Counseling Points - Psychiatric Nurse 11/08 - (Page 7)

symptoms, and to what extent the disorder interferes with normal daily functioning. For instance: Is this just a temporary reaction to a situation (parental divorce, family death, etc.) or is it an ongoing problem? Do the symptoms occur in more than one setting? In order to make a definitive diagnosis of ADHD, the evaluation must include a complete cognitive, psychosocial, and psychiatric assessment, as well as a review of the appropriateness of the school setting and the individual’s social and employment functioning. Although the majority of children with ADHD have an unremarkable medical history, a more comprehensive medical evaluation may be required in some children to rule out metabolic or brain dysfunction. A physical examination that includes thorough vision and hearing tests as well as appropriate laboratory testing may be indicated. Unless there is strong evidence in the medical history, tests such as an electroencephalogram (EEG), magnetic resonance imaging (MRI) scan, single photo emission computed tomography (SPECT) scan, or positron emission tomography (PET) scan are not indicated.8 When appropriate, the health care professional should refer the individual to a specialist for further evaluation and testing. Neuropsychological testing is most useful to estimate an individual’s overall IQ and potential for academic underachievement. In addition, neuropsychological testing will help to identify specific individual cognitive and executive functioning deficits. During the psychosocial evaluation, the health care professional needs to evaluate the family environment for marital discord/family conflict; parenting inconsistencies; potential issues of abuse and neglect; adoption/attachment issues; social relationships with peers and family; family psychiatric history; perinatal complications; socioeconomic status; and the individual’s use of unstructured leisure time. When examining the individual’s school, employment, and social functioning, it is critical to gather information regarding his/her overall functioning and performance; the school environment and grade placement; special education services or work modifications provided to the person; involvement in extra-curricular activities; and overall behavior at school or work. A classroom or work observation, including during social interactions with peers and employment managers and staff, will further help to assess the individual’s level of functioning. It is also important to interview the family and observe the family relationships/dynamics for potential sources of conflict and for stressors. A complete psychiatric assessment should include a structured diagnostic interview; clinical review of pertinent records; psychological and neuropsychological testing; family, child and teacher feedback; use of specific 7 diagnostic tools (Table 2); review of the patient’s sleep patterns and use of substances and alcohol; and additional information from counselors, daycare workers, school nurses, and psychotherapists. Table 2. Recommended Rating Scales Utilized in Diagnosis and Treatment Monitoring of ADHD • • • • • • SSQ-01 Barkley School Questionnaire ACTeRS Parent Report Form Connors Teaching Rating Scale* Connor’s Parent Rating Scale* Child Attention Profile Child Behavioral Check-List (CBCL—Teacher/Parent Report Form)* • Adult ADHD Self-Report Scale Symptom Checklist • Home/School Situations Questionnaire • Academic Performance Rating Scale ( APRS) *Most commonly used and best-normed tools. Differential Diagnosis Many conditions can produce symptoms that mimic those seen in ADHD, and may even co-exist with ADHD, making the differential diagnosis of ADHD complex. These conditions include but are not limited to learning disabilities, sensory deficits (e.g., hearing or vision problems), Tourette syndrome, insufficient sleep syndromes (e.g., too few hours of sleep or obstructive sleep apnea), poor nutrition resulting in hypoglycemia (e.g., skipped breakfast), allergies (e.g., pruritus), depression, anxiety, conduct disorder (CD), and oppositional defiant disorder (ODD).14,18,22 In addition, the side effects of many medications (e.g., first-generation antihistamines, anti-epileptics) may be mistaken for symptoms of ADHD.15 Table 3 lists a full array of conditions and situations to consider when performing a differential diagnosis. ADHD and Co-morbid Conditions in Children and Adolescents The lifetime prevalence of co-morbid psychiatric and/or lear ning disorders with ADHD may be as high as 84%.8,18,22 The incidence of co-morbid conditions with ADHD increases with the individual’s age.23 Recent studies support the early identification and treatment of ADHD to help prevent the subsequent development of co-morbid disorders.23 Psychotherapy, in additional to pharmacotherapy, is useful in children with co-morbid ADHD and other psychiatric disorders. Co-morbid Anxiety Disorders. Children with significant anxiety may have co-morbid ADHD, or they may NOVEMBER 2008

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