Assessing Attention-Deficit/Hyperactivity Disorder (Topics in Social Psychiatry)

Over the past two decades, the assessment of Attention-Deficit/Hyperactivity Disorder (AD/HD) has evolved into a sophisticated balance of science and clinical judgement essential for arriving at reliable and valid diagnostic de- sions. Because of the precarious mix of clinical and empirical skill needed to evaluate children with this disorder, diagnostic practice in this area has been found wanting by many critics. In fact, a 1998 National Institutes of Health consensus panel concluded that “existing diagnostic treatment practices … point to the need for improved awareness by the health service sector conce- ing an appropriate assessment, treatment, and follow-up. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance” (p. 21). Drs. Arthur D. Anastopoulos and Terri L. Shelton have designed a book that addresses this need. A number of themes are highlighted throughout the text. Perhaps the most important is that the assessment guidelines set forth in this book represent a balance between science and practice. The authors account for the realities of clinical practice in an age of managed care while challenging clinicians to heed the lessons of empirical research. Although the use of empirically based asse- ment procedures may at times fly in the face of cost constraints (e. g. , systematic evaluation of medication effects), the authors present a strong argument for them. Further, they call upon their vast clinical experience to provide concrete suggestions for translating research findings into effective evaluations.

Knowledge about attention-deficit-hyperactivity disorder (ADHD) expands by the day, thanks to the efforts of many academic investigators and research centers. However, there is a plethora of books by ``experts'' with dubious credentials and experience. Therefore, we are happy to report that Assessing Attention-Deficit/Hyperactivity Disorder by Anastopoulos and Shelton makes a major contribution to a field awash in myths, critics, skeptics, pariahs, personal agendas, and pseudoscience. With so many books aimed at the lowest common denominator, this work stands far above the crowd.

The book includes rigorously studied and field-tested methods and pragmatic suggestions on how to diagnose and assess ADHD. After a clear presentation of the diagnostic criteria, primary and secondary features, and implications for assessment, the book reviews the procedures and methods for establishing the diagnosis of ADHD. Other sections focus on treatment planning and feedback for parents and professionals. The last chapter addresses the measurement of treatment outcome.

Why do we recommend this book? The authors have immense clinical experience and an excellent track record of publication in academic journals. Consequently, the authors' views are based on a vast, data-driven, peer-reviewed literature. The book is thorough to a fault and provides critical analyses of the measures it endorses. Clinical vignettes are well chosen and keep the work from reading like a textbook.

The book is appropriate for academic physicians who are interested in a comprehensive reference work as well as primary care providers who are asked to evaluate patients for ADHD on a regular basis. The diagrams and tables are excellent, and the organization of the book makes information easy to find. Finally, in discussing the myriad scales and interviews available as aids in diagnosis, the authors address the advantages and disadvantages of each.

The work keeps the focus on the definition of the disorder found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; Washington, D.C.: American Psychiatric Association, 1994). The authors break down the often vague criteria of the DSM-IV into domains that can be more objectively quantified and clarify concepts such as developmental deviance and impairment across settings. Guidance is given when conflicting data exist. In truth, the book is much more of a teaching tool about ADHD than the title suggests. One comes away with a much broader view of the assessment of children and adolescents with behavioral difficulties in general.

Readers with backgrounds in pediatrics or those who are not psychologists may get the impression that the evaluation of ADHD requires a multitude of scales, forms, and interviews and many hours to perform. One of the few shortcomings of the book is the lack of a chapter designed specifically for the harried pediatrician in full-time private practice or the family doctor. No guidance is given on the minimal acceptable data needed for a valid assessment to be made in a busy pediatrician's office. Although the book acknowledges the pressures of managed care, a concise section on this issue would have been helpful.

The appendixes are particularly useful, with actual scales often reproduced. The resources appendix, however, is rather sparse, although the text itself refers to other related books. A suggested-reading section broken down into categories for different consumers (e.g., parents, teachers, primary practitioners, pediatricians) would have been welcome. The recently updated practice parameters of the American Academy of Child and Adolescent Psychiatry and similar professional organizations should be cited in future editions.

Another shortcoming of the book is the lack of specifics about the differential diagnosis in the rather anemic section on medical evaluation. More direct advice about when medical testing is appropriate (and inappropriate) would have been useful. Similarly, we found the recommendations for when and whether formal psychometric testing should be undertaken to be vague, although we applaud the authors for addressing this controversial topic. Indeed, to their credit, they clarify the particular and limited value of psychometric tests (i.e., IQ and achievement tests) in the diagnosis of ADHD and highlight the importance of such tests in the identification of the learning problems so often seen in children with the disorder.

ADHD is a common disorder that is occasionally very difficult to diagnose and assess properly. An overwhelming number of tools and instruments are available for use as aids in diagnosis. Anastopoulos and Shelton have made an important contribution by reviewing the existing methods and giving clear guidance. We commend them for taking on such a project and succeeding so admirably. Thanks to this book, more children with ADHD will be identified appropriately and treated properly, and less overdiagnosing or misdiagnosing will occur.

Monique Ernst, M.D., Ph.D.
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