head trauma, or recovery from an central nervous system infection or cerebral-vascular disease. The physician should obtain details of these surrounding events as well as the child’s developmental, psychiatric, and educational status prior to the event and significant changes in these domains of adjustment since the event. The physician should also document ongoing treatments related to such events. In other cases, the ADHD may be associated with significant lead or other metal or toxic poisonings, which will require treatment in their own right.
It is also necessary to determine whether the child’s conduct or learning problems are related to the emergence of a seizure disorder or are secondary to the medication being used to treat the disorder. As many as 20% of epileptic children may have ADHD as a comorbid condition and up to 30% may develop ADHD or have it exacerbated by the use of phenobarbital or dilantin as anticonvulsants (Wolf & Forsythe, 1978). In such cases, changing to a different anticonvulsant may greatly reduce or even ameliorate the attentional deficits and hyperactivity of such children.
A second purpose of the medical exam is to thoroughly evaluate any coexisting conditions that may require medical management. In this case, the child’s ADHD is not seen as arising from these other conditions but as being comorbid with it. ADHD is often associated with higher risks not only for other psychiatric or learning disorders but also for motor incoordination, enuresis, encopresis, allergies, otitis media, and greater somatic complaints in general. A pediatric evaluation is desirable or even required for many of these comorbid conditions. For instance, the eligibility of the child for physical or occupational therapy at school or in a rehabilitation center may require a physician’s assessment and written recommendation of the need for such. And, although most cases of enuresis and encopresis are not due to underlying physiological disorders, all cases of these elimination problems should be evaluated by a physician before beginning nutritional and behavioral interventions. Even though many of these cases are “functional” in origin, medications may be prescribed to aid in their treatment, as in the use of oxybutinin or imipramine for bedwetting. Certainly children with significant allergies or asthma require frequent medical consultation and management of these conditions, often by specialists who appreciate the behavioral side effects of medications commonly used to treat them. Theophyline, for example, is increasingly recognized as affecting children’s attention span and may exacerbate a preexisting case of ADHD. For these and other reasons, the role of the physician in the evaluation of ADHD should not be underestimated despite overwhelming evidence that by itself it is inadequate as the sole basis for a diagnosis of ADHD.
A third purpose of the medical examination is to determine whether physical conditions exist that are contraindications for treatment with medications. For instance, a history of high blood pressure or cardiac difficulties warrants careful consideration about a trial on a stimulant drug given the known presser effects of these drugs on the cardiovascular system. Some children may have a personal or family history of tic disorders or Tourette’s Disorder, which would dictate caution in prescribing stimulants in view of their greater likelihood of bringing out such movement disorders or increasing the occurrence of those that already exist. Instead, the nonstimulants such as atomoxetine or guanfacine XR may be more appropriate. These examples merely illustrate the myriad medical and developmental factors that need to be carefully assessed in considering whether a particular ADHD child is an appropriate candidate for drug treatment.
In the course of the physical examination, height, weight, and head circumference require measurement and comparison to standardized graphs. Hearing and vision, as well as blood pressure, should be screened. Findings suggestive of hyper- or hypothyroidism, lead poisoning, anemia, or other chronic illness clearly need to be documented, and further workup should be pursued. The formal neurological examination often includes testing of cranial nerves, gross and fine motor coordination, eye movements, finger sequencing, rapid alternating movements, impersistence, synkinesia, and motor overflow, testing for choreiform movements, and tandem gait tasks. The exam is often used to look for signs of previous central nervous system insult or of a progressive neurological condition, abnormalities of muscle tone, and a difference in strength, tone, or deep tendon reflex response between the two sides of the body. The existence of nystagmus, ataxia, tremor, decreased visual field, or fundal abnormalities should be determined and further investigation pursued when found. This evaluation should be followed by a careful neurodevelopmental exam covering the following areas: motor coordination, visual-perceptual skills, language skills, and cognitive functioning. Although these tests are certainly not intended to be comprehensive or even moderately in-depth evaluations of these functions, they are invaluable as quick screening methods for relatively gross deficiencies in these neuropsychological functions. When deficits are noted, follow-up with more careful and extensive neuropsychological, speech and language, motor, and academic evaluations may be necessary to more fully document their nature and extent.
