Evidence-Based Assessment of ADHD in Children - Case Study Example

Evidence-based Assessment of ADHD in Children Total Number of Words: 2,097 Introduction Attention deficit hyperactivity disorder (ADHD) is “a childhood mental disorder characterized by inattention, impulsiveness and over activity” (Hazelwood, Bovingdon, & Tiemens, 2002). As one of the most common mental health disorder among children and adolescents, several studies revealed that there is a higher number of ADHD cases in male children and adolescents who belong to low-income families (Hoza et al., 2005; Evans, 2004). ADHD is a serious mental health condition because the child’s inattentiveness, impulsiveness, and over activity could negatively affect the child’s academic performance and self-esteem including the child’s relationship with family members and friends (Hoza et al., 2005; Hazelwood, Bovingdon, & Tiemens, 2002). ADHD can also lead to behavioural problems which often make the child unable to socialize with other people (Kerns et al., 2001). In rare cases, Fleischmann et al. (2005) found out that approximately 20.8% of the suicidal cases in young people have disruptive behaviour disorder which is related to ADHD. In the absence of proper treatment such as medicine and behavioural therapy, children with ADHD could cause behavioural problems not only at home but also in school, work, and relationship with the opposite sex. Eventually, the negative effects of ADHD could cause a child to become depressed, frustrated, or engage with the use of illegal drugs if left untreated. To effectively provide children with ADHD with proper treatment, early detection of ADHD is important. Concerning the increasing number of ADHD throughout the United Kingdom, this study will focus on assessing some of the evidenced-based assessment method used in detecting ADHD in children. In the process of going through the main discussion, evidences behind the psychological assessment of ADHD in children will be evaluated. Evidenced-based Assessment Method Used in Detecting ADHD in Children As part of assessing whether a child has ADHD, medical professionals would often use analogue methods such as conduct an interview with the child, go through the patient’s medical history which includes issues related to social, emotional, educational, and behaviour of the child, physical exam, and the use of behaviour rating and/or checklist in detecting ADHD (Kooij et al., 2008; Parker & Benedict, 2002; ; Forbes, 2001; Barkley, 1991). Likewise, laboratory measures such as the Conners’ Continuous Performance Test (CPT) and Gordon Diagnostic System – a self-contained computer device can also be utilized in detecting symptoms of ADHD (Kelley, Noell, & Reitman, 2002, p. 28; Barkley, 1991). Behaviour Rating and/or Checklist in Detecting ADHD In case the patient’s medical history data is not available, behaviour rating or the checklist such as the Nisonger Child Behaviour Rating Form (NCBRF) is often used in detecting ADHD cases in children especially (Parker & Benedict, 2002; Forbes, 2001). This method of assessing a child for ADHD can either be a broadband scale or a narrowband scale. Basically, a broadband scale like the Conners’ Rating Scale is used when a psychiatrists or psychologist is measuring a wide-range of child psychopathology whereas the narrowband scale is more preferred when measuring a more specific mental health disorder such as in the case of a child with ADHD (Kelley, Noell, & Reitman, 2002, p. 27). When using a behaviour rating, Barkley (1991) revealed that it is important to have an adequate range of variation should be present in scores that comes from the laboratory methods and the home or school criteria. By examining the correlation between the laboratory test result and the criteria, medical professionals will be able to conclude whether or not the assessment on detecting ADHD in children is accurate and reliable. Connors’ Continuous Performance Test (CPT) Recently, laboratory measures like the Conners’ continuous performance test (CPT) can be used in detecting symptoms of ADHD. In general, CPT can be obtained from a CD which can be loaded onto a standard PC (Kelley, Noell, & Reitman, 2002, p. 28). When measuring the correlation between the laboratory test result and the criteria, a maximum score of 1.00 can be observed given that the laboratory test result is in consistent with the home or school criteria that was directly gathered in a natural setting (Barkley, 1991). Upon examining the ecological validity of the commonly used laboratory assessment technique, Barkley (1991) revealed that it is best for medical practitioners to have a closer to direct observation of the patients behavior within a natural setting in order to have a more accurate and valid result. When conducting a laboratory methods such as the continuous performance test (CPT), it is best that the patient can be directly observed in a natural setting such as the patient’s home or school where the patient can freely behave and act