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Running head: ADHD ASSESSMENT PROCESSES 1

Attention-Deficit/Hyperactivity Disorder: Assessment Processes

Dianne L. Ballance

ID#00939966

University of Calgary

APSY 693.89

ADHD ASSESSMENT PROCESSES 2

Attention-Deficit/Hyperactivity Disorder: Assessment Processes

Children with attention-deficit/hyperactivity disorder (ADHD) display difficulties with

attention and/or impulse control and hyperactive behaviour relative to their peers that causes

significant impairment in the majority of life domains (Smith, Barkley, & Shapiro, 2007).

ADHD is a prevalent disorder with estimates between 2.0 to 9.0% of the general population

(American Psychological Association [APA], 200; Pelham, Fabiano, & Massetti, 2005; Smith et

al., 2007). It is usually diagnosed in childhood and typically persists throughout the lifespan

(Schwean & McCrimmon, 2008). ADHD presents as a heterogeneous disorder, and response to

treatment may vary for individuals (Smith et al., 2007). Given these factors, it is an important

disorder to identify properly and treat effectively (Smith et al., 2007). The assessment of ADHD

in children requires a comprehensive and thorough evaluation in multiple settings with multiple

informants that includes interviews, rating scales, observations, and a battery of psychological

tests (Brock & Clinton, 2007; Sattler, Weyandt, & Willis, 2006; Smith et al., 2007). A multi-

method approach is particularly important in the assessment of ADHD because symptoms and

related impairments can manifest differently across different settings and relationships

(McConaughy et al., 2010). There is considerable research on ADHD given its prevalence and

impact, yet there are still some practical issues with assessment processes (Mash & Hunsley,

2005; Pelham et al., 2005; Schwean & McCrimmon, 2008; Smith et al., 2007). Interventions are

the direct outcomes of valid assessments. This paper will investigate current evidence-based

assessment processes of ADHD in children within the framework of school psychology.

Assessment Issues

Assessment must address symptomology (presence, type, and severity), onset, subtype

(inattentive, hyperactive/impulsive, or combined), and developmentally inappropriate behaviour,


document multiple setting impairment, and rule out alternative diagnoses (APA, 2000; Brock &

Clinton, 2007; Smith et al., 2007). ADHD children display a diversity of attention and behaviour

problems, and many have a co-occurring disorder (Learning Disorder, Oppositional Defiant

Disorder, Conduct Disorder, Depressive Disorder, and Anxiety Disorder) that make differential

diagnosis difficult (Brock & Clinton, 2007; Sattler et al., 2006). In addition, children may have

associated cognitive deficits; social and adaptive functioning deficits; motivational and

emotional deficits; and motor, physical, and health deficits (Brock & Clinton, 2007; Pelham et

al., 2005; Sattler et al., 2006; Smith et al., 2007). Children with ADHD are different from their

peers on measures of attention span, activity level, and impulse control (Smith et al., 2007). The

three subtypes of ADHD set forth in the DSM-IV-TR are comprised of ADHD Predominantly

Inattentive Type (ADHD-I), ADHD Predominantly Hyperactive-Impulsive Type (ADHD-HI),

and ADHD Combined Type (ADHD-C) and diagnosis involves looking at the two sets of core

symptoms of inattention and hyperactivity/impulsivity (APA, 2000; Smith et al., 2007).

Differences exist between subtypes, gender, and development in the expression of these

symptoms, and although not discussed in detail here should be considered during the assessment

process (Brock & Clinton, 2007; Smith et al., 2007). Pelham, Fabiano, and Massetti (2005)

suggest that ADHD assessment should focus on impairment, adaptive skills, and functional

assessment that targets domains for goals of treatment planning and monitoring. As such,

assessment goes beyond measuring symptoms.

