Showing posts with label adhd. Show all posts
Showing posts with label adhd. Show all posts
How do doctors diagnose ADHD?
ADHD should only be diagnosed by a medical professional with appropriate training. Where possible this should be a child or adolescent psychiatrist, or a paediatrician familiar with ADHD.There isn't a simple test that determines whether someone has ADHD or not. A specialist can only diagnose ADHD after assessing a child thoroughly.
It's important for the specialist to do a detailed assessment of the child's behaviour. This will usually involve finding out about the child from his parent(s) and school.
What will the specialist ask parents?
You will be asked about the following things:
- your child's medical history, including any mental health problems
- any family history of ADHD and of mental health problems
- your child's development and temperament
- specific ADHD symptoms and when they started
- any other problems the child has
- your child's relationship with you (and your partner)
- any parenting problems, if present.
Sometimes parents will be asked to assess their child's behaviour using a rating scale, which is like a questionnaire to find out how severe someone's symptoms are.
What will the specialist want from your child's school?
With parental permission, the specialist will usually seek information from your child's teachers about:
- behaviour in class
- academic achievement
- relationships with other pupils
- response to discipline and authority.
The teachers will usually be asked to use rating scales to assess your child's behaviour.
What other things will the specialist look at?
The specialist will often ask about your child's history, especially older children, teenagers and adults. Sometimes your child may mention issues relevant to the assessment that you or your family don't know about.
The specialist will also want to examine your child, to find out whether there could be a physical disease causing his symptoms, or making them worse. The examination will also allow the specialist to assess the person's mental state and note down details she needs to know if prescribing medication. And it will help the specialist to decide if your child needs to be assessed in other ways, for example by a psychologist or hearing expert.
The specialist might also want to carry out 'psychometric' assessments, which are used to assess mental abilities. These tests might measure things such as your child's reading ability, IQ, or speech. There are also special tests to measure attention and impulsiveness.
If your child has another condition, such as dyspraxia (which affects co-ordination), learning disabilities, depression or autism, this can mask the symptoms of ADHD. So screening for other conditions is also part of the assessment process.
What rules does a specialist follow when diagnosing ADHD?
There are two special sets of criteria for doctors to follow when diagnosing someone with ADHD. These are called ICD-10 and DSM-IV-TR.
ICD-10
ICD-10 is a set of criteria from the World Health Organisation that is used to diagnose 'hyperkinetic disorder'. This is a narrower definition than ADHD.
DSM-IV
The DSM-IV-TR criteria is published by the American Psychiatric Association. It can be used to diagnose different types of ADHD, including hyperkinetic disorder, which is a severe type.
What are the differences?
Someone can be diagnosed with ADHD using DSM-IV when they have mainly symptoms of inattention.
But a person must show symptoms of inattention, impulsivity and hyperactivity to be diagnosed using ICD-10.
This means that a broader group of people will be diagnosed as having ADHD using DSM-IV than having hyperkinetic disorder using ICD-10.
DSM-IV is used more in the US and ICD-10 in the UK and Europe.
ICD-10 diagnoses fewer children with more severe symptoms, so using this set of criteria could mean children who would be diagnosed as having ADHD using DSM-IV don't get treatment.
On the other hand, some experts think that too many people might be diagnosed with ADHD using DSM-IV.
There isn't a straightforward way of deciding who has ADHD and who doesn't. Even though these sets of criteria are important when making a diagnosis, a specialist will still need to use her clinical judgement.
At what age is ADHD usually diagnosed?
Children are usually diagnosed with ADHD when they are at primary school (ages 5 to 11). Symptoms can be clearer when your child has started school, because the discipline and routine in the school environment makes ADHD symptoms stand out more.
It can be hard to diagnose pre-school children, because it's common for children aged between three and five to be very active, and often this behaviour isn't abnormal.
If a younger child is extremely hyperactive, this can often mean he has another condition affecting his development, such as autism.
Older children, teenagers and adults can also be diagnosed with ADHD.
What happens after diagnosis?
When someone has been diagnosed as having ADHD, the specialist will develop a treatment plan. Treatment may include medication, behavioural therapy, psychotherapy and educational approaches.
The specialist will assess your child's behaviour and work with you, your child and his teachers before treatment is started.
