What is the approach to assessing attention and concentration deficits in children and adolescents?

Approach to Assessing Attention and Concentration Deficits in Children and Adolescents

Initial Evaluation Trigger

Initiate an ADHD evaluation for any child or adolescent aged 4-18 years presenting with academic or behavioral problems accompanied by symptoms of inattention, hyperactivity, or impulsivity. 1

Step 1: Verify DSM-5 Diagnostic Criteria

Before proceeding with extensive testing, confirm the following mandatory criteria:

• At least 6 symptoms of inattention and/or hyperactivity-impulsivity (5 symptoms for adolescents ≥17 years) 2, 3
• Symptoms present for ≥6 months 2
• Several symptoms present before age 12 1, 2
• Symptoms and impairment documented in at least 2 settings (home, school, social environments) 1, 3

Critical pitfall: Failing to obtain information from multiple settings before concluding ADHD criteria are met leads to misdiagnosis. 4

Step 2: Gather Multi-Informant Data

Obtain standardized rating scales from at least 2 teachers plus parents/guardians to document cross-setting impairment. 4, 3 This is non-negotiable for accurate diagnosis.

Recommended Rating Scales:

• DSM-IV/DSM-5-based symptom rating scales (most evidence-based) 5, 6
• Conners' Parent Rating Scale (CPRS) and Conners' Teacher Rating Scale (CTRS) 7, 5
• Child Behavior Checklist (CBCL) 7

These brief, DSM-based rating scales are highly correlated with longer assessments and are more efficient while equally effective at diagnosing ADHD. 6 Structured interviews confer no incremental validity when parent and teacher ratings are utilized. 6

Step 3: Mandatory Comorbidity Screening

The majority of children presenting with ADHD-like symptoms meet criteria for another mental disorder, making comorbidity screening essential rather than optional. 4 The American Academy of Pediatrics recommends systematic screening for: 1, 3

Psychiatric Conditions:

• Anxiety disorders (present in ~14% of children with ADHD, rates increase with age) 4
• Depression 1, 2
• Post-traumatic stress disorder (PTSD) - can manifest with impulsivity, hyperarousal, and attention difficulties that closely mimic ADHD 4
• Oppositional defiant disorder 3

Developmental Conditions:

• Learning disabilities and language disorders (commonly present with inattention and behavioral dysregulation) 1, 4, 2
• Autism spectrum disorder (can manifest with impulsive behaviors and difficulty with behavioral regulation) 4, 3

Physical/Medical Conditions:

• Sleep disorders (including sleep apnea - produce daytime hyperactivity, inattention, and impulsive behavior that resolves with treatment) 4
• Tic disorders 4
• Seizure disorders (particularly absence seizures can mimic inattention) 4

Substance Use (Adolescents):

• Marijuana use (can produce effects mimicking ADHD symptoms) 4
• Stimulant-seeking behavior (adolescents may feign ADHD symptoms to obtain medications for performance enhancement) 4

Critical pitfall: Assigning an ADHD diagnosis when symptoms are better explained by trauma, substance use, or other psychiatric conditions results in inappropriate treatment. 4

Step 4: Clinical Interview and History

Conduct a comprehensive clinical interview focusing on:

• Onset timing: Verify symptoms were present before age 12 in adolescents (not establishing this leads to misdiagnosis of conditions that emerged later) 4, 2
• Trauma history: PTSD and complex PTSD include trauma-specific reexperiencing, avoidance, and emotion dysregulation that ADHD lacks 4
• Functional impairment: Document specific impairments in academic, social, and family domains 3, 8
• Developmental history: Assess for developmental coordination disorder, language delays 4
• Sleep patterns: Screen for sleep disorders systematically 4, 3

The clinical interview of the child and family is one of the cornerstones of the assessment process. 8

Step 5: Neurocognitive Testing (Optional, Not Required)

While not mandatory for diagnosis, the following tests can provide additional information:

• WISC-IV Working Memory and Processing Speed indexes (children with ADHD perform poorly on processing speed; working memory deficits more prominent in children than adolescents) 9
• d2 Attention Test (measures processing speed, concentration, accuracy, impulsivity) 9
• Continuous Performance Tests (CPT, TOVA, IVA-CPT) 7

However, no test is diagnostically definitive for ADHD. 8 These tests have validity but limited practical utility for clinical diagnosis when rating scales are already obtained. 6

Step 6: Age-Specific Considerations

Preschool Children (Ages 4-6):

• Hyperactive symptoms are often more prominent than inattentive symptoms 2
• Look for excessive motor activity, difficulty sitting still during activities, and impulsive behaviors 2
• Refinement of developmentally informed assessment procedures for evaluating ADHD in preschoolers remains an area needing further research 1

School-Age Children:

• Both inattentive and hyperactive-impulsive symptoms typically present 2
• Academic impairment becomes more apparent 8

Adolescents:

• Symptom threshold reduced to 5 symptoms (instead of 6) for those ≥17 years 2, 3
• Inattentive symptoms may predominate as hyperactivity becomes less overt 9
• Mandatory substance use screening 4

Step 7: Gender Considerations

• Boys are more than twice as likely as girls to receive an ADHD diagnosis (possibly because hyperactive behaviors are more easily observable) 2
• Girls with ADHD are more likely than boys to have comorbid anxiety or depression 2

Step 8: Special Population Considerations

African American and Latino children are less likely to have ADHD diagnosed and less likely to be treated. 1 Special attention should be given to these populations when assessing comorbidities and treating ADHD symptoms. 1

Common Diagnostic Pitfalls to Avoid

1. Relying solely on parent or teacher reports without corroborating information from multiple sources 4, 2
2. Failing to screen for common comorbid conditions that may alter treatment approach 2
3. Not establishing that symptoms were present before age 12 in adolescents 4, 2
4. Failing to obtain information from multiple settings before concluding ADHD criteria are met 4

Documentation Requirements

Document all aspects of the diagnostic procedure in the patient's records, including: 1

• Standardized rating scale results from multiple informants
• Cross-setting symptom verification
• Comorbidity screening results
• Functional impairment in specific domains
• Age of symptom onset