So the psychologist I'm seeing for an evaluation gave me some rating sheets to take home to my parents, to rate my behaviours in childhood. The sheet listed the 9 inattentive symptoms and 9 hyper-impulsive symptoms, with a 4-point rating scale (very often, often, sometimes, rarely) and left plenty of space for examples.

My mother rated me as "very often" or "often" on 5 hyper-impulsive symptoms from childhood, and between 6 and 8 inattentive symptoms. (She was a little indecisive about a few, so she drew arrows between them.)

My father rated me as "rarely" on EVERYTHING except for "forgets" ("very often") and "avoided things that required concentration" ("sometimes"). He rated me with "rarely" on every single thing my mother put "very often" for!

What would a psychologist do in this situation?

I think this is a good one for me to take a shot at...:)

Since it's an open ended type of question, I'll be glad to cover what constitutes an "evidenced based (research substantiated)" ADHD assessment.

Evidenced based assessments really mean that the psychologist has to use techniques ( or therapies, etc.) that have been proven to work for whatever it is they're trying to do.

While there's no one specific way to do this, the examples you'll find on the internet basically look the same in most cases.

An evidenced based ADHD assessment is driven by questions and not by test results.

Having said that, parent rating scales are still the most accurate test instrument for dxing ADHD.

Before you can even think about testing though, there are a number of other things to address first.

RISK FACTORS :including

1) FAMILY HISTORY :

a) this would cover any history of family/extended family members having previously been diagnosed with ADHD;

b) if there's no formal diagnoses, then you'd look at things like : anyone determined to have a Learning Disability in school,?

c) anyone receive special ed services, if so, for what?

d) any history of quitting school?

e) any histories of delinquency?

f) any histories of excessive traffic tickets or accidents?

g) any history of problems with alcohol or drugs and/or chemical dependency treatment of any kind (inpatient or outpatient)?

h) any history of occupational problems; including difficulty holding or keeping a job, frequent firings, etc. ?

i) any histories of early pregnancies ?

Those are most of the areas that have been shown by research to represent Risk Factors

2) PRE AND PERI- NATAL CARE:

a) alcohol or drug use during pregancy?

b) smoking cigarettes during pregnancy?
(Most people don't realize what a huge risk factor this is. Smoking during pregnancy is the main cause of low birth weight and hypoxia (lack of oxygen to the brain at birth).

c) PREMATURE BIRTH- the number #1 risk factor at birth

d) complications during delivery?

e) low birth weight?

f) hypoxia?

After all that's covered, then a thorough

3) DEVELOPMENTAL HISTORY is needed.
(ADHD is a developmental disability, as the symptoms represent "delays" that other same age (non-ADHD) peers don't have)

4) REMAINING DIAGNOSTIC CRITERIA :

a) symptoms must be present from an early age ;

(The previous cut off age of 7 has been dropped because there's nothing to support that.Hyperactivity usually emerges between the ages 3-5yrs ,while Inattention usually emerges between 5-7 yrs of age (assuming that you recognize it). These are ballpark estimates. They're not etched in stone).

b) symptoms cannot be accounted for by some other disorder that can "mimic" ADHD, such as anxiety, depression, thyroid disorders, sleep disorders, grief & loss issues, allergies, trauma, etc.;

c) occur at least 6 months in a row ( a year is better);

d) happen everywhere (more than just one setting);
(This can be problematic, due to ADHD children being able to sit still in a doctor's office, or perhaps the teacher doesn't pick up on the behavior due to a bias, or teatcher has a very structured classroom setting that helps control the behavior or maybe different value system, etc.)

and most importantly...

e) the symptoms MUST cause .. "impairments in major life activites (not experienced by non-ADHD children)
(Impairments are "problems" caused by the symptoms. Examples of impairments in major life activities for kids are schoolwork, friendships, household responsibilities (chores, homework, etc.) and later on, driving.

Failing a grade is an example.

Remember : NO IMPAIRMENT, NO DISORDER:)

5) A MEDICAL SCREENING is called for somewhere in all of this too.


Now, getting back to checklists, parents often disagree.

What I have to try and discern is whether one of them or perhaps both, have strong biases against mental health treatment, or especially against ADHD.

Included in "biases" would be whether or not they actually believe it exists.

