Over the past two decades there has been an explosion of diagnosis, treatment and research regarding Attention Deficit Hyperactivity Disorder (ADHD). As clinicians and researchers have gained more experience working with ADHD, it has become clearer that its impact on life is far greater than we had ever appreciated. ADHD not only can interfere with learning and behavior control in childhood, but, as a critical neurobehavioral condition, it can profoundly compromise functioning in multiple areas throughout the life span. Research and clinical experience suggest that ADHD difficulties can lead to significant educational, occupational, and family dysfunction and can be a significant contributor to a variety of health, social, and economic problems.
ADHD is a common disorder. The Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition (DSM-IV) estimates that ADHD is found in 3%-5% of school-age children. A recent review of thirteen community studies of the prevalence of ADHD indicated that between 1.7% and 16% of children have ADHD, depending upon the populations and the diagnostic methods. As more and more is written and broadcast about ADHD, increasing numbers of adults and parents wonder whether ADHD might be underlying the problems they or their children are experiencing.
As a national organization whose role is to educate and advocate for the needs of individuals with ADHD, we talk with thousands of individuals each month who are seeking help regarding the diagnosis and treatment of ADHD. From these conversations we know that most first turn to their family physician, pediatrician, or a mental health professional for help. We also know that the care they receive varies greatly, ranging from a brief office visit that ends with a prescription for medication to a thorough evaluation cooperatively conducted by members of several different disciplines. We are concerned that paradoxically, ADHD is both over diagnosed and under diagnosed; ADHD is both over treated and under treated.
National ADDA believes that one of the most critical steps in properly addressing the significant impact that ADHD has on contemporary society is to establish a standard of care for its diagnosis and treatment. While gaps exist in our knowledge about the precise cause of ADHD and controversy abounds about aspects of its diagnosis and treatment, research and clinical experience over the past few decades have been sufficient to begin to identify certain principles regarding the evaluation and treatment of ADHD.
As clinicians and researchers have gained more experience working with ADHD, it has become clearer that its impact on life is far greater than we had ever appreciated.The National ADDA Guiding Principles for the diagnosis and treatment of ADHD represent an attempt to enhance the overall health care of individuals and their families who are affected by ADHD. These Guiding Principles seek to define the essential elements of diagnosis and treatment that are necessary for realizing a high quality of care. The Guiding Principles should not be viewed as a diagnostic tool or a therapeutic cookbook. Rather, they represent an organizational framework to guide consumers in navigating the healthcare maze and to focus on our understanding of the essential ingredients of diagnosis and treatment. In addition, we hope that these Guiding Principles will positively impact the activities of health care providers, educators, and clinicians, as well as, the policy making decisions of health insurance companies, governmental agencies, educational administrators and corporate executives whose actions can have a profound impact on the lives of individuals with ADHD.
These Guiding Principles represent a synthesis of lay and professional literature, the experiences of clinicians and conversations with thousands of patients and families. This is National ADDA's working philosophy regarding some critical components of high quality assessment and treatment.
As a consumer advocacy organization, National ADDA's goal is that these Guiding Principles serve as a step towards identifying the essential components of assessment and treatment of ADHD. We hope that they will improve the quality of life for everyone affected by ADHD.
1) Evaluate and treat the whole person.
A comprehensive diagnostic protocol for ADHD provides a description of the whole person. That is, it should seek to identify how a person's ADHD symptoms interact and contribute to his or her physical and mental functioning, as well as his or her personality. Each person is unique, with unique strengths and weaknesses. Making a diagnosis based solely on "plugging" attentional symptoms into a diagnostic checklist, for example, is inadequate. After considering the complete person, the role of ADHD, if present, can be placed in its proper context. The success of treatment is dependent upon understanding andmanaging ADHD within the context of an understanding of the whole person.
2) ADHD should be suspected but not presumed. ADHD is a common problem and may be suspected as a contributing factor whenever a child or an adult experiences problems in learning, self- control, addiction, independent functioning, social interaction, or health maintenance. ADHD symptoms present across a wide spectrum- from extremely mild to extremely severe. The appro-priate diagnosis of ADHD can help clarify the presence of other physical, learning, and emotional disorders, or may be present in combination with any number of these. The professional will need to identify and address potentially coexisting conditions. These may include:
3) ADHD may present across the life span.
ADHD is the result of biological differences in the parts of the brain associated with paying attention, impulse control, and activity level. While ADHD is biologically- based and usually present from birth, symptoms may not become problematic until the individual begins to struggle trying to meet life's expectations.
As a result, ADHD can present clinically anywhere along the life span and in any life domain.
Even though the symptoms of ADHD may not impair an individual until later in life, some of these symptoms must be present since childhood to make a positive diagnosis. Thus, an early history of ADHD symptoms is essential in making a diagnosis of ADHD in an adult. The evaluator should look for evidence of a childhood onset of ADHD symptoms through third party interviews, transcripts, report cards, teacher comments, medical records, past psycho educational testing, and other archival data.
