To the Editor: </P>No single test or group of tests is diagnostic of attention-deficit/hyperactivity disorder (ADHD)  . Williams et al.  introduced IntegNeuro, which they hoped would serve as a diagnostic test. IntegNeuro included 11 neuropsychologic tests; previous research has shown that single tests have adequate sensitivity but lack specificity. Williams et al. argued that including additional tests theoretically related to ADHD might enhance specificity.</P>Williams et al. showed that a combination of sustained attention, impulsivity, intrusions, inhibition, and response variability had adequate sensitivity (0.88) and specificity (0.91). However, sensitivity and specificity are based on prior knowledge of the presence or absence of the disorder. Clinicians are rarely asked to confirm existing diagnoses. Instead, clinicians are asked to describe children without diagnoses who have developmental problems. The statistics of most interest are therefore positive and negative predictive power.</P>The positive and negative predictive power of IntegNeuro were 0.96 and 0.88, respectively. These data show clinical promise for IntegNeuro and indicate that the test deserves further investigation. However, the data fall short of the claim of Williams et al., that the study “supports the utility of a standardized approach to computerized cognitive assessment of (ADHD), to aid in clinical decision making.”</P>The primary criticism of the study of Williams et al. is the use of healthy control subjects as comparisons. A patient’s presentation for assessment implies that developmental issues are present. Comparing ADHD to healthy control subjects therefore seems irrelevant. More relevant is whether IntegNeuro is able to discriminate between ADHD and other developmental disorders. Studies have shown that developmental disorders overlap at both the cognitive and genetic levels  . Children with dyslexia are impaired—in some cases even more so those with ADHD—on several of the measures that Williams et al. claim aid decision making in ADHD. Overlap between developmental disorders implies that IntegNeuro may not have such good specificity when children with ADHD are compared to children with other developmental disorders, such as dyslexia.</P>The search for endophenotypes in ADHD will continue, and assessing objective measures of ADHD is laudable. However, Williams et al. have not presented a test that will add much more to the current DSM-IV symptoms and rating scales—at least for now. The next step must be to test the predictive power of IntegNeuro in children with developmental disorders, not in healthy control subjects.</P>
Pediatric Neurology – Elsevier
Published: Feb 1, 2011
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