Evaluate parents and children before diagnosing ADHD

Most family doctors and pediatricians have been approached by distraught parents requesting psychostimulants for their children who have been labeled a behavior problem by their schools. The scenario goes like this:

Parents meet a teacher at home and at school night. The teacher informs the parents that the child, usually a boy, is not doing very well and has a behavior problem.

The school hands the parents a report stating that their child has a behavior problem and that his doctor should assess him for attention deficit hyperactivity disorder (ADHD). The parents then show this "diagnostic" report to their doctor, who dutifully prescribes psychostimulants with little or no independent evaluation. The drugged child becomes more docile, the teacher is pleased, and the parents are relieved and grateful to the doctor who has "cured" the child's problem. The doctor, implicitly trusting the wisdom of the educational system, continues to prescribe psychostimulants, thinking that drugs are the solution.

Teachers, not knowing that behavior in normal children is suppressed by psychostimulants, assume that all disruptive behavior is the result of ADHD and thus are encouraged to pin this label on other children with the hope that other obliging physicians will prescribe psychostimulants without questioning their "diagnosis." The result of this often-repeated pattern is an explosion in the diagnosis of ADHD and the prescribing of psychostimulants.

The tragedy is that, in most instances, children have been misdiagnosed. Disruptive behavior and poor attention often are a cry for help, and psychostimulants simply mask symptoms. In addition, contrary to widespread belief, psychostimulants are not harmless drugs. They can cause severe and long-lasting neurologic and psychiatric damage and may even be carcinogenic.

In the past 10 years, the percentage of school age children receiving psychostimulants has increased 2.5 times, so that there are an estimated 1.5 million children in the United States alone taking these drugs.

ADHD is one of the most difficult conditions to diagnose, as the physician not only must have extensive knowledge of pediatric illnesses but also must be familiar with developmental milestones.

According to the Diagnostic Reference Criteria for Psychiatric Disorders, published by the American Psychiatric Association, the essential features of ADHD are inappropriate inattention, impulsivity, and hyperactivity that are developmentally inappropriate for the child and are in the absence of other conditions that can be mistaken for ADHD.

The behavior must be present in two or more settings, must begin before age seven, and must have lasted for six months.

A difficulty in diagnosing ADHD is that inappropriate inattention, impulsivity, and hyperactivity are common to a number of conditions. The differential diagnosis includes conduct disorders such as depression and anxiety, developmental problems, and learning disorders. Children also may exhibit unusual behaviors as a result of family and social problems.

Before making a diagnosis and reaching for the prescription pad, physicians should begin an assessment process consisting of at least three visits. The first visit should consist of an interview with the child's parents. The second visit should focus on evaluating the child. In the third visit, clinical findings and a course of action should be discussed with the parents.

In addition, an evaluation should be done by the school to determine the child's educational level. If it turns out that the child is performing at a level well above his or her peers, the behavior problem may be a result of boredom and the child may benefit from placement in a class for gifted students.

Interviewing the parents during the first office visit establishes a rapport with them. They are a source of valuable information, and questioning them can uncover areas of conflict within the family. The interview is also therapeutic because it allows them to express their frustrations about certain issues that previously have been ignored or suppressed. Both parents and the child should be present at the initial interview to allow the physician to observe first-hand the interaction between family members.

The physician should obtain a complete history, including the child's developmental milestones. Once rapport is established, the examiner should inquire about relationships within the family and such problems as marital difficulties and substance abuse.

The examiner should try to get a sense of what the home situation is like. Questions about discipline and behavioral expectations are necessary to understand family dynamics. A child who is brought up in a home where chaos and conflict are rampant will behave accordingly.


by Rosemary Hutchinson, M.D.

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