How is a child assessed for ADHD?
By Sherri Johnson, Psy. D
The diagnosis of ADHD should be made through a well defined process that looks at a variety of factors in the child’s life. Just exhibiting behaviors of inattention, hyperactivity, or impulsivity should not result in a diagnosis of ADHD. These behaviors should have an observable adverse effect on the child’s functioning at school, home, and in social settings. This evaluation should be completed by a trained professional with experience in the diagnosis and/or treatment of children. The evaluation should incorporate data from a variety of sources in an effort to determine the pervasiveness of the presenting problems.
Parents are asked to complete behavior rating scales to assess observed behavior within the home and community settings. The child’s teacher/s should also be asked to complete a similar behavior rating scale for behaviors observed within the school setting. The child may also be asked, depending upon age, to complete a self-report related to inattention, hyperactivity, and impulsivity. It is also likely that the child will be referred for additional assessment to rule out learning disabilities through private insurance or through the public schools.
There are a variety of formal or standardized behavioral checklists that are utilized in aiding the clinician in the diagnostic process. There are also a number of screening instruments utilized by physicians and clinical psychologists. Some of the most commonly used standardized rating scales are as follows:
Conners 3rd Edition
Attention Deficit Disorders Evaluation Scale 3
Brown Attention Deficit Disorder Scale
Attention Deficit/Hyperactivity Disorder test
Behavior Assessment System for Children 2 (screening)
A thorough medical and developmental history is necessary when evaluating a child for ADHD. The clinician should also gain an understanding of the child’s family and social life through interview and questionnaire. Differential diagnosis is a part of the evaluation process to rule out a variety of other issues that may be contributing to the reported and observed behaviors of the child. Certainly, ruling out vision and hearing problems is a first step. There also may be medical conditions such as sleep disorders, hyperthyroidism, and learning difficulties that underlie the behaviors that the child is manifesting. Factors such as disruption in the child’s family life often have a significant impact on the child’s emotional and mental health.
Direct assessment of the child is an important component of the assessment, but is not generally completed by most clinicians within school or medical settings. This type of assessment is necessary to rule out other processing difficulties that may appear to parents and teachers as attentional concerns, hyperactivity, and/or impulsivity. There tends to be an over reliance on behavior rating scales as diagnostic indicators of ADHD. It is this writer’s contention that it is essential to determine the underlying processing deficits that may be impacting the child’s functioning. It may or may not include ADHD! There also may be co-morbid or co-existing disabilities in addition to ADHD that may be diagnosed when the child is fully evaluated.
There are a number of tests that can be used to directly assess attentional functions. Continuous performance tests (computer based) are quite popular with physicians and are certainly a nice addition to behavior rating scales. Continuous performance tests require the child to selectively attend and sustain attention to visual and/or auditory targets. An integrated CPT is ideal because it allows for assessment of attention to visual and auditory stimuli. There a number of well recognized CPT tests on the market. The IVA Plus is one that this writer uses for assessments of a regular basis. The IVA Plus is described by BrainTrain (2012), the test developer and publisher, as follows:
“The IVA+Plus is a combined auditory and visual CPT which is designed to help the clinician make an accurate diagnosis of ADHD/ADD in children, adolescents, and adults. The test provides objective data about a person’s ability to concentrate and to avoid making impulsive errors. Following the diagnostic criteria outlined in the DSM-IV, IVA+Plus provides a wealth of data to help clinicians diagnose and differentiate between the four sub-types of ADHD/ADD.”
While a CPT may evaluate the DSM-IV subtypes, it does not fully assess all areas of attention that are recognized by neuropsychologists and school based neuropsychologists. These particular subtypes are often not recognized and certainly not directly assessed by even experienced clinicians in the field. According to a number of well known clinicians in the field, the following subtypes of attention require assessment to fully determine the extent to which attentional functions effect a child’s learning and general functioning in a variety of settings. According to Miller (2007) the following represent the different forms of attentional functions:
Selective Attention involves the child’s ability to pay attention when there are distracting events around him. An example might be a child paying attention to a lesson being presented by the teacher and not paying undo attention to distracting events in the classroom such as other children talking and/or moving around, a lawn mower outside the classroom, etc.
Sustained Attention involves the child’s ability to pay attention over a period of time. A continuous performance test measures both selective and sustained attention. The ability to listen to a story being read by the teacher or parent is an example of a child’s ability to sustain attention.
Divided Attention is the ability to attend to and respond to more than one task or activity. An example of divided attention is a child coloring while listening to the teacher give directions.
Shifting Attention is the ability to be mentally flexible to shift from one task to another or from one skill set to another. Completing a division problem requires the ability to shift as a various skill sets are required to correctly solve the problem. Another example is the child who has difficulty shifting from addition to subtraction on a page with a mix of both types of problems. The child may ignore signs and add all the problems and not shift his attention to observe the subtraction problems.
Attentional Capacity refers to the ability to attend to information as it becomes progressively longer, more complex, etc. A child with difficulties in attentional capacity may become overwhelmed when information or stimuli that are presented gets progressively longer. In the classroom. The child may have difficulty attending to lengthy instructions or multi-step directions. Short term memory may also be a concern for the child.
There are many tests that clinicians utilize to assess a child’s attention in the above described attentional functions. The skilled clinician will be able to assess the child in a variety of other areas to determine the extent to which attention or another processing difficulty may be impacting the child’s functioning. Other possible processing areas may include but is not limited to the following:
Short term memory
The diagnosis of ADHD is made utilizing all of the information obtained through structured interviews, direct assessment, behavioral interviews, observations, and ruling other disorders that may be contributing to the reported behavioral concerns. The clinician then utilizes the diagnostic criteria of the Diagnostic and Statistical Manual IV as a guide in providing a diagnostic impression of ADHD or one of the subtypes described in Part I of this series. A final report should be provided for parents to share with concerned parties. The school district cannot make a diagnosis; however, the report will provide a trained clinician with ample information to aid them in the diagnostic process.
Mather, N., & Jaffe, L. (2002). Woodcock-Johnson III: Reports, Recommendations, and Strategies. New Jersey: John Wiley & Sons.
Miller, Daniel. (2007). School Neuropsychological Assessment. New Jersey: John Wiley & Sons