Attention-Deficit Hyperactivity Disorder (ADHD) is one of the psychiatric disorders affected children of all ages. Thus, many are misdiagnosed by practitioners who see unusual behavior, anxiety, and stress as possible symptoms of ADHD. Neither method is intended to be used as the sole means of assessment. In keeping with the multiperson, multimethod, developmental approach to child assessment, the combined use of interviews, observations, and other assessment strategies will be most productive in obtaining a comprehensive evaluation of the child and family. Moreover, efforts to develop interview and observation methodologies that are culturally sensitive and appropriate represent an important and essential direction for the future.
The main problems of misdiagnosis are caused by inadequate standards and symptoms applied to children with ADHD. For instance, in the infancy periods, the velocity of neuromaturational and behavioral change is greater than at any other time. Subsequent development of children exposed to pre-, peri-, and postnatal problems is the result of an interchange among normal developmental processes, recovery of function (either physical or neurodevelopmental), and environmental influences (Ambrosini, 1988).
Psychologists who work with neonates and infants are advised to consider several general guidelines. First is the concept of risk. Risk refers to influences that have a potentially negative effect on the infant’s development. In many cases, when a child shows anxiety or shyness he/she can be treated with ADHD.
Second, behavioral/developmental, medical/biologic, and environmental/psychosocial risk and protective factors should be considered routinely when working with infants. Whereas risk factors are associated with developmental and mental health vulnerability, protective factors, in contrast, refer to attributes or situations that would enhance the infant’s resilience or resistance to negative influences. The balance between risk and protective factors and the magnitude of each will determine the infant’s ultimate level of adaptation (Ambrosini, 1988). For example, the infant’s intrinsic biologic vulnerability can be moderated to some degree by the influence of extrinsic (environmental) protective factors (Does Iron Deficiency Cause ADHD 2005).
With the increasing popularity of attention-deficit/ hyperactivity disorder, a frequent differential diagnostic question posed to child clinicians is whether the behavioral disturbance is due to deficits in attention or the presence of anxiety. It is often assumed by non-clinicians that these conditions are mutually exclusive, whereas, in fact, they may co-occur with considerable frequency. In fact, comorbidity, in general, is more common than not in psychopathological conditions in childhood.
There is some indication that children with comorbid anxiety disorder and ADHD may be less impulsive and more overactive than children with only the ADHD diagnosis and less likely to develop a conduct disorder (. Indeed, it has been suggested that children with comorbid ADHD and anxiety disorder and comorbid ADHD and aggressive conduct disorder represent unique subtypes with different etiologies and developmental courses (Flatow, n.d.).
Investigators are focusing increasing attention on the observation that individuals who manifest psychopathological conditions often possess preexisting tendencies or traits for those particular conditions, especially when exposed to certain experiences and environmental stimuli.
Shyness is depicted as feelings of discomfort in social situations but not nonsocial situations, whereas behavioral inhibition reflects a propensity to react with inhibition to both social and nonsocial novel situations. Infants and children with behavioral inhibition are described as being wary around unfamiliar people, excessively timid in situations that contain the risk of harm, and highly cautious in situations that involve the risk of failure. It has been estimated that up to 10% to 15% of White American children are born with a behavioral predisposition toward irritability as infants, shyness, and fearfulness as toddlers, and cautiousness and introversion at school age (Peacock, 2002; Ambrosini, 1988).
Ambrosini’s (1988) studies classified as either behaviorally inhibited or uninhibited reveal dramatic behavioral consistencies several years later, suggesting that a child’s tendency to approach or withdraw from novelty is an enduring temperamental trait that predisposes them toward certain pathological conditions. Indeed, the inhibited children in their study manifested such difficulties as avoidant behavior on attending school as well as frequent symptoms consistent with separation anxiety (Ambrosini, 1988). These traits may predict such specific behaviors as presurgical distress. A difficult temperament should not be considered ADHD.
However, the difficult child is more prone to behavior problems in early and middle childhood, with 70% of these children from the NYLS manifesting behavioral problems before 10 years of age (Peacock, 2002). These infants and toddlers require more effort by parents to deal with tantrums, crying, and oppositional behavior, and a difficult temperament in conjunction with other child risk factors such as developmental delays, language disorders, or physical handicaps may be particularly demanding on parents. Parents react by feeling inadequate, intimidated, threatened, and anxious, or by resenting and blaming the infant.
