Six reasons why a psychologist’s full ADHD evaluation is recommended over a checklist diagnosis
Most people have heard of Attention-Deficit/ Hyper Activity Disorder (ADHD), a condition with primary symptoms of inattention, distractibility, and, sometimes, hyperactivity and impulsivity. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ADHD includes three subtypes: 1) Primarily inattentive, 2) Primarily Hyperactive/ Impulsive, and 3) Mixed symptoms of inattention and hyperactivity/ impulsivity (American Psychiatric Association, 2013). ADHD is most commonly diagnosed in children, which can last into adulthood or resolve on its own, but also may be diagnosed exclusively in adults.
While some people may feel comfortable discussing symptoms of ADHD with their physician or their child’s pediatrician, others prefer the more thorough ADHD evaluations conducted by Psychologists, who have doctoral degrees in Psychology and extensive training in psychological assessment. Due to the complexity of symptoms and high rate of co-occurring disorders, many researchers and practitioners recommend an evaluation that involves more in-depth evaluation (e.g., Gupta & Kar, 2010). There are numerous reasons to consider pursuing a more thorough ADHD evaluation from a psychologist, even after receiving a physician’s diagnosis.
(The video posted below is a quick overview of this blog, posted for those of you who may be struggling with symptoms of inattention.)
Reason 1 for a full evaluation: Many mental health conditions have symptoms that mimic ADHD.
The hallmark symptoms of ADHD (e.g., inattention, difficulty concentrating, and impulsivity) are symptoms that share commonality with a host of mental health conditions, including Depressive Disorders, Anxiety Disorders, Sleep Disorders, Eating Disorders, Bipolar Disorders, Psychotic Disorders, Schizophrenia, Intellectual Disability, Post-Traumatic Stress Disorder (PTSD), Specific Learning Disorders, and Autism Spectrum Disorder, just to name a few (American Psychiatric Association, 2013). The first-line treatment for ADHD is stimulant medication (Singh et al., 2015), which can have adverse effects on other psychiatric conditions, especially Bipolar Disorder, Insomnia, Psychotic Disorders, and Anxiety Disorders (Hvolby, 2015; Mosholder et al., 2009). Without an evaluation of the full spectrum of symptoms and their origin, the diagnosis may be incorrect or incomplete.
For example, children and adolescents with depression and anxiety often fidget, display irritability, and may be impulsive (American Psychiatric Association, 2013). Individuals who have PTSD may also present as hyperactive, inattentive and impulsive as they remain on-edge and alert to potential danger (American Psychiatric Association, 2013). Children with Autism Spectrum Disorder can appear inattentive, impulsive, and hyperactive when attempting to cope with overstimulation (American Psychiatric Association, 2013; Kentrou et al., 2018). The subtle differences in symptoms and their origin can be better understood with the kind of thorough psychological evaluation conducted by Psychologists.
Reason 2 for a full evaluation: Many people with ADHD have another mental health condition, too.
Proper diagnosis isn’t always a matter of identifying ADHD or another condition, but rather ADHD and another condition. Recent research suggests that 80% of adults with ADHD have another mental health condition (Katzman et al., 2017; Sobanski et al., 2007). According to a recent national study of parents with children who have ADHD, roughly 64% of children with ADHD have another psychiatric or behavioral condition, such as Oppositional Defiant Disorder, an Anxiety Disorder, Autism Spectrum Disorder, a Depressive Disorder, Conduct Disorder, and Tourette’s Disorder (Danielson et al., 2018; Kentrou et al., 2018).
The medical and mental health communities refer to two or more diagnoses as comorbid or co-occurring. The most common disorders to co-occur with adult ADHD include mood disorders (e.g., Depressive Disorders, Bipolar Disorders), Anxiety Disorders, substance use disorders, and personality disorders (Katzman et al., 2017). In terms of treatment of ADHD and co-occurring disorders, current recommendations emphasize the importance of treating the most severe disorder first. Therefore, it is essential that an evaluation include measures that allow for norm-referenced comparisons (i.e., comparing individuals of the same age) of symptom-severity and symptoms related to a broad range of disorders. If symptoms related only to ADHD are assessed, only ADHD can be diagnosed and treated, potentially limiting the effectiveness of treatment of up to 2/3 to 3/4 of individuals who have ADHD because of an unidentified co-occurring disorder.
Reason 3 for a full evaluation: Children who are younger than their peers are more likely to be (mis)diagnosed with ADHD.
Worldwide research has raised concerns regarding the role of immaturity (e.g., younger age at school entry) resulting in a greater likelihood of an ADHD diagnosis (Bonati et al., 2018; Layton, Barnett, Hicks, & Jena, 2018; Wendt et al., 2018). This trend has been found for other neurodevelopmental disorders, as well, and is also more likely to affect boys (Bonati et al., 2018).