naturally without being hesitant that someone is observing his/her behaviour. The problem with relying too much on the use of CPT is the fact that there has been a lot of past research studies suggested that the use of this particular assessment method alone can lead to a high incidence of false-negative ADHD diagnosis (Kelley, Noell, & Reitman, 2002, p. 28). Reaction Time Task (RTT) Reaction time task (RTT) is another assessment method that is used in assessing a child for possible ADHD. When using the RTT method, medical professionals are expected to get the dependent measures by considering the mean reaction time as well as the variability of response time throughout the clinical trials (Van der Meer & Sergeant, 1988). Using EEG, children with ADHD would normally show “a pattern of slow and variable reaction times which suggest that the child is experiencing a momentary lapses in performance” (Larimer, 2005, p. 11). Likewise, several studies revealed that children with ADHD often times have longer mean reaction time as compared to children who do not show symptoms of ADHD (Barkley, 1991; Douglas, 1983). On top of these past research findings, the study of Querne & Berquin (2009) revealed that response time of children with hyperactive-impulsive ADHD and inattentive ADHD met the criteria for hyperactive-impulsive ADHD and inattentive ADHD except for the response time of children with combined ADHD subtypes after testing the response time of children with ADHD. Based on the research findings of Querne & Berquin (2009), it is possible to consider use of mean reaction time when assessing children with ADHD for specific mental health concern or criteria. It is possible to mix the use of reaction or response time label with the teaching rating scale. After evaluating the effects of changing the response labels of teacher rating scale in a population-based study of ADHD, Rowland et al. (2007) concludes that changing the response scale does not make a significant difference in the psychometric properties of the assessment method but in the sample used in the study. Parent and Teacher Rating Scales Conners’ scale is a reliable instrument designed to support the psychiatrists, psychologists, paediatricians and clinicians in diagnosing and identifying children with ADHD (Arffa, 2009) whereas the brief scale is commonly used in assessing the daily functioning of children with ADHD (Mausbach et al., 2007). Similar to brief scale, the parent and teacher rating scales can also be used in assessing a child with ADHD. (See Appendix I – Parent / Teacher DBD Rating Scale on page ) Although Sullivan & Riccio (2007) concluded that the use of the parent and teacher ratings on the BRIEF and Conners’ Scales could effectively distinguish research participants with ADHD from those individuals without the symptoms of ADHD. On the contrary, the study of Manning & Miller (2001) revealed that children with ADHD have a higher t-score on scales and composites including hyperactivity, attention problems, adaptability, atypicality, leadership, social skills scales, and behavioural symptoms index except that not all scores gathered from the research participants fell with the at-risk or the typical clinically considered range for children with ADHD after using the parent and teacher rating scales on behaviour assessment scale for children (BASC) On top of the research findings of Manning & Miller (2001) which showed the difference between the scores of research participants with ADHD and the clinical range that has been considered for children with ADHD, several studies have concluded that children with ADHD have greater variability and more commission errors or a correlation score of (0.34) as compared with the parents’ ratings on the child’s hyperactivity at home (Weissberg, Ruff, & Lawson, 1990; Douglas, 1983). It simply means that the use of parents and teacher rating scales may vary depending on the way psychiatrists use this type of assessment method. Diagnostic and Statistical Manual (DSM-IV) Factors of Mental Disorders The assessment method based on DSM-IV factors was originally designed in children for symptoms of ADHD. The two ways of determining whether or not a child has ADHD, oppositional defiant disorder, or conduct disorder includes counting the symptoms of each disorder through the use of Disruptive Behaviour Disorder (DBD) rating scale and by comparing the target child’s factor scores on the DBD rating scale as a way of establishing norms (University at Buffalo Center for Children and Families, 2009). (See Appendix II – Scoring Instructions for the Disruptive Behaviour Disorder Rating Scale on page ) To determine whether a child has ADHD, the child must be able to demonstrate at least 4 out of 8 defiant behaviours like losing temper, refuses to comply with other people, argues with parents, blaming other people, etc. for the last six months to be able to qualify for ADHD diagnosis (Kelley, Noell, & Reitman, 2002, p. 28). Based on the research findings of Mayes et