This may include giving a score for different aspects of the child's behaviour. The specialist can use this assessment as a starting point, or baseline, so that he can measure how much your child improves in the future.
The specialist will set targets for different aspects of your child's behaviour. This means your child can be scored after treatment has started, to measure how effective the treatment is. For example, your child's teachers may be asked to record how many times your child leaves his seat during a lesson.
The specialist will continue to monitor your child to assess:
- how effective the treatment is for your child's main symptoms
- the most suitable dose of medication and any side-effects
- how your child is getting on socially, emotionally, academically and in terms of self-esteem.
Once your child is being treated, you (and teachers) can use rating scales similar to those used during diagnosis. Rating scales can be a good way to assess how your child is responding to treatment.
Dealing with doctors Q&A
If you're worried about your child's behaviour, the first port of call is often your GP. And if the GP refers your child, you will also need to see a specialist who makes the diagnosis.
Use the tips below to get the most from your appointments.
How to prepare for your appointment with a GP
Give some thought to the problems you and your child are having before your appointment.
The more information you give, the easier it is for your doctor to ensure you get the help you need.
- Describe your child's symptoms as accurately as you can. Try to be specific – 'for some time' can be anything from days to years.
- Make a list of symptoms. Writing them down means you're less likely to forget something important. It also helps the doctor to not miss any issues. Your GP probably won't have time to look through a lot of information with you during the consultation and may find it more helpful to do so afterwards.
- Check your list is complete. Don't dismiss things that worry you about your child's behaviour as minor – that's what your GP is there to help with.
- Try to request a double appointment. The average appointment time is just eight minutes, which isn't enough to deal with a complex problem like ADHD. Don't be put off if the receptionist asks why – everything you say inside the surgery should be confidential, which also applies to the receptionists. If a double appointment system isn't run, it's likely you’ll need a few appointments to get all the issues looked at.
- Take stock of medicines. Make sure you know the names of all the medicines your child is taking, including ones you've bought over the counter.
- Talk to your relatives about their health. This is because family history of disease can be important, especially with new symptoms.
What happens at the first appointment
If you're worried about your child's development, or are responding to concerns raised by the school, your GP is the first step to getting help. But because of the complexities of diagnosing ADHD, it's not one a GP will make without the help of a specialist.
So what can you expect from the first appointment?
With all the bad press that ADHD gets – and for that matter any mental health or learning difficulty – you may be nervous about broaching the subject with your GP.
But media and general attitudes are different to a GP's perspective – afterall, ADHD is recognised as a medical condition, as are a whole range of childhood behavioural disorders. Therefore, it's likely your GP will be sympathetic and helpful.
You need to explain what your specific concerns are about your child – this is where your preparation comes in handy.
After listening to your concerns, the doctor will:
- ask about your child's general health
- check what medication, if any, that they are taking
- ask further questions to clarify your concerns – for example the extent the problems affect your child
- ask about your child’s medical history and your family medical history.
Your GP might also perform a simple physical examination and check your child’s hearing or sight.
All these questions and tests are there to rule out other causes for their behavioural problems.
It's important to keep in mind that your child's demeanour and behaviour, in the setting of a GP's consulting room, may not be entirely typical or representative of what's usual for them – eg in unstructured or less supervised settings.
Don't be put off or embarrassed by this – an experienced and sympathetic GP will take this into account.
In some circumstances, you may wish to take the opportunity to discuss your concerns and describe behaviours without your child present. Children and young people may be upset to hear negative comments made in front of them.
After this preliminary assessment, your doctor will decide whether your child needs to be referred to specialist services for assessment, diagnosis and management.
What sort of specialist your child needs to see first, eg paediatrician, child psychiatrist etc, depends partly on the nature of the problem and partly on local availability. For example, if tummy pains are prominent, these may need to be looked at by a paediatric specialist first.
Questions you may want to ask the doctor
The consultation is a two way process, and at some stage you’ll want some answers to your own questions.
Examples of things to think about and be clear on are:
- how long will I have to wait for referral?
- what help can I get now?
What happens at the specialist appointment
The aims of this second appointment with a specialist are to make a diagnosis and then draw up a treatment plan, if required.
Any one or more of these specialists may be involved in assessing your child:
- psychiatrist
- psychologist
- paediatrician
- speech and language therapist
- occupational therapist.
