Tuesday, February 26, 2013

ADHD - Making the Diagnosis

We need to proceed to accurately describe the two major barriers obstructing our path from chief complaint of school and behavioral problems to valid diagnosis and effective treatment.
     The first barrier to diagnosis is the pitiful lack of hard scientific evidence.  There are currently no specific physical findings or laboratory tests that we can use to help us diagnosis any behavioral problem such as ADHD, depression, anxiety or obsessive compulsive disorder.  Our vaunted medical problem-solving system that should flow from history, physical and lab test to correct diagnosis fails us miserably.  This not to say that a complete physical examination including a neurological assessment should not be performed on every child with school problems.  Certainly there may be specific labs that we may want to obtain if the physical examination suggests disorders such as anemia, lead poisoning, hyperthyroidism or fetal alcohol syndrome, Such causes of “acquired” ADHD are for the most part very rare.  Medical research is daily adding to our knowledge concerning the genetics, neuroanatomy and physiology (structure and function of the brain) associated with ADHD.  Although it is encouraging and enlightening to discover evidence supporting the existence of a brain-based disorder, none of them separately or together can be used as a gold standard for the official stamp of approval for diagnosing ADHD.  The bad news for us all is that there is no test for ADHD.
     What to do?  Actually this is a dilemma that occurs more often in medicine than physicians would like to admit.  Life and death treatment decisions must sometimes be based on our best guesses at underlying causes when there is limited supportive physical or laboratory evidence.  Asthma, for example, is not diagnosed by any specific test or sign but rather on the history that the parent and child describe.  Our confidence in our diagnosis is increased if we are able to add findings of audible wheezes heard while listening to the lungs and flattened diaphragms or hyperinflated lungs seen on chest X ray films.  We fare better in the case of the strep throat because current technology provides a rapid, reliable test for the presence of the bacteria.   Not too long ago, however, we had to wait 24 to 48 hours for our bacterial colonies on the throat swab to grow on blood agar plates incubated at 100 degrees and show a zone of growth inhibition around the bacitracin discs to prove the presence of beta-hemolytic Group A strep.  Despite these limitations we were able to immediately correctly diagnose and treat patients for strep in the “old days”. We simply had to work harder.  Without the weight of the positive strep test to confirm the diagnosis we had to gather more information to tip the balance one way or the other.  We were forced to expand our history, increase our physical findings and augment our laboratory tests to be as certain as we could be before risking definitive treatment.
     The conscientious physician would ask a lot more questions after “Does your throat hurt?”.  For instance “Do you have a headache or stomach ache? (common with strep).  How about cold symptoms or cough? (rarely associated with strep). Have you ever had an illness like this before?  Do you know what strep feels like? Have there been strep infections in your class recently?  Has anyone else been ill at home? In the same way we would look for more positive evidence from our physical examination.  We would not simply note the red throat, but we would look more closely for white or yellow exudates on the tonsils, tiny red spots or petechial rash on the roof of the mouth or a strawberry appearance on the surface of the tongue, We would palpate the neck at the angle of the jaw for the presence of enlarged and tender lymph nodes.  We would check the abdomen to see if the liver and spleen were enlarged – signs more compatible with mononucleosis.  A severely ill child with strep-associated complication of rheumatic fever might have warm swollen joints, subcutaneous nodules on the arms, unusual choreioform movements of the extremities and a heart murmur.  And although we did not have the new rapid strep test , we could order stat some more general tests that are often positive in patients with bacterial infections such as a complete blood cell count (CBC) with differential white cell percentages, erythrocyte sedimentation rates or C-reactive protein levels. 
      None of these findings prove that strep is present and causing the illness but the weight of the evidence improves the odds in our favor.  Lawyers use this strategy of building a case when they defend their client or prosecute a defendant.  This painstaking process done in partnership with families is the only sure way to develop enough data to tip the diagnostic balance in our favor and lead us to effective therapy and successful future follow-up care.  We will use this approach to navigate around the two major barriers or roadblocks on our journey to solve our children’s school and behavioral problems. Those barriers of uncertainty and complexity will next on our agenda.


  1. Have you considered that ADHD might have an environmental cause? Schools are organizations primarily run by women and they have created an environment only suitable for girls. Boys behavior is forbidden in school. Instead boys are held down and forced to sit still for longer than they can stand. Boys are not allowed to read books that would interest boys. Boys are not allowed rough and tumble play, which is an important part of being a boy. Boys are not allowed to right about things that are interesting to boys. No wonder they can't sit still, are not interested in reading or writing, and get in trouble on the playground. Of course there is a solution to boys being boys--we can pump them full of drugs and turn them into nice little girls.

    1. School is jail for the innocent. It's odd how people are surprised when the inmates act out.


    2. You make an excellent point. This is one reason why both the academic and social success of our child at school often depends on who the teacher is and how she (or he) runs her classroom.
      Of course some girls may complain that we overgenerlize. Equality of the sexes may apply even to 1st grade where some girls may prefer the rough and tumble play and reading and writing interests that most boys enjoy. Certainly since my grade school experience (long ago) there has been considerable progress towards providing an individualized educational experience for all children. Laws are in place that parents can take advantage of to ensure that their unique child has such an IEP.
      There is no question that there are multiple pathways to ADHD with both genetic and experiential risk factors. Joel Nigg in his book "What Causes ADHD" includes exposure to prenatal smoking, alcohol,lead, food additives, allergies, sugar, caffeine, organophosphate pesticides and other evironmental toxins and even television and video games.
      The question for us as parents is often not so much what caused the problem as what do we do about it. Parents are in the best position to make these decisions about how to create the optimal learning environment possible for their unique child. To me it would be just as big a mistake to not consider the possiblity that a trial of medication might be reasonable once all our educational and behavioral strategies are in place.
      Our ultimate goal is for our boy or girl to simply be themselves in these troublesome but real school or social settings that they have to face througout their life.
      Thanks for your thoughtful comments.