Dr. Weiss is head of the Provincial ADHD Program and clinical professor at the University of British Columbia Children’s and Women’s Health Centre in Vancouver.
Disclosure: Dr. Weiss is a consultant to and receives grant support from Eli Lilly, Janssen, Purdue, and Shire. She also receives grant support from the Canadian Institutes of Health Research.
Please direct all correspondence to: Margaret D Weiss MD PhD, Head, Provincial ADHD Program, Clinical Professor, University of British Columbia, Children’s and Women’s Health Centre, Box 178 , 4500 Oak St, Vancouver, BC V7T 2Y2; Tel: 604-875-2010; Fax: 604-875-2099; E-mail: firstname.lastname@example.org.
All assessments in child psychiatry involve evaluation of particular areas that are not typical in an adult assessment. These include a detailed school history, developmental history, a family interview, and collateral information obtained usually by rating scales from teachers and parents. In certain aspects of adult psychiatry some of these child procedures may also serve to augment the assessment process. Collateral information may be useful in assessment of a patient without insight, such as a patient with hypomania. Rating scales can be useful in identification of severity and follow up of improvement. Broad-based rating scales can be used to assure identification of diagnoses that might be missed by the clinician, or that the patient is reluctant to discuss.
Just as there are procedures that are unique to child psychiatry that may be of benefit to adult psychiatry, there are procedures unique to assessment of attention-deficit/hyperactivity disorder (ADHD) for patients of all ages that may be useful to general child or adult psychiatrists. I will identify the modifications to the assessment process now in place in our Provincial ADHD Program which I think may be of use to those in general practice seeing patients with ADHD, or even to practitioners who are seeing patients with other diagnoses where the same type of issues arise.
In order to improve the efficiency of the assessment process and optimize the time available for discussion of psychosocial care we need to know quickly and as easily as possible Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition1 diagnoses that might have been missed, are comorbid, or represent differential diagnoses. We also need to identify those diagnoses that are apparent to different observers and in different settings. The Kiddie-Schedule for Affective Disorders and Schizophrenia (KSADS) has been used clinically for diagnoses, but the reality of the constrictions on the clinical time we have available is that this is expensive and limited to information from the family. The KSADS and other diagnostic interviews were designed for research. However, the objective of such interviews is as germane in practice as in research. For this reason, the Canadian ADHD Resource Alliance2 has developed a DSM-IV checklist that is completed by the patient and a collateral informant prior to interview. The advantage of this interview is not a substitute to the mental status, but to serve as a guide to the mental status and to assure the clinician remembers what the DSM criteria are as well as to identify important patient/collateral differences.
Since the emergence of the DSM, the diagnostic process has focused heavily on symptoms, and diagnostic criteria. However, patients do not typically present with the chief complaint that they have a DSM disorder. More often, they present with a problem in life functioning where they have difficulty meeting the new expectations of a developmental transition. While Axis V is meant to identify impairment, there is no description of what impairment is—whether it represents absolute impairment or impairment relative to potential—or the settings in which such impairment occurs. Nor on Axis V is there anything like the diagnostic criteria that bring interrater reliability and definition to Axis I.
The reality familiar to all clinicians is that there are patients who have significant diagnoses and function well and patients who have a vague mixture of symptoms from different diagnoses who are severely impaired. For this purpose, prior and post interview from the Weiss Functional Impairment Rating Scale for Self (WFIRS-S: adolescents or adults; Table 1) or WFIR for Parents (Table 2) examines impairment in each of the major domains. Like the Symptom Record, this can be reviewed, discussed with the patient, and used as a cross check on the interview. Within the busy service requirements of the ADHD clinic, psychiatrists do not have the luxury of psychologists to score complex scales. We use the simple rule of rating both symptoms and functional items that are of clinical significance by simply counting those items rated as 2 (pretty much) or 3 (very much) by the patient or informant. While simple, this is much like the Clinical Global Impression–Severity scale in that it gives a precise and clear characterization of the patient’s difficulties.
