If you were looking for an online test to find out if your child has ADHD, you won't find it here. Although the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is based on specific behavioral criteria listed in the Diagnostic and Statistic Manual (DSM-V), an effective evaluation is more complex than checking off whether your child displays those behaviors. As a parent, being informed helps you be the best advocate for your child and will help you make a decision when considering an evaluation.
Many psychological, learning, and biological problems can mimic or heighten behaviors characteristic of ADHD. Such conditions include but are not limited to anxiety, depression, sensory processing disorder, head trauma, life stress, and developmental disorders. For example, anxiety can cause poor concentration and focus. Poor sleep has consistently been associated with behavior problems that may look like ADHD.
Two-thirds of children with ADHD also have a co-occurring disorder. Common disorders include disruptive behavior disorders, anxiety, depression, learning problems, tic disorders, and substance use. Without a thorough evaluation, a child may be misdiagnosed or associated problems may be overlooked. A thorough evaluation provides invaluable information not only about whether a child may meet the criteria for ADHD, but also offer information about specific academic, emotional, and behavioral functioning that will inform treatment.
Components of a thorough evaluation may include:
- Hearing and vision screen. Prior to seeking an evaluation for ADHD, children need to be screened for any hearing or vision problems, as both hearing and vision problems are known to be associated with behavior problems characteristic of ADHD.
- A structured interview with a licensed professional (physician, psychologist, psychiatrist). A structured interview is designed to gather specific information about possible symptoms of ADHD in addition to possible issues that could mimic or exacerbate attention, hyperactivity, or impulsivity (for example, disrupted sleep, changes in environment, etc). Information is obtained about a child's emotional and behavioral functioning across settings (e.g., at home, at school, with peers). The child can be interviewed separately or together with parents, depending on the age, to gather this information. The interviewer will explore whether behaviors associated with ADHD negatively impact a child's functioning in the home, at school, and socially.
- Standardized questionnaires, general and specific, completed by at least one parent, one teacher, as well as the child if possible. Nationally-normed, standardized questionnaires assess overall emotional, social, and behavioral (including attention and hyperactivity) functioning, indicate the severity of symptoms relative to child's peer group, and screens for other contributing or co-occurring conditions. Examples include the Conners' Rating Scales and the Behavior Assessment System for Children (BASC). Specific questionnaires provide information on frequency of specific ADHD symptoms that mirror diagnostic criteria. Commonly used questionnaires include the Vanderbilt NICHQ, the SNAP-IV, or the ADHD rating scale. Some professionals may also include measures of executive functioning such as the Behavior Rating Inventory of Executive Functioning (BRIEF) or Comprehensive Executive Functioning Inventory (CEFI). Executive functioning overlaps with but is not identical to problems associated in cognitive functioning and attention in ADHD.
- Observations of the child. It should go without saying that the professional should meet and interact with the child. Ideally, observations are made during informal conversation and play as well as in structured tasks or play.
- Testing. Testing provides specific scores relative to peers as well as useful observations of a child in a testing situation and while performing certain types of tasks. The amount and type of testing often depends on information obtained during the initial interview. No specific test can provide a definitive diagnosis of ADHD, but results and observations from testing aid the diagnostic process. Many professionals administer a visual and/or auditory continuous performance task (CPT), a task designed to assess sustained and selective attention and identify problems with distractibility and impulsivity. Additional tests can further evaluate memory, processing speed, and other executive functions. If a child is having academic difficulties, formal IQ and achievement tests can identify specific learning disabilities. Although formal testing is not required for a diagnosis of ADHD, it can provide invaluable information to aid in a diagnosis and provide a more complete picture of a child's attention, executive functioning, and learning profile of strengths and challenges.
- Feedback. A feedback session reviews the results of the evaluation, discussing how information obtained in the evaluation led or did not lead to a diagnosis and the presence of any co-occuring problems. Following diagnostic impressions, the professional typically provides recommendations for treatment, brief intervention strategies, and resources.
- Written Report. Once an evaluation is complete, parents receive a written summary of the evaluation and diagnosis for their records and to provide to collaborating professionals as appropriate (e.g., school, pediatrician, psychiatrist, therapist, etc.)
Obtaining a diagnosis for ADHD is a complex process. Components and specifics of an evaluation will vary, but in the end, a thorough evaluation provides information that helps parents understand their child better and what options are moving forward to set their child up for success. Here's how I ultimately categorize ADHD evaluations:
- Basic: Interview and specific questionnaire regarding ADHD that contains screening for other disorders, completed by at least 2 out of 3 sources (parents, teacher, or self). This is standard practice in many pediatrician's offices.
- Thorough: Structured interview, broad-based and specific questionnaires from multiple sources. Some type of testing or observations. The evaluation is conducted by a licensed professional. This testing is often sufficient for school-aged children or for those with no concerns about possible learning problems or if a clinician already knows the child well. For example, some children present with anxiety. Once the anxiety component is better addressed, the possibility of ADHD may become more apparent and more easily established with this type of testing. This slightly more comprehensive evaluation can better inform treatment.
- Comprehensive: All of the above as well as intelligence, learning, and memory testing. I often recommend the gold standard testing for adolescents, especially high school and beyond as it provides necessary information to help prepare for college and beyond. If you need accommodations for the SAT or ACT, many require this type of testing as well.