Continuity Clinic Curriculum

Lucile Packard Childrens Hospital

ADHD Testing
ADHD Testing
Case: You are seeing Charlie, a 7 year old boy, along with his parents due to
concerns for hyperactivity and inattention. After reviewing the history and
completing a thorough physical exam, you think it is appropriate to begin testing for
ADHD.
Learning Objectives:
1. Review the current options for ADHD testing
2. Understand the benefits and downsides of the various forms of ADHD testing
________________________________________________________________________________________________
ADHD Basics
Affects 6-7% of school-age children
3:1 male: female
Coexisting conditions
o 35% oppositional defiant disorder
o 26% conduct disorder
o 25% anxiety
o 18% depressive disorders (often lasts into teenage years or
adulthood)
When evaluating for ADHD, always evaluate for learning disabilities and
emotional problems that may be affecting behavior
Diagnosis
o 6/9 behaviors in hyperactive/impulsive domain and/or in the
inattentive domain
Hyperactive:
Fidgets with hands or feet or squirms
Leaves seat in classroom or other settings when
remaining seated is expected
Runs about or climbs excessively in inappropriate
situations
Has difficulty playing or engaging in leisure activities
quietly
On the go or often acts as if driven by a motor
Talks excessively
Impulsivity
Blurts out answers before question has been completed
Difficulty awaiting turn
Interrupts or intrudes on others
Inattention
Fails to give close attention to details or makes careless
mistakes
Difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly

Continuity Clinic Curriculum

Lucile Packard Childrens Hospital
ADHD Testing
Does not follow through on instructions and fails to
finish schoolwork, chores or duties
Difficulty organizing tasks and activities
Avoids, dislikes or is reluctant to engage in tasks that
require sustained mental effort
Loses things necessary for tasks or activities
Easily distracted by extraneous stimuli
Forgetful in daily activities
o Presence of behaviors in 2 or more settings for at least 6 months
o Behaviors must occur prior to 7 yo
o Behaviors cause significant impairment in learning/social interactions
Clinical Evaluation
AAP guideline states diagnosis requires evidence directly obtained from parents
or caregivers in various settings as well as from a school professional
Use of ADHD specific scales to diagnose ADHD is not required, but can provide
important descriptions of patient behavior that can be helpful to clinicians
o Use of broad scales not recommended
Should include evaluation for coexisting conditions
No lab tests or other imaging techniques are necessary
Overview of Options for Screening Forms:

Continuity Clinic Curriculum

Lucile Packard Childrens Hospital
ADHD Testing

From: AACAP Practice Parameters for Assessment and Treatment of Children and Adolescents with AttentionDeficit/Hyperactivity Disorder

Scale

Ages

Benefits

Limitations

Brown

3-18 yo
(multiple
forms)

Good for ADD and

attention only or
information
processing problems

Must be purchased;
long; mostly selfreported symptoms

Child Behavior
Checklist

2-3 yo
4-18 yo

Includes self-report
form for teens;

Less specific for

ADD/ADHD

**Conners -3
(commonly used)

6-18 yo

Adolescent selfreport available; Has

convenient carboncopy tear off sheets
for scoring

Multiple versions
available, may be
confusing; must
purchase

Conners- EC (early
childhood); Conners
(7,8)

2-6 yo

Only scale available

for preschool
children

Must purchase; very

difficult to diagnose
in this age range,
often used for
specialists

SNAP IV (Swanson,
Nolan and Pelham IV
Questionnaire)

5-11 yo

Electronic scoring
available on the
internet

Limited normative
data; no separate
parent and teacher
version

ADHD Rating Scale IV

(ADHD RS IV) (DuPaul
1998)

5-18 yo

**Vanderbilt ADHD
Rating Scale (VARS)
(Wolraich 2003)
(commonly used)

Elementary
School

ADHD Symptoms
Rating Scale (ADHD-

5-18 yo

Only asks about

DSM IV ADHD
Symptoms
Includes rating of
impairment; asks
about comorbid
conditions; available
free online

No normative data
on adolescents

Lengthy

Continuity Clinic Curriculum

Lucile Packard Childrens Hospital
ADHD Testing
SRS) (Holland 2001)
Attention Deficit
Disorder Evaluation
Scale 3rd edition
(ADDES-3_ (McCarney
2004)

4-18 yo

ACTeRS 2nd edition

(Ullman 2000)