Routine physical examinations of ADHD children are frequently normal and of little help in diagnosing the condition or suggesting its management. However, the physician certainly needs to rule out the rare possibility of visual or hearing deficits which may give rise to ADHD like symptoms. Also, on physical inspection, ADHD children may have a greater number of minor physical anomalies in outward appearance (e.g., an unusual palmar crease, two whirls of hair on the head, increased epicanthal fold, or hyperteliorism). However, studies conflict on whether such findings occur more often in ADHD, but certainly they are nonspecific to it, being found in other psychiatric and developmental disorders. Shaywitz and Shaywitz (1984) state that examining for these minor congenital anomalies may only be beneficial when the physician suspects maternal alcohol abuse during pregnancy, to determine the presence of fetal alcohol syndrome. The existence of small palpebral fissures and midfacial hypoplasia with growth deficiency supports this diagnosis.
Finally, given the considerably greater distress ADHD children present to their caregivers, their risk of being physically abused would seem to be higher than normal. Greater attention by physicians to physical or other signs of abuse during the examination is therefore required.
The routine examination for growth in height and weight is also often normal, although one study reported a younger bone age in children with minimal brain dysfunction, including hyperactivity. Nevertheless, when the physician contemplates a trial on a stimulant drug, accurate baseline data on physical growth, heart rate, and blood pressure are necessary against which to compare subsequent repeat exams during the drug trial or during long-term maintenance on these medications.
Similarly, the routine neurological examination is frequently normal in ADHD children. These children may display a greater prevalence of soft neurological signs suggestive of immature neuromaturational development, but again these are nonspecific for ADHD and can often be found in learning-disabled, psychotic, autistic, and retarded children, not to mention a small minority of normal children. Such findings are therefore not diagnostic of ADHD, nor does their absence rule out the condition (Reeves, Werry, Elkind & Zametkin, 1987). Instead, findings of choreiform movements, delayed laterality development, fine or gross motor incoordination, dysdiadochokinesis, or other soft signs may suggest that the child requires more thorough testing by occupational or physical therapists and may be in need of some assistance in school with fine motor tasks or adaptive physical education.
ADHD children may also have a somewhat higher number of abnormal findings on brief mental status examinations or screening tests of higher cortical functions, especially those related to frontal lobe functions (e.g., sequential hand movement tests, spontaneous verbal fluency tests, and go-no-go tests of impulse control). When these are found, more thorough neuropsychological testing may be useful in further delineating the nature of these deficits and providing useful information to educators for making curriculum adjustments for these children. In some cases, findings on brief mental status exams may have more to do with a coexisting learning disability in a particular case than with the child’s ADHD. When problems with visual-spatial-constructional skills or simple language abilities are noted, they are most likely signs of a comorbid learning disorder as they are not typical of ADHD children generally. It is often the case that these brief mental status examinations are normal. This does not necessarily imply that all higher cortical functions are intact as these screening exams are often relatively brief and crude methods of assessing neuropsychological functions. More sensitive, and lengthier, neuropsychological tests may often reveal deficits not detected during a brief neurological screening or mental status exam. Even so, the routine assessment of ADHD children with extensive neuropsychological test batteries is also likely to have a low yield, as discussed above. It should be undertaken only when there is a question of coexisting learning or processing deficits that require further clarification, and even then tests should be selected carefully to address these specific hypotheses.
