Beyond DSM 5 Symptomatology:
Focusing on Cognitive, Academic, Linguistic and Social Behavioral Profiles in the Evaluation and Management of Attention Deficit Hyperactivity Disorder (ADHD)

KANCHANA S. BOSEROY, MD
Developmental-Behavioral Pediatrics & Neurodevelopmental Disabilities
Associate Professor of Child Health, University of Arizona, Phoenix College of Medicine
Lead DBP, Kaiser Permanente, Riverside, California

ADHD is commonly diagnosed by checklists completed by parents and teachers focusing on symptoms present in Category A of DSM -5 to see if criteria are met. However, ADHD is also associated with a wider constellation of strengths and difficulties in short-term rote memory, executive functioning, graphomotor coordination and planning, and academic, social, and occupational functioning – to name just a few. Unfortunately, a full neuropsychological evaluation is not feasible for all children needing evaluation for ADHD. To respond to this access barrier, our team offers a multi-step evaluation and management model for ADHD administered primarily by Developmental Behavioral Pediatricians (DBPs), focusing on assessing functioning and impairment in performance in relation to potential.

These comprehensive evaluations are usually conducted in two visits, each of them billed as 96112 (Developmental Testing Extended plus a visit code). Additional visits are sometimes needed in cases where there are more complex co-occurring conditions. In the first visit, a brief cognitive test, for example the Kaufman Brief Intelligence Test (KBIT), is done to assess cognitive profile. Usually, non-verbal scores are equal to or lower than verbal scores in ADHD. Short-term rote memory weaknesses are assessed using Digit Span subtests. The Visual Motor Integration (VMI) and Visual Perceptual skills (VP) are also assessed. In ADHD, VMI scores are typically lower than VP scores and non-verbal scores on KBIT, with poor quality of figures, drawn quickly and impulsively with low attention. In the next visit, we administer a brief achievement test, such as the Wide Range Achievement Test-5, to assess academic performance in relation to cognitive potential. Usually, the ADHD academic profile shows underachievement in spelling, attention issues in decoding of isolated and unrelated words, and weakness in calculation with careless mistakes and procedural difficulties. To gather valuable information on the functional impairment of the child in different settings, and to screen for possible co-occurring conditions, we gather parent and teacher reports as well as administer open-ended clinical interviews and projective testing (helpful for assessment with younger children).

The time-based billing with 25 modifier and testing codes makes this model financially viable with high RVUs. It can be administered by a single DBP or a multidisciplinary team. From our experience, parents love this comprehensive and strengths-based approach, where the focus is on functioning and not just diagnosis. We demystify the diagnosis from the very beginning of care and discuss academic intervention recommendations, practical and effective behavior management strategies, and judicious medication management.