Given the heterogeneity of ADHD, assessors need to be prepared to deal with variability

with and across persons (Smith et al., 2007). A child with ADHD may appear focused,

persistent, and well controlled in novel, stimulating, or highly rewarding activities or situations

(Smith et al., 2007). A comprehensive assessment of ADD will identify situations in which there


are few problems and identify a range of competencies to highlight positive influences (Sattler et

al., 2006; Smith et al., 2007). School psychologists have a history of endorsing strength-based

perspectives and focusing on strengths and competencies within their framework of working

with children (Jimerson, Sharkey, Nyborg, & Furlong, 2004). A child’s strengths are as

important to consider as their weaknesses in helping them manage and cope with their

difficulties, understanding their potential for succeeding in all areas of functioning, and

identifying protective factors that can provide a buffer to associated risks of ADHD (Jimerson et

al., 2004; Modesto-Lowe, Yelunina, & Hanjan, 2011). Including at least one strength-based

measure in the assessment would shift the focus towards resilience and positive outcomes for

children (Jimerson et al., 2004; Modesto-Lowe, 2011). A strength-based approach in assessment

increases ecological validity of the assessment and informs intervention and treatment

approaches and goals (Jimerson et al., 2004).

These complexities of assessment should be addressed through multi-method assessment.

This approach involves obtaining information from several sources and reviewing the child’s

records and previous evaluations, using several assessment techniques, and assessing several

areas (Sattler et al., 2006).

Goals of Assessment

Clinical assessment is intended to obtain relevant, reliable, and valid information about a

child that can be used to assist them in their world (Mash & Hunsley, 2005; Sattler et al., 2006).

The process of assessment typically is guided by the referral questions, what is being measured,

and the goals of the assessment. The goals of ADHD assessment are to determine the presence

or absence of ADHD, identify broader life-context factors relevant to the child’s functioning (life

stress, peer relations, academic functioning), delineate types of interventions needed to address


various impairments, determine possible comorbid conditions, identify patterns of strengths and

weaknesses and consider how they impact treatment planning, and evaluation of outcomes

(Mash & Hunsley, 2005; Pelham et al., 2005; Smith et al., 2007). Initial assessment focuses on

diagnosis, whereas the remainder of assessment focuses on a child’s specific impaired areas of

functioning and the treatment of those behaviours (Pelham et al., 2005). Ongoing assessment

allows for the possibility of early identification of treatment response and needed actions (Mash

& Hunsley, 2005). Assessment is essential to all forms of intervention (Mash & Hunsley, 2005).

Specifically in the school setting, assessment has the overarching goal of identifying needs of the

child in order to assist with the development of interventions (Ricco & Rodriquez, 2007). Best

practice in school psychology has consistently advocated for multi-method assessment (Ricco &

Rodgriquez, 2007). It would appear that school psychology assessment processes are a good

match for the assessment of ADHD.

Interviews

Interviews with parents and teachers, as well as with the child, form a key part of ADHD

assessment (Brock & Clinton, 2007; Sattler, et al., 2006). General goals of the interview are to

clarify the presenting problem, obtain a history and context of the problem, and gather

developmental history (Brock & Clinton, 2007; Ricco & Rodriquez, 2007; Sattler et al., 2006).

Interviews can be used to expand upon the results of the other methods in ADHD assessment. In

addition, interviews can assess parent’s and teacher’s knowledge about ADHD and effective

interventions, and their readiness for change (Smith et al., 2007). Recommended interview

methods for ADHD assessment include semi-structured and structured interviews (Pelham et al.,

2005). Structured diagnostic interviews are typically used for diagnosis, where semi-structured

interviews obtain further information about relevant factors (Brock & Clinton, 2007). Interviews


should also probe strengths, protective factors, and resources that will eventually be key

considerations in suggestions interventions (Smith et al., 2007).

Parents and teachers are the most familiar with the child’s behaviour under sustained

conditions and should be given considerable weight in the assessment process (Sattler et al.,

2006; Smith et al., 2007). Parents typically provide the most detailed and ecologically relevant

information in the assessment process (Brock & Clinton, 2007). Parent interviews are critical for

obtaining information about the child’s prenatal and postnatal development; medical, social, and

academic history; medications; their view of the problem; what age the problems began; the

pervasiveness of the problems, parenting styles; environmental factors that may contribute to the

problems; and resources available to the family (Brock & Clinton, 2007; Sattler et al., 2006).