Some differentials that are more common in ADHD, and therefore a necessary part of the evaluation. However, while they may be more common, they are by no means unique to ADHD. An ADHD assessment requires an evaluation for learning disabilities, sleep, nutrition, bullying, family discipline, and parental frustration. as well as capacity for activities of daily living, school or work success and adaptations, and risk factors such as drug use, driving, or injuries. Evaluation of these differentials and risk factors by self and other report on the Symptom Record and the WFIRS assures that patients receive the clinical attention they deserve.
Perhaps the most important and most often missed aspect of psychiatric assessment is that we are trained to be pathology sensitive. However, from the patient’s point of view identification and reinforcement of strengths and successes sets a tone and models a positive experience. We know very little about what determines long-term outcome apart from obvious advantages such as income, personality, family support, and resilience. However, one aspect of possible prognostic signficance that is likely to be stable over time is the capacity to be compassionate and kind. For example, one of the most widely used child broadband rating scales in the public domain that is age and gender normed, the Strengths and Difficulties Questionnaire,3 has as one of its five subscales “prosocial skills.” Kindness may well be a stable characteristic that when assessed at any age represents a relative strength that can be drawn on to identify to the patient that whatever the symptomatology, her or she is “a good person.” Outcome is not only determined by what is disturbed, but also by what the patient does well. Are they empathic? Do they have a special passion for a skill they do well? Are they psychologically minded?
Apart from inclusion of the whole family, one aspect of child psychiatry that is unique and critical to ADHD is the developmental history. Has their been in utero exposure to nicotine, alcohol, or other drugs? Was their compromise to the newborn during delivery? What was the child’s early temperament? (Temperament tends to be relatively stable, and early memories are of interest.) Were there notable developmental delays, such as clumsiness, indicative of residual developmental coordination disorder? An assessment of ADHD in adults requires the same type of evaluation, since like all neuropsychiatric conditions grown up, early childhood history is critical to establishing a developmental onset of difficulty. Again, while these questions are critical to assessment of ADHD, they may identify early onset prognostic deficits relevant to all adult conditions.
When one asks a child if they have problems paying attention or whether they get into trouble, they often know the answer. When asked if the problem is small, medium, or large, their assessment is also not unlikely to match the results of systematic interview. The point is simple: in adult psychiatry we have the advantage that we interview the patient directly, but nonetheless we may fail to bring into the office those significant others who know the patient in a way he cannot know him or herself. In child psychiatry, we often focus our interview on parent and teacher information. However, the informant who remains critical to an ADHD assessment or any child assessment is the child. A child might say, “I am lazy.” “I only like recess because it is the only part of school that is not boring.” “I have no friends because I am bad.” Assuring that the child remains an important part of the interview provides clues to diagnosis, child insight, and functional impairment. It also tells the clinician the child’s own experience of the impact of his or her disorder on quality of life. Whether this is an assessment of an adult with ADHD and we decide to include the spouse, or an assessment of the child and we interview the caregivers and obtain information from the school, assessment of ADHD is a reminder to all psychiatry that collateral information often brings surprises. In adult psychiatry, where most patients are seen individually for 1 hour, the use of collateral scales has a major role to play that has been under utilized.
The Symptom Record completed by patient and collateral provides a simple, cost effective way to obtain a pathway into the key problems, and an assurance that we won’t miss disorders such as learning problems, sleep, or tics that might otherwise be missed. The Weiss Functional Impairment Rating Scales reminds us that patients came to the interview hoping to be able to do things or meet developmental milestones that have remained closed to them. It reminds the patient and the doctor that even when we get the diagnosis right, if we do not know the problem, the patient will not significantly progress.
ADHD is a neurodevelopmental condition which like many mental health disorders carries through the life cycle, presenting new difficulties as the patient faces new challenges. What we have to learn from assessment of ADHD in adults and children is that a developmental history, collateral information, and assessment of developmental cormorbidities such as sleep or learning have the possibility to deepen and create a better understanding for patients of all ages and all disorders. PP
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. CADDRA. The Canadian Attention Deficit Hyperactivity Disorder Resource Alliance. Available at: www.caddra.ca. Accessed April 12, 2010.
3. SDQ. Information for researchers and professionals about the Strengths & Difficulties Questionnaires. Available at: www.sdqinfo.com. Accessed April 12, 2010.