Steven M. Nordby
October 1994
Mass media in the United States seemed to center faddish attention on Attention Deficit Hyperactivity Disorder (ADHD) following the American Psychiatric Association's (APA) 1994 publication of revised ADHD criteria in The Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV). However, recent research findings have not received wide media attention. This paper examines the DSM-IV criteria and review recent research and recommendations regarding the identification and assessment of ADHD which may be useful to educators.
The earlier DSM-III-R (APA, 1987) criteria were based on expert agreement, but the developers of DSM-IV used empirical studies to cluster ADHD symptoms around inattention and hyperactivity-impulsivity. The presence of six of nine inattentive symptoms and/or six of nine hyperactivity-impulsivity symptoms are needed for diagnosis. Three subtypes of ADHD were thus created:
Additional criteria include onset before age seven, the presence of symptoms in at least two situations, and the ruling out of other psychiatric disorders.
Because the criteria require symptoms to be present for at least six months in multiple settings, diagnosis of ADHD is not possible at a clinical visit, yet medical doctors promote the idea of office diagnosis (see, e.g., Patricelli, 1994). Because of the unreliability and subjectivity of measurement tools, no single objective measure can diagnose ADHD (McBurnett, Lahey, & Pfiffner, 1993). Assessment should include a network of parents and professionals using multiple methods in multiple situations, along with a thorough review of school records (Hunt, 1988; McKinney, Montague, & Hocutt, 1993). Assessment instruments should be used to detect learning disabilities and emotional-behavioral disorders which can co-occur with ADHD (McKinney, et al). Likewise, testing must include sensitivity to other DSM-IV disorders which may co-occur with ADHD, preclude a diagnosis of ADHD, or which need to be considered as alternative explanations before a diagnosis of ADHD is made (DSM-IV). Webb and Latimer (1993) discuss another condition which can complicate ADHD diagnosis: giftedness. Traits of gifted children which may lead to false ADHD diagnosis include off task behavior, less need for sleep, questioning of rules and traditions, power struggles, and resistance to repetitive tasks. Suggestions are made to help differentiate ADHD and giftedness:
Medication may be prescribed during assessment on the basis that "paradoxical" response to central nervous system (CNS) stimulants indicate ADHD. However, Swanson et al. (1993) report that similar responses occur in children and adults with and without ADHD, so response to medication is of no value in diagnosis.
Disorders are social constructs (see, e.g., Berger & Luckman, 1967; Goffman, 1962; Szasz, 1960), and Reid, Maag, and Vasa (1993) use this idea to question the validity of ADHD as a differentially diagnosable and identifiable disorder. Whalen (1989, cited in Reid et al.) points out that at some ages, 50% of children are seen by adults as hyperactive. Koriath, Gualtieri, Van Bourgondien, Quade, and Werry, (1985, cited in Reid et al.) find that demographic information more accurately classified children with conduct disorders, emotional disturbance and hyperactivity than a battery of measures purported to be diagnostic of ADHD. Rutter (1983, cited in Reid et al.) reports that ADHD is 50 times more likely to be diagnosed in the U.S. than in Britain or France. Response to CNS medication provides a tautological explanation for the existence of ADHD, and that "[t]he availability of the ADHD label may both enable and encourage diagnosis for difficult children" (Reid et al., p. 204).
Identification and assessment of ADHD remains complex. Parents and teachers should carefully consider social variables and screen for giftedness before recommending assessment for ADHD. The assessment process must consider possible preemptory and co-occurring disorders. Regardless of assessment outcomes, parents and teachers "should address any co-occurring learning disabilities, language differences, talent/giftedness, or retardation before they provide accommodations for ADHD" (Zentall, 1993, p. 150).
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