One of the most common reasons families come to see me is because of a suspicion of problems with attention, focus or distractibility. I am often asked to “test” children for Attention Deficit Hyperactivity Disorder, or ADHD. Other families assure me that their child was “tested” for ADHD and found either to have or not have the disorder. The fact is that there is no test for ADHD, not in the sense of a definitive test that will tell us for certain which children have it and which do not. The diagnosis of ADHD must be made by gathering many types of information from multiple sources, and can never be made by relying on a single assessment, such as a questionnaire or list of symptoms.
The process of assessing a child follows the same steps outlined on my Assessment page. It begins with meeting with parents to get a detailed and thorough history of your child’s development and behavior, and your observations about the concerns that bring you to see me. I will then generally have you and your child’s teacher complete some questionnaires. Occasionally, I may do a classroom observation at your child’s school. In some cases I may recommend some psychological testing, especially if your child is struggling in school.
I will talk to your child and observe them in my office, but that tells me almost nothing about what they may be like in their real world. Children with ADHD often are attentive and cooperative when they see me, and children without ADHD may act up and bounce around the room. The time I can spend with a child in my office is so brief, and so novel and different from their normal environment that what I see during that time tells me very little about what they are really like. I have no special powers, and the observations of parents and teachers who know the child well are much more important in understanding what is going on.
Perhaps the most important part of my work when assessing whether a child may have ADHD is going over the results with parents, and helping them understand my conclusions, why I came to those conclusions, and what they tell us about what is likely to be helpful. As mentioned above, an assessment for ADHD involves bringing together numerous sources of information. The more those different sources point to the same conclusion, the more confident we can be. Even when I am as confident as I can be that a child meets the requirements for the diagnosis of ADHD, I always tell parents that it is a tentative, working diagnosis that must be proven over time. ADHD is a chronic, lifelong condition, and it takes observation of your child’s development and adjustment, as well as their response to intervention, over long periods of time to be “sure” that you are truly dealing with ADHD.
One of the most crucial stages of understanding and coming to terms with the diagnosis of ADHD is understanding what that diagnosis actually means. What is ADHD? Many books have been written on the subject, including several that I often recommend to the families I work with. To begin with, the name Attention Deficit Hyperactivity Disorder is a poor one. ADHD is much more than not paying attention, and there are many children with ADHD that are not noticeably any more active than other children. A better way of understanding the disorder is as a problem with Executive Function, or the brain’s ability to control its own behavior in pursuit of a goal. Executive function is a broad term that involves self-control, planning, self-awareness, the way in which we use memory and the things we have learned, and our ability to always keep track of whether we are doing what we need to be doing. Children with ADHD have a particular problem self-regulating when they are trying to do something that they do not especially want to do. We all have to work harder under those circumstance, but the child with ADHD has much more trouble managing when the task at hand is not interesting or immediately rewarding. While the child with ADHD will improve in these abilities as they get older, everyone else improves too, so that the child who started out behind stays behind. We used to believe that most “hyperactive children” (as we called them when I began my training in the early ‘80s) would outgrow the problem. We now understand why this is not the case.
The understanding that the basic problem for children with ADHD is a deficit in the ability to self-regulate their behavior leads to the most important strategy for treating the problem. Studies over the past several decades that have relied on helping children learn to be better at tracking what they do, and thinking before they act, have generally failed. Research has pretty convincingly shown that therapy for children with ADHD must focus on helping parents and teachers learn to work with them in a different way. I call the process “building an executive scaffolding” around the child. Children who suffer from ADHD need more structure to meet the demands of school, to complete tasks at home, and to navigate the rules, distractions and temptations of daily life. They require more explicit instructions, more prompts to follow those instructions, more immediate and more powerful rewards for their successes, and sometimes more negative consequences for their missteps. They need parents and teachers to work at a higher level of consistency and technical sophistication in their approach to helping kids get things done. Above all they require a positive and supportive environment. My job is to help families put those principles into action in their day to day lives.
Russell Barkley, Ph.D.: “It’s not that kids with ADD don’t know what to do — it’s that they don’t do what they know.”