al. (2009), the application of DSM-IV factors is valid when used in assessing ADHD combined with inattentive subtypes. On the contrary, Kooij et al. (2008) revealed that the use of this particular assessment technique does not provide the psychiatrists with a high patient-informant agreement as compared to the use of other types of assessment method. Although DSM-IV factors is effective in assessing ADHD combined with inattentive subtypes, this particular assessment method is not effective in terms of assessing children with ADHD for attention, impulsiveness, and processing the speed of the child. To assess children with ADHD for attention, impulsiveness, and processing the speed of the child, Mayes et al. (2009) highly recommends the use of Gordon Diagnostic System (GDS), Wechsler Intelligence Scale for Children Freedom-from-Distractibility/Working Memory Index (FDI/WMI), and Processing Speed Index (PSI) respectively. Upon examining the difference between the five-factor model (FFM) and DSM-IV in assessing a child with personality disorder, Rottman et al. (2009) revealed that the use of DSM-IV is more accurate as compared to the use of FFM for the reason that FFM’s criteria is more uncertain as compared to DSM-IV’s criteria. Discussion There are so many assessment techniques that are commonly used in detecting ADHD in children. In line with this, there is no single method could provide the medical practitioners with a justifiable result given that the use of each assessment technique would provide the medical practitioner with a totally different result. However, Kooij et al. (2008) revealed that it is safe and accurate to make use of self-report rating scales when assessing the ADHD symptoms in adult patients because adults are capable of verbalizing their behavioural experiences with the psychiatrists but not the children. On the other hand, the use of BADDS and ADHD rating scale is best when used in predicting clinical diagnosis (Kooij et al., 2008). Because of the limitations of each type of assessment method available in examining a child with ADHD, Parker & Benedict (2002) recommends the need to develop a comprehensive assessment technique before treating a child with ADHD. However, the study of Handler & DuPaul (2005) revealed that only 15% of psychologists have adopted multiple assessment methods that are consistent with the recommended standards of best practice. Conclusion Considering the fact that most children are unable to verbalize their personal behaviour as compared to adults, the use of self-reporting rating scale is not advisable in assessing children for ADHD. Instead, it is recommended that psychologists should have a direct observation on children within a natural setting when using assessment method like CPT, BRIEF, DSM-IV factors, Conners’ Scales, and/or the behaviour assessment scale for children. A direct observation is necessary to ensure that the child would behave normally without the need to be conscious that a medical professional is watching the patients’ move. To be able to have a close and direct observation on children with ADHD, the use of hidden camera at home or in school is highly recommended. Other than using pure observational assessment method, a child can also be diagnosed with ADHD using EEG. This is possible since the past and current studies revealed that people with ADHD would reflect a pattern of slow and variable reaction times. Appendix I – Parent / Teacher DBD Rating Scale Parent / Teacher DBD Rating Scale Child's Name: _____________________________________ Form Completed by: ______________________________ Grade: ____________ Date of Birth: ____________ Sex:_________ Date Completed:________________________ Check the column that best describes your/this child. Please write DK next to any items for which you don't know the answer. Not at all Just a little Pretty Much Very Much 1. often interrupts or intrudes on others (e.g., butts into conversations or games) 2. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) 3. often argues with adults 4. often lies to obtain goods or favours or to avoid obligations (i.e., "cons" others) 5. often initiates physical fights with other members of his or her household 6. has been physically cruel to people 7. often talks excessively 8. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) 9. is often easily distracted by extraneous stimuli 10. often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking 11. often truant from school, beginning before age 13 years 12. often fidgets with hands or feet or squirms in seat 13. is often spiteful or vindictive 14. often swears or uses obscene language 15. often blames others for his or her mistakes or misbehaviour 16. has deliberately destroyed others' property (other than by fire setting) 17. often actively defies or refuses to comply with adults' requests or rules 18. often does not seem to listen when spoken to directly 19. often blurts out answers before questions have been completed 20. often initiates physical fights with others who do not live in his or her household (e.g., peers at school or in the neighbourhood) 21. often shifts from one uncompleted activity to another 22. often has difficulty playing or engaging in leisure activities quietly 23. