You are working at the walk-in clinic. Obviously, the waiting room is full. Nathan is 10 years old and in Grade 5. He has come to see you with his father, Peter Harvey, who asks you to prescribe a psychostimulant because the school thinks that his son has ADHD. He hands you the school psychologist’s assessment report. You are Nathan’s family physician and have known him since he was an infant. His parents depend on you to decide whether or not to medicate their son. How will you handle this?
You start by explaining to Nathan’s father that ADHD is not a medical emergency and that it takes time to perform a thorough assessment. You tell him that the tests performed by the school psychologist act as a complement to an in-depth medical assessment, which will determine if Nathan really has ADHD and not another problem that can mimic it (Table 1).1
Dr. Michel Sirois, family physician, practises at the Family Medicine Group and at Clinique Focus at the Centre médical l’Hêtrière in Saint-Augustin-de-Desmaures. Dr. Katia Sirois, neuropsychologist, practises at Clinique Focus and at the Institut de réadaptation en déficience physique de Québec. Dr. Simon-Pierre Proulx, family physician, practises at the GMF de Loretteville in Quebec City. Dr. Sophie Lemelin, neuropsychologist, practises at Clinique Focus and at the Institut universitaire en santé mentale de Québec.
When scheduling the next appointment, you set aside 45 minutes for the first step. You give the father information sheets recommended by the Canadian ADHD Resource Alliance (CADDRA) and a few questionnaires (Table 2)1 to be completed by each parent. You also ask him to obtain the observations of a teacher who knows his son well and his last report cards, while telling him that the teachers’ opinions are important to you.2 All this information will be useful for establishing a diagnosis and identifying co-occurring problems.
On the day of the appointment, you read over the information collected by the parents and teacher and notice that all three of them have basically made the same observations. You then invite the family into your office. Nathan’s father forgot to bring the report cards.
You get a medical history to determine Nathan’s psychomotor development and lifestyle habits. In accordance with the CADDRA recommendations, you look for known ADHD diagnostic criteria (Table 3)3 and the effects on Nathan’s school, home and social life (see the article “ADHD: Truths and Misconceptions” in this special edition). You establish a differential diagnosis and check for problems that could potentially complicate the assessment or treatment (Table 1).1 You pay attention to signs of oppositional
defiant disorder, which is very common in young people with ADHD (Table 4).4-7
As an experienced practitioner, you know it is important to have Nathan take part in the interview. You ask him a few questions to make sure that he understands the process. You look for emotional elements that can be mistaken for, or even exacerbate, ADHD, such as performance anxiety and complicated family situations (separation, conflicts, separation anxiety). You end with a physical examination focusing on cardiovascular issues: weight, height, blood pressure and heart rate. If no red flags appear, there is no indication to perform more extensive tests. Your diagnostic opinion is now clearer and you think that Nathan probably has ADHD with hyperactivity (DSM-5: current combined presentation). You also noticed during the consultation that he kept squirming around, fidgeting with your instruments and interrupting his parents.
You inform the parents of your probable diagnosis. You stress the importance of therapy as the best way of preventing the complications of untreated ADHD.8 You schedule another 30-minute appointment to explain about ADHD and the relevance of pharmacotherapy. You give them a few references and websites to consult before the next appointment. Nathan will obviously be present at this appointment.
While leaving your office, Peter mentions that he was exactly like his son when he was a child. He mentions that his problem is still debilitating because he is unable to achieve his full potential at work. In addition, his relationship with his spouse is often turbulent. He would like to be assessed as well. You then ask him a few key questions to which he answers yes (Table 5).9
You hand him a series of questionnaires for adults (Table 2)1 to be completed by him, by someone who knew him as a child and by someone who is currently close to him. At his next appointment, you review the process by focusing on adult characteristics. In adults, symptoms must have been present since childhood and must have persisted without remission into adolescence and adulthood. There must be functional impacts on their daily, social, family, school or professional lives.10 Problems that can complicate adult ADHD assessment or treatment must be investigated (Table 1).1 As in children, co-occurring problems are common, but they differ in nature (Table 4).4-7
Since this is the first time that you have had to interpret school-based psychological tests, you ask a neuropsychologist colleague of yours to help you interpret the assessment conducted by Nathan’s school psychologist.
Your colleague explains that a psychological assessment helps establish the child’s intellectual functioning and cognitive function profile (e.g., attention, memory, executive functions) (see the article “Who Does What?“ in this special edition for the definition of these terms), which will complete your medical assessment. Depending on the child’s test results and profile, the psychologist can provide clinical impressions about the possibility of ADHD, a psychological disorder, a learning disability or a non-specific profile. When children present with learning disabilities, for example, it may be advisable for a neuropsychologist to perform a more in-depth assessment of their higher cognitive functions to determine whether their profiles correspond more specifically to neuropsychological disorders (e.g., dyslexia, dysorthographia, dysphasia).
A school psychologist’s evaluation generally consists of at least an assessment of intellectual functioning, attention and daily behaviours based on questionnaires or classroom observations.
The CADDRA assessment forms are useful for diagnosing ADHD and for investigating co-occurring conditions.
