Although it has been hypothesized that the heterogeneity of problems related to ADHD makes it worthwhile to evaluate distinct aspects of attention, efforts at developing “an ADHD battery” have met with limited success. This is not surprising as ADHD increasingly is recognized as a disorder of inconsistency, not necessarily inability. It is the complex, myriad demands of everyday life under which ADHD causes impairment, not so much functioning in laboratory settings. Because of the pervasive, multi-setting nature of problems related to ADHD and the significant rate of comorbidity with other childhood and adult disorders, assessment for ADHD involves a thorough emotional, developmental, medical, and behavioral evaluation. The comprehensive evaluation should collect data concerning the child’s or adult’s behavior at home, with friends, at school or work, academic and intellectual achievement, medical status and emotional or personality functioning.
Numerous authors have suggested frameworks for evaluation. Achenbach (1985) described a multi-axial system for evaluating children including domains of parent report, teacher report, cognitive assessment, physician assessment and direct observation. Multiple assessment techniques are typically suggested for the comprehensive evaluation of children as well as adults with ADHD (DuPaul, 1992; Schaughency and Rothlind, 1991). Gordon (1995b) suggests a framework specifically for organizing clinical assessment data regarding ADHD. This author discusses six factors: 1) impulsiveness; 2) age of onset of symptoms; 3) chronicity of symptoms; 4) severity of symptoms; 5) pervasiveness of symptoms; and 6) intentionality, which must be met before a diagnosis of ADHD is made. Direct interviews with teachers and adults, as well as other forms of face-to-face assessment with the child are necessary, depending upon specific problems identified during an initial history taking session.
Barkley (1994) suggests that if ADHD primarily reflects problems responding, inhibiting, and managing impulses, this population of individuals will have trouble separating affect, with prolongation, internalization of language, and weak reconstitution. These skills would be expected to begin maturing at different ages, reach maturity at different points and have different life trajectories. There are significant increases in executive function. Sensitivity to feedback, problem solving, concept formation and response inhibition improve between 7 and 12 years of age, for example (Levin and Culhane, 1991). Memory strategy, planning, problem solving and hypothesis seeking skills improve between 9 and 12 and again between 13 and 15 years. Organized strategies and planful behavior, however, can be detected in children as young as six years of age (Passler, et al., 1995). More complex planful behavior and hypothesis testing skills mature by 10 years; verbal fluency, motor sequencing and complex planning abilities, however, do not reach adult level performances until well after 12 years of age. Grodzinsky and Diamond (1992) have found a stable pattern of delay between 6 and 8 and again between 9 and 11 children with ADHD versus normals on measures of response inhibition, verbal fluency, problem solving, and response planning.
Clinical batteries for ADHD have been proposed, discussed and in some cases evaluated. Considerations in the selection and use of assessment techniques should result in a best estimate diagnosis (Schaughency and Rothlind, 1991). At this time, however, there is no precise battery or specific test that has been found to be more valid, accurate or reliable than obtaining a careful history and evaluating for comorbid diagnoses. Efforts at comparing and contrasting various assessment methods and strategies routinely lead authors to conclude that multiple methods and strategies should be utilized in the assessment of ADHD (Cohen, Riccio and Gonzalez,1994).
Given the significant comorbidity of ADHD with both childhood and adult emotional, behavioral, and personality disorders, evaluators must consider a number of issues and strategies in an effort to provide a thorough, comprehensive diagnosis that seeks to offer a best fit explanation for symptom presentation and problems. These should include a focus upon and understanding of at least the following issues:
Demographics: It is important to understand the environment including family system as well as the community at large, a particular individual lives, works, and is educated in. An absence of understanding of environmental forces and factors limits an evaluator’s insight and understanding of the history and symptom presentation.
Symptoms versus Consequences: There are 18 defined symptoms of ADHD used in making the diagnosis. There are an endless number of negative consequences that result from living with these symptoms and the interaction of these symptoms with other environmental factors. The effective understanding and separation of symptom versus consequence allows for a thorough investigation of comorbid problems and developmental pathways. Increasingly, it is recognized that myriad, biological, experiential, and environmental factors weave together to form each individual’s unique developmental pathway. An evaluation represents a frozen moment in time. It should provide an understanding of a particular road an individual took to arrive at that point, as well as allow for the assessment of risk and prognosis in making treatment decisions.
Category versus Dimensional Models: The DSM-IV is a categorical model. It presents an all or nothing phenomenon in regards to the diagnosis of ADHD. However, on a dimensional basis, it is assumes that everyone exhibits symptoms of ADHD from a minimal to a maximal degree. A dimensional model predicts a complete and unbroken gradient for a particular skill or symptom such as impulsivity (Ellis, 1985).
Take Time: The most ecologically valid means of making the diagnosis of ADHD is probably be to follow the affected individual for days on end. In all likelihood, the next best course of action would be to obtain a careful and well defined history.
Assess the Environment: The severity of ADHD symptoms is often defined by the observer. Thus very similar children are described with varying severity based upon the tolerance, expectations, and understanding of reporters.
Sensitivity versus Specificity: For behaviorally defined disorders such as ADHD that are so easily influenced, it is not surprising that questions arise concerning the issue of sensitivity (making the diagnosis so general that it includes 50 percent of the population; everyone with ADHD is identified, but so too are an excess number of false positive) and specificity (identifying a very small group of children, all of whom clearly have the disorder, but also identifying too many false negatives). Too liberal an interpretation results in seemingly every child having the disorder, too conservative fails to identify children in need. The process of diagnosis must take into account the sensitivity and specificity of the data collected and the assessment instruments utilized.
Assess for Intervention: The majority of time spent during the assessment should yield data that will assist in making important treatment decisions.
This presentation will review these and a number of additional strategies in an effort to offer participants a framework for the comprehensive assessment of individuals suspected of ADHD. Common and some uncommon comorbid disorders including Oppositional Defiance, Conduct Disorder, depression and anxiety will be discussed. Low incidence disorders in which ADHD occurs beyond a chance level such as Tourette’s, high functioning Autism, Fragile X, and Neurofibromatosis – Type I will also be reviewed.
