With the increased theoretical focus of ADHD as a problem of faulty executive skill related to poor self-control and self-regulation, the potential advantages of administering tests, particularly neuropsychological measures, as part of an assessment for ADHD has become increasingly attractive. It is important to recognize that neuropsychological tests do not encompass all tests given by psychologists or educators, as they specifically attempt to evaluate brain-based skills (e.g., reasoning, speed of processing, problem solving, etc.) comparing the evaluated individual to a normative sample. However, even as a unifying theory of ADHD is being developed, the ecological validity of laboratory tests to identify, define and determine the severity of symptoms of ADHD has been increasingly questioned. Since ADHD is a condition defined by behavior in the real world, it is not surprising that laboratory measures frequently fall short in defining and identifying symptoms of the condition in comparison to real life observation, history and organized report in the form of questionnaires.
The development of a norm-referenced, psychometric assessment battery specifically designed for ADHD has been an elusive goal for researchers and clinicians. There is no tried and true battery or specific pattern of test impairment that comes to light consistently across all studies that can be used to evaluate a single individual in a clinical setting. Further, the comorbidity or co-occurrence of many other conditions with ADHD makes it difficult for a test to discriminate ADHD from other conditions; Thus, compromised scores may be due to a variety of causes. Though in some studies neuropsychological tests distinguish children with ADHD from those with anxiety or affective problems, these tests may not as efficiently distinguish children with ADHD from those with other disruptive conditions such as oppositional defiance.
Among tests that have been found in research to identify weaknesses in executive skills related to planning, speed of processing, problem solving and organization found in children with ADHD, are those involving matching or checking tasks, delayed responding, problem solving, reasoning and continuous performance tests. The latter have become popular and a number are marketed for clinicians, including the Gordon, Conners and TOVA. Although in group research studies these tests may demonstrate sensitivity and specificity, that is they can identify if you are in the ADHD group or not, most of these instruments lack negative predictive power. Therefore, if you perform well on the instrument in a clinical setting the clinician cannot use this performance to determine whether or not you have ADHD. Thus, these instruments tend to have much lower utility in clinical settings and the clinician must defer to real life reports.
In this article I will briefly describe a five step process for the clinical evaluation of ADHD. A comprehensive evaluation should include data concerning the child’s behavior at home, with friends, at school, academic and intellectual functioning, medical status and emotional development. Classroom observation should be obtained whenever possible, and direct interviews supplemented by completion of standardized questionnaires, should also be utilized.
Step One: Obtain a Complete History
This is not a cursory process. Sufficient time, at least one to two hours, should be set aside to obtain a narrative of the child’s development, behavior, extended family history, family relations and current functioning. This interview should allow the evaluator to identify not only the potential that the child experiences ADHD, but also symptoms and consequences consistent with a range of common externalizing and internalizing problems as well as less common conditions.
Step Two: Supplement the History with Standardized Questionnaires
At least two adults who interact with the child on a regular basis, ideally a parent and teacher, should be requested to complete questionnaires. These questionnaires should be well-developed and factor analyzed. The most common questionnaires in use today with sound histories in evaluating ADHD are the Child Behavior Checklist, Conners, Comprehensive Teacher’s Rating Scale, Childhood Attention Problem Scale and the Attention Problems Scale. These questionnaires alone, however, do not provide sufficient information for diagnosis. They provide organized reports of behavior that can be used to supplement anecdotal history and observation. Essentially they describe only what the observer sees but not why it is being seen.
Step Three: Obtain School Data
Requests should be made to review school records, including report cards and results of group achievement testing. If weak performance or learning disabilities are suspected or if the child is already receiving special education services, the evaluator should review all assessment data, as well as the child’s Individualized Education Plan.
Step Four: Generate a Series of Hypotheses
Based upon the history and questionnaires, the evaluator should be able to generate a number of hypotheses concerning the reasons for presenting problems and a means to begin testing each hypothesis. As comorbid problems for children with ADHD are the rule rather than the exception, it is important for the evaluator to attempt to set into place a chronology or developmental trajectory following from a young age the presentation, onset and relationship of various symptoms and consequences.
Step Five: Evaluate the Child
Keep in mind that no specific laboratory test for ADHD holds a gold standard possessing sufficient positive and negative predictive power to be relied upon. The primary purpose of a face to face assessment should be to address issues related to the child’s emotional status, self-esteem, cognitive development and possibly learning disability. Observation of the child’s behavior during assessment may also yield clues regarding his or her interpersonal style, temperament and mindset. The evaluator should not spend hours administering "ADHD tests"’; however, it is reasonable to include a number of brief testing measures in the course of the assessment. These might include a short computerized continuous performance test, simple paper and pencil tasks such as the Matching Familiar Figures Test or Rapidly Recurring Target Figures Test, or if time permits, a battery sensitive to attention and planning such as the Cognitive Assessment System.
Evaluation should also lead directly to treatment. Providing a pronouncement of diagnoses may put closure on the assessment but often does little to assist families in structuring a treatment plan. As I discussed in a recent monthly article, the transition from assessment to treatment is the most critical piece of the assessment process. Providing an assessment that does not lead to a change in the status quo is for all intents and purposes a waste of time or little more than an academic exercise. With the increased interest in the treatment of ADHD and the proliferation of specialized clinics for ADHD, it is important for evaluators to keep in mind that throughout their lives individuals with ADHD appear to experience multiple co-occurring problems. Experts in the evaluation of ADHD must also be experts across the life span in all domains of neurodevelopmental, emotional, behavioral and psychiatric problems.