There are IQ tests for all ages, the most common being the Weschler intelligence tests (WPPSI-III11 for 2- to 6-year olds, WISC-IV12 for 6- to 17-year-olds, and WAIS-IV13 for those aged 16 years and over). The most widely used questionnaires are the Conners Comprehensive Behavior Rating Scales.14 The Test of Everyday Attention for Children (TEA-Ch) measures attention.
A child’s global intelligence score, or IQ, is obtained by measuring four main components (verbal skills, perceptual reasoning, processing speed and working memory). Each component has specific subtests. The scores for each component, along with the global score, indicate a specific level of functioning (Table 5).16 Most of the time, IQ test results help determine cognitive functioning and thus the child’s expected potential.
In intelligence tests, the indicators generally most sensitive to attention deficits are working memory and processing speed. Heterogeneous results, or component scores deviating from average, can complicate the overall interpretation of global intellectual functioning. However, mixed results or widely fluctuating scores in the various components may indicate attention deficits or even learning difficulties. Moreover, the scores on psychometric attention tests should match up with the assessed intellectual potential. Attention test scores that are lower than the assessed potential may also indicate ADHD.17,18
Observations of daily behaviour are essential for establishing the child’s profile. School psychologists most often use three versions of the Conners behaviour rating scales (parent, teacher, child over the age of 10 years).15 Parents, the child and teachers answer questions on the child’s daily psychological functioning, attention and executive functions. The scores indicate if the child has clinically significant symptoms of ADHD or another mental health problem (e.g., anxiety).
In neuropsychologists’ assessments of higher cognitive functions, other psychometric tests can occasionally be used to specifically pinpoint strengths and weaknesses in the areas of attention, working memory and executive functions (Table 6).12,19,20 These tests are recognized as being discriminating and reveal specific problems in a clinical population.21
To help you with your diagnostic medical assessment, your colleague suggests that you should focus on the sections in the psychologist’s report that relate to attentional, intellectual and behavioural functioning, as well as functional impacts. You review that report by paying special attention to those elements and to the most important ones (expected intellectual potential, differences and wide fluctuations in performance, and functional effects). The report indicates that Nathan’s intellectual functioning was assessed with the Weschler IQ test (WISC-IV)12 and scored according to Québec standards. It shows that Nathan has an average global intelligence score (66th percentile) and above average functioning on both the perceptual reasoning scale (78th percentile) and the verbal comprehension scale (76th percentile). His scores on the subtests for information processing (7th percentile) and working memory (9th percentile) are below average and weaken his general profile. Your neuropsychologist colleague points out that a lower score in these two components, compared with the global profile, is often a sign of fluctuating attentional abilities and may support a diagnosis of ADHD.
In adults, symptoms must have been present since childhood and must have continued without remission into adolescence and adulthood.
In the section on attention in the report, you notice that Nathan has fluctuating attention abilities. His TEA-Ch test results range from “below average” to “above average.”
Nathan has trouble sustaining his attention during auditory tasks but has average abilities for simple visual tasks. This result means that he generally manages to sustain his attention during visual tasks for an adequate amount of time. However, he has trouble maintaining concentration during auditory tasks. His ability to sustain his attention in class is probably more fluctuating and poor. Nathan’s selective and sustained attention scores are slightly below average. His divided attention abilities (doing two things at the same time) also range from “below average” to “above average,” but he obtained lower results for auditory tasks. His test results are clinically significant for the subscales of inattention and hyperactivity, according to the DSM-IV-TR criteria and the Conners scale. No other symptom of a mental disorder (e.g., anxiety, depression) was noted. Nathan’s parents tell you that their son regularly forgets his homework materials at school, that he can carry out only one instruction at a time, that he is quick to anger, and that his soccer coach has to frequently remind him to pay more attention to the game.
This information completes your medical assessment and confirms that Nathan’s attention problems reduce his intellectual potential, which may hinder his learning and cause major functional effects on his daily life.
In intelligence tests, the indicators generally most sensitive to attention deficits are working memory and processing speed.
The consultation with your neuropsychologist colleague reinforces your diagnosis of ADHD. Nathan is of normal intelligence. However, according to the IQ test, his working memory and processing speed are below average, which means that they are lower than his assessed potential.
You noted no significant signs of co-occurring conditions. You did not identify any signs of autism spectrum disorders or physical disorders, such as sleep apnea or the effects of a moderate to severe brain injury. If you had, you would have referred your patient to a specialist.
Nathan’s problems affect both his school performance and his family life. Convinced of your diagnosis, you feel satisfied with the job you have done, despite your heavy workload! The fact that you split up the visits and used the CADDRA questionnaires made the job seem more manageable. You now feel confident and ready to assess Nathan’s father. //
French Version: Received: January 27, 2013 Accepted: March 21, 2013
Translated in English: September, 2014
Dr. Michel Sirois was a speaker for Janssen Pharmaceuticals in 2012–2013 and an advisory committee member for Shire and Janssen Pharmaceuticals in 2012. Dr. Katia Sirois and Dr. Sophie Lemelin have no conflicts of interest to declare. Dr. Simon-Pierre Proulx is a speaker for Janssen and Shire and an advisory committee member for Janssen and Novo-Nordisk