        
                           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.
        