A number of studies of ADHD children have used a variety of physical, physiological, and psychophysiological measures to assess potential differences between ADHD and other clinical or control groups of children. Although some of these studies have demonstrated such differences, as in reduced cerebral blood flow to the striatum or diminished orienting galvanic skin responses, none of these laboratory measures are of value in the diagnostic process as yet. Parents, teachers, or even other mental health professionals are sometimes misled by reports of such findings or by the conclusion that ADHD is a biologically based disorder, and they frequently ask for their children to be tested medically to confirm the diagnosis. At this moment, no such tests exist. Consequently, laboratory studies, such as blood work, urinalysis, chromosome studies, electroencephalograms, averaged evoked responses, cerebral blood flow, magnetic resonance imaging (MRI), positron emission tomography (PET), or computerized axial tomograms (CT scans) should not be used routinely in the evaluation of ADHD children. Only when the medical and developmental history or physical exam suggests that a treatable medical problem exists, such as a seizure disorder, or that a genetic syndrome is a possibility, would these laboratory procedures be recommended, and yet such cases are quite rare.
Blood assays of levels of medication have so far proven unhelpful in determining appropriate dosage and therefore are not recommended as part of routine clinical titration and long-term management of these medications.
The feedback session with parents concludes the diagnostic evaluation. This session should take place after all the direct testing with the child is completed and scored and after the clinician has reviewed all the data and drawn diagnostic conclusions (the family may need to wait while the clinician makes any necessary collateral phone calls to the school, current therapist, etc.). As with the parent interview, children under the age of 16-years-old are not generally included in the feedback session, but they may be invited in at the end of the session to be given diagnostic conclusions at a level appropriate to their age and cognitive development.
The first step in the feedback session is to give parents some information about ADHD. I generally explain to parents that ADHD is defined as a developmental disorder, not mental illness or the result of stress in families. The developmental delay affects the child’s ability to regulate behavior, control activity level, inhibit impulsive responding, or sustain attention. In other words, the child with ADHD will be more active, impulsive, and less attentive than other children of the same age.
I then explain that there is no direct test for ADHD – no lab test, X-ray, or psychological test that definitely tells us that a child has ADHD. What I have to do instead is collect a lot of information and analyze it statistically. Therefore, everything that has been learned about their child has been scored, and these scores are compared with the scores that have been collected on hundreds if not thousands of children of the same age. If their child’s scores are consistently placing him or her at or above the 95th percentile in the areas of activity level, impulse control, or attention span, that suggests ADHD because it suggests that the child is having more difficulty than 95 of 100 children of the same age. This is the level of “developmental deviance” that must be established.
The second step is to establish a history consistent with the notion of a “developmental” problem. Do these symptoms have a long-standing history that stretches back over time, for at least the past year or since before the age of 7-years-old – not something that cropped up last week or last month, or something that only came about after a trauma occurred in the child’s life.
The third step is to rule out any other logical explanation for the problem. Is there anything else going on that would overrule ADHD as a diagnosis or be a better explanation than ADHD for the problems the child is having.
I then walk parents through the data obtained about their child, step by step, so they can see clearly how the diagnostic conclusion was reached. These steps include the following:
Before any discussion of a treatment plan occurs, parents are asked if they have any questions about the diagnostic process or any comments about the conclusions that were drawn. Parents are always asked if they are surprised that their child was (or was not) diagnosed with ADHD.
By walking parents through the data this way, any confusion can be quickly clarified. Parents should leave the diagnostic interview with the impression that the clinician was comprehensive and competent. This sense of security will help them cope with the grief and disappointment they may experience at being told that their child has a developmental disability, as well as the confidence to follow any treatment recommendations that are made.
It should be clear from the foregoing that the assessment of ADHD children is a complex and serious endeavor requiring adequate time (approximately 3 hours, exclusive of medical exam and psychological testing), knowledge of the relevant research and clinical literature as well as differential diagnosis, skillful clinical judgment in sorting out the pertinent issues, and sufficient resources to obtain multiple types of information from multiple sources (parents, child, teacher) using a variety of assessment methods. When time and resources permit, direct observations of defiant and ADHD behaviors in the classroom could also be made by school personnel. At the very least, telephone contact with a child’s teacher should be made to follow-up on his or her responses to the child behavior rating scales and to obtain greater detail about the classroom behavior problems of the defiant child. To this list of assessment methods would be added others necessary to address any comorbid problems often found in conjunction with ADHD in children.
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