Potential bias from parent interviews may not accurately reflect a child’s functioning, and

triangulation of data sources is required (Brock & Clinton, 2007). Interviewing teachers is

important as they are often sources of referral as children with ADHD often have difficulties in

the classroom setting (Pelham et al., 2005). Teachers can make judgments about

developmentally appropriate behaviour, and are likely to be involved in the intervention process

(Smith et al., 2007). Teachers can offer valuable information about when the symptoms occur,

the specific behaviours that interfere with school functioning, the severity of the symptoms,

factors that exacerbate the problem, academic strengths and weaknesses, social skill strengths

and weaknesses, the quality of the child’s peer relationships, and treatment effects (Brock &

Clinton, 2007; Sattler et al., 2006). However, as children get older, teachers may not know the

child as well, and teacher reports may be less reliable in middle and high school (Smith et al.,

2007). Given the amount of time spent at school and the importance of attention in relation to

academic success, the teacher interview is critical (Brock & Clinton, 2007). Differences in the


attitudes, experiences, and judgements between different people are common, and should be

considered as information in a particular context for the child (Smith et al., 2007). Probing key

informants about the degree of problems and success with tasks, the influences of behaviour on

tasks, and the developmental appropriateness of the behaviour is very informative regarding the

child’s fit with the environment and is person-centered (Smith et al., 2007).

Interviews with children can supplement the assessment process. However, self-report of

ADHD symptoms does not appear to be very dependable and including both interviews and

ratings with children in the assessment process have questionable validity (Brock & Clinton,

2007; Pelham et al., 2005; Sattler et al., 2006; Smith et al., 2007). Children tend to

underestimate their difficulties and exhibit a positive illusionary bias (Brock and Clinton, 2007;

Smith et al., 2007). Of note, interviews of internalizing symptoms (such as anxiety or

depression) do seem to contribute to a valid assessment when assessing for comorbid anxiety or

mood disorders with ADHD (Brock & Clinton, 2007; Smith et al., 2007). Interviews with

children in general may reveal levels of insight or motivation of a child, and brief interviews to

establish rapport and cooperation with interventions might be worthwhile (Smith et al., 2007).

Rating Scales

Rating scales provide a standardized format for collecting information about a child’s

behavioural characteristics from an informant who knows them well, and are a widely advocated

procedure for ADHD assessment (Brock & Clinton, 2007; Ricco & Rodriquez, 2007; Smith et

al., 2007). Rating scales provide a structured format for documenting the presence and degree of

ADHD symptoms using a normative framework (Brock & Clinton, 2007). Both broadband and

narrowband rating scales administered to parents, teachers, and children can help identify

behaviours related to ADHD, assist in screening for comorbidity and differential diagnosis, and


discriminate between ADHD subtypes (Brock & Clinton, 2007; Collett, Ohan, & Myers, 2003;

Pelham et al., 2005; Sattler et al., 2006; Smith et al., 2007). Rating scales are an efficient and

easy means of gathering information about the child’s behaviour in multiple settings and they

facilitate the integration of information from multiple sources; however, they do not provide for

a functional analysis of the variables that interact with the child’s behaviour or provide

information regarding impairments, age of onset, or chronicity of the symptoms (Pelham et al.,

2005; Ricco & Rodriquez, 2007; Sattler et al., 2006; Wright, Waschbusch, & Frankland, 2007).

In addition, rating scales may also be insensitive to low base rate or covert behaviours that may

be underestimated or unknown by the rater (Pelham et al., 2005). Rating scales administered

over longer durations or on multiple occasions, and including observational measures will be

more effective in the assessment of ADHD (Pelham et al., 2005; Schwean & McCrimmon,

2008). Rating scales focus most often on pathology as opposed to strengths (Ricco & Rodriquez,

2007). Components of resilience can be tapped by the inclusion of some specific rating scales

that include competencies such as adaptability, leadership, coping styles, and social skills (Ricco

& Rodriquez, 2007).

Data from multiple raters is important information in understanding why a child does

better in an activity or setting (Collett et al., 2003; Smith et al., 2007). Different raters,

responding to the same rating scale, often provide different results (Brock & Clinton, 2007). As

with interviews, there can be low correlation between parents and teachers ratings of ADHD

(Smith et al., 2007). Differences in ratings may reflect actual differences in children’s behaviour

with informants from different settings, as well as potential bias in ratings of ADHD (Collett et

al., 2003; Pelham et al., 2005; Ricco & Rodriquez, 2007; Vale & Tannock, 2010). For example,

parents may be unaware of difficulties present within the classroom, or report higher symptoms


due to parental stress or depression, and teachers of adolescents may not know the child well

enough to accurately rate their behaviour (Brock & Clinton, 207; Evans, Allen, Moore, &

