ADHD Position


Michigan Psychological Association Position Regarding the Evaluation of ADD/ADHD by Physicians
January 9, 2012

Attention Deficit/Hyperactivity Disorder is a complex of symptoms related to both observable and non-observable pathologies.  The observed pathologies relate to disorders of attention regulation and behavior regulation.  These are frequently observed in a person’s overt behavior.   Implied pathologies relate to cognitive and executive pathology which are internal to the individual and only become apparent in failure to adaptively handle specific academic or daily tasks or become apparent with the use of specialized testing procedures such as fluency tests, tests requiring cognitive flexibility or set shifting.

DSM-IV-TR requires the documentation of specific criteria which must be met for the diagnosis of ADD/ADHD.  The question at hand is how the complex symptoms be documented so that clinical methods are both sensitive and selective in reaching accurate diagnostic decisions.  For the purpose of discussion, references to public statements/policy statements of two national authoritative entities will be made, the National Institute of Mental Health public statement regarding the diagnosis of ADD/ADHD and the American Academy of Pediatrics which published a policy statement on the evaluation and diagnosis of ADD/ADHD.

The National Institute of Mental Health (NIMH) Public Statement:

How is ADHD diagnosed?

Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly “out of control.” Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently “spaces out” in the classroom or on the playground.

No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment. A family may want to first talk with the child’s pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders such as ADHD. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. For example, certain situations, events, or health conditions may cause temporary behaviors in a child that seem like ADHD. Between them, the referring pediatrician and specialist will determine if a child:

Is experiencing undetected seizures that could be associated with other medical conditions
Has a middle ear infection that is causing hearing problems
Has any undetected hearing or vision problems
Has any medical problems that affect thinking and behavior
Has any learning disabilities
Has anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms
Has been affected by a significant and sudden change, such as the death of a family member, a divorce, or parent’s job loss.
A specialist will also check school and medical records for clues, to see if the child’s home or school settings appear unusually stressful or disrupted, and gather information from the child’s parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted. The specialist also will ask:
Are the behaviors excessive and long-term, and do they affect all aspects of the child's life?
Do they happen more often in this child compared with the child's peers?
Are the behaviors a continuous problem or a response to a temporary situation?
Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home?

The specialist pays close attention to the child’s behavior during different situations. Some situations are highly structured, some have less structure. Others would require the child to keep paying attention. Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment. A child also may be evaluated to see how he or she acts in social situations, and may be given tests of intellectual ability and academic achievement to see if he or she has a learning disability.

Finally, if after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder.

Michigan Psychological Association Comment:
The NIMH public statement makes several critical statements:
While "some" pediatricians conduct the assessment themselves, many refer to a mental health professional for the assessment.
No single test can diagnose a child with ADD/ADHD
There is a need to rule out other medical, psychiatric/psychological, or cognitively based reasons for the behavior.
There is a need to assess both home and school settings for signs of stress. Multiple sources of information are needed, including school records and adults other than the parents.

The American Academy of Pediatrics Policy (AAP) Statement:

Summary of key action statements:

The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (quality of evidence B/strong recommendation).

To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria have been met (including documentation of impairment in more than 1 major setting); information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation).

In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorders or other neurodevelopmental disorders), and physical (e.g., tics, sleep apnea) conditions (quality of evidence B/strong recommendation).
The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home (quality of evidence B/strong recommendation).

Michigan Psychological Association Comment:

The American Academy of Pediatrics' policy statement reiterates the NIMH public statement that ADD/ADHD requires cross setting evaluation and that data should be collected from multiple sources.

The American Academy of Pediatrics' policy statement reiterates that the assessment should rule out other conditions which might be an alternate cause of the symptoms.

The American Academy of Pediatrics' policy statement goes beyond that of NIMH in stating that coexisting conditions such as behavioral or emotional conditions, cognitive conditions, or physical conditions should be evaluated prior to diagnosis.

The American Academy of Pediatrics' policy statement strongly recommends that management of children and youth with ADD/ADHD should follow those principals of the chronic care model and the medical home.

Based on these statements by two nationally recognized authoritative entities and the combined ethical and clinical standards of care within the practice of Psychology, the Michigan Psychological Association draws the following conclusions and makes the following recommendations:

It is recognized that Physicians have standing to assess and diagnose ADD/ADHD in children and youth.  It is also recognized that some, but not all Physicians have the clinical training and skill to conduct such evaluations.  This is true of all licensed healthcare professionals, including Psychologists.  It therefore should be routinely required that all licensed healthcare professionals who perform these assessments, including Physicians, have the necessary training and skills to conduct these assessments in accordance with prevailing clinical standards.

In accordance with the public and policy statements of two national authoritative entities, assessments for ADD/ADHD require a multifactorial and multimodal approach.  It is not a recognized standard to take a history and use one “test” to make a diagnosis of this condition.  Regardless of the licensed profession involved, it is recommended that Value Options considers these national standards in defining an acceptable assessment for ADD/ADHD.  Graduate training and ethical and clinical standards in Psychology are very consistent with public and policy statements presented by NIMH and AAP.  It is therefore recommended that in most cases, it is desirable for Physicians to work collaboratively with Psychologists in establishing an ADD/ADHD diagnosis.  In those exceptional cases where Physicians choose to do the assessment and make the diagnosis without collaboration, special attention should be paid that the procedures used adhere to the national standards set forth by NIMH and AAP.

The diagnosis of ADD/ADHD is an excellent example of the manner in which Psychology, as a profession and as a body of knowledge could positively affect outcomes when used in integrated health management.  The Michigan Psychological Association makes the observation and the recommendation that Psychologists should be included in the medical home model for management of chronic health conditions.  In this way, ongoing collaboration between Physicians and Psychologists would be seamless.  The results would be cost effective health management provided at the highest clinical standards.

The Michigan Psychological Association recognizes the viability of Physician/Psychologist collaboration is challenging in parts of Michigan outside major metropolitan areas.  The Michigan Psychological Association’s Child and Family Committee and Rural Psychology Committee welcome opportunities for collaboration with Value Options and Physician groups to increase access to integrative services in outstate portions of the State.
The Michigan Psychological Association would be happy to provide any additional references or assistance in regards to this issue.

Respectfully submitted on behalf of the Michigan Psychological Association,
William Bloom, Ph.D., Licensed Psychologist
Troy, Michigan

References:
National Institute of Mental Health Website:
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/how-is-adhd-diagnosed.shtml