THE ASSESSMENT OF ADHD ADHD: Assessment and Diagnosis in Psychology ADHD in children is characterised by developmentally inappropriate overactivity, distractibility, inattention, and impulsive behaviour. It affects an estimated 5-10% of children and is associated with cognitive, social, and academic impairments. Positron emission tomography (PET) scanning strongly supports ADHD to be a neurodevelopmental disorder owing to differences in the superior prefrontal cortex and the premotor areas of the brain. In its simplest form, a diagnosis of ADHD must conform to the criteria outlined by the Diagnostic and Statistical Manual Version 5 (DSM 5). The DSM 5 describes 9 Inattentive features and 9 Hyperactive-Impulsive features. On close scrutiny, these represent underlying neurodevelopmental difficulties, and not naughty behaviour or poorly disciplined children (which may be present as well). The Inattentive features often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities (e.g. overlooks or misses details, work is inaccurate). often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
The Inattentive features often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the work place (e.g., starts tasks but quickly loses focus and is easily sidetracked). often have difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). often avoids or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). is often easily distracted by extraneous stimuli (e.g., for older adolescents and adults may include unrelated thoughts). is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). The Hyperactive-impulsive features often fidgets with or taps hands or squirms in seat. often leaves seat in situations when remaining seated is expected (e.g., leaves his other place in the classroom, in the office or other workplace, or in other situations that require remaining in place). often runs about or climbs in situations where it is inappropriate (e.g., in adolescents or adults, may be limited to feeling restless).
The Hyperactive-impulsive features often unable to play or engage in leisure activities quietly; is often "on the go" acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). often talks excessively; often blurts out answers before questions have been completed (e.g., completes people's sentences; cannot wait for turn in conversation). often has difficulty awaiting turn (e.g., while waiting in line). often interrupts or intrudes on others (e.g. butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). Number of features, and age at onset required for a diagnosis For a diagnosis of ADHD, individuals younger than 17 must display at least 6 of 9 inattentive and/or hyperactive impulsive symptoms. Features must date to before the age of 12 years. For individuals 17 and above, however, only 5 or more symptoms are needed. While most children and some adults display some of the above features some of the time, for a diagnosis of ADHD, these behaviours are judged to be present significantly more often than would be for the child s age.
Not everything that looks like ADHD is ADHD One of the important goals of a clinical psychology assessment is to ascertain whether the person being assessed actually has ADHD, or whether the presenting symptoms instead are those of another disorder, or even just a variation of normal childhood. The process of investigation is referred to as a differential diagnosis. There are several possible disorders that need be excluded. It is the role of a psychiatrist or paediatrician to determine whether this may be a medical condition. The role of the clinical psychologist is to determine whether this may be an emotional, developmental, or educational disorder. There are common non-psychiatric events that are likely to cause difficulties with concentration, restlessness and hyperactivity. Childhood trauma, depression, stress, anxiety and worry (which may be associated with divorce or separation), a house or school move, the death of a family member or pet, or underachievement at school - any of these could result in behaviour similar to ADHD. ADHD-like behaviour may also be associated with children who experience difficulty following instructions, whether due to auditory difficulties, a language disorder, or a range of learning problems. Further, there are pervasive developmental disorders, such as Autism Spectrum Disorders (ASD), Social (Pragmatic) Communication Disorder, and Intellectual Disability that may present with ADHD-like behaviours. There are also psychiatric disorders, which depend on the severity of the presenting behaviour problems and the child s age. A child or adolescent might also receive a diagnosis of Oppositional Defiant Disorder or, if of adult age, Antisocial Personality Disorder. In short, an appropriate assessment for ADHD must rule out all of these possibilities, and then must rule in the essential features of ADHD.
Who can offer a differential diagnostic assessment? In Australia this would be a clinical psychologist who has completed an extensive post-graduate training in this area. Please check with the psychologist you contact whether they have the appropriate training to complete a differential diagnostic assessment. What is the assessment process? Individually, Clinical Psychologists may differ in the method by which they undertake to gather all the relevant information. For example, some psychologists prefer to meet with parents first, without the child present, to obtain the necessary background information. Others may choose to meet with the parents together with the child present. Regardless of these preferences, all clinicians will gather the same information. As noted above, the initial stage involves gathering information about the child and his/her family. This includes current and past behavioural difficulties, social and personal information, and academic and learning records. Details of the developmental history need to build a picture of any possible developmental delays, the child s health, and social and play interests. The family history is also relevant, since there may be current or past emotional issues and relationship conflicts that could be affecting the child s emotional wellbeing. There is also the possibility that other family members have experienced learning problems and/or ADHD. This is relevant since these disorders may be inherited, and pass on through families. The information above must be completed by interviewing parents, or other relevant family members. It is simply too complex, and with often much subtle details, for it to be collected with questionnaires. Indeed, it is quite common to set aside two appointments to gather all the relevant information. This is especially the case when children have a complex presentation or with multiple difficulties.
It is important that information from sources other than parents is also obtained. One of the criteria of the DSM 5 is that the ADHD behaviour is present in more than one environment. The two most common environments are home and classroom (or work). Others include the playground and other social environments. The clinical psychologist will often send questionnaires to the school to be completed by teachers. A common questionnaire used is the Connors. The third area is a psychometric assessment. The aim here is to evaluate language skills, visual perceptual skills, eye-hand coordination or visual-motor skills, and working memory. The cognitive hallmark of the ADHD child is a lowered working memory, notably visual working memory. Along with this are difficulties with planning and sequential memory. These are referred to as the executive functions. They are central to impulse control, organisational skills, and emotional regulation. Impulse control refers to a child s ability to tolerate frustration. Organisational skills including planning and time management, both of which are typically weak in ADHD. This area also includes academic areas such as written expression, which involve planning and multi-tasking. Lastly, both auditory and visual working memories are responsible for the way one is capable of following instructions and recalling information. There is a wide range of possible tests that may be administered to a child. Typically it will begin with a general intelligence test, such as the WISC IV. This is generally insufficient on its own (it does not delve into the working memory areas in depth), and is likely to be supplemented with tests that specialize in language, visual skills, and specific working memory types. The psychometric assessment may also include an educational assessment if a reading difficulty, or any other academic problem is suspected. Tests assessing the level of anxiety or depression may also be administered, although it is often enough for a skilled clinician to determine this during interviews.
What happens once all this information is completed? An assessment for ADHD does not end with a diagnosis. A diagnosis is really the start of the treatment phase. What diagnosis does is provide a way of communicating information in shorthand to other clinicians. It also has predictive value in that it is possible to anticipate what other difficulties may possibly occur in the future, along with the likely duration and the complexity of treatment. For example, it is quite common for ADHD to co-exist with other disorders, such as ASD or anxiety or a learning difficulty. The ultimate goal of an assessment is to create a treatment plan. This should cover behaviour, emotions, the academic area, family relationships, and medication. The format for treatment is the subject of a separate article. It is enough to note at this point that the first step towards treatment is a solid understanding of what the problems are, and where they lie. A thorough assessment covers the Big Picture, and it is only then that one narrows the target towards the development of specific skills and problems. Too many parents struggle to make headway with their ADHD children because the treatment they chose at the start is actually incidental to the important problem areas. Assessment is about determining what is important for treatment.