How a wide-ranging process delivers a more reliable ADHD diagnosis

Seeing the full picture

With ADHD hitting the headlines across the Asia Pacific region, it’s a challenging time for professionals who work with children and adolescents. Psychologists, special education/needs coordinators, teachers, and school counsellors are fielding a growing number of enquiries from parents seeking ADHD diagnoses.

“ADHD is a really important condition to recognise, diagnose, understand, and treat – but it's equally important to identify other associated neurodevelopmental disorders which also occur at quite a high rate,” says Dr Renee Testa, a seasoned clinical paediatric neuropsychologist based in Melbourne, Australia. “A single diagnosis assessment can give you an incomplete understanding of the child or adolescent, meaning their difficulties may persist and their developmental trajectory deteriorates.”

Informed by more than a decade of clinical work with children, adolescents and their families, Dr Testa emphasises that the symptoms of ADHD are not exclusive to people who have ADHD. “We often see children who have a developmental language disorder. They will present as if they've got ADHD because they can't focus and they can't process or understand what's going on in the classroom. They seem disorganised because they don't know what they’re meant to be doing. If psychologists or teachers or counsellors have ADHD front of mind, they might think, ‘Well, the child's got all these symptoms, it must be ADHD’.” 

What’s required, says Dr Testa, is an understanding of the spectrum of neurodevelopmental disorders, including their symptoms and the different ways they present at different stages of childhood. Armed with this knowledge, clinicians can ask more questions and test various hypotheses. This comprehensive approach also helps parents to gradually come to terms with their child’s situation, and to feel confident in the assessment outcome. 

Asking the right questions, finding the right answers

For clinicians, the aim is to gain a deep understanding of the child. A comprehensive process typically includes a combination of neurodevelopmental assessments and qualitative work (listening to people close to the child – including family and teachers – as well as the child themselves), before conclusions are reached, and feedback is provided to the family along with a formal report. 

For clinicians, the process starts with documenting all the challenges a child has, then exploring the possible reasons for these. Here, it’s vital to gain an understanding of the child’s environment because, while children who have ADHD are likely to have a genetic predisposition to the condition, other factors (e.g. stress, conflict) can make symptoms more acute.

“There are gentle ways to start exploring what’s going on and broaden the view of parents,” says Dr Testa. “We hear what parents say and we also let them know we’ll be gathering information from other sources. It's like putting all the pieces of a jigsaw together. We review any allied health assessments, any past psych assessments, teacher reports from the past year, and so on. 

“Sometimes schools have been encountering issues for years, but they’ve been hesitant to raise these with parents,” continues Dr Testa. “So, we listen to everyone. We write down all the different types of strengths and challenges the child has in learning, memory, literacy, in the playground, social skills, etc. Once we see that list, we can look at what may be going on.”

And perhaps most importantly, clinicians should speak with the child themselves. “When they feel comfortable, children are fantastic at describing how they feel, what's hard, and what's easy,” says Dr Testa. “We try and make the assessment process enjoyable for them. This can actually be an opportunity to boost their self-esteem so that they walk away feeling proud.”  

Of course, this process can generate a lot of raw information and variance in the way different people describe symptoms. Which is one reason why clinicians like Dr Testa use standardised, validated measures as the anchors of their assessments. Examples of such anchors include:

• The Wechsler Intelligence Scale for Children (WISC-V): A cognitive profile of learning strengths and challenges in a child’s visual and verbal skills. This provides invaluable context for the wider assessment (e.g. if a child has a very high IQ or intellectual disability, that influences a clinicians’ understanding of the challenges the child is experiencing). 

• The Weschler Individuals Achievement Test (WIAT-4): This assesses a child’s academic skills, mapping their comprehension of listening, speaking, reading, writing and maths, which can often impacted by ADHD, autism spectrum disorder and other conditions. 

Depending on the child or adolescent, these assessments can be combined with others, such as the Wide Range Assessment of Memory and Learning (WRAML), which helps clinicians understand how a child memorises and learns new material. 

“We use these tests due to the standardised way in which they’re designed and normed,” says Dr Testa. “Parents will sometimes question the veracity or validity of a psychologist’s findings. These tests give us great confidence to say, ‘These are proven, standardised tests that are used worldwide.’ We can rely on the results and so can the parents.”

Assessors should also qualitatively observe how the child approaches the assessments, to gain a deeper understanding of the child. And for anyone new to using the assessments, Dr Testa recommends having a supervisor or mentor who has experience interpreting these, “because interpretation provides a richer understanding which then helps address the needs of the child, the parents, and the school”. 

Expert-led training and professional development can also provide a reliable source of knowledge for assessors, when tailored to their level of experience. Professionals should seek out reliable providers that offer training and support to flex around their work and home life.

Laying solid foundations for growth

The final stage of the assessment process is to provide feedback to the parents, to explain the findings and describe any diagnoses. A face-to-face discussion can serve as a counselling session where parents begin to come to terms with the findings and understand what it means for them and their child. Clinicians might also conduct a separate session with the child themselves, too.  

A written report should also be prepared to provide an accurate record for the family and the professionals who work with them in future. The report can also suggest the most effective interventions, including how and when to structure and sequence these, and how progress can be monitored.

In short, a comprehensive assessment process is much more likely to result in a comprehensive diagnosis and a comprehensive action plan. And that’s a solid foundation to bring out the best in a child in the short, medium, and longer term.