CLINICAL USE OF RATING SCALES IN DIAGNOSIS AND TREATMENT OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

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The syndrome we now refer to as attention-deficit/hyperactivity disorder (ADHD) had its origins in pediatric practice, beginning with the seminal observations of George Still,32 a British pediatrician and honorary member of the American Academy of Pediatrics. We currently recognize ADHD as a developmental disorder that begins early in life and continues into adulthood. A great deal of empirical data have been accumulated regarding this syndrome, both with respect to reliability and validity of diagnosis as well as optimal treatment practices. Clinical practice regarding ADHD has evolved into a mature art. However, there are still significant difficulties in applying this knowledge in a consistent manner, particularly in primary care settings.

Section snippets

PROBLEMS IN DIAGNOSIS

A diagnosis of ADHD currently requires that five diagnostic criteria be met2:

  • 1

    Presence of either six symptoms of inattention or six symptoms of hyperactivity-impulsivity, which have persisted for at least 6 months, “to a degree that is maladaptive and inconsistent with developmental level.”

  • 2

    Presence of some symptoms that caused impairment before age 7 years.

  • 3

    Presence of some impairment from symptoms in two or more settings (e.g., school or work and at home).

  • 4

    Clear evidence of clinically

PROBLEMS IN TREATMENT

The NIMH Consensus Development Conference also highlighted wide variations in treatment practices, particularly in the way stimulant drugs are prescribed. Specifically mentioned were concerns that adequate measures of treatment response at both home and school are used infrequently. One of the consequences is that drugs are often both overprescribed and underprescribed. Evidence comes from recent epidemiologic studies that show that many children who fail to meet diagnostic criteria are being

METHODOLOGY OF RATING SCALES

It is useful to point out a few aspects of the methodology by which rating scales are created so that clinicians understand what to expect from these scales. This brief excursion attempts to convey the point that rating scales are not just soft impressions or subjective guesses, rather, that their careful methodology meets the same standards of rigor found in laboratory tests. Particular attention is applied to selecting items for the scale and the use of statistical methods to develop the

DESCRIPTION OF NEW SCALES

The most recent versions of the Conners' Rating Scales were planned to accomplish several aims for enhancing clinical practice:

  • 1

    To provide a set of longer child rating scales for ages 3 to 17, appropriate for comprehensive initial evaluation. These scales cover a broad range of psychopathology for the most important comorbid diagnoses for ADHD (anxiety, oppositional defiant/conduct, obsessional, and somatizing). They are most useful as part of an initial or extended evaluation.

  • 2

    To provide

Initial Evaluation

This section describes typical clinical practice for evaluating ADHD in a specialty clinic. The procedures my colleagues and I have developed are meant to be comprehensive as well as brief and practical enough to satisfy the current managed care environment. Typically, for a new case referred for possible ADHD, we mail out copies of the parent and teacher long forms and ask the parent to return those before the first visit. These forms can be scored readily by hand using a new patented “Quik

DIAGNOSTIC UTILITY OF THE RATING SCALES

Clinicians wonder why one should use rating scales at all if one must still carry out a sometimes tedious diagnostic interview to cover the relevant information needed for accurate diagnosis. As in all of medicine, specialized measures for ADHD are no substitute for clinical intuition, experience, or history taking. Rating scales are, however, helpful adjuncts to the diagnostic and management process. The clinical use of the scales has been examined carefully in terms of a number of indices

OTHER RATING SCALES

A variety of rating scales has appeared on the scene, although few innovations in basic content or methodology are evident. Wide variation in the scope and precision of the normative data is evident among the various scales. The reader is referred to more extensive reviews in major texts.5, 18 Table 3 briefly describes some of the scales currently used for ADHD and related conditions.

CONCLUSION

Rating scales capture a lot of information at a relatively low cost and are of particular value in pediatric settings, in which patient volume is high and there is limited time available for making crucial diagnostic and treatment decisions. They identify the expectations for children at a given age and gender for most behavioral problems encountered in practice. Rating scales provide an important empirical complement to the sketchy categorical medical diagnostic schema of DSM-IV. Used

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    Address reprint requests to C. Keith Conners, PhD, Attention Deficit Program, DUMC, Box 3431, Durham, NC 27710, e-mail: [email protected]

    *

    Duke University Medical Center, Durham, North Carolina

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