ADHD often negatively affects a person's educational achievements. Lack of school success can contribute to a myriad of economic, social and life adjustment problems throughout a person's life. Educational functioning should be reviewed carefully. In children, adolescents, or adult students, a review of educational functioning should include administration of intelligence and achievement tests. However, it should be noted that success in the educational arena is not by itself a reason to rule out the diagnosis of ADHD.
4) A comprehensive assessment is necessary for an accurate diagnosis.
ADHD is complex and impacts all aspects of a person's life. It can co-exist and/or mimic a variety of health, emotional, learning, cognitive, and language problems. An appropriate, comprehensive evaluation for ADHD includes a medical, educational, and behavioral history, evidence of normal vision and hearing, recogni-tion of systemic illness and a developmental survey. The diagnosis of ADHD should never be made based exclusively on rating scales, questionnaires, or tests. The evaluation should be designed to answer three basic questions:
5) The evaluation and treatment of ADHD should be conducted by a qualified professional.
A qualified professional may be from any one of the following disciplines and would have the appropriate license to practice this discipline: psychiatrist, pediatrician, internist, family physician, other qualified physician, psychologist, social worker, professional counselor, and psychiatric nurse. A qualified professional not only has a license to practice but has training and experience in the differential diagnosis and treatment of ADHD and the full range of psychiatric disorders.
6) Response to medication should not be used as the basis to diagnose ADHD.
There are a number of reasons why an individual's response to a stimulant or other medication is not a valid indication of the presence of ADHD.
First, stimulant medications doesn't just work for people with ADHD; individuals with other disorders and without any disorders may respond positively to them.
Second, failure to respond to medication may be because the dose was incorrect or the person's body is not responsive to that drug, rather than because the person does not have the diagnosis of ADHD.
Third, a positive response to medication may theresult of a placebo effect rather than a true indication of the presence of ADHD.
Fourth, the use of medication as a diagnostic tool may lead the physician to prematurely conclude the diagnostic process without considering disorders that coexist with ADHD and jointly interfere with the individual's functioning.
7) Diagnosis should be based primarily upon the DSM-IV ADHD criteria.
In order to promote standardization, the diag-nosis of ADHD should be based upon the prevailing professional criteria for the diagnosis of mental conditions. At the present time, the prevailing criteria are the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, known as DSM-IV.
A number of professionals have justifiably criticized the DSM-IV ADHD criteria, noting several problems. In particular, they are not adjusted for age, making them too stringent in their published form for diagnosis of adults, e.g. adults will be under diagnosed.
Minor adjustments have been suggested in the professional literature, but nonetheless, it is strongly recommended that diagnosis be based primarily upon these criteria.
8) Diagnosis and treatment of ADHD should involve others familiar with the person undergoing the evaluation.
Proper diagnosis and treatment of ADHD should involve others such as parents, spouses, teachers, and when appropriate, employers. These indivi-duals can corroborate and provide information and can be enormously helpful in the diagnostic and treatment process. When guided to better understand and accept ADHD, they can also become positive supports for the person with ADHD.
9) Treatment should often involve more than one discipline working cooperatively.
Since there is currently no way to cure ADHD, the goal of treatment is to enhance the individual's ability to cope with it. Coping successfully with ADHD often requires a combination of treatments provided by specialists from different disciplines. The physician prescribes stimulant or other types of medication. The mental health professional and/or the coach provides supportive counseling for the individual with ADHD and the family, teaches the individual compensatory strategies for home and school/workplace, and provides training in behavior management.
The educator helps to remediate school- based problems, and often provides feedback to the parents and the physician about the effectiveness of medication. Members of different disciplines should communicate with each other to coor-dinate their efforts to help the individual cope with ADHD.
Generally, medication should not be started until a comprehensive evaluation has been completed and the need for other forms of treatment has been evaluated. Coordinated treatment by physi-cians, mental health professionals, educators, coaches, and other health care professionals will maximize the indivual's opportunities for treatment success.
10) Practitioners should become familiar with current research and diagnostic tools.
It is the responsibility of each professional involved in the evaluation and management of ADHD to continually integrate the most up to date understanding of ADHD into his/her repertoire of clinical skills. The improved understanding of the cause, diagnosis, and treatment of ADHD which comes from a review of the current literature will improve the quality of care.
National ADDA urges all professionals to become familiar with updated diagnostic tools and treatment methods, as well as standards for a comprehensive assessment. National ADDA is committed to facilitating the process of keeping professionals abreast of the latest developments in the field of ADHD through its conferences and publications.
Notes: Goldman, L.S., Genel, M., Bezman, R.J., and Slanetz, P.J. (1998). Council report of diagnosis and treatment of Attention Deficit Hyperactivity Disorder in children and adolescents. Journal of the American Medical Association, 279, 1100-1107. (c) 1998 National Attention Deficit Disorder Association. Since there is currently no way to cure ADHD, the goal of treatment is to enhance the individual's ability to cope with it.
This document may be reproduced for personal nonprofit use, otherwise expressed permission from National ADDA is required.
Questions and inquiries should be directed to: National Attention Deficit Disorder Association, 9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH 44060
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