The Key Components of a Comprehensive Assessment of ADHD

It is well known that symptoms of inattention, impulsivity, and/ or hyperactivity are the hallmark features of the condition now referred to as attention-deficit/hyperactivity disorder (AD/HD). For most parents and teachers, noticing that a child is displaying these symptoms is a relatively easy task. Such behaviors stand out like a sore thumb, because of the disruption that they cause in the child’s home and school functioning. What is not so easy is figuring out what to do about these problems. In order to make this determination, it is usually necessary to have some sense of what might be causing them. Although AD/HD very well may be responsible, there are various other childhood conditions, such as learning disorders, depression, and conduct problems, which can produce symptoms that look like AD /HD and therefore need to be considered as possible causes. So how does one know whether or not a child has AD/HD versus something else? Although some people seem to think that you can just tell from watching a child, arriving at such a conclusion requires a formal evaluation. Unfortunately, there are many different ways to assess AD/HO, and some assessment approaches are clearly more accurate and more cost-effective than others.

Understanding the clinical picture

In part, we can understand what type of assessment should be conducted by considering how the child mental health field defines AD /HD. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994), multiple criteria must be met before concluding that AD /HD is present. The first of these guidelines stipulates that a child must frequently display at least six of nine inattention symptoms and/ or six of nine hyperactivity- impulsivity symptoms. Such behaviors must also have an onset prior to seven years of age, a duration of at least six months, and a frequency above and beyond that expected of children of the same mental age. Furthermore, they must be evident in two or more settings, have a clear impact on psychosocial functioning, and not be due to other types of mental health or learning disorders that might better explain their presence.

At face value, establishing an AD/HD diagnosis would seem to be a relatively straightforward matter. You simply use whatever means necessary to gather information that allows you to address the above diagnostic guidelines, and then decide whether AO/HO is present or not. Unfortunately, it’s not quite that simple. One factor complicating this situation is the situational variability of AD/HD symptoms. Contrary to popular belief, AD/HD is not an all-or-none phenomenon -either there all the time or not there at all. Instead, it is a condition whose symptoms mayor may not be present, depending on the situation. AD/HD symptoms are much more likely to occur in situations that are boring versus interesting, in situations that are unstructured versus structured, and in situations that are low in feedback versus high in feedback. Group settings are also more problematic for children with AD/HD than would be the case in one-to-one situations. Being aware of the situational variability of AD/HD symptoms is central to understanding the frequently irregular clinical presentation of this disorder; therefore, it is imperative to obtain information from individuals who observe a child across different settings. At the very least, this should include input from parents and teachers. When appropriate, other significant caretakers, such as day care providers and babysitters, should provide similar input. Another critical factor affecting the evaluation process is the increased likelihood that children with AD/HD will display secondary or co-occurring problems. For example, up to 65 percent of the children with AD/HD may display secondary behavioral complications, such as noncompliance, argumentativeness, temper outbursts, lying, stealing, or other manifestations of oppositional-defiant disorder and conduct disorder. Virtually all children with AD/HD experience some type of school difficulty. An especially common problem is that they don’t produce adequate amounts of work, and the quality of work that they do produce is often highly variable and well below their capabilities. Up to 50 percent of children with AD/HD may also exhibit dyslexia or other types of specific learning disabilities. As a result of such complications, many of these children receive some form of special education assistance. They may also experience significant problems in their relationships with other children, both in school and at home. Such difficulties sometimes involve not being able to make friends. However, keeping friends is of even greater concern, because children with AD /HD frequently do things that alienate their peers, who then respond by rejecting, teasing, or avoiding them. Possibly as a result of such behavioral, academic, and/or social problems, children with AD /HD very often exhibit low self-esteem, low frustration tolerance, symptoms of depression and anxiety, and other emotional complications.

