By Richard Lewis, Ph.D.,
A New Start Counseling Center, Inc.
Attention-Deficit/Hyperactivity Disorder, or ADHD, affects a large number of people in our community, children and adults. The primary problems seen in ADHD are difficulties with attention/concentration, poor impulse control, and excessive activity or movement. Most people will experience at least some of these problems from time to time, and the younger the child, the more common these issues will be. Some people can experience these problems, and can continue to function well at school or work, and in their family and social lives. If these issues cause significant problems in functioning at work or school, or in family or social life, then testing for ADHD should be considered.
The primary reasons to have school-aged children tested for ADHD are if their academic performance is lagging behind their intellectual potential, and if they are experiencing some kind of social alienation. Some indicators of lagging academic performance are grades being lower than they typically have been, or parents and teachers having the sense that the child is intellectually capable of better performance. Problems with social alienation may involve difficulty getting along with peers (e.g., because of impulsive or intrusive behavior), or frequent reprimands from the teacher (e.g., for behavior that disrupts the class, or off-task behavior). Either type of problem may have a negative impact on the child’s self-image (e.g., “I’m no good at school work,” or “nobody likes me”). The primary reasons for adults to consider being tested for ADHD include poor work performance, and problems in home life because of poorly attending to instructions, poor organization, numerous incomplete tasks, and a general sense of frustration with one’s own functioning.
There are four primary reasons for poor concentration and off-task behavior. One reason is that people at times have significant life events and emotional concerns that weigh heavily on their minds. For example, it is difficult for a person to concentrate if he or she has ongoing problems with depression or anxiety, or is in the midst of highly stressful circumstances (e.g., divorce, death in the family, job loss). Poor concentration because of these kinds of issues tends to be temporary. Another reason for attention problems is poor comprehension. A person who does not understand an academic task at hand (e.g., a person with a learning disability) will have difficulty attending to that task. Trying to attend to someone speaking an unfamiliar language would be very difficult to do. The third primary reason for poor concentration and off-task behavior is poor motivation, in which the person has no interest in performing a task, and they are indifferent to the probable consequences of performing or not performing the task. The final of these reasons for attention problems is that a person simply does not have much ability to attend to tasks, keep things organized, and inhibit restless and impulsive behavior. It is this lack of ability in these areas to which we refer as ADHD.
Obviously, to make a determination about ADHD, these other issues need to be considered, although they do not necessarily need to be ruled out. For example, it is possible for a person to have depression and ADHD, a learning problem and ADHD, or a motivation problem and ADHD. In fact, it is not uncommon for these problems to co-exist. If a person has had ADHD for some period of time, and has not had an understanding of what is happening, he or she may become depressed because of conflicts with peers, teachers, and bosses. He or she is likely to be very frustrated with efforts being less productive than they should be, which can cause a loss of motivation.
The assessment of ADHD typically begins with an interview to determine the primary issues that are present. For a child, an interview with the parents usually precedes an interview with the child, to obtain relevant information about any problematic family circumstances, developmental or medical history, and other issues about which the child may lack awareness. ADHD becomes a primary consideration if the problems with concentration and/or off-task, excessive behavior have been present at least since the early elementary school years. It is important to have some information that indicates that the attention problems are not primarily related to comprehension issues (e.g., standardized achievement test scores, which many schools obtain annually). For example, if a child has always been well behind same-grade peers in academic performance, it is likely that there are comprehension issues that are at least partly affecting attention. However, if a child was roughly on grade level in reading and math in kindergarten, and is starting to fall behind same-grade peers after a couple of years of school, this would be more of an indication that the attention-issue is the primary issue. As indicated above, if emotional issues are related to social and performance issues that are often seen with ADHD, then ADHD becomes a primary consideration.
There are often parent, teacher, and self (for adolescents and adults) behavior rating forms that are used in the evaluation of ADHD. These should be carefully evaluated, because they may be affected by the rater’s tolerance for unusual behavior. If a rater has a high tolerance for unusual behavior, then he or she may not indicate a problem with behavior that is abnormal. If a rater has a low tolerance for unusual behavior, then he or she might indicate a serious problem with behavior that is relatively normal.
In the assessment of ADHD, it is helpful to have some objective measure of attention/concentration and impulse control. There are a number of computerized tests, referred to as continuous performance tests, which can be very helpful in obtaining this objective measure of these abilities that are affected by ADHD. Probably the most helpful thing about such tests is that they do not represent a rater’s tolerance for behavioral issues, or lack thereof. One potential problem with these tests is that a person may not put forth his or her best effort on the test, which would result in an indication of an attention problem that is more serious than it really is.
It is hoped that this article gives a helpful summary of the issues involved in the evaluation of ADHD, and the nature of the evaluation process. As indicated, these issues can have complex interactions, and it is important to have the evaluation completed by professionals who have experience with these issues, and the tools to determine which issues are primary and which issues are secondary (e.g., tests for attention and academic achievement). Please contact our office at 770-461-9944 if you would like more information about Dr. Lewis or wish to schedule an appointment or evaluation.