Assessing ADHD in Children and Adults: A Comprehensive Guide

By: Clinical Psychologist, Shannon Grassby



Introduction

Attention-Deficit/Hyperactivity Disorder, or ADHD, is a neurodevelopmental brain style characterised by differences in the development of a person’s executive function and pre-frontal cortex, and impacts upon a person’s ability to:

  • Pay attention.
  • Concentrate or focus on tasks, especially tasks that are boring or repetitive.
  • Initiate, or start tasks.
  • Plan and organise tasks or sequences within instructions.
  • Monitor their completion of work or a task, which may lead to incomplete tasks or “carelessly” or rushed task completion.
  • Inhibit behaviours, which can lead to being impulsive or seeming to act before thinking.
    • This can mean a person fidgets or moves often.
    • May intrude on others by speaking or finishing their sentences.
    • Be very talkative.
    • Be easily distracted by their thoughts or their environment, like noises.
  • Regulate their emotions.

ADHDers, or people with an ADHD brain style, are interest-based learners. This means that despite not being able to pay attention to some things, on topics of interest they are often able to be very focussed and pay attention for long periods of time.

These differences can lead to a range of difficulties within the persons school, work or home environments. ADHDers may be labelled as lazy or unmotivated, may not “live up to their potential”, or may otherwise feel frustrated with themselves for not being able to “do” seemingly simple everyday tasks.

Recognising and identifying neurodivergent brain styles plays an important role in helping to support a person’s mental health and understanding of themselves. It also helps to ensure  appropriate supports and strategies can be put in place to help the person and their family manage their everyday life. Usually, the first step in understanding whether you or your child is an ADHDer is to seek an assessment, either with a psychologist, paediatrician or psychiatrist who understands neurodiversity and ADHD.

Why Get a Formal Assessment?

Many people avoid a formal assessment as they believe the processis lengthy, cost-prohibitive, and potentially not available in their area especially if they live in a rural or remote area.

However, a formal assessment process can be very useful and important for both children and adults. For both children and adults, a formal process is helpful is to ensure that the supports that are provided are tailored and appropriate, as some supports or strategies which may be suitable for a neurotypical person may not be the best choice for an ADHDer.

For children, a formal assessment process and diagnosis can assist you and your child in accessing appropriate supports, such as medication or therapeutic supports. It assists health professionals in having a “short hand” but accurate summary of the strengths and difficulties your child may have, and it can help schools to better understand your child also.

For adults, a formal assessment process is often a validating experience, providing recognition and better understanding of many strengths and difficulties that person may have experienced over their life. A formal process can often be more reassuring than a self-diagnostic process for some people.

Formal assessment processes also allow for consideration and possible assessment of other co-occurring or differential diagnoses or brain styles which may also form an important piece of understand a person’s strengths and differences.

What are Co-occurring and Differential Diagnoses?

All assessment processes should include appropriate consideration of co-occurring brain styles or diagnoses as well as differential diagnoses. Co-occurring brain styles or diagnoses are those that are present at the same time as ADHD or the primary diagnosis. Differential diagnoses are different diagnoses which should be considered and may better explain the current difficulties a person is experiencing.

Common co-occurring or differential presentations or diagnoses that your chosen assessor may consider including, (but are not limited to):

  • Anxiety.
  • Autism.
  • Learning Difficulties and Disorders including Specific Learning Disorders in Reading (Dyslexia), Writing or Mathematics.
  • Behavioural Difficulties including diagnoses such as Oppositional Defiant Disorder or Conduct Disorder.
  • Cognitive difficulties.
  • Tic Disorder or Tourettes.

Your assessor may include additional questionnaires or tests to appropriately consider, and “rule-in” or “rule-out” the presentations, conditions, diagnoses or brain styles which are relevant to you and your child.

If throughout the course of the assessment process, your assessor feels it is important to consider in more detail potential co-occurring brain styles or diagnoses, they may add to the assessment procedures to include more specific questionnaires or assessments.

The Assessment Process

Assessment: What to Expect

Throughout the assessment process, you should expect to be asked detailed questions throughout unstructured or structured interviews (or both), as well as for you to complete a variety of formal questionnaires.

Most of all, you should expect to be listened to and to feel heard and validated by your assessor and the assessment process. You should also expect the assessment process to be conducted in a neuro-affirming way, which means that you are able to feel that the strengths and differences of your brain are understood and taken into account, rather than feeling that there is something “wrong”, “deficit”, “disordered” or “bad” about you.

If your assessment is being conducted by a psychologist, at the completion of the assessment you should also expect to receive a feedback session where the outcome of the assessment is shared with you and you are able to review the report that your assessor has compiled, as well as their recommendations for support.

Assessment Tools and Methods

A Comprehensive assessment process should include information gathering from a range of sources, using a range of methods and across large periods of the person’s life. This is the same for both children and adults.