Whether alone or in combination with various other conditions, AD /HD can also have a significant impact on family functioning. For example, many parents of children with AD /HD experience considerable frustration and stress, which very often can lead to viewing themselves as less skilled and less knowledgeable in their parenting roles. Many parents of these children may also find themselves constantly involved in resolving various school and peer relationship difficulties, which occur throughout childhood and into adolescence as well. As a result of such complications, some parents may get to the point of becoming very depressed or angry over their inability to raise their child as they would like. For some mothers and fathers, marital tensions may arise, resulting from constant disagreements over how to manage their child’s difficulties. Brothers and sisters may be affected as well- partly because their sibling with AD /HD does so many things that bother them, and partly because they resent the amount of parental time and attention that the child with AD/HD receives.

The cornerstones of evaluation

Given that the problems of children with AD/HD very often go beyond the disorder itself, any assessment of this condition should address not only primary AD/HD symptoms, but also other aspects of the child’s behavioral, emotional, and social functioning. Equally important is the need for gathering information about the child’s parents and siblings. Although obtaining this type of family information may not shed much light on whether or not an AD/HD diagnosis is present, it nevertheless provides a context for understanding how problem behaviors may be maintained. Moreover, such information often serves as a basis for determining how well parents and other caretakers will be able to implement recommended treatment strategies on behalf of their child. If there is reason to believe that a parent may have difficulty helping their child, then steps may be taken to address such difficulties, either prior to or concurrent with the delivery of treatment services to the child. For example, some parents may need to receive marital therapy to reduce strains in their marriage, before participating in a parent training program aimed at teaching them new ways of dealing with their child.

Implicit in the preceding discussion is that clinical evaluations of AD/HD must be comprehensive and multi- dimensional in nature, so as to capture its situational variability, its associated features, and its impact on home, school, and social functioning. This multi-method assessment approach should include not only the traditional methods of parent and child interviews, but also parent- and teacher-completed child behavior rating scales, parent self- report measures, direct behavioral observations of AD/HD symptoms in natural or clinical settings, and clinic-based psychological tests. A review of prior school and medical records should also be included as part of this overall assessment process. If the child has not undergone individually administered intelligence testing, educational achievement testing, or screening for learning disabilities within the past year, then such testing should be added to the assessment battery. Similarly, if the child has not been seen recently by his or her physician, a standard pediatric examination or neurodevelopmental screening should be considered in order to rule out any unusual medical conditions that might produce AD/HD-like symptoms. As needed, additional assessment procedures may be recommended, including vision and hearing screening, as well as formal speech and language assessment.

Clinical child psychologists, child psychiatrists, school psychologists, and pediatricians are among the many types of child health care professionals who very often possess the necessary training, experience, and skills for conducting comprehensive assessments of AD/HD. Unfortunately, there is no way for parents and teachers to know this ahead of time, based solely on their knowledge of someone’s professional degree. For this reason, parents and teachers are strongly encouraged to take an active consumer-oriented approach to obtaining this information, by contacting professionals and asking them to describe their assessment approach before setting up an appointment for their child.

The cornerstones of an ADHD evaluation

• Parent and child interviews
• Parent- and teacher-completed child behavior rating scales
• Parent self-report measures
• Clinic-based psychological tests
• Review of prior school and medical records
• Individually administered intelligence testing, educational achievement testing, or screening for learning disabilities (only necessary if not completed within past year)
• A standard pediatric examination or neurodevelopmental screening should be considered in order to rule out any unusual medical conditions that might produce AD /HD-like symptoms

Additional assessment procedures may be recommended, including vision and hearing screening, as well as formal speech and language assessment

About the authors

Arthur D. Anastopoulos, Ph.D. currently is an associate professor in the Department of Psychology at the University of North Carolina at Greensboro, where he also directs an AD/HD specialty clinic for children, adolescents, and adults. An active researcher, Dr. Anastopoulos has given numerous presentations at scientific meetings and has authored many articles and book chapters on the topic of AD/HD.

Paige Temple, M.A. is completing a clinical internship at the University of North Carolina at Chapel Hill. Erika Klinger, M.A. is completing a clinical internship at Monmouth Medical Center in New Jersey.