ADHD: The Need for Comprehensive Assessment

I am often asked why it is necessary to do such a comprehensive assessment for the evaluation of ADHD. It seems like an easy diagnosis - why does it involve so many tests and so much time? In order to answer that question, we need to look at the reasons that a parent would want an assessment in the first place. There are five main reasons for getting an assessment:

  1. To identify the ADHD behaviors and determine their magnitude. To be honest, this is the easiest part of any assessment. In fact, most parents already know if their child is not paying attention at home or in school, if the child's behavior is impulsive, or if she seems overactive or forgetful. Of course, it is important to see how that child compares to other kids her age to determine whether the extent of the problem is unusual. To do this we rely on parent reports and teacher reports and compare their assessment of the child to other kids. But, again, this is not particularly difficult and is often something the parent or teacher can tell the psychologist before any testing is done at all. The primary symptoms of ADHD are available on the internet: look them up, and if your child fits the criteria you do not really need to spend a lot of money to find this out. It makes no sense to pay a professional money to find out what you already know, so an assessment should not just tell you that your inattentive child is not paying attention. That's like going to a doctor to find out that your leg is hurting because of the pain in your leg. If your leg hurts, you don't need to go to a doctor to find out that it hurts. You need to go to a doctor to find out why it hurts and what to do about it.

  2. Even if you know that your child is behaving in ways that fit the ADHD criteria, you really do not know why. There are many reasons that a child can appear to be inattentive, hyperactive or impulsive, and many of them are not immediately apparent to parents and teachers. For example, many kids are overly sensitive to background noise, which is common in most classrooms. Such a child might be very verbally able and understand everything that is said to him but may be "spacing out" in class because the background noise interferes with what the teacher is saying and he is struggling to understand. The same child might be acting out at home because of the stress of a frustrating schoolday. Other children may have hidden processing problems that make schoolwork so difficult that they quickly wear themselves out and have problems concentrating. They appear tired or inattentive or resistant, not because they have ADHD but because they have been working too hard. Some kids react to depression or anxiety by exhibiting exactly the symptoms that describe ADHD. Thus, the diagnosis becomes a bit more tricky. For example, since depression or anxiety are experienced by many kids who are having problems at school, we are faced with a problem of "which came first, the chicken or the egg?" Is ADHD causing anxiety, or is anxiety causing attentional problems? It is very important for a professional to look at all the possible reasons for ADHD behaviors and to rule them out as causes or to tease out the interaction between the symptoms. It is also important to note that research indicates that as many as 50% to 70% of children with ADHD also have some other learning disorder or diagnosable emotional problem. For this reason, to diagnose ADHD without looking at these other factors is simply irresponsible. (Incidentally, the same degree of thoroughness is necessary for the diagnosis of learning disorders. Clearly, the fact that many learning disorders are not immediately apparent means that every attempt should be made to look at all aspects of a child's cognitive development. Just knowing that a child can't read, for example, does not tell you why he can't read.)

  3. A good assessment does not just tell you what is wrong with your child. A good assessment also measures her strengths. It is important that you, your child, and your child's teachers all have a good understanding of your child's gifts, as well as her weaknesses. Not only is this essential to the child's self-esteem and acceptance of problem areas, but it also is useful because a child (and a good teacher) can use those strengths to compensate for the areas of difficulty. All too often, a child is very aware of what she can not do as well as her peers, but doesn't realize how well she compares in other areas. An assessment should reflect the child as a whole human being, not simply report on her deficiencies. A good teacher will focus on each child's unique learning style, which includes both strengths and weaknesses.

  4. For many kids with ADHD, medication is one very effective strategy for addressing the problems. But research has shown that medication alone never completely solves the problems associated with ADHD. At best, medication is only one of a number of things that should be looked at when a child has ADHD. A good report should include a number of specific recommendations for home and for school, including other strategies that can be used by the child, his parents and his teachers to make the problems associated with ADHD more manageable. Educational and emotional success may depend just as much on the child developing a repertoire of strategies, the parents helping to foster a positive attitude, and the teacher implementing specific structures, as it does on a certain dosage of psychotropic medication. Unfortunately, children are often being put on medication to "cure" ADHD without addressing these other very necessary strategies.

  5. One of the most pragmatic reasons to have a child assessed is to be able to present information to a teacher, school or doctor in the future. Thus, other professionals will be looking at the report to determine its credibility. A report that has diagnosed ADHD based on slim evidence and without examining other possible causes for the ADHD behaviors will not be very convincing, especially to professionals who understand the complexities of the diagnosis. If you plan to use the report to inform, educate or convince other professionals, you will need a report that is believable and complete.

It may seem cheaper and easier to get an assessment from someone who will spend a couple of hours with your child and give you a diagnosis. But this is no substitute for a good assessment. You are often left with the necessity of getting a complete assessment later, either because problems persist or because the first report is not accepted by a school or another professional. In the meantime, possible other factors such as processing problems or emotional distress may not have been appropriately addressed and may have become more serious. Even if it seems more cumbersome, it makes much more sense to get all the information you need to address the problems that exist now, and a good report to use in the future.

- Dr. Jadis Blurton