What the specialist will ask you
The specialist will need to know your child's medical, family and psychiatric history – as well as a detailed account of your child’s behaviour problems, including any previous difficulties.
Some assessment services send on a detailed developmental and behavioural questionnaire in advance of the appointment and will have this handy to help in the assessment.
You may also be asked a specific set of questions about your child's behaviour, using prepared questionnaires known as rating scales.
What the specialist will ask your child
The specialist will ask your child some questions about her behaviour and how she feels about her problems.
This is an important part of establishing a rapport with your child, making older children feel included in the process and so more likely to comply with any treatment plan.
How the specialist evaluates your child
- Physical examination: the specialist will carry out a further physical examination of your child to make sure there's no underlying medical cause for the development problems, eg a hearing problem. Depending on the results, a specialist may occasionally order specific tests, such as blood tests, to confirm or rule out certain conditions.
- Educational history: the specialist will look at comments from your child's teacher or school. They may decide a more formal assessment by an educational psychologist is necessary.
- Clinical observation: because of the artificial environment of a clinic, it can skew your child's behaviour – they may act up or tone down her actions. For this reason, the specialist will sometimes arrange to observe your child in another setting (eg at home or school) before making a diagnosis.
- Development tests: the specialist may use physical tests to assess your child's motor skills (which affect development) – for example by testing your child's ability to catch a ball or write. Written or oral tests may be used to check how well your child understands what's being said and ability to express themselves.
Conclusion
After all these tests and questions, the specialist will make a diagnosis. Depending on what is or isn't causing your child difficulties, the specialist will draw up a treatment plan.
At this stage, you may have a number of questions. Again, don't be afraid to ask because it could save you a lot of anxiety later.
Questions you may want to ask the specialist
- How severe is the problem?
- What does your diagnosis mean for my child?
- What treatments are available?
- Would simple alteration of lifestyle help?
- Does my child need medicines?
- If so, what side-effects could there be?
- How long will the treatment need to be given?
- How often will you be checking on my child’s progress?
- How quickly will the medication take effect, and does it need to be taken every day?
- What happens if one treatment doesn't work?
- Will the problem ever go away, so my child can stop treatment?
- Would you be willing to see my partner and explain the situation to him or her?
My child may have ADHD – what next?
If you think your child might have ADHD, you’re likely to go through the following process.
Talking to your GP
Your GP is likely to:
- ask about your child’s medical history and your family medical history
- talk about your child’s behaviour and whether they're underperforming at school
- check your child’s hearing and sight (or make referrals for these to be checked) to rule out behaviour problems caused by not being able to hear or see properly
- look for signs of any intellectual disability, autism, epilepsy or depression.
Talking to the school
Your school may already know there's a problem.
It may ask you to get the medical side checked out before it can refer your child for an assessment for a statement of special educational needs.
In practice, the medical and educational referrals tend to happen at the same time.
Referral to medical specialists
This depends on your local health authority. Your GP may refer you first to a community paediatrician or possibly to a specialist ADHD team.
Other specialists may be involved such as:
- psychologist
- psychiatrist
- paediatrician (particularly one experienced in behavioural or development problems)
- speech and language therapist
- occupational therapist.
How long does it take?
The time from referral to the first meeting and assessments depends on the workload of the specialists.
Some areas tend to have longer waiting lists, which can be anything from three months to a year. This includes speech and language therapy, occupational health and mental health specialists.
Access to care
GPs will usually refer your child to a specialist – although lessening, the problem tends to be the waiting time.
If you’re faced with a long wait, ask if the specialist can give any advice on behaviour management that you can try before your child is assessed.
If you're willing to accept a cancellation slot at short notice, this sometimes helps to get an earlier appointment.
Your GP or school may be able to recommend private specialists, who can assess your child. They’re likely to have a shorter waiting list, though assessments can be expensive.
Assessment
The assessments vary depending on which specialist you see. They include:
- observation of your child in a situation, such as school or home or at the specialist’s office
- looking at written evidence, for example a teacher’s comments about difficulties your child has experienced. It’s also worth keeping a home behaviour diary too, so you can pinpoint examples and show you’ve already tried to find triggers for your child’s behaviour
- physical tests: an occupational therapist may check your child’s physical abilities including ‘gross motor skills’, such as catching a ball or hopping, and ‘fine motor skills’ such as handwriting or threading beads
- written or oral tests: a speech and language therapist will check how well your child understands what he hears and how he can express himself. An educational psychologist may do IQ tests.
