Benefits of a Comprehensive Evaluation for ADHD

I value a comprehensive evaluation process for ADHD (and  many other diagnoses) due to a number of factors.

Numerous other conditions or issues can appear ADHD-like as they have some impact on overall executive functioning, although most do not evidence a history of executive functioning symptoms from birth. You are born with ADHD and it is highly heritable. Conditions or issues that I am always differentiating from and ruling out as the primary cause of reported ADHD symptoms include Autism Spectrum Disorder, Obsessive-Compulsive Disorder, Anxiety Disorders, Trauma history, Dissociation, Depression, frontal lobe or other brain related injuries or abnormalities (e.g., tumors), sleep disorders, Oppositional Defiant Disorder, Learning Disabilities (Dyslexia, Dysgraphia, Dyscalculia), Speech/Language Disorders (also including significant speech delays due to a number of factors), Personality Disorders, and high intelligence.

Specialization in evaluation of high intelligence. This is not included as a condition/diagnosis, but rather in order to describe a cluster of related issues that are often present for individuals who have high intelligence. You often do not hear about the difficulties associated with high intelligence in public discourse, although it is common to see a number of issues that arise with high intelligence, many of which overlap with ADHD symptoms. Psychologists and/or neuropsychologists who specialize in cognitive evaluations are more likely to have training and/or specialization in identification of high intelligence than many other types of providers who diagnosis ADHD, such as medical prescribers, psychiatrists, masters level therapists who do not complete cognitive testing, etc. Related issues for intelligent individuals often include:

• Delayed early emotional development can appear like ADHD emotional dysregulation.

• Delayed social development can mimic early difficulties children with ADHD have with peer interactions (both are also often bullied by peers)

• Strong proclivity for displaying obsessive and/or compulsive coping strategies from a young age driven by their precocious verbal and reasoning development. (Obsessive and compulsive compensation strategies are frequently present for individuals with ADHD)

• A higher rate of sensory aversions and enthrallments than their less intelligent peers, which can look like fidgeting, restlessness, and hyperactivity in ADHD (or even ASD)

• A driving need to be stimulated at all times, with active vigilance against boredom. Their need for constant stimulation appears like ADHD hyper-focusing (or even ASD repetitive/restrictive behaviors).

Comprehensive identification of all conditions and issues is important. Cooccurring conditions with ADHD are common. For Children (via Larson, 2011): Learning Disability (45%), Conduct Disorder (27%), Anxiety Disorder (18%), Depression (15%), Speech Problems (12%), Oppositional Defiance Disorder (41%). For Adults (via Kessler et al. 2006): Mood Disorder (38.3%), Anxiety Disorder (47.1%), Substance Abuse Disorder (15.2%), Intermittent Explosive Disorder (19.6%). And these are just to name a few of the findings on cooccurring conditions with ADHD. Comprehensive identification of cooccurring conditions and issues is something that most evaluations by prescribers are not going to exhaustively address. Diagnosis over time by a therapist may touch on many aspects of concurrent conditions or issues, although lack of cognitive testing may leave out important clues to different diagnoses and how symptoms actually present in day to day functioning. Diagnosis from within school systems will often be the most limited as the information pertains to functioning in school and does not constitute actual clinical diagnosis. Rather it is considered educational designations (e.g., ADHD, ASD, Learning Disabilities) that constitute the need for a 504/IEP plan and related accommodations. I tend to view school evaluations as helpful and often necessary in getting the accommodations process started, but families should always seek a more comprehensive evaluation in the community to confirm, expand, and clarify conditions and issues for their child's functioning not only at school, but in the rest of life.

Validation. I often tell adult clients, even if they have a prior ADHD diagnosis from elsewhere, that it is beneficial to go through a comprehensive evaluation for ADHD at least once in adulthood. I cannot count the number of times over the years (12+) that adult clients have been in tears during the testing feedback process. Not because they were shamed about their performance or their symptoms, but because they felt validated, informed, empowered, and more fully understood as complex persons by a medical/mental health provider. The nature of ADHD symptoms are elusive. The frontal lobe cooperates some moments resulting in effective working memory, attention, and behavioral restraint; while at other moments the frontal lobe does not cooperate. This results in variable presentation of symptoms from moment to moment for individuals with ADHD. I believe this contributes to many individuals’ complaints of why it was so hard to get diagnosed in the first place or for them to really believe that they actually have ADHD. Previously they may have attributed many symptoms to life stressors, their anxiety symptoms, a perceived learning disability, or some other internal or external phenomenon. For adults to have someone identify and validate symptoms that are occurring in the moment during the evaluation process, explore unidentified presentation of symptoms they may not have been previously considered, explanation of how symptoms may generalize to other areas of their functioning, and then to see their actual variability in cognitive performance explained moment to moment— is extremely validating. The same can be said for parents of children or teens who are finally better able to understand the challenges their children face and the strengths they possess.