Another example would be cases where the school has been trying to get the child assessed for ADHD. I've seen many parents who're angry with the school(s) and report feeling "pressured" to get an assessment.

Parent checklists REALLY start to take turns for the worse if there's a custody dispute.

By the time I'm through with my parent education portion of the initial Diagnostic Assessment, most parents have no problem with the idea of further testing.

I use 2 sets of Parent checklists; one of which is specific measure of the Executive Functions
(EF's are the management portion of the brain. ADHD impairs those).

The PRIMARY CARETAKER, which is usally the mom, has been consistently shown to be the most accurate rater.

In addition, parents and teachers checklists only match between 30-50% of the time.

Therefore, the old notion some clinicians had about them having to , isn't true.

Interestingly enugh, when they do actually match, teachers do a better job of rating ADHD, while parents rate Oppositonal behavior better.


6) OTHER TESTS:

Most evidenced based assessments call for a cognitive screening to check for possible low IQ, as well as look at strenghts & weaknesses, an academinc screen to see if additional testing by the school for possible Learning Disabilities is needed (Keep in mind that 50% of ADHD kids have a Learning Disability, so you need to check).

I also throw in some personality or emotional level of functioning measures such as projective drawings, semi-projective sentence completion tests, or if they're old enough and mature enough to be able to read an MMPI-A (Adolescent version), I'll add that.

That's an excellent personality test.

I realize thats a lot more info than you asked for, but there's no other way to adequately explain it.

Now, I've just given you an "average" day in my practice.

I hope this helps.

Thanks for asking the question, as it gave me an opportunity to cover a lot of ground.


One last thing : I'm NOT saying that the psychologist doing your eval HAS to do these things exactly the same way, because there is no one way to do it.

I forgot something very important

That's what I get for trying to hurry and get out of the office.

I left out the need to go over the DSM-IV symptom checklist.

Earlier today, I had the priviledge of participating in another UBH (United Behavioral Health, which is a managed care company) teleconference on:

... ADHD and Positive Outcomes for Treating Comorbidity... with Russ Barkley

I was fortunate enough to be able to ask him a question over the phone.

We've kept in touch over the years, so it was gratifying to be recognized on a personal basis, especially over a nationwide broadcast.

It really made my day,and also helped me get thru the afternoon, as I'm still struggling with my meds.

During the teleconference today, he spent some time on the subject of the DSM symptoms.

What he pointed out, I think most people were somewhat acquainted with in terms of the normative sample (on wich they were based),containing kids between 4-16 yrs old and also being more heavily weighted towards boys.

He referred to this as a "gender bias "and recommended that clinicians diagnosing girls, use standardized ADHD Parent Rating Scales that are normed on BOTH girls and boys INSTEAD of going over the symptom right out of the DSM.

In getting back to the list of symptoms, I always use a printed out version, which I make sure they know is non-standardized.

I believe that people with ADHD do better if they have a multisensory learning experience, which is what I try and give them,instead of just reading them off.

I also sincerely believe that my having ADHD gives me a different (better) perspective than a non-ADHD clinician, so when I go over the list of symptoms, I try and explain it from an ADHD person's perspective.

I've posted on this before, so I won't go into any details now.

The criteria says that the person has to meet 6 of 9 symptoms for either Inattention and/or Hyperactivity.

There is also a category called Not Otherwise Specified (NOS).

This includes cases where the clinician believes that ADHD is present but there aren't enough symptoms.

The main thing to remember is that there must be evidence of IMPAIRMENT.

I hope this helps you understand some of what goes into an evidenced based assessment.

Thanks so much, McT! I always prefer a more detailed explanation on these things, so don't apologise for length! It's very interesting to me.

My mother IS the one I'm living with, but only since I was 18, which is when my parents divorced. (Unless "primary caretaker" also means the one who mostly took care of you at home; still my mother, my father worked all day.)

My father is being a d*nk. He believes in ADD just fine (my cousin has it); he just doesn't think I have it. He refused to allow me to explain anything about the disorder to him because he thought it would "taint" his "data." (i.e. the way he filled out the rating form.) But he also claimed that he can't remember anything about what I was like as a child. Not helpful.

