A British Perspective on the Psychological Assessment of Childhood AD/HD

Reproduced by kind permission of Jenny Lyon - International Psychology Services
Jenny Lyon, Cert.Ed., B.A.(Hons.), M.Sc., C.Psychol.

Introduction

It is unfortunate that the majority of recent publicity about AD/HD, in the UK, has focused almost entirely upon examples of bad practice: short and inadequate assessment procedures, the use of medication in the absence of other forms of support, the use of medication with very young children, the failure of private clinics to liaise with schools, etc. While I am not disparaging the importance of these issues, I was concerned at a recent training day to find a group of professionals so concerned with bad practice that they were unreceptive to talking about good practice.

Good practice regarding the treatment of AD/HD depends upon the initial diagnosis being correct, and for the following reasons AD/HD is not an easy disorder to identify. Firstly, a child can be inattentive, impulsive and hyperactive for many reasons other than AD/HD. Secondly, AD/HD is a continuum disorder, which is to say that we all suffer from the defining symptoms to some extent, and it is only when those symptoms persist over time and across situations in a severe form that an AD/HD diagnosis is appropriate. Thirdly, many children who suffer from AD/HD also suffer from other childhood disorders, all of which interact upon one another. Lastly, AD/HD itself can lead to secondary problems which are more damaging than the initial problems.

We cannot X-ray a child to find out if s/he is AD/HD, and even if we could this would only provide a starting point. The purpose of a psychological assessment is to establish what problems a child is experiencing and generating, and how these can be alleviated. A child's problems exist within the context of his/her home and school, and it is inevitable that some families and teachers will cope better than others with an AD/HD child. Furthermore, it is perhaps wrong of us to use the term "AD/HD child", as this describes only one part of the whole child. Some of the children I see have excellent social skills, while others have problems relating to adults or peers. Some are articulate, while others have problems with speech and/or language. Every human is an individual, and the term "AD/HD child" can be misleading in terms of differential diagnosis and treatment.

As a result, the assessment of childhood problems is often a complex, lengthy, multi-professional process, and one which should be properly explained to parents. Where parents understand the nature of an assessment, it will follow that they understand the diagnosis and the recommendations that follow. It is hoped that the following "good-practice guidelines" will help parents in this process.

The Basic Principles of Assessment

The psychologist who assesses your child will not start from the premise that his or her problems are due to AD/HD. S/he will want to gather as much information as possible, and then "identify and define symptoms and problems which differentiate the target child from those in a similar population", i.e. from his/her peers (Goldstein, 1994). As Goldstein points out, this means that a specialist clinic will not differ, in principle, from a general clinic. The psychologist will want to learn as much as possible about the child's behaviour, and any preconceptions would only cloud his/her judgement. However convinced parents feel that their child is AD/HD, they should approach a psychologist with a careful and accurate description of the child's behaviours rather than a diagnosis.

Gathering Information

As an Educational Psychologist I am committed to the principle of observing a child at home and at school. As noted above, problems do not exist in a vacuum, and it is important to see how "within child" factors interact with the environment. Questionnaires and rating scales can assist this process, and if it is difficult to observe the child directly the psychologist may depend upon this information. I use the Achenbach parent, teacher and child questionnaires. Results are computer analysed on 8 scales, and the 3 forms are compared to see how well they correlate. I also use the ACTeRS questionnaire, which differentiates between hyperactivity and attention problems. In addition, many psychologists use a comprehensive developmental history form (I have designed my own, as there was no British version available, and this is an up-dated version of the one I originally designed for my work at the Learning Assessment Centre in West Sussex). A developmental history form is an efficient way of gathering important information about the child and family prior to meeting. I often ask teachers to compare the referred child to his/her peers using a simple observation schedule such as the TOAD (an acronym for "Talking", "Out of Seat", "Attention" and "Disruption").

Parent/Child Interview

It is essential that the meeting between psychologist, parent and child should be non-judgmental. The aim is to identify and solve the child's problems, and all concerned will need to work in close co-operation if this process is to be successful. Part of the problem-solving is to see how parents and children relate to one another, remembering that the interaction between parents and child is complex and two-way: thus bad parenting can lead to childhood problems, and a difficult child can cause parents to lose their confidence and thus become less able in managing the child. This downward spiral of events can place tremendous stress upon a family, which is exacerbated by the fact that parents almost invariably blame themselves for their children's problems. Learning that the boot can be on the other foot can relieve guilt and anger, and set the scene to move forward. I frequently marvel at how well parents cope with immensely demanding children, and feel saddened that they have received criticism rather than support. The psychologist should be providing this support: educating parents and teachers regarding the management of AD/HD, offering on-going advice and acting as an advocate for the child and family.