The specialists may also want to discuss things with you and find out more about how your child reacts in certain situations and how you’ve tried to manage things so far.
With ADHD, you can never predict a child's behaviour. They may be able to do something one day and not the next. They may behave absolutely perfectly while they're being assessed and then be difficult the next day.
Diagnosis
The paediatrician or psychologist will confirm:
- if your child has ADHD
- what type of ADHD it is – combined, primarily hyperactive or primarily inattentive
- how severe the ADHD is – mild, moderate or severe, and what degree of 'impairment' is identifiable
- whether your child has any other conditions as well as ADHD, such as oppositional behaviours or conduct disorder, coordination problems, learning difficulties, anxiety or depression, or problems with social interaction communication and obsessive behaviour (that may indicate the need for an autism assessment).
Treatment
Treatment depends on the age of your child, the type of ADHD he has and any other conditions. It should be tailored to the individual child, and may include:
- counselling for the child and parents from a psychologist
- behaviour management advice
- strategies to help your child learn and deal with social problems, eg teasing by other children
- strategies to increase your child’s self-confidence and self-esteem
- one-to-one help at school
- medication (tends not to be for children under six, except in severe cases). Most of the types of medication offered are neurostimulants that work by changing levels of brain chemicals called neurotransmitters. These work by ‘controlling’ and ‘inhibiting’ part of brain, making the brain work in a more efficient way – so your child can concentrate better and behave more calmly.
Treatment issues
Below is a checklist of questions you may like to ask the specialists.
- Where and when will any counselling take place?
- Who is going to be involved with the strategies (parents, teachers, one-to-one help)?
- Who will oversee the strategies and review whether they’re working or not?
- When and where will the review take place, and who needs to be there?
- When and how often will your child need to take medication? (what side-effects may be encountered and how often will medication be reviewed? How long will medication be required?)
- Will he need to take it at school?
- How does the school manage medication?
Long-term care
ADHD is a long-term condition.
Many clinicians talk of 'care rather than cure'. Some children appear to grow out of it, but many don't.
Management comprises a mix of compassion and common sense, based on a reliable foundation in 'evidence based' practice.
Research shows that up to 60 per cent will still show signs of ADHD as adults, often sufficient to cause difficulties at work or college and with relationships.
Why is ADHD controversial?
ADHD has become a controversial topic: some experienced clinicians and specialists believe the condition isn't adequately recognised, and so many children are not being diagnosed.Others claim parents are pushing too hard to get their children a label and i
t's over-diagnosed.
So what are the problems?
Diagnosis
- There's no physical test (such as a blood test) for ADHD.
- No single cause has been established.
- There's no standardised method of assessment – it's down to the clinician whether he uses written tests or makes a judgement based on what you and the teachers tell him. What one expert would classify as ADHD, another might not. Although methods of assessment are increasingly standardised the final diagnosis of ADHD depends on clinical judgement that may vary from one specialist to another.
- Other problems can cause behaviour similar to ADHD, such as hearing problems, dyslexia, family problems, anxiety and depression.
- ADHD can exist with other conditions and this can complicate the assessment process. There are overlapping areas with conditions such as language difficulties, dyspraxia, sleep disorders, autism spectrum disorders and Asperger's Syndrome – this is increasingly recognised by most specialists however and will be taken into account during assessment.
- All children have problems with self-control to some extent – where do you draw the line between normal and difficult behaviour?
- Our modern lifestyle, with greater use of technology, means we're used to getting information quickly and in bite-size pieces. Some experts feel children have a shorter attention span because of this lifestyle, rather than because of a medical condition.
- ADHD services tend to be underfunded and overloaded, so it can take a long time to see a specialist and get a diagnosis.
History
In the past, researchers thought that ADHD was caused by:
- drug or alcohol abuse by the mother during pregnancy
- psychological trauma at an early age
- minor head injuries or brain damage.