Strauss, 2005; Pelham et al., 2005). Research finding suggest that secondary teachers provide

less reliable ratings than elementary teachers, due to differences between settings, time together,

time of year, and student/teacher ratios (Evans et al., 2005). Ratings from secondary teachers are

can be considered reliable in regards to hyperactive symptoms and academic progress, or when

collecting data during the winter months (Evans et al., 2005). As with interviews, child self-

report ratings have been found to underestimate problems associated with ADHD (Brock &

Clinton, 2007; Collett et al., 2003; Hoza et al., 2004). Ratings scales chosen for the assessment

should have correction factors to adjust for potential biases (Smith et al., 2007). It is evident that

raters from a single source do not provide a comprehensive picture of the current levels of

functioning for a child with ADHD (Pelham et al., 2005). Information from multiple raters will

directly influence the assessment of ADHD and contribute to meeting the criteria of impairments

in multiple settings set forth by the DSM-IV-TR (APA, 2000; Vale & Tannock, 2010). Collett,

Ohan, & Myers (2003) provide a comprehensive review of rating scales and their applications to

the ADHD assessment process, and suggest that when used appropriately rating scales have the

potential to improve the assessment and treatment process.

Observations

Direct observations are frequently recommended in ADHD assessment (Brock & Clinton,

2007). In the absence of specific tests for ADHD, direct observations of children’s behaviour

provide alternative methods for obtaining external validations of ADHD (McConaughy, et al.,

1020). As noted by Pelham et al. (2005) there is a long tradition of using observations with

children presenting with ADHD symptoms. Observations provide a picture of children’s


spontaneous behaviour in everyday life settings; provide a systematic record of behaviours that

can be used for evaluation, intervention planning, and monitoring changes; allow for verification

of parent and teacher reports and rating scales; and allow for comparison of behaviors between

test situations and naturalistic settings (Sattler et al., 2006). Observations are particularly

valuable in ecological assessment, which focuses on the physical and psychological attributes of

the setting in which the behaviour occurs (Sattler et al., 2006). Of note, observations may not be

particularly useful for studying behaviours that are less frequent or are covert, such as inattention

(Ricco & Rodriquez, 2007; Sattler et al., 2006). In those situations you may need to observe

behaviours associated with the psychological processes as they cannot be observed directly, or

refer to the parent and teacher reports that are based on more experience with the child

(McConaughy et al., 2010; Sattler et al., 2006). Alternatively, different observation approaches

such as partial interval coding or event coding over longer durations might be more sensitive to

detecting inattention in an assessment (McConaughy et al., 2010).

Test sessions and school classroom settings offer opportunities for observations of

children’s behaviours (McConaughy et al., 2010). Test sessions allow the examiner to directly

observe behavioural manifestations of ADHD symptoms while a child is engaged in cognitive or

academic tasks (McConaughy et al., 2010). However, one should also keep in mind the factors

associated with testing that may impact ADHD symptom expression and resulting observations

(novel situation, structure, highly motivating, etc.). Observations in classrooms can be

particularly revealing because key symptoms of ADHD may be more pronounced in school

settings than in one-on-one test sessions or at home (McConaughy et al., 2010). School

psychologists are in a unique position to include these types of observations in their assessment.


Behavioural observations collected on multiple occasions, within natural settings, and

over longer durations are more useful than those taken within clinical settings on single

occasions (Schwean & McCrimmon, 2008). Observational methods valuable in the assessment

of ADHD include narrative recording, interval recording, event recording, and ratings recordings

(Brock & Clinton, 2007; Sattler et al., 2006). Observations of symptoms of inattention,

hyperactivity, and impulsivity may indicate the presence of ADHD (i.e. repetitive purposeless

motions, leaves seat, attending to irrelevant information, stopping in the middle of tasks,

response to distractions, etc.) (Sattler et al., 2006). A common observation procedure in school

settings is a functional behavioural assessment (Ricco & Rogriquez, 2007). A functional

behavioural assessment (FBA) can assist in developing hypothesis and guide intervention plans

(Sattler et al., 2006). Environmental events can be manipulated (type of activity, instruction,

accommodation, etc.) and effects observed to assess interventions. Observations of the child’s

behaviours will provide information about the antecedents and consequences of the behaviours;

intensity, duration, and rate of behaviours; and factors that contribute to the behaviours (Ricco &

Rodriquez, 2007; Sattler et al., 2006). Attention to functional impairments rather than attention

to symptoms are more useful in targeting interventions (Smith et al., 2007).

