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.
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.
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").
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 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
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.
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
Back to Information
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:
1. Every child is an individual who needs an individual management plan
2. 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
3. Plans only succeed if they are regularly monitored and revised
4. Older children must play a central role in the formation, monitoring and revision
of their management plan
5. 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
6. 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
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