Diagnoses are only a small part of the full picture. This is a central value that I work under when completing evaluations. Diagnoses are often a necessary evil: They label definable problems, guide specific and proven treatments, and provide access to specific needed services or supports. Diagnosis alone without broader understanding of history, personal strengths, psychological and cognitive adaptive strategies, held personal/community values, can be damaging or misleading. This is especially true with ADHD as executive functioning symptoms are really presented through and defined by an individual’s personality: How social are they, how do they cope with stress and symptoms, strengths and weaknesses with self-esteem and self-efficacy, how they make various decisions in their life, etc. No two people with ADHD present the very same way. I tend to actually even avoid the dichotomizing of ADHD into different subtypes as it is often misleading and tends to minimize individuals personality, symptom presentation, and uniquely tailored compensation strat

egies for those symptoms. My goal is that those I evaluate leave better understanding themselves or their family member over just labeling them with the correct diagnoses. In an age of efficient, impersonal, and sterilized medical care; my evaluation process is intentionally very different. My office is a cozy living room environment where dialogue happens, not interrogation.

Comprehensive reports provide detailed explanation and specialized referrals.  Evaluation reports (typically 6-10 pages) include history of symptoms and functioning, cognitive performance and interpretation of results, overall summarization of diagnoses and how it fits in an individual’s broader functioning and history, and then recommendations for treatment and improved functioning  in different domains of life. For any age, results can be used to seek educational accommodations. Recommendations for either 504 or IEP accommodations, whatever is relevant for each individual. This helps to guide accommodations for children and teens through school, into SAT and ACT examinations, and in establishing appropriate accommodations for college. Adults can also use the report to seek accommodations for undergrad, grad school, med school, law school, and beyond. Accommodations can also be sought with a report for professional exams including MCAT, LSAT, graduate entrance exams, realtor licensing test, etc.; and even for state driver’s license tests. Individuals can seek occupational accommodations with a report if needed. Other specialized recommendations in reports often include specific areas or issues to focus on in new or ongoing therapy, referral to address medical issues or to rule them out (e.g., hormone, thyroid, neurological issues, sleep testing, etc.), appropriate educational settings and/or models for children/teens, referral for application of state disability (social security and/or developmental disability), additional helpful services (occupational therapy, speech therapy, physical therapy, etc.), recommendations for parents to help their children function better at home, etc.

Comprehensive evaluations help to avoid unwanted and complicated functional medication trials to diagnosis ADHD. Medical providers certainly gather history when diagnosing ADHD, although limits in their training regarding mental health, psychological development, and cognitive abilities and related functional concerns mean that their evaluation process is often limited in scope and relies more heavily on simply trying various classes of medications to determine if a positive response is clearly visible, which then confirms the suspected diagnosis or rules out hypothesized diagnoses. In such situations, patients often become frustrated if an effective medication is not identified quickly. And the longer medication trials continue, often the more confused patients become. This occurs because medical prescribers have to change medical diagnoses in the patient’s record to provide reasoning/support to establish medical necessity for prescription of a new and/or different class of medication, so that insurance will cover them. Over time this can result in poorly defined conceptualization of patients’ lives, symptoms, and diagnoses; which can be extremely frustrating and/or discouraging to patients. I want to be clear that not all medical prescribers fall into this category, although some certainly do. Effective psychiatric treatment occurs in a developing relationship of trust, education, and dialogue. I also do not want to imply that ADHD medication treatment is not a trial and error process, because it is to some degree. There are a lot of options for stimulants alone and that is not including treatment for other cooccurring conditions. It can be complicated. My point is that it is important to understand the complexity of ADHD diagnosis, especially when cooccurring conditions are present, and to understand what type of provider can provide what type of evaluative/diagnostic process.

Access to medication treatment and efficient continuation of services. Comprehensive evaluations with a report help to ensure that medical providers are willing to start or keep prescribing needed medications. Many non-psychiatrically trained medical doctors prefer that a comprehensive evaluation by a psychologist or neuropsychologist be completed to formally diagnosis ADHD and/or other conditions before they are wiling to consider stimulant medications trials for a patient. Comprehensive reports also help individuals as they move to a new area/state/country, or even when they need a new prescriber for various reasons, as it promotes more efficient continuation of services. Recent research suggests that around 84% of psychiatric prescriptions are now prescribed in the U.S. by non-psychiatrically trained medical providers. This is especially relevant in the Treasure Valley as we have a shortage of psychiatric prescribers and long wait lists abound for the ones we do have.

Observation of current response to prescribed stimulant medication. An additional benefit of my model of evaluation for individuals who are already diagnosed with ADHD and are on a stimulant medication is that I will, with their and their doctor’s approval, have them take their medication mid-evaluation so that I can determine how long it takes to identify observable differences in their functioning, to document what did and did not change in their functioning, to weigh the pros and cons of what was observed, and to make recommendations in writing to inform their discussion with their prescriber that may facilitate more effective medication trials. I am not a prescriber, and do not claim to be. My evaluation model over numerous hours in a single day allows for a unique view on stimulant medication effectiveness in real time that easily integrates with the behavioral observations and cognitive performance that I am already monitoring for and documenting. For most formulations of stimulants, that are appropriately dosed for the individual, noticeable symptom reduction and behavioral differences are identifiable in 10 to 15 minutes.

Hopefully, this blog has been helpful in highlighting the benefits of a comprehensive evaluation for ADHD, differentiating between different types of evaluation/diagnostic processes by different types of providers, while also highlighting my own values in the evaluation process.