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"Tested?"
From time to time I will hear that an individual "is being tested for ADHD" as though there were some objective diagnostic tool which allows certain identification of the underlying condition, in the sense that one may be "tested" for Lyme disease.
Would that we had some objective "test"! Such wishful thinking was displayed a few years ago, in an article in the New York Times describing a souped-up continuous performance test as a "biomarker for ADHD." More recently, the press is abuzz about the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System which is proffered as a "test" for ADHD.
Examples of true biomarkers for neuropsychiatric disorder are the specific cerebrospinal fluid protein abnormalities in Alzheimer's disease. Or a positive dexamethasone suppression test in the case of clinical depression. The concept has been extended, in psychiatry, to include cognitive phenotypes in addition to "substances" like proteins.
In the case of, ADHD, however there is no "biomarker." In fact, as a clinical entity ADHD is heterogeneous, with multiple genetic contributors, several identified environmental risk factors, and variable clinical presentations.
In fact, there is no "test" for attention deficit hyperactivity disorder. Rather, ADHD is a clinical diagnosis made on the basis of
- an interview
- a thorough history
- behavioral observations
- review of pertinent school and medical records
- collateral report (interview with a roommate, spouse, parent, or teacher)
- and, frequently, standardized testing of general cognitive ability, academics, vigilance, and executive functioning.
A quote from a recent ABC story on the NEBA device is telling: "An ADHD diagnosis is typically based on interviews with parents and teachers, though ... not all general practitioners have time to take such a thorough history."
As patients and families begin to consider the role of NEBA or similar products in treatment planning, it may be helpful to ask the types of questions I raise for similar families considering a formal neuropsychological evaluaiton. Such evaluation requires a greater commitment of time than a briefer office consultation. And we want to direct our resources -- time and money -- in the most helpful direction.
Three Considerations
My perspective as a clinician who conducts this particular type of evaluation is threefold:
First, consider the complexity of the clinical presentation. If in addition to attention/focus/impulsivity challenges are there are other clinical concerns? Significant depression or substance abuse or trauma-related anxiety, or attachment disorder, or questions about general intellectual functioning? If so, then a complete neuropsychological evaluation may help "tease out" these factors so that we may speak to the specific functional impact of ADHD versus some of these other contributors.
A second consideration is this: "what exactly will we do with this information?" Practically speaking, how will these test scores facilitate services or treatment or predict success in an academic or vocational setting?
A final concern is the extent to which a client actually needs my consultative input. Many parents, or adult patients, come to me fairly certain, they have some of the attentional and executive challenges associated with ADHD. And what they need from me is not a confirmation of this diagnostic label but, rather, some specific direction or consultation.
So What about NEBA?
So how might brainwave scans or other purported diagnostic tools improve upon the interview and clinical history for determining the presence and functional impact of ADHD? I have enormous interest in how my colleagues and patients will respond to NEBA and similar approaches to data collection.
And I can't help but recall the unsavory and unforgettable advice of a graduate program supervisor. His advice regarding clinical data collection was this: "It's like picking your nose - if you find something, what are you going to do with it?"
As patients and families and consulting doctors consider neuropsychological evaluation or elaborate continuous performance tests or brain scans, we do well to ask ourselves "what will we do with this information?" Practically speaking, how will this feedback facilitate services or treatment or predict success in an academic or vocational setting? What will you do with these data?
photo: flickr