Slow-to warm-up infants are often stressed by parental insistence that they adapt quickly to a new situation (e.g., daycare), food, or a peer play activity. When an infant with an easy temperament develops a behavioral concern, the clinician should look to situational stresses or parenting issues as causative factors. Particular emphasis has been placed on infants and young children with behavioral inhibition. Moreover, investigations of the relationship between temperament and attachment (see below) have suggested an association between the pattern of mother-infant attachment and the infant’s biological responses to stress. (Vatz and Weinberg, 1995).
Emotional and behavioral concerns in infancy range from the obvious (failure to thrive, pervasive developmental disorder to the very subtle (excessive irritability). However, in infancy and early childhood, there are many adverse psychological symptoms or situations of a more “subclinical” nature that do not meet the criteria for a specific mental disorder. Developmental variations are within the range of expected behaviors and can be handled with reassurance. The second category involves behaviors that are sufficiently problematic as to disrupt the infant’s functioning within the family, yet are not severe enough to warrant the diagnosis of a mental disorder.
Disorders, constituting the last category, are more extreme and warrant referral to mental health clinicians (Ambrosini, 1988). The former is constitutionally and maturational based sensory, sensorimotor, or organizational processing problems that produce difficulties in regulating behavior (hypersensitive, underreaction, motorically disorganized, impulsive). Multisystem developmental disorders provide an alternative to the diagnosis of pervasive developmental disorders for youngsters who have significant problems relating to and significant motor and sensory processing difficulties, yet who maintain some potential for closeness (Peacock, 2002).
Development is dynamic, and as such, the infant is constantly rearranging and reorganizing cognitively, behaviorally, and emotionally in a transactional matrix. Risk factors that may disrupt development can be of an established, biological, or environmental nature. Conversely, protective factors may be infant- and/ or environmentally based. The vast numbers of permutations and combinations of these risk and protective influences, superimposed on a given infant’s constitutional and behavioral predispositions, help to explain individuality. Early identification of an infant’s problems and strengths is critical to afford comprehensive intervention and maximize development (Vatz and Weinberg 1995).
Following Ambrosini’s (1988) dimensional diagnosis allows one to describe multiple behavior patterns for any individual child. Dimensional systems do not lead to a statement that a child has a particular disorder but rather describe the degree to which one or more behavioral characteristics are present. Cutoff scores are used to determine the clinical significance of specific behaviors for different age groups.
Although normative developmental considerations can more readily be taken into account with dimensional systems, they generally do not address important relational and cross-situational issues, the length of time the behavior has occurred, or how the behavior impairs functioning. His is an important cautionary note, particularly with preschool children who exhibit a significant number of problem behaviors that are age-appropriate and transient (Vatz and Weinberg 1997). Although the authors indicate that they have little data to recommend either the categorical or dimensional approach over the other, it appears that clinical judgment is enhanced when information is gathered through multiple methods and sources and across situations.
Overall, prevalence studies indicate that behavior problems are relatively common in the preschool years and are most often associated with a particular developmental period. Thus, issues with toileting, sleep, and eating are more likely to occur during the first three years, and struggles for independence and autonomy at age 3 often result in increased disobedience and defiance (Ambrosini, 1988). For most children, these problems are transient and decrease in meaningful and predictable ways with development, yet some appear to persist and may even worsen. Understanding the factors that predict increased severity is important for the assessment and treatment of these children.
Assessment of problems in the preschool years is a complex task. To begin the process, it is important to have knowledge of the developmental processes and what would be expected of the “typically” developing child. This, in combination with knowledge of risk and protective factors, sets the stage for developing hypotheses about the origins of the behavior of concern and planning intervention strategies. Most notably, the authors caution that many existing self-report measures of anxiety and depression may be outdated, thus accounting for the high correlation between measures of different constructs. As such, items should be generated that specifically tap empirically established factors of negative affect and its components (Vatz and Weinberg 1995).
Ethnic and cultural diversity issues are especially important to consider when evaluating children’s problems using observations or any other means of assessment. For example, ADHD is now one of the most commonly diagnosed childhood disorders, yet there are serious concerns regarding the assessment of ADHD among culturally diverse students. Recently, this concern has led investigators to examine various behavior rating scales used to evaluate ADHD in culturally diverse youth. Similar work with other childhood problems and with other assessment methods, including behavioral observations, is very much needed (Timimi and Taylor 2004).
