Clinical Assessment of Child and Adolescent Personality and ...

CHAPTER 17 Assessment of Attention Deficit Hyperactivity381typically meet the diagnostic criteria forADHD (American Psychiatric Association,2000). It is important to note that theappropriateness of this threshold has beenquestioned for young preschool children asbeing too liberal, because many very youngchildren show high rates of these behaviorsand eventually outgrow them (Campbell,1990), and for adolescents and youngadults as being too conservative, becausethe frequency and severity of many of thesymptoms seem to decline in adolescence(Barkley, 1997a).The second parameter that differentiatesnormal and abnormal patterns of inattention,impulsivity, and overactivity is theonset and duration of the symptoms. DSM-IV-TR specifies that “some hyperactive-impulsiveor inattentive symptoms must havecaused impairment before age 7 years”(American Psychiatric Association, 2000,p. 92). This criterion is consistent with theconceptualization that ADHD is a lifelongpattern of maladaptive behavior and not atransient reaction to a specific stressor orto the demands of a particular developmentalstage (Barkley, 1997a). While theage of onset criterion is consistent withthis conceptual framework, there are severalpractical problems in using this criterionin clinical assessments. First, it is oftendifficult to gain accurate accounts of whensymptoms became problematic, especiallywhen assessing adolescents and adults,which involves recall of events over a longperiod of time (Barkley, 1997a).Second, it is not uncommon for manyof the symptoms of ADHD, especially theinattention ones, to only become problematiconce the demands for sustainedattention and organization increase in laterelementary school years (Lahey et al., 2005;Loeber, Green, Lahey, Christ, & Frick,1992). This developmental change in inattentionsymptoms is likely the reason thatthe age of 7 onset criterion may be particularlyproblematic for the PredominantlyInattentive Type of ADHD. Specifically,in a sample of 380 clinic-referred children(mean age 8.7 years) who met DSM-IV criteriafor ADHD, almost all of those whomet the symptom cut-off for the PredominantlyHyperactive-Impulsive Type andthe Combined Type met the age of 7 onsetcriterion (Applegate et al., 1997). In contrast,only 48% of those children with PredominantlyInattentive Type met this age ofonset criterion and those who did not meetthe criterion did not differ from those thatdid on several important validity indexes,including level of impairment and level andtype of comorbidity with other disorders.Therefore, the validity of the onset criterionfor this ADHD subtype was questionable.Third, it is important to recognizethat, while the core deficits underlying thesymptoms of ADHD may be stable acrossdevelopment, how these deficits are manifestedin symptoms and secondary characteristicsmay change across development(Barkley, 1997a). In Table 17.2, we providea brief summary of some of these developmentalchanges in the symptom patternsand secondary characteristics acrossdevelopment. One criticism of the DSM-IV-TR definition of ADHD that includesthe same number and types of symptomsfor children, adolescents, and adults is thatthis static definition may not capture thesedevelopmental changes adequately (Barkley,1997a).A third parameter in the DSM-IV-TRdefinition of ADHD that is importantfor separating normative from disorderedlevels of attention and overactivity is thespecification of cross-situational consistencyof symptoms. That is, to be diagnosed withADHD, a child must show impairmentrelated to the symptoms in two or moresettings. This criterion is consistent withthe conception that ADHD should not besolely a function of a single set of environmentalcircumstances (e.g., a disorganizedclassroom, a chaotic home environment)and clearly suggests that an adequate assessmentof ADHD must involve an assessment