- Psychological Issues
As children with ADHD initially present to professionals with problems affecting behavior and learning, a comprehensive assessment is necessary to confirm a diagnosis according to criteria previously outlined. It is also necessary in order to exclude other conditions and to determine whether co-morbid conditions exist. This assessment also provides the basis for the formulation of appropriate management strategies for presenting problems and conditions which underlie them. Thus, a careful history of the individual case is required, followed by relevant examinations, reports and additional investigations if indicated by findings from the initial assessment.
Multiple sources of information on duration of symptoms as well as assessment in multiple settings, such as school, home and clinic, increase the accuracy and validity of assessments and are necessary if diagnoses are to meet the criteria set down in DSM-IV. Rating scales assist in obtaining systematic information from different settings and treatment responses. It should be taken into account, however, that there are difficulties in categorizing behavior as either “normal” or “abnormal”. Even when rating scales with cutoffs are used, assessments of behavior components are subjective.
The goals of the evaluation process are to establish the child’s diagnostic status and to translate assessment data into a potentially successful intervention plan. According to DuPaul (1991) the optimal methodology for addressing both goals of the evaluation process uses an assessment approach which incorporates:
Medical assessment of a child with behavior and learning difficulties should include a full medical history, relevant neurological examinations and family history. The assessment should focus on physical and mental health, and should exclude vision and hearing defects. Observation in the clinical consultation is important but ‘clinic hyperactivity does not reflect the pervasiveness of symptoms (Tripp and Luk 1997).
Further assessments may be necessary for selected children. children who appear to have auditory problems require additional comprehensive audiological assessment, including auditory acuity, ‘speech-in-noise’ discrimination and auditory memory. Psychological assessment is recommended for children who appear to be developmentally intact and/or who exhibit a specific disability in learning. Speech pathology assessment is necessary for children with significant language difficulties, especially in younger children. Occupational therapy assessment is recommended, especially for younger children who have problems with motor function, handwriting and spatial and body awareness difficulties. In addition, physiotherapy assessment may be necessary for some children with gross motor dysfunction, for whom self-esteem and confidence are impaired with resultant negative effects on behavior and learning.
Children with behavior and learning difficulties should have a full assessment of developmental functioning. Assessment should focus on determining delays in development and difficulties with gross or fine motor abilities, visual motor function, auditory short-term memory, receptive and expressive language and attention. Assessment of such skills may identify factors contributing to behavior, and especially learning, difficulties (such as poor fine motor skills causing slow and labored handwriting).
Assessment of visual-perceptual difficulties may indicate problems with letter reversals, copying forms, confusion over spatial relationships and organisation of work. Assessment of sequencing problems may identify difficulties in following instructions, and with the concepts of time and relationships. The assessment of language – expressive, receptive syntactical, semantic and pragmatic ÷ may assist in the understanding of behavior and learning difficulties. Developmental assessment should include assessment of the maturity of the central nervous system (CNS) as evidenced by delayed laterality (tendency in activity to prefer to use one side of the body) or altered control of complex movement.
Although the symptoms of ADHD are commonly observed before the age of six in a child who is later identified as having ADHD, it is often not until the child enters formal schooling that the seriousness of these symptoms is first noted, typically by a teacher.
Children who have ADHD may experience academic functioning problems on several levels. They may fail to learn or they may underachieve in the classroom due to the inattention and impulsivity imposed by their attention deficits. They may be unable to demonstrate what they do know because of difficulties, for example, with taking tests in a group. They may also have learning disabilities in addition to their problem with ADHD.
The assessment of children who have ADHD should encompass a review of school observations and previous testing. These should cover estimates of intellectual capabilities, strengths and weaknesses and measures of academic achievement, including language development.
The problems of intellectual or academic functioning in most children with emotional or behavioral disorders appear to be significant, yet findings in this area are characterized by considerable variability (Forness, Kavale, Guthrie et al 1987). There is some evidence that modes of test presentation, such as timed versus untimed components, may be a critical factor in at least some of this variability (Scruggs and Mastropieri 1986).
Hyperactive children tend to perform less effectively than nonhyperactive children on tests of perceptual-motor functioning, measures of sustained attention (especially in situations in which the stimulus is unpredictable), and measures requiring delay of impulse (Campbell 1976). In these and other situations, hyperactive children tend to respond quicker and make more errors than do nonhyperactive children. Possibly their poorer performance reflects problems of attention and impulse control rather than problems of perceptual-motor control.