K-8th grade

Lengthy

Adolescent selfreport available

No normative data
on parent and
adolescent version
available

Adapted from: Peds in Review 2010 Wilms Floet et al 31 (2): 56 Table 2

Specific Screening Forms

ADHD Rating Scale-IV
o http://elcaminopediatrics.com/forms_medrecords_adhdhome_pf.htm
o http://elcaminopediatrics.com/forms_medrecords_adhdschool_pf.ht
m
Brown Rating Scales
o http://www.drthomasebrown.com/assess_tools/index.html
Child Behavior Checklist
o Categorizes data into 6 categories: withdrawn, somatic complaints,
anxious/depressed, social problems, though problems, attention
problems, delinquent behavior, and aggressive behavior and
compares to normative values
o http://www.aseba.org/forms/schoolagecbcl.pdf
Connors Scales
o Forms for parents, teachers, and for adolescents to self-evaluate
o Short (<30 questions, 4 point Likert scale) and long (60-90 questions,
3 point Likert scale) version forms available
o One of the most popular, has been around for 30+ years
o Appropriate for children ages 3-17
o IOWA (Inattention/Overactivity with Aggression) version for teachers
o Proven reliability and clinical utility
SNAP-IV-C Rating Scale
o One form, can be completed by parents, teachers or other caregivers
o 80 questions
Shorter, 18 question form: http://www.adhd.net
o Includes questions that may assess for oppositional defiant disorder,
conduct disorder, intermittent explosive disorder, tourettes disorder,
stereotypic movement disorder, OCD, generalized anxiety disorder,
narcolepsy, manic episodes, major depressive episodes, and
dysthymic disorder

Continuity Clinic Curriculum

Lucile Packard Childrens Hospital
ADHD Testing
o Contains 10 questions from the SKAMP to assess or classroom
manifestations of inattention, hyperactivity and impulsivity
(estimates severity of impairment in classroom)
o Not as recommended by AAP because is a more general assessment,
not as specific to ADHD
o http://www.chironeuroindy.com/PDF/assesstools_snap-iv-C-6160C80tems.pdf
Vanderbilt Assessment Scale
o Separate parent and teacher assessment forms, 43-55 questions each
o Two parts per form: symptom assessment and impairment of
performance at home/school/social settings
o Can also screen for oppositional defiant disorder, conduct disorder,
anxiety and depression
o Proven reliability and clinical utility
o http://www.brightfutures.org/mentalhealth/pdf/professionals/bridg
es/adhd.pdf
o Parent form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/03VanAssesScaleParentInfor.pdf
o Teacher form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/04VanAssesScaleTeachInfor.pdf
o Parent follow up form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/05VanFollowUpParentInfor.pdf
o Teacher follow up form:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/06VanAssessFollowUpTeachInfor.pdf
o Provider scoring instructions:
http://www.psychiatry24x7.com/content/backgrounders/psychiatry
24x7-nd.emea_com/07ScoringInstructions.pdf

General Problems with Scales

May be gender biased (boys diagnosed more often than girls)
Not created for children under age 4 or for adults
May be culturally biased
May not be good measures of developmental variations in expression of ADHD
Diagnosis may be missed when childs behaviors do not conform to DSM IV
criteria
Scales differ in normative data (ie age ranges) make sure scale range correlates
to patient age/race/sex if possible
Limited data to evaluate whether scales can be repeated to be used to monitor
medication effectiveness
Validity of scales for screening for comorbid conditions not as well established

Continuity Clinic Curriculum

Lucile Packard Childrens Hospital
ADHD Testing
Scales alone do not confirm a diagnosis must use clinical judgment to integrate
scales into entire clinical assessment

Peer Reviewed by David Bergman, MD 2011

References/Resources
Peds in Review 2003:
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
ll/24/3/92?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=ADHD+testing&
searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
Peds in Review 2010:
http://pedsinreview.aappublications.org.laneproxy.stanford.edu/cgi/content/fu
ll/31/2/56?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=adhd&searchid
=1&FIRSTINDEX=10&sortspec=relevance&resourcetype=HWCIT
Connors, CK. Clinical use of Rating Scales in diagnosis and treatment of ADHD.
Pediatric Clinics of North America. Oct 1999.
http://www.mdconsult.com.laneproxy.stanford.edu/das/article/body/2257920
514/jorg=journal&source=MI&sp=10952538&sid=1080298365/N/153917/1.htm
l?issn=0031-3955
AACAP Practice Parameters:
http://dbptraining.stanford.edu/4_readings/readingdocs/Practice%20paramet
er%20for%20the%20assessment%20and%20treatment%20of%20children%2
0adoles%20ADD.pdf
Cordes M, McLaughlin, TF. Attention Deficit Hyperactivity Disorder and Rating
Scales with a Brief Review of the Connors Teacher Rating Scale (1998).
International Journal of Special Education, 2004. Vol 19 (2).
Auerbach article on the Child Behavior Checklist:
http://ch.missouri.edu/Education/STUDENTSYLLABUS/Articles/behavioral%2
0checklist.pdf