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WHAT IS NECESSARY AND SUFFICIENT TO
EVALUATE ADHD?
Sam Goldstein,
Ph.D.
A health
insurance representative informed me last week that it was her opinion and her
company's policy that an evaluation for ADHD can be completed in as short a
time as an hour. Yet some professionals take hours administering a variety of
tests before a diagnosis is made. In this month's article I will review
important issues in the diagnostic process of ADHD.
It is important
for parents to understand that when children struggle emotionally,
behaviourally or developmentally it is more likely than not that they may
experience difficulty in a number of important life activities. The process of
assessment is not just to count symptoms and proclaim diagnoses but to
understand a child's strengths as well as weaknesses in ways that assist in
providing support and help. To be wise consumers of an ADHD assessment, parents
must first understand the important role normally maturing self-control plays
in child development. Self-control is critically important to learn, behave,
manage emotions, develop friendships and function effectively in community
activities. Thus, it is not surprising that the co-occurrence of learning,
behavioural and emotional problems is the rule rather than the exception for
children receiving diagnoses of ADHD. The diagnostic process, therefore, must
carefully explore many of these co-occurring problems not only to provide
appropriate diagnoses and assistance but also to identify early signs or risk
factors that may speak to an emerging problem in the future. This process
allows parents, educators and professionals to provide help and assistance
before children fail. For example, preschoolers with delayed development of
self-control are often disinterested in sedentary, pre-academic activities.
Their lack of practice leads to limited proficiency. This often makes them appear
as if they may have a learning disability. Yet some children with ADHD also
demonstrate weaknesses in key skills necessary for early academic achievement.
A thorough assessment allows a professional to not only examine the issue of
ADHD but also the possibility that beyond the symptoms of ADHD lie weaknesses
in skills necessary for early academic learning. Further, it is well recognized
that among children with early language and learning problems, parent and
teacher reports of hyperactive, impulsive and inattentive behavior are often
elevated, not necessarily the result of a biological risk but as a result of
the child's day in and day out frustration. Only a thorough assessment can
tease out and provide an understanding of these risks and their relationships.
In the clinical
diagnostic process there are eighteen symptoms of ADHD. These symptoms can be
assessed through direct observation and history taking but can also very
efficiently be assessed by asking parents and teachers to complete well-researched
normative questionnaires. In fact this quickly allows a professional to obtain
parent and teacher input specifically concerning the presentation and severity
of ADHD symptoms. However, parents should be cautioned that when this type of
questionnaire process is the only means of assessment the rate of false
positive diagnoses may equal the rate of accurate diagnoses of the general
population. Time saving questionnaires and even a brief history provide a very
efficient means of identifying the 20% of children in the general population
who may struggle. To truly understand the reasons for these struggles, a good
evaluator must take a much more detailed and careful history as well as explore
the possibility that symptoms could be the result of other conditions. Keep in
mind that complaints of inattention, off task behaviour and non-compliance are
the most common complaints parents make about children. In particular
inattentiveness is a characteristic description of children with depression,
anxiety, oppositional behavior and even learning disability. For many of these
children their inattentiveness is not the result of a biologically based
problem with developing self-control.
At the other
extreme, it is also not necessary to administer a ten hour neuropsychological
battery to a child referred for symptoms of ADHD in which a brief history and
general questionnaires reveal no indications of delayed academic achievement or
performance, severe emotional problems or family adversity. When parents
suspect their children may experience problems as a result of ADHD, a good
place to begin is by obtaining a book or video about the subject and becoming
educated about common signs, symptoms and behaviours as well as co-occurring
problems. If parents are then concerned their child may experience symptoms of
ADHD to an impairing degree, I suggest they speak with their paediatrician or
family practitioner. Most physicians working with children today also work
closely with child psychologists and can refer the child for an initial
consultation. I also suggest parents request a consultation with their child's
school psychologist. Although school personnel usually are not in the position
to make a diagnosis of ADHD, the input they can provide to the physician and
community psychologist is invaluable in the diagnostic process.
Finally, keep in
mind that when children leave school they are not asked their weakest subject
and most annoying behaviour and then assigned a job involving both for life. In
fact, it is just the opposite. We accomplish our goals in life through our
strengths and assets. For me, an evaluation considering ADHD in a child must
also place equal focus on defining and understanding that child's strengths and
abilities.
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