It is not uncommon for parents to feel uncertain about finding a private practitioner to provide a comprehensive evaluation for ADD/ADHD. Generally parents will approach this need by first consulting with their child's pediatrician. This tends to be a good first step in the process given the pediatricians familiarity and expertise with ADD/ADHD. A pediatric office generally will treat a good number of ADD children in their practice either as products of community diagnosticians or their own internal office evaluative process. The high frequency of ADD referrals will often prompt the pediatrician to seek consultative evaluations completed by a familiar mental health practitioner usually a child psychologist. The framework of this professional association will then allow the pediatrician the opportunity to evaluate the child patient medically to rule out any physical problems that may be presenting.Following the completion of a routine physical exam, the pediatrician or family physician would then form a cooperative partnership with the mental health provider to complete the remainder of the evaluation.
Child psychologists are more frequently involved in completing the remainder of the evaluation which will include a choice of various child rating scales and behavior checklists provided to the parents and classroom teacher for completion. Although the rating scales can be a useful piece of information on child behavior and performance, greater emphasis should be placed on additional child and family information that is available. The following areas will provide extremely useful data regarding child functioning:
1. A contact with the child's classroom teacher to discuss the child's typical classroom behavior and performance. Useful information gathered should include a description of the child's general classroom behavior, ability to listen and participate in classroom instruction, ability to engage in assigned tasks, amount of work routinely completed in work periods, motivational aspects that support or interfere with work production, level of physical activity observed in child's work space, the child's interest in meeting learning expectations, the child's level of self confidence when performing academically, and the possible interference of unidentified learning disabilities.
2. An in-depth interview with the parents that includes questions related to pregnancy, birth history, developmental history including landmarks for speech development, early history of illness or injury, family genetic contribution (i.e. immediate or extended members presenting with ADD/ADHD, learning concerns, mood problems, etc), parent's description of the child's typical home behavior, parent's description of classroom performance, and any relevant recent family history that may be recognized as disruptive (i.e. parent conflict or divorce, recent family moves, mental health contacts, difficulties with behavior management at home, emotional or behavioral concerns observed in the child).
3. Observation of child behavior. Brief but relevant behavioral observations of the child are possible in the waiting room prior to the evaluative contact as well as during the period of time when parents and child are together in the examining room.
4. An individual child interview is critical in evaluating the child's general presentation for activity level, maturity level, general orientation, mood, anxiety, task engagement, engagement and maintenance of reciprocal conversation, comprehension and organization of auditory information, speed of processing verbal information, distractibility and attention.
5. School or private evaluations may be available to include in the diagnostic considerations. School evaluations can be an excellent resource for identifying learning disabilities or weaknesses that may be actively interfering with a child's learning and performance in the classroom. It is important to recognize the overlap of inattention and poor task engagement with students struggling with learning concerns. Students with learning concerns are often misidentified as disrupted by ADD/ADHD. Difficulties with inattention and distractibility should be immediately evident in any achievement or cognitive testing that has been attempted with the child.
Once the larger volume of information has been gathered, it then becomes possible to more accurately diagnosis the presence or absence of ADD/ADHD. This can either be attempted by the consulting psychologist independently, or can be offered in a collaborative effort between the pediatrician and the psychologist. If the psychologist should diagnose ADD/ADHD, the pediatrician could then be available to provided a medication intervention if indicated. The psychologist may also have additional recommendations for further intervention as warranted. These recommendations could include:
a. Comprehensive achievement testing to identify possible learning disabilities or weaknesses.
b. Introduction of learning strategies and classroom accommodations based upon the specific learning style suggested for the student.
c. Positive reinforcement contracting in the classroom to target specific on-task and work completion behavior in the classroom.
d. Individual and/or family counseling to address behavior management concerns or perhaps other emotional issues identified by the evaluation.
e. Additional private assessment to address other identified areas of concern to include Sensory Regulation impairment, Learning Issues, Psychiatric Concerns, or other Social/Emotional disorders.
Finally, it is important to recognize the diagnosis of ADD/ADHD to be founded on clinical judgment and diagnostic experience. It should only be attempted by professionals with expertise, practice, and familiarity in the area of ADD diagnostics. Unfortunately, there is not a single testing measure or tool available that can reliably identify the occurrence of this condition. This means that all of the above information will form the data necessary in order to make the best determination. However, extreme caution should be exercised to avoid child practitioners who diagnose this condition based primarily on the results of rating scales. Too often, rating scales are used by practitioners as the main source of collected data on a child patient. While rating scales can provide a "piece of the puzzle" surrounding the areas of concern for a child, they by no means provide the most significant information obtainable concerning child behavior and performance. It is imperative to recognize that "inattention" is a mere symptom of behavior, not an outcome that definitively defines the occurrence of ADD/ADHD. As a symptom, inattention can be observed in multiple diagnostic presentations including learning disabilities, developmental immaturity, cognitive limitations, sensory integration dysfunction, anxiety problems, and mood disorders among the few.
By George Gallegos, Ph.D.
George Gallegos is a licensed clinical psychologist practicing in the Sate of Colorado. He has maintained a private practice for over twenty five years during which time he has developed a long developing expertise with ADHD children. His current work with ADHD assessment and identification is conducted cooperatively with a large pediatric practice. Dr. Gallegos has more recently developed a 78-item test for ADHD entitled the ADHD Pre-Diagnostic Assessment (PDA). The PDA is an ADHD test for parents to use when initial concerns arise about their child. The PDA is intended as a primer measure to help parents decide if a professional evaluation is truly necessary for their child. The PDA can be used to discriminate essential factors that are predictive of ADHD or alternate conditions that interfere with classroom performance including learning disabilities, sensory integration dysfunction, developmental delays, or emotional/behavioral problems.
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