Wondering if Your Child has ADHD? Why a Getting Comprehensive Evaluation is Important
Last month, we discussed evaluation and deciding if it is the right next step for your child. If you missed that, check it out here: Evaluations.
This month, I want to focus on a subset of evaluations I always get questions about- ADHD evaluations. If you have concerns about your child’s attention, you might be wondering if they should have an ADHD evaluation. Or maybe your pediatrician diagnosed your child with ADHD, and you are wondering if a more robust evaluation would be helpful. This month, I will cover what ADHD is, when to consider an evaluation, the three parts of a high-quality evaluation of attention, and how to ensure your child gets a comprehensive evaluation.
What is ADHD
First, let’s talk about what ADHD is and isn't. It’s important to highlight that the name “Attention Deficit Hyperactivity Disorder” is a misnomer. It implies that people with ADHD lack the ability to pay attention. This is not true. Instead, ADHD is characterized by difficulty regulating or directing one's attention. Parents often think that their child can’t have ADHD because they can focus intently during certain activities. However, one common feature of ADHD is the ability to dive deeply into topics of interest. As they age, people with ADHD often become a trusted source of information on a variety of topics because each time they have a new interest, they become experts on the topic.
Secondly, ADHD is not a good or bad thing. The attention circuits in the brain simply work differently in people with and without ADHD. When a person with ADHD and the people around them understand how their brain works, they can cultivate and leverage their strengths while getting support in areas that might be more challenging.
When to Consider an ADHD Evaluation
ADHD symptoms vary from person to person and can look different as a child gets older. ADHD symptoms are not inherently strengths or weaknesses, but they can create difficulty for students in certain situations. For example, increased movement needs can lead to children getting in trouble in the classroom unless their unique needs are adequately understood and accommodated. Evaluation can get students the accommodations and supports they need to be successful. If you notice some of these themes for your child that negatively impact their daily life, you may want to consider an evaluation.
Creative with robust inner worlds
Many people with ADHD are creative with robust inner worlds. For younger children, this often looks like very elaborate and creative pretend play. This might also look like not seeming to hear someone directly speaking to them, losing track of time, or hyperfocusing on areas of interest.
Moves from one idea to another
Many people with ADHD are out-of-the-box thinkers, idea-generators, and risk-takers. Constant brainstorming of new ideas often makes them great problem solvers. This can also look like moving on before something is finished, playfulness, misplacing things, seeming impatient, or having difficulty organizing a task.
Increased sensory needs
Many people with ADHD have increased sensory needs. This can look like not liking how clothes feel or needing particularly high or low levels of light or sound.
Heightened emotionality
Many people with ADHD are deeply feeling people with keen observation skills. People with ADHD are often highly compassionate and accepting, with strong intuition. This also makes mental health concerns like anxiety and depression more common in people with ADHD.
Increased movement needs
Some people with ADHD have a higher need for movement than people who don’t have ADHD. Sometimes, this is described as seeming like their body is run by a motor. This can also look like fidgeting, standing regularly, preferring active activities, or feeling restless. Some people with ADHD experience more mental than physical restlessness. This group is often described as dreamy or in their heads.
The Three Parts of a High-Quality Evaluation of Attention
If you have decided that an evaluation of attention is right for your child, the next step is to find an evaluator. In most cases, a psychoeducational evaluation done by a psychologist will provide the most robust and useful information. Psychologists specialize in learning, mental health, and academic achievement in relation to the developmental timeline. They conduct in-depth psychoeducational evaluations that provide information about both learning and mental health impacts.
When looking for a psychologist, you want to find one that will use multiple assessment methods to gain a comprehensive view of your child. A comprehensive assessment for ADHD will typically include three types of assessments:
Rating scales
Direct assessment
Clinical interviews
These three types of assessments work together to help the psychologist accurately identify any attention concerns AND identify the root cause of any attention concerns they find.
So, let’s look at each type of assessment and what each adds to an ADHD evaluation.
Rating Scales
Rating scales are assessments given to people your child interacts within different settings. Typically, a clinician asks the parents, teachers, and sometimes other adults they interact with regularly to complete them. There are two main types of rating scales: global rating scales and targeted rating scales.
Often, a clinician will start with a global rating scale that covers everything from depression symptoms to leadership abilities. Then, if the clinician notices a theme emerging, they may follow up with a more tailored rating scale to get more targeted information in a particular area. Rating scales are an effective way for a clinician to get multiple views of a child's functioning. This can help clinicians triangulate data and find patterns.
