AD/HD 101: Across The Lifespan

November 14, 2012 | By

A wise thought to consider as we begin to think about the evaluation of AD/HD: Everything that looks like AD/HD is not AD/HD. (In fact, much of it is not!) The symptoms of inattentiveness, impulsivity, and restlessness are all quite common and universal. For example, most people tend to experience one or more of them “on a bad day” or “some of the time” or “here and there.” As such, it is very easy for people to identify with these symptoms, and believe that they have this disorder. Furthermore, “distractibility” (or being functionally distracted) is a secondary symptom of many other physical, emotional, metabolic, neurological, and other problems: Chronic fatigue, chronic stress, poor diet, depression, anxiety, Bipolar Disorder, allergies, diabetes, chronic pain, sensory integration problems, visual or auditory processing problems, andvirtually anything that can make a person feel bad on a regular basis. In other words, people with any of the above problems might even show chronic distractibility and/or impulsivity and/or restlessness, but still not have AD/HD, nor respond to treatment for AD/HD! (We can see why AD/HD is so often over-diagnosed, and so many children are put on medication for AD/HD inappropriately.)

At the same time, AD/HD does exist. It is a bona-fide neurological disorder, which many people (legitimately) have. In severe cases, it can create devastating consequences in a person’s life. In mild or moderate cases, it can still present formidable challenges. However, it is a treatable disorder. It should never be treated with medication alone, but the combination of medication (if needed), thorough education about AD/HD, AD/HD-related skills training, and (also if needed) counseling or psychotherapy, can be very effective. (AD/HD-related skills training can involve any of the following: organizational, attention, memory, time management, social skills, self-control, self-discipline, behavior modification, and other forms of training, all geared toward helping the young person or adult compensate for the attention, behavior, and/or motor problems which characterize AD/HD.) Counseling or psychotherapy is needed when the individual has developed depression, anxiety, relationship problems, or other painful issues, which commonly co-occur with AD/HD, especially with pre-adolescents, adolescents, and adults (e.g. someone who has lived with the difficulties of AD/HD long enough for it to take an understandable toll).

Therefore, the process of evaluation for AD/HD must: (1) establish that the individual experiences not just occasional, but regular and chronic symptoms of inattentiveness, plus possibly: (a) impulsivity, (b) emotional over-reactivity, and (c) restlessness/hyperactivity. (It is possible to get the diagnosis of AD/HD with distractibility alone, although this type of AD/HD is less common.) The evaluation must also: (2) systematically rule out the many other potential causes of AD/HD-like symptoms, and (3) establish that the individual is functionally impaired in some way(s) by the AD/HD symptoms.

When AD/HD is suspected, a good first step is to have your child seen by the pediatrician or family physician. (Adults suspecting AD/HD should also start with a physical examination.) The physician will then usually refer the child or adult to a psychologist for an evaluation that requires about three appointments.

In the first appointment, a thorough clinical history is taken. As above, the psychologist both will be looking for evidence of functional impairment, and ruling out the many possible causes of “phantom AD/HD” (that which looks and acts like AD/HD, but comes from another source). In a child or adolescent AD/HD evaluation, to corroborate the clinical interview, the psychologist will send the parents home with behavioral checklists and inventories for them and the teachers to complete. There usually will be several checklists, where the psychologist is looking for the same patterns across checklists (cross-validation).

Checklists are also used in an adult AD/HD evaluation, but in a different way. The client rates their own AD/HD symptoms on one checklist, and closely related adults (i.e., spouse, best friend) rate them on the same checklists. When possible, a corroborating interview is done with parents of the adult, or a much older sibling, to get at early life history. (If it is truly AD/HD, the individual should have had the symptoms life-long.)

In a child or adolescent evaluation, after the teacher evaluation forms are received, a phone interview is always done with the teacher. Teachers are excellent sources of normative behavior with any particular age, as they spend all of their time with that age. Some teachers (not unlike some parents) can tend to be over-invested in the diagnosis of AD/HD and getting the child onto medication. During the call, the psychologist steers clear of any commitment to medication or not, and is careful not to put the teacher into the position of making a decision about diagnosis.

During the second visit of a child or adolescent AD/HD evaluation, the psychologist usually spends the entire visit with the child. The child generally works hard to be on their best behavior (since it is a new setting) and hence does not tend to show the AD/HD symptoms! (However, the psychologist takes this into account.) The point is not necessarily to see the AD/HD symptoms, but more so for the psychologist to get a feel for the child’s self-esteem, strengths and weaknesses, and how he relates and communicates. It can be diagnostic, of course, if the child’s behavior does end up deteriorating, and the psychologist gets to see the AD/HD symptoms. More often than not, though, the child is able to maintain control, even if just until after they get out of the door!

The second session with an adult AD/HD evaluation will usually involve a more detailed search into their school, work, and social history. Again, the psychologist is looking for signs of functional impairment, and alternative explanations for symptoms.
At times, a corroborating interview is done with a spouse, parent, or close friend during part of the second visit.

Usually, there is enough information from the first two sessions for the psychologist to be ready to make a diagnosis of AD/HD (or rule it out) by the third session. If there is not, then the psychologist is able to be clear with the parents (or adult) about what information is still needed. Sometimes, the psychologist may need to do educational (IQ and achievement) testing, i.e., if there is a question about a possible learning disability.

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