The goal is to detect children whose development is at risk and who otherwise would not be identified. Screening is indicative and flags children who need further assessment. Assessment is a more detailed evaluation or estimation of development, the end product being a clinical decision as to what intervention would be appropriate to facilitate development. As assessment is conclusive and incorporates data from multiple sources, it results in a definitive “diagnosis.
However, screening techniques are often misapplied, as they are used in situations where the clinician already suspects a developmental delay and simply uses the screening test to verify these concerns. Moreover, in many pediatric offices, patient volume, time, and reimbursement issues make screening difficult. Therefore, the concept of prescreening has been forwarded (Timimi and Taylor 2004). Prescreening is a two-step process in which the parent or caretaker completes a questionnaire or developmental surveys such as the Parents’ Evaluation of Developmental Status (Glascoe, 1997), the Ages and Stages Questionnaire (Bricker, Squires, & Mounts, 1995), or the Child Developmental Inventories (Ireton, 1992).
Prescreening is estimated to have sensitivity and specificity figures in the 75% to 80% range and is quite efficient, given that 25% of infants will fail a screening test, and of these, approximately 10% will have a confirmed developmental delay. The terms sensitivity and specificity are heavily emphasized in developmental screening and assessment (Ambrosini, 1988). The former (true positive rate) measures the proportion of babies with a developmental problem who are also identified by the test. Specificity (true negative rate) measures the proportion of infants who have no developmental problems and whom the test identifies as normal.
However, because there are no true gold standards in developmental screening and assessment with the screening test being compared to a reference test, the terms positivity and negativity are more appropriate (Vatz and Weinberg 1995).
In sum, many children are diagnosed with ADHD in order to excuse their behavior and possible psychological problems such as shyness or anxiety. It is not the individual developmental function nor ability per se that is most important in the evaluation of infants. An individual function such as visual perception of a pellet is not in itself very predictive of later cognitive functioning. There is growing dissatisfaction with the use of formative assessments in ADHD.
These tests are designed to discriminate among children on a linear scale, by comparing the child’s performance to a reference group on which the test was normed, and are administered on a single occasion. The end result of formative assessment is a diagnosis. Critics of this approach endorse a “new vision” and emphasize that intervention strategies cannot be readily extrapolated from this procedure. Because of the natural linkage between assessment and intervention, emphasis is placed on assessments that rely on criterion-referenced (proportion of skills in an area that the infant has mastered) and curriculum-based (specific objectives to be achieved) approaches.
In the former, the score the child obtains measuring a developmental domain criterion (e.g., language, gross motor skills) indicates the proportion of the domain the child has mastered. The individual items reflect specific levels of competence that are arranged on a developmental sequence or continuum. The curriculum-based assessment focuses less on developmental hierarchies and more on specific objectives or skills that are to be achieved by the child.
These techniques provide an absolute criterion against which a child’s performance can be evaluated (level of mastery-based on achievement of a specified number of successes) and involve observation by a team of evaluators on multiple occasions. Rather than have testing occur in an office or clinic, evaluation has moved into more familiar, naturalistic surroundings such as homes, child care locations, and intervention programs.
References
Ambrosini, P.J. (1988). Schedule for Affective Disorders and Schizophrenia for School-Aged Children–Present version. Unpublished manuscript.
Does Iron Deficiency Cause ADHD. (2005). Pediatric Alert.
Flatow, I. (n.d.). Analysis: Prescribing drugs for attention deficit hyperactivity disorder in very young children, and whether medications are prescribed prematurely. Talk of the Nation/Science Friday (NPR).
Peacock, J. (2002). Chapter One: What Is ADD and ADHD?. (p. 4). Capstone Press.
Peacock, J. (2002). Chapter Two: Causes of ADHD.. (p. 11). Capstone Press.
Vatz, R., & Weinberg, L. (1995). Overreacting to attention deficit disorder. USA Today Magazine, 123(2), 84.
Vatz, R., & Weinberg, L. (1997). How accurate is media coverage of attention deficit disorder?. USA Today Magazine, 126(2), 76.
Timimi, S., Taylor, E. (2004). ADHD is best understood as a cultural construct. British Journal of Psychotherapy, 184 (8-9), p. 18.