What Is Necessary And Sufficient To Evaluate ADHD?

Dr. Sam Goldstein

A health insurance representative informed me last week that it was her opinion and her company’s policy that an evaluation for ADHD can be completed in as short a time as an hour. Yet some professionals take hours administering a variety of tests before a diagnosis is made. In this month’s article I will review important issues in the diagnostic process of ADHD.

It is important for parents to understand that when children struggle emotionally, behaviorally or developmentally it is more likely than not that they may experience difficulty in a number of important life activities. The process of assessment is not just to count symptoms and proclaim diagnoses but to understand a child’s strengths as well as weaknesses in ways that assist in providing support and help. To be wise consumers of an ADHD assessment, parents must first understand the important role normally maturing self-control plays in child development. Self-control is critically important to learn, behave, manage emotions, develop friendships and function effectively in community activities. Thus, it is not surprising that the co-occurrence of learning, behavioral and emotional problems is the rule rather than the exception for children receiving diagnoses of ADHD. The diagnostic process, therefore, must carefully explore many of these co-occurring problems not only to provide appropriate diagnoses and assistance but also to identify early signs or risk factors that may speak to an emerging problem in the future. This process allows parents, educators and professionals to provide help and assistance before children fail. For example, preschoolers with delayed development of self-control are often disinterested in sedentary, pre-academic activities. Their lack of practice leads to limited proficiency. This often makes them appear as if they may have a learning disability. Yet some children with ADHD also demonstrate weaknesses in key skills necessary for early academic achievement. A thorough assessment allows a professional to not only examine the issue of ADHD but also the possibility that beyond the symptoms of ADHD lie weaknesses in skills necessary for early academic learning. Further, it is well recognized that among children with early language and learning problems, parent and teacher reports of hyperactive, impulsive and inattentive behavior are often elevated, not necessarily the result of a biological risk but as a result of the child’s day in and day out frustration. Only a thorough assessment can tease out and provide an understanding of these risks and their relationships.

In the clinical diagnostic process there are eighteen symptoms of ADHD. These symptoms can be assessed through direct observation and history taking but can also very efficiently be assessed by asking parents and teachers to complete well-researched normative questionnaires. In fact this quickly allows a professional to obtain parent and teacher input specifically concerning the presentation and severity of ADHD symptoms. However, parents should be cautioned that when this type of questionnaire process is the only means of assessment the rate of false positive diagnoses may equal the rate of accurate diagnoses of the general population. Time saving questionnaires and even a brief history provide a very efficient means of identifying the 20% of children in the general population who may struggle. To truly understand the reasons for these struggles, a good evaluator must take a much more detailed and careful history as well as explore the possibility that symptoms could be the result of other conditions. Keep in mind that complaints of inattention, off task behavior and non-compliance are the most common complaints parents make about children. In particular inattentiveness is a characteristic description of children with depression, anxiety, oppositional behavior and even learning disability. For many of these children their inattentiveness is not the result of a biologically based problem with developing self-control.

At the other extreme, it is also not necessary to administer a ten hour neuropsychological battery to a child referred for symptoms of ADHD in which a brief history and general questionnaires reveal no indications of delayed academic achievement or performance, severe emotional problems or family adversity. When parents suspect their children may experience problems as a result of ADHD, a good place to begin is by obtaining a book or video about the subject and becoming educated about common signs, symptoms and behaviors as well as co-occurring problems. If parents are then concerned their child may experience symptoms of ADHD to an impairing degree, I suggest they speak with their pediatrician or family practitioner. Most physicians working with children today also work closely with child psychologists and can refer the child for an initial consultation. I also suggest parents request a consultation with their child’s school psychologist. Although school personnel usually are not in the position to make a diagnosis of ADHD, the input they can provide to the physician and community psychologist is invaluable in the diagnostic process.

Finally, keep in mind that when children leave school they are not asked their weakest subject and most annoying behavior and then assigned a job involving both for life. In fact, it is just the opposite. We accomplish our goals in life through our strengths and assets. For me, an evaluation considering ADHD in a child must also place equal focus on defining and understanding that child’s strengths and abilities.