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 24. is often angry and resentful 25. often leaves seat in classroom or in other situations in which remaining seated is expected 26. is often touchy or easily annoyed by others 27. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) 28. often loses temper 29. often has difficulty sustaining attention in tasks or play activities 30. often has difficulty awaiting turn 31. has forced someone into sexual activity 32. often bullies, threatens, or intimidates others 33. is often "on the go" or often acts as if "driven by a motor" 34. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) 35. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) 36. has been physically cruel to animals 37. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Source: University at Buffalo Center for Children and Families, 2009 Appendix II – Scoring Instructions for the Disruptive Behaviour Disorder Rating Scale Method 1: Counting Symptoms To determine if a child meets the symptom criteria for DSM IV diagnoses of Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, or Conduct Disorder as measured by the DBD Parent / Teacher Rating Scale, count the number of symptoms that are endorsed "pretty much" or "very much" by either parent or teacher in each of the following categories: Note that impairment and other criteria must be evaluated in addition to symptom counts. Attention-Deficit/Hyperactivity Disorder Attention-Deficit/Hyperactivity Disorder - Inattention Symptoms (items 9, 18, 23, 27, 29, 34, 37, 42, 44) 6 or more items must be endorsed as "pretty much" or "very much" to meet criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. The six items may be endorsed on the teacher DBD, the parent DBD, or can be a combination of items from both rating scales (e.g., 4 symptoms endorsed on the teacher DBD and 2 separate symptoms endorsed on the parent DBD). The same symptom should not be counted twice if it appears on both versions (parent and teacher) of the rating scale. Attention-Deficit/Hyperactivity Disorder - Hyperactivity/impulsivity Symptoms (items 1, 7, 12, 19, 22, 25, 30, 33, 35) 6 or more items must be endorsed as "pretty much" or "very much" on the parent and/or the teacher DBD to meet criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type If 6 or more items are endorsed for Attention-Deficit/Hyperactivity Disorder - inattention and 6 or more items are endorsed for Attention-Deficit/Hyperactivity Disorder - hyperactivity/impulsivity, then criteria is met for Attention-Deficit/Hyperactivity Disorder, Combined Type Some impairment from the symptoms must be present in two or more settings (e.g., school, home) Oppositional Defiant Disorder Oppositional Defiant Disorder (items 3, 13, 15, 17, 24, 26, 28, 39) A total of 4 or more items must be endorsed as "pretty much" or "very much" on either the parent or the teacher DBD to meet criteria for Oppositional Defiant Disorder _______ Conduct Disorder Conduct Disorder - aggression to people and animals (items 6, 20, 31, 32, 36, 40, 45) Conduct Disorder - destruction of property (items 16, 41) Conduct Disorder - deceitfulness or theft (items 4, 8, 43) Conduct Disorder - serious violation of rules (items 2, 11, 38) A total of 3 or more items in any category or any combination of categories must be endorsed as "pretty much" or "very much" on either the parent or the teacher DBD to meet criteria for Conduct Disorder Method 2: Using Factor Scores Factor scores for the two ADHD and ODD dimensions for teacher ratings on the DBD are reported in Pelham, et al (1992), Teacher ratings of DSMIII-R symptoms for the disruptive behaviour disorders: Journal of the American Academy of Child and Adolescent Psychiatry, 31, 210-218. The factor scores for DSM IV factors are the same as for the DSM III-R factors reported in that paper. To determine how a child's scores compare to normative data, compute the average rating for the items from each factor (listed below) using the following scoring: Not at all = 0, Just a little = 1, Pretty Much = 2, Very much = 3. Then, using the information from the attached table of norms, determine where the child falls in relation to other children. A variety of cutoff scores can be used (e.g., 2 standard deviations above the mean). Factors Oppositional / Defiant (items 3, 13, 15, 17, 24, 26, 28, 39) Inattention (items 9, 18, 23, 27, 29, 34, 37, 42, 44) Impulsivity / Over activity (items 1, 7, 12, 19, 22, 25, 30, 33, 35) Source: University at Buffalo Center for Children and Families, 2009 References Arffa, S. (2009). Buros Institute’s Test Reviews Online . Retrieved September 24, 2009, from Test review of the Conners 3rd Edition™ (Conners 3™). In K. F. Geisinger, R.A. Spies, & J. 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