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Assessment and Diagnosis of ADHD in the Child or Adolescent
What is involved in a thorough assessment and diagnosis of ADHD?
The assessment and potential diagnosis of ADHD is not an easy fifteen-minute doctor's visit. The process should be thorough and take more than one visit. The diagnostic procedure for children, adolescents or adults should be comprised of: a physical and psychiatric medical history, an extensive interview with the patient, parents or significant other, and the administration of various symptom rating scales. Usually more than one scale is used to confirm the results.
The process is one of evaluating symptoms and defining their inclusion into the typical ADHD symptom profile while, at the same time, excluding any other possible reasons for these symptoms. For a diagnosis to be made symptoms need to be seen in more than one setting, such as at school and at home. This is necessary because symptoms may be caused by conditions in a particular environment, rather than being due to a medical condition. Currently to qualify for a diagnosis, symptoms are required to be present before the age of twelve. If symptoms are less severe and coping strategies are extensive, ADHD may not be detected early on.
It is not uncommon for a diagnosis of ADHD to be missed on the first and even second assessment, if the symptoms are mild, or do not present in the typical manner. If the child if not visibly hyperactive or displaying other symptoms that parents and teachers find annoying they can often be missed. This is quite common for girls or women, but also in males with the primarily inattentive subtype of ADHD.
Children with ADHD who are very bright can often cope at school by relying on their sheer intelligence, however, not only does their ADHD go undiagnosed, frequently their giftedness often goes undetected as well. These children can end up feeling extremely frustrated and bored, and rarely demonstrate their academic potential. They may be able to make it through elementary and possibly even high school without too much trouble, but when good executive functioning skills, such as working memory, time management and organization, as well as attention regulation, are required at the post-secondary level, many struggle and fail without the proper assistance.
During a complete diagnostic procedure, a screening for other conditions that often coexist with ADHD should be completed. Only one in five people have uncomplicated ADHD, or ADHD without any other co-existing conditions. Some of the conditions that we routinely see with ADHD are: learning disabilities (LDs), anxiety, depression, and oppositional defiant disorder (ODD). On the flip side, ADHD can also be a co-existing disorder of (or often seen with) many other disorders such as Tic Spectrum Disorders, Bipolar Disorder, Conduct Disorder, Mental Retardation, Mood Disorders andAutistic Spectrum Disorder. For this reason it is very important to have a thorough assessment to accurately record all symptoms and 'red flag' any potential disorders. Unfortunately, some conditions do not fully present until a child is older, making them difficult to diagnose at an early age. The longer ADHD goes undiagnosed and untreated and the longer it persists into adulthood without treatment, the more likely co-existing conditions will occur.
A thorough assessment by the physician should include: a complete medical history and physical, including some type of screening to rule out any possible physical disorders such as: hyper or hypo thyroid disorder, kidney or liver disorders and epilepsy. A vision assessment that looks at perceptual problems and not just the function of seeing is essential, especially if the child is having problems with reading. A complete hearing assessment, including a central auditory processing assessment, can determine if the child or adolescent is processing or understands what they are hearing and not just if they are able to hear. CAP disorder can be misdiagnosed as ADHD, but can also occur with ADHD. Testing for CAP disorder is done by a specially trained audiologist. Eyesight and hearing tests should always proceed psychoeducational testing. Please access our website for more detailed information on CAPD, under the 'School' dropdown menu.
It is also recommended that a complete psychoeducational test be done for all children who arestruggling at school academically or behaviourally. Behavioural issues, or a reluctance to do school work, may actually be a 'red flag' that an LD or ADHD exists.While it is important to rule out other potential causes for academic difficulties, which might mimic ADHD symptoms, it is also important to assess whether any coexisting learning disabilities may exist along with ADHD. Students with undiagnosed LDs who are being treated for existing ADHD will continue to struggle academically. Therefore, a complete assessment of a child's learning strengths and needs is essential for a student who continues to struggle at school.
The psychologist must be currently accredited and officially registered to make a diagnosis and should be familiar with testing for all possible learning disabilities and ADHD. They should be prepared to produce a detailed report outlining all areas of difficulty and strength without clustering all findings into an ADHD diagnosis. It will be important that difficulties with executive functioning, processing, written output, sequencing, graphomotor functioning, active working memory as well as long and short term memory be well documented along with other learning disabilities. These are all areas in which children with ADHD may be impaired. If a student demonstrates learning impairments, and is struggling academically, they should have the right to special education resources and accommodations.
Please access the CADDAC website for further information on how your province identifies students with ADHD as exceptional learners: 2010 Provincial Report Card.
Click on the link in this text to access information on The Ontario Ministry of Education memorandum on ADHD.
Who Can and Should Diagnose ADHD?
An assessment can be done by a child and adolescent psychiatrist, (developmental) paediatrician, psychologist, neurologist or a family doctor who is trained in ADHD. In most cases, more than one professional will be required to complete a thorough assessment. Only physicians, not psychologists, may prescribe medication treatment. However, psychologists and other mental health professionals may be the ones to turn to for additional therapy. Since making a diagnosis is not a simple procedure, it is recommended that all professionals working with your child have specialized training and experience in the field of ADHD.