How to assess ADHD

Intelligence testing gives a baseline for general intellectual functioning. It also allows a comparison of verbal and non-verbal intelligence, as well as working memory and processing speed. Individuals with ADD/ADHD often show difficulties with working memory and sometimes processing speed as compared to their general intellectual abilities.

Executive function testing allows a deeper understanding of the capabilities in this area: ability to plan, to organize, to shift between contexts, and to guide behavior despite distracters.

Working memory is a faculty often included within the executive system, and in any event closely related to it. Prefrontal and parietal areas of the brain are involved in retaining a very small number of items of information through active maintenance of a brain network for a few seconds. Sharply limited in number of data bits, working memory is trainable but also susceptible to stress and anxiety. Two parts of working memory reside in different areas of the brain. Verbal working memory is maintained in the left dorsolateral prefrontal cortex (left front of head) while non-verbal working memory resides in the right parietal lobe (both locations are for left-dominant brains).

Academic testing is done when indicated to rule out or specify learning disabilities such as dyslexia and dyscalculia. As Gillberg (2014) shows, learning disabilities are frequently seen with ADHD.

Memory and learning tests measure kinds of mental processing and storage that generally do not go with ADHD but may be present as additional problems. If present, it is important to find these sorts of difficulties.

Dexterity vs clumsiness is noted by Gillberg and others to be part of a pattern sometimes called DAMP (Deficits in Motor Control, Attention, and Perception).

Sustained attention is generally quite deficient in ADHD and ADD. We assess it routinely using the Test of Variables of Attention, a computerized measure of ability to respond to unpredictable stimuli in a boring task over a period of twenty-two minutes. This test is particularly sensitive to stimulant medication, and can be used to help titrate doses (scores often normalize with correct medication, but get worse on an overdose).

Our clinic, Alaska Neuro/Therapy Center, LLC, specializes in a multi-modal approach to diagnosing and treating ADHD and associated conditions in all ages (such as depression, anxiety, memory and learning problems, sleep issues, and Autism Spectrum Disorder). Our approach involves clinical interviews; collecting background information; psychological testing (including forms and questionnaires for other family members, and teachers when indicated); biofeedback and neurofeedback; as well as a single channel, or 21 channel QEEG.

Quantitative EEG

Brain functioning is more directly examined via quantitative Electroencephalograph (EEG), using either one or 19 leads and comparing the results to normal individuals of the same age as well as a set of persons diagnosed independently as having ADHD or ADD. In a one-channel evaluation, we look for the theta-beta ratio (the proportion of slow brain waves compared to faster ones) to be higher than usual. Most children with ADHD will show a theta-beta ratio well above 4.0 and most adults with ADHD will have a ratio of 2.5 or above. A case where brain wave testing allowed better treatment of ADHD is reported by Michael Linden, Ph.D. at http://www.lindenalc.com/media/dr-linden-on-the-doctors/ . This video from “The Doctors” describes evaluating a young boy with ADHD and seizure disorder.

19 channel quantitative EEG allows both a more complete assessment to look for other subtypes of ADHD/ADD as well as conditions that mimic or accompany ADHD symptoms (anxiety, depression, autism spectrum disorder, etc.). Whole head EEG also allows a rational decision about neurofeedback, whether a simple one-channel approach is enough or whether information from all 19 channels should be used in the more complex technique of “z score” feedback.

Assessing concomitants and consequences

Personality testing is used to assess the presence of emotional and behavioral disorders that may accompany or be the result of ADHD or ADD. The MMPI family of tests aids diagnosis of basic “axis I” disorders like depression, thought disorder, and anxiety, while the Millon tests are aimed at personality disorders such as histrionic, borderline, and sociopathic styles.

Interviews are always done to get a sense of the mental status of the person (their mood and affect, ability to sustain conversation and eye contact, history of ADHD symptoms and their impact on school, social functioning and family life, etc.)

Assessing cultural influences and ramifications

Most persons with ADHD/ADD have been the object of disparagement, bullying, or ridicule for being “lazy” or odd. It is always important to discuss this topic, in spite of the embarrassment of raking up old feelings of chagrin and hurt. In fact, in the long run it helps to accept the reality of ADHD or ADD as a neurological fact, difficult in many circumstances and especially in electronic media culture, but in other ways beneficial both to the individual and to society. Getting into the specifics of how the person has been hurt but also helped by his or her neuropsychological difference can aid in learning to cope with, change, and use it as well as possible. If the client is a child, it is especially important to help parents understand how their own perceptions of their child’s behavior have been influenced by cultural stereotypes and expectations, and to develop a more realistic understanding of their son’s or daughter’s brain strengths and limitations.