However, since rating scales are perspective-based assessments, they are prone to confirmation bias. Simply put, if someone thinks a child has an attention concern and then fills out a rating scale about the child’s attention, the rating scale is very likely to show that the child does have an attention concern. This is not a reason not to use rating scales but a good reason only to use them in conjunction with other assessments.
Rating scales are also limited in that they can identify an attention concern but do not, by themselves, help us understand what is causing it. This is particularly important for ADHD because many other things can cause attention concerns with symptoms that look like ADHD, such as trauma, lack of sleep, injury, or other disorders.Direct Assessment
Direct assessments are assessments done by a clinician that directly measure attention. Instead of getting information second-hand, like rating scales, direct assessments allow clinicians to look directly and specifically at someone's attention. These assessments can also zoom in on specific aspects of attention, such as impulse control, attention span, and what happens when the person is asked to shift their attention from one thing to another. There are many direct assessments of attention, each looking slightly different. This is not a comprehensive list; however, these are some common direct assessments a clinician might use if they are concerned about ADHD:
A Developmental Neuropsychological Assessment (NEPSY)
Test of Memory and Learning (TOMAL)
The Wisconsin Coard Scoring Test (WCST)
The Test of Variables of Attention (TOVA)
Test of Everyday Attention (TEA)
Conners’ Continuous Performance Test (CPT)
Comprehensive cognitive or IQ assessments such as Kaufman, Wechsler, or Stanford-Binet
Direct assessments are a key part of the puzzle because of the specific first-hand information they give clinicians. However, they do not show the complete picture either. They provide information about how someone's attention is functioning, but they do not tell the clinician how this impacts their daily life or what the root cause of the attention concern is.
Clinical Interviews
Clinical interviews are the third and final part of a strong evaluation of attention. They involve the clinician spending time one-on-one with the child. For older children, this may be an interview and observation. For younger children, the clinician may mainly play with the child and then observe the child playing. For any child, the clinician will also do a parent interview. In the child and parent interviews, the clinician will ask about a wide variety of topics, including medications, sleep, diet, schedules and routines, trauma, and injuries.
The clinical interview allows the clinician to get more nuanced information that is not captured by rating scales or direct assessments. It also allows the clinician to dive into WHY attention is impacted. After rating scales and direct assessments, the clinician might be confident that there is an attention concern, but they still don’t know the root cause. It could be ADHD, or it could be many things that impact attention and look like ADHD. You may wonder, “But why does that matter?”. Knowing the cause of an attention concern is important because the cause dictates the treatment, and recommended treatments vary greatly depending on the cause. For example, one of my patients had a traumatic brain injury as a baby. In school, he had difficulty regulating his attention and had symptoms that looked like ADHD. He was misdiagnosed with ADHD and put on a stimulant, a common ADHD treatment. This medication was a terrible fit for him. He felt awful, his symptoms and behaviors increased, and he reported that he felt like his brain was “on fire.” This occurred because his symptoms were caused by a brain injury, not ADHD, making a stimulant an inappropriate treatment for him. A more robust evaluation of attention allowed this misdiagnosis to be found and for him to get a treatment that was the right fit.
A strong three-part assessment with rating scales, direct assessment, and a clinical interview allows the clinician to find areas of concern, learn details about what is occurring, and contextualize this information. The result is an evaluation that reflects what the child is experiencing, how that impacts their life, and what is causing it. This approach allows the clinician to make informed decisions based on detailed, well-rounded information.
Finding a Comprehensive ADHD Evaluation For Your Child
To ensure your child gets a robust and complete evaluation, look for a psychologist who offers psychoeducational assessments and specializes in ADHD. Before committing to a clinician, ask them about their evaluation process to ensure they are a good fit for your family. Some helpful questions are:
What assessments do you use to evaluate attention?
Listen for the names of direct assessments of attention listed above. If you do not recognize an assessment, ask them, “What type of assessment is that? What is its purpose?”If they do discuss any direct assessments of attention, ask them, “How do you make sure an attention concern is not caused by something other than ADHD?”
What is your clinical interview process like?
Listen for various questions or topics they would ask you and your child, including medical history, sleep, and diet.
How do you support families post-diagnosis, if one is warranted?
Listen for robust recommendations, ability to ask follow-up questions after the debrief session, and referrals to other providers as appropriate.