ADD DIAGNOSTIC CRITERIA Deborah S. McCacher How does one recognize ADD in a child and discern ADD from the high-end energy level of a bright, active, healthy five-year-old preschooler? What leads you as a doctor to investigate whether a child is potentially ADD? What kinds of tests are there (both psychological and physiological) to diagnose the condition? Not a naive question at all, and a difficul;t one to answer. To recognize ADD in a child, the first step ius to de3termine if there is a problem, that is there must be some impairment. I kids that means, school or family, sometimes socially. If they have have a problem, the next step is to determine if there is a pattern to the problem, i.e. a description, course etc which fits something we know something about. ADD is one of many disorders or problems which can account for a describe a child's difficulties (there is a bit of a tautology here). There is no "test" for ADHD, however a proper evaluation should include a thorough assessment, which means getting information from several individuals who know the child,as well as tests under standardized conditions. Psychological tests are helpful in assessing frequent associated problems , such as learning disabilities or depression; medical tests are helpful in identifying potentil mediating factors (i.e. hearing deficits, seizures-lead levels), and behavior ratings are helpful in quantifying severity from different perspectives. The "gold standard" in a multi, meaning several disciplines involvesd evaluation which assesses several domains. In a five year old, it is difficult, it's even harder in a four year old, and almost impossible to diagnose ADD in a three year old.Hope this helps. I couldn't agree more, especially about the following: In a five year old, it is difficult, it's even harder in a four year old, and almost impossible to diagnose ADD in a three year old. The younger the child is, the more I look for other issues, though I keep in mind that (in retrospect) most parents with ADD child feel problems began early on. In most cases, some sort of training in parenting skills is helpful, and after that needs vary. I strongly discourage meds for children under 4, except in exceptional cases, and I don't consider them a first line treatment in children 4 to 5, or even 6 years old. Several years ago, I looked at the relationship between age of referral and liklihood of having ADHD. CHildren a under 5 had a much higher prevalence of other disorders, overall 60% of those referrred to my ADHD clinic had ADHD, but for under age five it was about 15% of the total, with common diagnosis being PDD, reactive attachment disorder, mr, or ODD. Stimulant medicatio in this age group has been underwhelming, although we are probably dealing with a more severe problem with an earlier onset. Have you had much success with clonidine? I also find parent training helpfull with the majority of these cases, although it only goes so far-- and generalization is week outside the home. I agree with you about ADHD in younger children, though your incidence of ADHD under 5 is smaller than what I've personally seen. In my case, the reason may be referral bias -- I have always worked in settings where I was the 2nd or 3rd or 4th person to see the child, usually after non-medical interventions had already been tried and failed. I would guess your results are more applicable to a primary care/first encounter setting. With the group of kids I've seen, stimulants have been helpful, though I tend to start at 2.5 mg of Ritalin twice a day and increase slowly, following ratings from parents and preschool/kindergarten teachers. A lot of the younger kids seem to have significant anxiety symptoms, too, so I don't hesitate to try tricyclic antidepressants. I have had no problems with them, and some success. An AACAP ad hoc committee recently completed a reassuring study of the safety issues, I think has submitted it to NEJM. I went over this and the literature for a review I did recently, and what I have seen doesn't convince me the TCAs are more/less dangerous than any other systemic medication in child psychiatry. I haven't used clonidine much, and when I have I have been unimpressed. Sedation is a big problem, and my patients haven't been able to get over it completely -- when it decreases they seem to need an increased dose for ADD symptoms, and the cycle starts over. Also, dosing is difficult even with the patch -- which irritates skin terribly in some cases. Clonidine also has potential for cardiovascular side effects, so monitoring it isn't much better than TCAs. Mostly I reserve it for TS patients whose tics need treatment, and who have troublesome ADD. Even in those cases, I haven't been very satisfied with the responses. I agree parental skills training only goes so far. The other problem is that some people pick up one set of methods and have success with it, but fail to adjust as their child grows older and needs change. Sometimes "retraining" or "refresher" course helps with this. I also use several tapes to help with this, especially if parents say they don't have time for a class. Faber and Mazlish (sp?) have a couple of good ones, including version of "How to Talk so Kids will listen, and Listen so Kids will talk." No need to feel the least bit naive. Some medical fields and some traits are very well understood, but ADD isn't one of them. Rummage around here, reading the messages of the past couple of days -- there have been some very good pointers to specific resources. Let me add my position, Deborah. I'm a child psychiatrist who works with schools. I get to see children in their classroom. It's pretty easy to see who are the high-end energy students and who are the hyperactive ones that are disordered. When I'm evaluating one student, I can often pick another out who will probably be referred later. What traits do you see in a child that gives you the clues? Starting with the basics, the triad of inattention, impulsivity and hyperactivity are the things that I notice, Kari. Sometimes I notice the child sitting quietly in the corner, not paying attention, as well. But it's usually the hyperactive students who are referred and I never see the one in the corner for a psychiatric evaluation. The number of tic disorders I see when evaluating folks as possible TS is startling. The number of PARENTS of TS kids, who themselves have TS and haven't a clue ---- Does, though, make me wonder every time I rub my nose or clear my throat. There's also an aura of sorts that the patients seem very adept at picking up on. My ten-year-old son, Karl, has diagnosed at least three other TS kids: "Mrs. Jones, did you know that Tommy has at least three motor tics and five vocal tics? I think he might have Tourette's!" "Gee, Mrs. Jones, why'd you grimace like that?" On at least one of those occasions, it was a kid who was being severely disciplined for actions that turned out to be motor tics and compulsions/impulsions.....Haldol worked better than spankings, it turned out. Do you know if there are any reports of TD (tardive dyskinesia) with haldol used for TS. I know the doses used are very low, but on the other hand a life time of exposure can predispose to TD. I raise the issue because now that respiradone is available, and is said to be like haldol, it may be a prefered alternative. PS respiradone is said to not cause TD. Most of what I've read about TD with Haldol is couched in words like "appears to be uncommon in low doses, such as those used for tic disorders." Nobody seems to use really flat-footed phraseology, like "has never been reported with..." I know that some practitioners use pimozide in preference to Haldol for that reason, especially if a phenothiazine or similar drug is also in the mix as part of the polypharmacy. Let me add my position, Deborah. I'm a child psychiatrist who works with schools. I get to see children in their classroom. It's pretty easy to see who are the high-end energy students and who are the hyperactive ones that are disordered. When I'm evaluating one student, I can often pick another out who will probably be referred later. Naivete is no crime; failing to ask an important question is much worse!! I think Mark's answer is a good one. There's a pretty smooth continuum from active to neurobehaviorally disordered, with a healthy gray area. Some folks are even directing self-help materials toward the gray area! There are fairly well established criteria for making the diagnosis of ADD, but they are there to make the terminology consistent rather than to define individual children. Use them with caution and with an appreciation that diagnoses are helpful descriptors rather than infallible and unalterable pronouncements from the Almighty. As Mark pointed out, you start to consider a neurobehavioral disorder when the child's unusual features become striking enough to be a problem. You try to evaluate the manifestations as objectively as possible, and you re-evaluate periodically (because manifestations change over time). And if the concern for neurobehavioral disorder becomes substantial, the evaluation should be done by someone knowledgeable about these disorders --- usually a pediatric neurologist, child psychiatrist or child psychologist who works with them a lot.....ideally, a team of all three, with perhaps a neurobehavioralist/neuropsychologist thrown in.