Assessing the Child

Many psychologists start an assessment with a clinical interview, but I prefer to begin with an assessment of overall ability, using the Wechsler Intelligence Scales for Children III UK (WISC III UK). Different versions of the WISC exist for very young and older children. While this sounds rather daunting, most children enjoy the games and puzzles, and success is built into the system: when the child begins to fail on any test the examiner moves to the next test. This part of the assessment allows me to establish a rapport with the child, and by when the battery of tests has been completed most children feel fairly relaxed.

The WISC III UK serves several purposes. Firstly, it establishes the child's IQ, or overall level of intellectual ability. Secondly, it allows me to examine the child's individual profile of results on 13 tests (6 verbal, and 7 non-verbal). For example, dyslexic and language-disordered children tend to do less well on verbal than on non-verbal tests, while AD/HD children are likely to have depressed scores on the "Freedom from Distractibility" and "Processing Speed" indices. Lastly, and most importantly, it enables me observe the child on a battery of tests with which I am very familiar: any unusual behaviours or responses are immediately apparent. AD/HD children typically lose marks because of impulsive responding, slow processing and erratic attention.

The next part of the assessment involves testing the child's levels of attainment in basic skill areas (reading, spelling, writing, oral language and maths), and seeing whether or not s/he is achieving appropriate scores for his/her age and ability. These tests also provide a wealth of information regarding the child's learning style ( impulsive, careful, determined, confident, easily discouraged etc.), processing skills (memory, attention, speed) and literacy skills such as handwriting and phonic awareness.

My findings from the WISC III UK and attainment tests determine what follows. For example, if I think the child is dyslexic, further assessment of phonic skills, memory skills and processing speed will be on the agenda. If the child has had problems with attention and/or impulsive responding, both computerised and manual tests of these skills will be administered.

Lastly, and only if I feel it is appropriate and useful, I may ask a child to complete one or more questionnaires which focus on such areas as anger, depression and self-esteem, or I may use other assessment tools such as a sentence completion test or personal construct therapy. The approach a psychologist takes will vary from child to child, and will also reflect the psychologist's views regarding the assessment of personality.

The initial assessment usually lasts around a half-day, and at the conclusion I need time to score results before I talk to the parents and child. A family should expect to devote a day to visiting a psychologist.

Feedback

Feedback should always start and end on a positive note. I have never assessed a child where this is not possible, as there are always some aspects of a child's personality and behaviour which are likeable and praise-worthy.

Feedback consists of explaining what has taken place in the assessment process, what conclusions I have reached and why I have reached them. It is very important, at this point, for parents and child to feel free to ask questions, and add information.

I always write a report, detailing the feedback I have given, on the day after I have seen the child while s/he is fresh in my mind. This provides the parents with a comprehensive account of my findings and recommendations. The report belongs to the parents, although I provide spare copies for them to distribute to school and any other professionals involved. I ask parents to contact me if they have any concerns or questions, or if they require any further explanation.

Ways Forward

The most important part of the feedback session lies in talking about ways forward. It is important for the family to leave on a positive note, and with a very clear understanding of the recommendations I am making. I try to be as specific as I can be, for example: "We have agreed that Stan has problems with sustained concentration, impulsivity and hyperactivity, and that he is a classically AD/HD child. These problems are affecting his learning, social skills and behaviour. In addition, and separately from AD/HD, Stan has the phonic difficulties associated with dyslexia. These two problems are acting adversely upon one another: children who find learning difficult will find it hard to attend, and children who find it hard to attend will find learning difficult. Poor Stan has 'double trouble', and it is not surprising that he also has very low self-esteem. This is how we can try to help Stan."

How we can help Stan is the subject of another article, which would include the controversial topic of medication. In conclusion to this article, I would emphasise only the following points:

• every child is an individual who needs an individual management plan
• most children require multi-modal intervention, involving parents, teachers, a psychologist, psychiatrist or paediatrician, and possibly other professionals, for example, a speech and language, or occupational therapist
• plans only succeed if they are regularly monitored and revised
• older children must play a central role in the formation, monitoring and revision of their management plan
• parents and teachers should try to adopt a problem-solving approach to dealing with behaviour problems, and avoid being judgmental, angry or guilty. This will help the child to acknowledge, and take responsibility, for his/her problems, rather than denying that s/he has a problem or blaming others
• children, parents and teachers require ongoing support: an assessment is only the first stop towards solving a child's problems.

© Jenny Lyon 1995 Goldstein, S. (1994) Understanding and Assessing AD/HD and Related Educational and Emotional Disorders Therapeutic Care and Education Vol. 3 (2) pp. 111-125