Assessment Tools

For your child, you should expect the assessment process to include:

  • An initial biopsychosocial interview with your chosen health professional, taking detailed information as to the current difficulties, education history, medical history, developmental history, family history, social history, mental health screening and appropriate differential diagnoses considered such as anxiety.
  • Use of validated psychological questionnaires, with reports from parents, school, and self if age appropriate.
    • At Spencer Health, we choose to use the Conners questionnaires, as well as the BRIEF.
    • Mental health screeners may also be used, or other relevant questionnaires.
  • The assessing health professional may wish to speak to your child’s teachers or educators.
  • The assessing health professional may also wish to include a cognitive and academic assessment to consider appropriate differential or co-occurring diagnoses or explanations for your child’s current difficulties, such as learning difficulties.
  • The assessing health professional may also wish to include formal neuropsychological assessments of executive function.
  • Review of any relevant documents, such as previous assessment reports, letters and school reports.

When conducting an assessment for an adult, you should expect the assessment process to include;

  • An initial biopsychosocial interview with your chosen health professional, taking detailed information as to the current difficulties, education and work history, medical history, developmental history, family history, social history, drug and alcohol history, previous intervention or support history including previous assessments that may have been conducted.
  • Use of validated psychological questionnaires, with reports from self and an “observer” report. People often choose to nominate their parent or partner to complete the observer report.
    • At Spencer Health, we choose to use the CAARS questionnaires, as well as the BRIEF, mental health screeners and other specific ADHD questionnaires.
  • Use of a structured diagnostic interview, to assess the presence of ADHD symptoms in your current life, as well as in your earlier years. Typically, this interview is also conducted with your chosen “observer” to provide collateral information.
  • Review of any relevant documents, such as previous assessment reports, letters and school reports.

Assessment Criteria

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition Revised (DSM-V-TR) sets out the formal diagnostic criteria that children and adults are required to meet to aide a diagnosis, or recognition, of an ADHD brain style. The symptoms of ADHD are clustered into an “inattentive” cluster and a “hyperactive/impulsive” cluster, which some people presenting with both clusters of symptoms. This is referred to as “predominantly inattentive”, “predominantly hyperactive”, or “combined” presentations of ADHD.

In previous editions of the DSM, inattentive presentations of an ADHD brain style was referred to as ADD (Attention Deficit Disorder), and hyperactive/impulsive presentations of an ADHD brain style was referred to as ADHD (Attention-Deficit/Hyperactivity Disorder). Whilst these terms are no longer used in clinical practice, you may still see people make reference to “ADD” online or in some schools.

In order to meet diagnostic criteria, a minimum number of symptoms within a symptom cluster should be met. The number of criteria within each symptom cluster are slightly different between children an adults, though the same symptoms are used to assess both children and adults.

Children are required to meet the following criteria:

5 or more inattentive symptoms for 6 months or more in adulthood.
OR
5 or more hyperactive/impulsive symptoms for 6 months or more in adulthood,
AND
Symptoms are currently impacting upon the person in at least 2 domains of their life, such as work, education, family life, social life and self-esteem,

Adults are required to meet the following criteria:

5 or more inattentive symptoms for 6 months or more in adulthood.
OR
5 or more hyperactive/impulsive symptoms for 6 months or more in adulthood.
AND
3 or more symptoms in either symptom cluster evident in childhood.
AND
Evidence of a lifelong pattern of symptoms prior to 12 years of age.
AND
Symptoms are currently impacting upon the person in at least 2 domains of their life, such as work, education, family life, social life and self-esteem.

Gender Differences

More recently, there has been a greater understanding as to how gender can affect how a person’s symptoms of their ADHD brain style are expressed which can lead to missed opportunities for recognition of their brain style, or wrong diagnosis.

Generally, girls and women may be more aware of aspects of their social environment. They may be able to determine from a younger age that certain aspects of them or how their brain copes with their environment may not be socially acceptable or appropriate. As such, they may seek to hide or cover-up for these differences in some way to reduce negative feedback, or how much they stand out from their peers, or may find other ways to compensate or mask. This is referred to as an “internalised” presentation, and it can make it difficult for caregivers, teachers and professionals to detect these “hidden” or “masked” difficulties.

Greater public awareness of the internalised, or masked, presentation of ADHD, particularly in girls and women has enabled many people to understand themselves and their brain in a more complete way, and it is important that your chosen assessor understands this presentation and takes this into account when conducted the assessment.

Ready to Take the Next Step?

At Spencer Health, we assess and work with ADHDer children, adults, parents and neurodiverse or neurospicy families. We offer a range of services including assessment, therapy and ADHD coaching and many services can be delivered via telehealth. If you are ready to book in an assessment for yourself or your child or are interested in just having an initial conversation with one of our trained psychologists to decide if it is worth pursuing an assessment, please get in touch. Spencer Health is a neuroaffirming organisation and we are lucky to count many neurodivergent psychologists as colleagues.

If you would like to meet more of our team, or learn more about our services you can do so here https://spencerhealth.com.au/spencer-health-team/ or if you are ready to book in, you can do so here https://spencerhealth.com.au/contact/