The Complexity of Assessment:
Assessing ADHD in adolescence is a complex task. First, adolescents may have strong feelings about the assessment and possibility of diagnosis. Some may resent parental efforts to have them evaluated. They may deny problems and blame others for their difficulties. Conversely, some may seek a diagnosis of ADHD (even initiating the evaluation) in an effort to explain failure to achieve at expected levels. Similarly, parents may have conflicting and multifaceted motives for seeking an evaluation. Second, childhood onset of problems must be established to make a diagnosis. Thus, parents have to recall and evaluate difficulties their child may have experienced 10 years ago. Third, other disorders and problems may account for the adolescents’ difficulties. Assessment must determine if substance abuse, other psychiatric disorders, family stresses, and/or learning problems account for or contribute to the adolescent’s current difficulties.
All ADHD symptoms are behaviors that people experience on occasion. Who has not been easily distracted, had difficulty sustaining attention or made careless errors? Thus, in diagnosing ADHD one needs to strictly adhere to established diagnostic criteria:
- sufficient number of symptoms are present (6 required)
- symptoms are of sufficient intensity, frequency and duration
- onset of symptoms occurred prior to age 7
- symptoms clearly interfere with functioning
- symptoms occur in more than one setting
- no better explanation for current difficulties exists
While there have been some who have questioned the validity of ADHD, as a real disorder, there is clear evidence that ADHD is a real disorder with potentially deleterious consequences (see Russell Barkley, Ph.D.’s, Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment, 2nd Edition, a comprehensive examination of ADHD research and theory).
The Diagnostic Process:
There is no simple or clear cut test that can be used to diagnosis ADHD. Diagnosis is based on obtaining a clear picture of the individual’s current functioning and history of difficulties. Detailed interviewing is the cornerstone of ADHD assessment. Interviewing is supplemented by rating scales. Interviewing and rating scales should be obtained from multiple sources: parents, the adolescent and teachers. It is important to obtain information from school personnel. Teachers typically observe adolescents in the setting where there is the greatest demand for sustained focus and self-regulation. Thus, they may be able to offer valuable information. However, many high school teachers only have students in one class. Thus, there are times when high school teachers do not have sufficient information about an adolescent’s functioning to offer useful information.
When assessing ADHD symptoms it is not sufficient to ask if symptoms are often present. Rather, interviewing must determine if:
- symptoms occur frequently
- are to such a degree that they interfere with functioning
- are typical of the adolescents’ behavior (longstanding)
Therefore, it is important to carefully evaluate descriptions of problems, seek out specific examples to support statements, and evaluate situations (homework completion) where adolescents with ADHD typically experience significant difficulty.
Many rating scales are available to assist in the diagnostic process. We utilize the Connors Rating scales because there is much research to support their validity and reliability. In addition, Connors and his associates have developed the Connors Wells Self-Report scale, specifically for adolescents.
While tests are available to assist in the diagnostic process there is no evidence to suggest that any tests are able to diagnosis ADHD directly. Continuous Performance Tests, often utilized to assess sustained attending and impulsive responding, are of limited utility. Adolescents may respond adequately to these time limited tests, if sufficiently motivated, but still experience significant difficulties in functioning. Barkley and his associates have found no evidence that psychological testing is of value in assessing ADHD. However, psychological tests are often useful in assisting with differential diagnosis.
Differential diagnosis (the process of determining an accurate diagnosis and distinguishing between different disorders) is particularly important with adolescents. A number of disorders and factors can account for ADHD symptoms. Depression can cause impairments in the ability to concentrate and impair motivation. Anxiety can also interfere with attending. Bipolar disorder is often characterized by impulsive and overactive behavior. Problems with substance abuse, particularly stimulant abuse, can mimic ADHD symptoms. Finally, learning disabilities and cognitive weaknesses can impair academic functioning and interfere with attending and task completion in school. Thus, careful assessment is needed to determine if other disorders or problems are present and/or if other disorders better account for current symptoms. This is particularly true in instances in which there is a relatively recent onset of symptoms and/or symptoms occur primarily in one setting (e.g., learning disabilities might better account for achievement problems). It is important to recognize that other disorders may exist along with ADHD. Thus, differential diagnosis is needed not only to rule out other explanations, but to provide a thorough assessment of the adolescent.
Major family stresses such as divorce and substance abuse negatively affect adolescents and may result in behaviors that mimic problems often associated with ADHD, i.e., underachievement and impulsive behavior (particularly rule breaking). Careful assessment should determine if the adolescent’s difficulties are more a reaction to family conflicts and stresses than an enduring aspect of the adolescent’s behavior.
