Do I Really Need a Comprehensive Evaluation for ADHD?

A couple of times a week, I get an inquiry that poses the question above. Usually it goes something like this – I suspect that I/my child have ADHD, can you diagnose it? My response is usually an attempt to explain why the testing I do is not just to confirm or disprove the suspected diagnosis but to figure out how your brain works and what is causing the challenges that you experience.

Why is this necessary if all you want to know is whether you have ADHD or not? The answer is that we need to know the cause of your symptoms to come up with an effective treatment plan, and there are many other causes for the symptoms that, on the surface, look like ADHD.

Perhaps you have a lot of trouble completing tasks or staying focused. Maybe your child gets in trouble for getting out of seat in class or calling out of turn. Could this be ADHD? Insurance companies will often tell you that a thorough neuropsychological evaluation is not necessary to diagnose ADHD and that the diagnosis can be made based just on a clinical interview and perhaps a few symptom checklists. Could the diagnosis be as simple as filling out a questionnaire, adding up the number of symptoms, and confirming that you have ADHD because you said yes to enough symptoms required for the diagnosis?

A symptom checklist is a good start, but the diagnosis is only accurate if there is no better explanation for the symptoms. Yet the checklist does not ask about another condition that may offer a better explanation. What else can cause symptoms of inattention, impulsivity, and general difficulty with self-regulation (executive functioning)? Lots of things, below are just some examples:

• Hearing loss or problems with auditory processing can look like inattention.

• Depression and anxiety can affect concentration and focus; social anxiety, in particular, makes it hard to pay attention to what others are saying.

• People with autism spectrum disorder (ASD) may interrupt others in conversation, not because of impulsivity, but because the use of language in social interactions is one of the main challenges in ASD.

• Reading and writing avoidance or failure to complete homework may be a sign of ADHD (avoidance of tasks requiring sustained attention), or a symptom of a learning disorder (dyslexia and/or dysgraphia).

There is also the issue of comorbidity; ADHD, more often than not, co-occurs with other conditions, complicating the diagnosis and treatment, including:

• Neurodevelopmental conditions – ADHD, ASD, language, learning, and motor disorders, frequently co-occur.

• Emotional difficulties, such as anxiety and depression, are frequently present along with ADHD, often overlapping with and exacerbating the ADHD symptoms.

• Oppositional and defiant behavior can be mistaken for ADHD or can co-occur with ADHD requiring a separate intervention.

Finally, while every person with ADHD shares some core symptoms with others with the same condition, everyone’s pattern of strengths and challenges is unique, warranting an individualized intervention. Knowing that you have ADHD does not give you nearly as much information as knowing, for instance, that your particular case of ADHD includes fantastic abstract reasoning skills and great verbal creativity but also difficulty with maintaining focus, planning, and slower information processing speed. Some of the ADHD-related challenges are best addressed with medication, others with psychotherapy, executive function coaching, school accommodations, or changes in your home environment.

A comprehensive neuropsychological evaluation should provide a lot more than a diagnosis. It should give you a better understanding of yourself, a plan of action based on your specific strengths and needs, and the tools to become a better advocate for yourself.