The first two firmly put the blame on parents, but none of them took account of ADHD in children whose mothers didn't take drugs or drink heavily during pregnancy, had a settled family background and didn't have any brain damage.
Influence of the US
The US has a higher rate of diagnosis and medication than the UK. This is because:
- the definition of ADHD (used in the US) is wider than that of 'hyperkinetic disorder', which is the diagnostic term often used in the UK
- prescription guidelines are looser in the US, where stimulant drugs are prescribed for children under the age of six
- some US schools are insisting that children with ADHD must take medication or they will be excluded from school.
More UK specialists are using the American DSM-IV-TR definition now, so rates of diagnosis are also rising in the UK.
With a larger number of children being diagnosed, there's also a rise in the number of prescriptions for stimulant drugsmedications to treat ADHD.
Some experts feel that because the criteria for ADHD are wider, children may be misdiagnosed. But other experts, increasingly in the majority, think these issues surrounding diagnosis mean ADHD is still under-diagnosed.
Media
The media often seizes on one thing that sells news, and ADHD has become very controversial in the media. Common areas of controversy are listed below.
Causes
According to some sections of the media, ADHD is a result of bad parenting, poor discipline, watching too much TV and diet (particularly a large intake of E-numbers, or food intolerance).
Depiction of ADHD
How a child with ADHD behaves is often misrepresented. The media view is often that children with ADHD are bouncing off the walls and are out of control, destructive, malicious and antisocial. This description is more likely to be of a child with oppositional defiant disorder and conduct disorder.
Oppositional defiant disorder and conduct disorder are categories of behaviour that can exist with ADHD. But it doesn’t cause ADHD.
It's understandable that parents don't want their child to be diagnosed with ADHD, in case he or she is labelled as a troublemaker. But without the ADHD 'label', it's unlikely the child will get the help he needs.
Stimulant drugs
Some sections of the media are against the use of medication and claim parents are 'drugging' their children for an easy life.
Others claim, incorrectly, that Ritalin causes problems – such as brain damage and seizures, or turns children into 'zombies', with withdrawn, automaton-like behaviours.
This makes parents (and some specialists) wary of trying medication in case it causes more problems.
However, when doctors prescribe medication for a condition, there's usually a period of adjustment while they find the right dosage to suit the patient, and then there are regular reviews of the medication.
There are sometimes side-effects with medication, although these are largely predictable and seldom serious. If the specialist advising you is considering drug treatment, they should always discuss this with you.
Trendiness
ADHD is seen as being a 'trendy' disorder because diagnosis rates are rising.
Benefits scam
Because children with ADHD may be eligible for disability benefits, the media claims that greedy parents are pushing for a diagnosis so they can get extra money.
Stimulants and parenting
There are four big debates in this area.
- Are parents drugging children for an easy life?
- Are neurostimulant medications, such as methylphenidate, being overused? They used to be given to school-age children until adolescence, but are now being prescribed for younger children and for a longer period of time.
- Are older children misusing drugs, such as Ritalin? Ritalin is in the same drug category as amphetamines. It's claimed that in the US, older children who were having social problems and wanted to make friends sold their Ritalin in the playground. But with slow-release medication increasingly available, it's unlikely that children will have to take the drugs to school at all.
- Parental guilt surrounding medication. Parents worry that medication may make their child into a zombie or have terrible side-effects – are they bad parents for giving it to their child?
So where does that leave parents?
Parents can feel that whatever they do, they're in the wrong.
- If they don't get a diagnosis, their child will suffer.
- If they do get a diagnosis, they're either jumping on a trendy bandwagon or are bad parents, who are drugging their children to compensate for their own shortcomings.
The bottom line is ADHD is a medical disorder and it needs to be recognised and treated.
Drugs aren't the only treatment. They should only be prescribed alongside other treatments, such as counselling and behaviour therapy, together with appropriate school based strategies – and if necessary, practical and social support for the hardest pressed, if the specialist and other members of the ADHD team consider they will help.
Recent updates
For a detailed discussion and examination of the evidence for the validity of ADHD as a 'disorder', which it's possible to diagnose reliably, see the NICE Guideline 2009.
This confirms that ADHD symptoms consistently 'cluster' together in the population, causing impairment and showing a characteristic pattern of development and change over time – together with reliable evidence of genetic, environmental and neurobiological causation.
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