FNU How We Can Improve Accurate Detection And Treatment Of ADHD Discussion Questions
FNU How We Can Improve Accurate Detection And Treatment Of ADHD Discussion Questions
Question: How Can We Improve Accurate Detection And Treatment Of Attention-Deficit/Hyperactivity Disorder (ADHD)?
Assessing children and adults for Attention Deficit Hyperactivity Disorder (ADHD) can offer crucial insight into one’s functioning and, thereby, guide life-impacting treatment decisions. These include providing input into educational interventions, determining eligibility for disability requirements, and evaluating therapeutic or scholastic outcomes.
Finding and utilizing reliable assessment tools – along with therapeutic supports to efficiently address ADHD – is key. This process begins with understanding the multitude of factors that can impact an ADHD diagnosis:
high prevalence rates (more on this below)
concerns about over-diagnosis
the adverse influence ADHD can have on functioning at home, school, work, and in social relationships
the fact that ADHD often coincides with another disorder.
These factors collectively provide an impetus for developing and implementing measures that can accurately diagnose this condition from the onset. This article reviews widely recommended professional guidelines in the scientific literature – that is, best practices – to assess ADHD and the limitations often faced with evaluating ADHD.
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Prevalence and Costs Associated with ADHD
ADHD is the most common behavioral condition seen in children and adolescents in the United States, affecting 10% of those ages 4 to 17 years old. Compare this to 7% seen in 1998 to 2000 and a worldwide prevalence rate of 5%, the latter explained by different diagnostic instruments and guidelines and access to healthcare.¹
It is notable that incidence rates increase with age. Estimates of ADHD among those 10 to 17 years old are almost twice as high as those for children 5 to 9 years old.¹
In 2013, US healthcare expenditures for ADHD totaled $23 billion.² Societal costs – such as healthcare, education, and reduced family productivity associated with childhood ADHD – have been estimated to range from $38 billion to $72 billion per year.³
Long-term studies show that “children and adolescents with ADHD are more likely to experience a variety of negative outcomes compared to their peers without the disorder, including lower academic attainment, impaired social functioning, increased risk of hospital admissions and injuries, increased substance use and risk of a substance use disorder, and reduced income and participation in labor markets as adults.
ADHD is now more accurately viewed as a neurodevelopmental disorder. This conceptualization has been widely supported by more than two decades of research noting how the condition often, but not always, is diagnosed in childhood and is intricately connected to brain-behavior relationships involving executive functioning (eg, attention, impulse control, self-regulation, organization/planning, and working memory) that presents differently across the lifespan. The American Psychological Association recognized and codified these distinctions in the DSM-5.
This shift in appreciating the connection between executive functioning and ADHD over the past 20-plus years has translated to the development of neuropsychological batteries to evaluate the disorder. In addition, current understandings have influenced targeted areas measured in continuous performance tests and led to appreciable revisions of rating scales. (See Table I below on the various assessment tools available.)
A challenge with diagnosing ADHD is that the characteristics associated with the disorder – such as difficulties with focusing, shifting/dividing attention, managing frustration, organization/poor time-management, working memory, and staying engaged – are common symptoms that could have a breadth of etiologies.
As noted, more often than not, ADHD coincides with another disorder. As per a national 2016 parent survey, 6 in 10 children with ADHD had at least one other mental, emotional, or behavioral disorder.⁹ The most common co-occurring conditions reported with ADHD include:⁹
52% behavioral or conduct problems
33% anxiety disorders
17% depression
14% autism spectrum disorder
1% Tourette syndrome
A small percentage (1.0%) of adolescents aged 12 to 17 years with ADHD also had a parent-reported current substance use disorder (SUD).
Clinicians Involved in ADHD Diagnosis
Assessment of ADHD is conducted within a wide range of professions, that include, but are not limited to:
clinical psychologists
school psychologists
neuropsychologists
psychiatrists
neurologists
pediatricians/neurodevelopmental pediatricians
internists/family physicians.
Evidence-Based ADHD Assessment: False Positives and False Negatives
Regardless of the healthcare expert charged with diagnosing/evaluating potential ADHD, a well-regarded and arguably gold standard approach is using an evidenced-based assessment that involves adherence to the DSM-5 diagnostic criteria along with the inclusion of multi-informant/multimethod methods. Such methods should incorporate empirically validated research and, when possible, test data about key clinical populations to guide and increase confidence with clinical impressions.
With all assessment measures, an overriding goal is to improve the sensitivity and specificity of the instrument. Sensitivity is the ability of a test, such as a rating scale, to correctly identify those with the condition, whereas specificity is the ability of a test to correctly identify people without the condition. These statistics are of particular concern with ADHD given its impact across the lifespan.
Erroneous diagnostic impressions have real-world consequences. A false negative could impede necessary treatment efforts (eg, academic/occupational accommodations, medication, counseling) for one who is struggling at home, school, or work. False-positive errors can lead to inappropriate provisions of medication, academic accommodations, diminish educational resources, as well as provide an unfair advantage to those without disabilities.¹⁰˒¹