My most recent session was this afternoon, and I think said psychologist is slightly perplexed, because all the info she's managed to get so far conflicts. My mother rates me highly, my father rates me very low. I say I've only ever had issues with Inattention, my mother claims I was highly impulsive - which I don't remember! My school records say I was a model student, with a number of absences that ought to have gotten me kicked out. (I'd forgotten about those absences, too!)

I thought my case was simple, honestly. :rolleyes:

Oh, and congrats on getting to talk to Russ Barkley! Very cool.

Moms do a much better job of remembering risk factors, pre and peri-natal care, birth complications and develpomental milestones.

Whenever I encounter a similar situation , I try and interview both parents .

In the process, I come right out and (politely ) ask about personal biases.

One advantage of doing a non-standardized symptom list, as well as having the parent, (which is usually the mom) fill out our mental health center's Intake Form, BEFORE they complete standardized checklists, is that I can make comparisons of any contradictions.

That helps a great deal.

Being able to show one parent,which is usually (but not always) the father, the written contradictions in black & white, really helps open the discussion up regarding how they honestly feel.

Often times, theer is a misconception that can be remedied with parent education and handouts on that aspect of ADHD.

I also have an extensive reference library of my own that includes journal articles.

I try and have copies made of the most popular ones ahead of time , so that they can take them home a look them over.

Because of this approach, I rarely have any problems.

Also, whenever I do an evaluation I try my best to involve as many parents/caretakers as possible.

Hmm. I doubt that either of my parents are going to end up in her office, so I'll have to try and explain BOTH of their biases, as best I can.

I like how it sounds like you do things, McT. Sounds like a good system!

Thanks.

I've been doing this a loong time now...lol.

I saw Rick Lavoine tonight. He talked about this issue. Basically he said learning that your child has ADHD is more stressful for the average parent then learning that the child has Down Syndrome. Once they learn the news all parents start out, however briefly, at denial and it can then evolve though emotions like anger, fear...etc. This is basic Psychology. Eventually, a healthy response is to get to acceptance. My Mom of 70 is still at the denial stage. :( :o

Parents don't travel down the same path at the same time. One may still be in denial, the other has accepted it, and the child's own path of acceptance may be stuck in anger. There can be loads of miscommunication and emotion. He said, no wonder 72% of families with such a child end up divorced. I would think that their current frame of mind about the subject would influence how they respond to a survey. Parents are not always in agreement, nor are teachers and always parents in agreement. Everyone comes at it with their own baggage.

Great information, McT! Thanks for taking time to share it.

Scattered

My son's doctor sent out the forms to teachers as well as parents. And I copied one so that our son could fill in his own. Seemed only fair! They were all different.

I think that the different perspective of each observer would be taken into consideration Bean.

I let the child fill out a non standardized symptom checklist to be a part of the procees.

After all, this is about them.

Keep in mind what's referred to as an "illusory bias," in that both children and also adults, tend to under report their symptoms.

Hope I'm not repeating anyone. What struck me if that there is no 'anchor' for often and very often. I had this problem when filling out a checklist about myself, and my friend said the same thing filling it out about me. What one person thinks qualifies as 'often' might be different than what someone else thinks. I much prefered the brown scales that had something like "daily" "twice a week" "once a week" etc.

Outsider,

That's an excellent point. It's also why you need multiple raters for dxing adults.

The cheklists are just one part of the overall assessment.

The main thing to look for is impairments.

The top parent checklists (BRIEF, ADHD -IV and the Conners ) are well put together psychometrically and I'm comfortable with using them.

I do use more than one though, just so I can look for any possible patterns.
As it turns out, I usually get some nice carry over in terms of significant impairments across scales,etc.

For kids, which is the population I work with, I've likened it to "putting a puzzle together in the dark".

That's a very good point, Outsider.

I know when I was doing research, I ran across one book that had a short chart of various behaviours (losing keys, losing important papers, says something "rude" accidentally, etc.) with approximate comparisons of how often an ADDer would do them vs. a non-ADDer. That helped, because I felt like I was going insane trying to figure out how my "often" matches other people's "often." I just wished the chart was longer and had more items.

On the other hand, it would be even harder to get my parents to fill that kind of thing out, because they wouldn't remember. I bet that sort of scale would be good for children, though.