Given increased awareness of ADHD and the fact that ADHD is characterized by early onset it is important to assess the circumstances that prompt families to seek assessment for an adolescent, particularly if there is not a history of previous assessments and/or problems. It is important to ascertain that a diagnosis of ADHD is not being sought as an explanation for failure to achieve up to expected levels. Failure to achieve at high levels does not equal ADHD.
What to do when diagnosis is unclear: An extended evaluation!
At times, it may be difficult to reach a definitive conclusion regarding the diagnosis of ADHD. The number and intensity of symptoms may be teetering on the border of significance. Patterns of symptoms and reports of problems may be inconsistent, either between parents, between parent(s) and adolescent, and between home and school. In these instances we recommend an extended evaluation process. This involves having a series of appointments over an extended time period, 2-3 months or a school semester, in order to evaluate how the adolescent’s difficulties persist and/or change, and to determine if other factors, family conflicts or other psychiatric disorders, are of greater or lesser significance than they appeared at the time of initial evaluation.
This approach is particularly useful for adolescents whose difficulties primarily involve school work and who are motivated to achieve at high levels. In these instances, we work with adolescents on improving their study habits and time management skills while encouraging parents to let their adolescent take responsibility for school work rather than monitoring, pressuring and checking up on them. If these adolescents make significant improvements (in work completion, organization) it is highly unlikely that a diagnosis of ADHD is warranted. Instead, it is likely that difficulties were related to the adolescent’s ambivalence about achievement or to conflicts with parents about achievement.
Once a diagnosis is made:
Helping adolescents and families accept and understand a diagnosis of ADHD is critical. Because inconsistent behavior is a hallmark of ADHD parents, teachers, and even the adolescent, may have difficulties grasping why the adolescent’s behavior is so variable and why they cannot do better if they simply try harder. It is important to help all family members fully understand the nature of the disorder and its implications.
The consensus within the field is that optimal treatment outcomes are achieved with a combination of medication based treatment and therapy. Family therapy is strongly recommended. First, difficulties with self regulation are inherent to ADHD. Many parents need assistance developing more effective ways to provide their adolescent with structure and guidance. Second, the adolescent’s ADHD affects all family members. The reactions of and interactions between family members may exacerbate problems. Family therapy can address the impact of the adolescents’ ADHD on the family. Third, parents of adolescents often struggle to find the right balance between allowing greater autonomy while still exercising control and influence. These challenges are even greater when the adolescent has ADHD. Family therapy can help parents find more effective ways to assist their adolescent in developing greater autonomy and responsibility.
Individual therapy is useful for adolescents who are willing to examine their own behavior and work on making changes in their ways of coping with and responding to life stresses and the challenges posed by ADHD. These adolescents can be assisted in learning more effective strategies for managing and regulating their behavior.
Coordination with school personnel is critical for assisting adolescents with ADHD. Helping parents and school personnel develop a more effective partnership and find the right balance between providing the adolescent with more structure while facilitating the development of responsibility for self, is a key part of the treatment process. In addition, therapist and prescribing physician need to coordinate their treatment efforts. This is particularly important with adolescents to help insure compliance with medication based treatment and to gauge the benefits of medication.
Finally, adolescents and parents may need additional assistance understanding
treatment options and limitations. Thus, therapy often includes education about resources and treatments for ADHD.
Bibliography and resources
Barkley, R.A., Taking Charge of ADHD, Revised Edition, Guilford Press, N.Y., 2000.
Barkley, R.A., Attention-deficit Hyperactivity Disorder: A Handbook for diagnosis and treatment, 2nd, Guilford Press, N.Y., 1998.
Barkley, R.A., Edwards, G., & Robin, A.R., Defiant teens: A clinician’s manual for assessment and family intervention, Guilford Press, N.Y., 1999.
Conners, C.K., & Jett, J.L., ADHD in Adults and Children: The Latest Assessment and Treatment Strategies. MHS, North Tonowanda, N.Y., l999.
Forgatch, M., & Patterson, G. R., Parents and adolescents living together. Castalia, Eugene, Or, 1989.
Parker, H. ADAPT: Attention deficit accommodation plan for teacher. Specialty Press, Plantation, Fl, 1992.
Parker, H.C., Put yourself in their shoes: Understanding teenagers with attention deficit hyperactivity disorder. Specialty Press, Plantation, Fl. 1999.
Helpful websites include:
www.chadd.org – Children and Adults with Attention Deficit/Hyperactivity Disorder, (CHADD), a national advocacy group’s website offering information, newsletters and support group listings.
www.nichq.org – National Initiative for Children’s Healthcare Quality (NICHQ), a site offering information for parents and professionals on ADHD, and other disorders of childhood.
www.psychcentral.com – Site established to review mental health sites. Provides ratings of sites and links to other sites. Site stays very current and provides frequently updates information.