Additionally, Layton et al. (2018) found that teachers were more likely to perceive ADHD symptoms in younger students than their parents, suggesting that the symptoms were not found across settings, which is contraindicative to a diagnosis of ADHD. The specific concern here is that children may be diagnosed with ADHD when they are just exhibiting behaviors consistent with their age.
Reason 4 for a full evaluation: Pharmaceutical medications, the most common treatment for ADHD, can have unpleasant or even serious side-effects.
Stimulant medications, like methylphenidate (e.g., Concerta, Ritalin, Daytrana, Aptensio XR, Metadate CD, Methylin, Quillivant XR) and amphetamine compounds (e.g., Adderall), have long been the first-line treatment for ADHD among prescribing physicians and psychiatrists (Subcommittee on ADHD, Steering Committee on Quality Improvement and Management, 2011). Numerous scientific journal articles report on the side effects related to stimulant medication treatment, including decreased appetite, stomach ache, weight loss, headache, rapid pulse, and difficulty sleeping (Holmskov et al., 2017; Lee et al., 2011; Ramtvedt et al., 2014). In rare instances, ADHD medications have been associated with cardiac events, particularly when taken in an excessive dose (Greenhill et al., 2002; Graham & Coghill, 2008). The risk of developing psychotic symptoms or conditions is elevated with medications used to treat ADHD, particularly for those with a family history of psychosis or mania (Mosholder et al., 2009). Adverse neurological side-effects, while less common, have also been reported (Ogutlu et al., 2018; Snell & Bakshi, 2015).
It is important to note that virtually all medications can cause side-effects and carry various risks. While the research on the cognitive benefits (e.g., enhanced school performance) is conflicted (Weyandt et al., 2016), there is greater agreement in the scientific literature that ADHD medications reduce inattention, impulsivity and hyperactivity (Konrad-Bindl et al, 2016). It is important to discuss the risk of side effects with the potential treatment benefits with your prescribing physician (Lee et al., 2011). It may be equally important to discuss non-pharmacological cognitive, academic and behavioral interventions with your physician. In the event your physician is uninformed of such interventions, consultation with a psychologist (i.e., an individual with a doctoral degree in psychology) is recommended.
Reason 5 for a full evaluation: Stimulant medications used to treat ADHD are among the most commonly abused drugs by college students.
Stimulant medications used to treat ADHD have a high risk of abuse and misuse, particularly among adolescents and young adults (Weyandt et al., 2013; Weyandt et al., 2016). The aforementioned medications are considered by the Drug Enforcement Administration (DEA) to have a high potential for abuse and dependence, as they are classified as Schedule II medications (DEA, US Department of Justice, 2017). College campuses, particularly in the United States, have been identified as a hotbed for ADHD medication misuse, which is thought to range between 13% and 43% (Benson et al., 2015; DeSantis et al., 2008). Misuse behaviors include taking a higher dose than prescribed, taking medication not prescribed to the individual, and taking the medication in a manner not prescribed (e.g., snorting or injecting).
Due to the demands of college-level work and the prolific myths among students about the enhancing effects of ADHD medication, some college students without ADHD seek the diagnosis (Dvorsky et al., 2016). Dvorsky et al. (2016) found that only parent report of college student’s childhood symptoms resulted in accurate diagnosis of ADHD as college students’ report of symptoms was abnormally elevated. A psychologist’s evaluation for ADHD involves collecting collateral and historical information about the presentation of symptoms and can help to distinguish between different sources of inattention.
Reason 6 for a full evaluation: Understanding how ADHD symptoms impact cognitive, academic, social, and occupational functioning can help with planning interventions and accommodations.
An in-depth ADHD evaluation should assess cognitive, academic, occupational, and social functioning—both past and present. Multiple modes for evaluation are recommended in order to obtain a comprehensive understanding of the need for intervention or accommodation. Medical providers rarely, if ever, provide tailored lists of recommendations for intervention or accommodation. Psychologists are better-suited to write tailored recommendations due to the in-depth nature of psychological evaluations.
Evaluating cognitive abilities, like short-term memory, auditory attention, visual skills, verbal ability, and problem-solving, can help identify both the need for intervention and areas of strength, which can so easily get overlooked in children and adolescents with ADHD. An initial evaluation can help identify areas of improvement in a future re-evaluation. Unfortunately, medical doctors are not trained to administer tests of cognitive abilities and other tests involved in a full evaluation. Psychologists, however, are specifically trained to administer an array of tests and to produce a multi-page interpretive report with tailored recommendations.
In-depth psychological evaluation allows for a psychologist to write tailored recommendations meant to help an individual perform at their best in various settings. Comprehensive recommendations for children enrolled in K-12 public schools can help guide the adoption of an Educational Access Plan (EAP) under the Department of Education’s Individuals with Disabilities Education Act (IDEA). Adults who request accommodations under the Americans with Disability Act (ADA) in their college education or work-settings may benefit from a list of tailored recommendations of reasonable accommodations. Psychologists consider recommendations as an essential part of a formal evaluation for ADHD and other learning disorders, but recommendations are not typically included with a physician’s diagnosis.
References
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