As children with ADHD initially present to professionals with problems affecting behaviour 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 categorising behaviour as either "normal" or "abnormal". Even when rating scales with cutoffs are used, assessments of behaviour 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 behaviour 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 behaviour and learning.
Children with behaviour 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 behaviour, and especially learning, difficulties (such as poor fine motor skills causing slow and laboured 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 behaviour 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.
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