ADHD: Getting the assessment and diagnosis right.

By Sophie Smith, Clinic Director and Clinical and Developmental Psychologist 

Last month, I spoke as Clinic Director of The Young Mind Clinic at the National Counselling and Psychotherapy Conference (National Maritime Museum in Sydney’s Darling Harbour) focussing on the challenges facing young people today. I spoke about two important topics, the first of which I wrote about a week or two ago (see article Sensitive parenting pays dividends for mental health outcomes in later life in previous News/Articles). The second of which I wanted to share with you today. 

I wanted to talk about the steep rise in requests for ADHD assessments. Not being an epidemiologist, I cannot reliably say why this is occurring, though I suspect the answer is not simple. Instead I gather that there are many factors contributing to this – awareness being one and the word spreading among the community about the natural neurodiversity of people and the lack of diversity of the school system (an obvious challenge of one system catering to many young people with many different strengths and challenges) and the need to provide a more level playing field for those who fall out of sync with the predominant system. We have all just lived through a pandemic. We have struggled – multiple generations together in locked down houses and apartments… trying to each handle our own daily tasks of work or study or school or child care and perhaps this has been difficult – very difficult for some. Perhaps we have noticed characteristics in members of our family we hadn’t previously. There is possibly some genuine biological factors in there – with our current utilisation of technology and all the instant gratification that this brings, together with the ability to be channelling many different information sources at once – could indeed be having a negative impact on our evolving brains to reduce attention span and make it harder to sustain mental effort on more humdrum stimuli. We can also never dismiss the impact of Dr Google in the age of information overload! People, hungry for answers as to what may be to blame for challenges in their lives, seek answers via reading about popularly discussed issues such as ADHD (even though I am often heard suggesting to others not to trust “Dr Google”, I will confess to have scoured the internet myself for answers to ailments which I cannot explain!)

But whatever the “why”, the challenge is to ensure we as professionals are getting it right, and not overlooking other explanations for the behaviours whilst simultaneously making sure we are postively identifying those correctly meeting the criteria. The temptation when a particular condition has an elevated profile is to approach it  as a quick tick a box diagnosis in order to address the need quickly. But it is a complex diagnostic process informed by years of training and experience on the part of the clinician.

What we know is that over simplification of the process may not adequately account for the differential diagnoses, that is, other explanations for why a given difficulty might be occurring. These might include learning disorders, emotional issues, family dynamics issues or other neurodevelopment disorders. Not addressing these -if they do better explain the symptoms for which an assessment is sought – can mean we never get to the heart of helping that young person and may in the process potentially make the journey more convoluted than it has to be. 

So what is best practice for an ADHD Assessment? What is needed first and foremost is a thorough clinical interview that looks carefully at that individual child’s health and development with close attention to the history of their symptoms. We also need to gather a careful understanding of the family’s history to understand the context for that child’s development. 

At the clinic we also ask that parents or carers and teachers who know the child well complete rating scales to capture broad information about a broad range of behavioural and emotional issues but then hone in on any areas of significance or areas that may have come up in the clinical interview (this would generally include attention measures but might also include autism screeners or scales that measure anxiety and mood difficulties).

Something that the recently published national guidelines made clear was that we shouldn’t be looking at someones cognitive profile to tell us whether they have ADHD or not, but it does clearly talk about the benefits of a psychometric assessment to identify potential differential diagnoses such as a specific learning disorder that may better account for what the young person is presenting with at the very least as well as for the obvious benefit of understanding how that young person learns, to better cater to their learning needs. 

We can also weigh up how much these difficulties may be impacting that young person – we do this via observing them during the assessment but we also gather information about their performance at school from school reports and we generally try to obtain some verbal or written comment from teachers. We may also use a specific computerised test of attention. The key thing is that no individual questionnaire or assessment should be taken alone to determine a diagnosis of ADHD. So many factors contribute to whether a young person is diagnosed or not.

The consequence of getting it wrong is that the person may miss out on the correct treatment – whether that be for ADHD or a specific learning disorder, or an emotional problem such as anxiety or something else. Our responsibility as clinicians is to remain vigilant against the temptation to cut corners to make things easier or more affordable (because we know a thorough assessment utilises a lot of clinician time and we know that is expensive). We should all be striving as professionals do the assessment as efficiently as possible (that is not adding in unnecessary and non-evidence based elements) but simultaneously ensuring that we are capturing the full picture of the young person taking into account their personal strengths and weaknesses. 

(Sophie supervises other professionals in this area and has provided free professional development to school counsellors in NSW to address the issues discussed above as well as providing training and guidance to all the clinicians at TYMC who provide assessment and diagnosis for ADHD.)

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