Of note, several issues in observation should be considered throughout the assessment

process. Developmental stages should be taken into account when making observations as

symptom expression can change (i.e. preschool children will display higher hyperactivity than

adolescents) (Sattler et al., 2006; Smith et al., 2007). It is crucial to conduct observations in

multiple settings as it is common for symptoms to vary as a function of differences in situational

demands and impairment must be documented in multiple settings (Brock & Clinton, 2007;

Smith et al., 2007). Observations can be repeated throughout treatment to evaluate and monitor


effects of interventions (McConaughy et al., 2010; Smith et al., 2007). Overall, observations are

an important element of ADHD assessment, and given that school psychologists are often trained

in observation procedures and they are readily accessible they should be used whenever possible

(Brock & Clinton, 2007).

Psychological Tests

The use of psychological tests is common in ADHD assessment (Brock & Clinton, 2007).

ADHD is associated with several cognitive impairments involving executive functions that result

in risks for poor academic achievement; impaired family, peer, and adult social relationships;

and comorbid conditions (Schwean & McCrimmon, 2008; Smith et al., 2007). The majority of

children with ADHD have varying degrees of poor school performance or co-existing learning

disabilities that require academic assessment and assistance beyond managing ADHD symptoms

(Smith et al., 2007). Appropriate psychoeducational assessment can lead to effective and

efficient methods of intervention that may reduce these risks (Schwean & McCrimmon, 2008).

Cognitive assessment, achievement tests, memory and neuropsychological tests, and measures of

adaptive functioning are useful in the assessment of ADHD (Sattler et al., 2006; Schwean &

McCrimmon, 2008). Specifically, these psychological tests can contribute to ADHD assessment

by documenting severity of impairment, generating information to help rule in or rule out other

possible explanations for presenting symptoms or co-existing disorders (i.e. mental retardation,

learning disabilities, anxiety, etc.), and identify patterns of strengths and weaknesses that are

implicated in ADHD symptomology (Brock & Clinton, 2007; Schwean & McCrimmon, 2008).

A major difficulty with psychological tests in the assessment of ADHD is that novel, structured,

one-on-one, and often highly stimulating situations in an individual assessment may not elicit the

same degree of ADHD symptomology as the child’s classroom or daily life settings (Sattler et


al., 2006). In addition, some tests may not tap relevant processes, constructs, or typical

responses in natural settings (Brock & Clinton, 2007). As such, the use of psychological tests

are not sufficiently sensitive enough to be used exclusively in making a diagnosis of ADHD or in

discriminating between subtypes of ADHD (Sattler et al., 2006). However, patterns of strengths

and weaknesses are useful in evaluating individual abilities and provide support in a more

comprehensive assessment that inform intervention planning, progress evaluations, prognosis,

and administrative decision-making (Sattler et al., 2006; Schwean & McCrimmon, 2008; Smith

et al., 2007).

Given that the Weschler Intelligence Scale for Children – Fourth Edition is considered

the gold standard in cognitive assessment several research findings relative to children with

ADHD should be noted. Scores of children with ADHD remain stable, and profiles of strengths

and weaknesses are often similar with lower performance on Working Memory and Processing

Speed as compared to Verbal Comprehension and Perceptual Reasoning (Schwean &

McCrimmon, 2008). However, children with ADHD are heterogeneous in their intellectual

profiles and the profile analysis is not diagnostic of ADHD (Schwean & McCrimmon, 2008).

What profile analysis can offer is assistance with differential diagnosis and designing

intervention supports. Additionally, the observations during test administration can provide

important information about the conditions and tasks that facilitate the child’s ability to learn,

and in some instances testing of limits can further elaborate the understanding of adaptations and

accommodations that enhance a child’s performance (Schwean & McCrimmon, 2008).

Research supports the notion that impaired attention processes in children with ADHD

are part of a larger domain of cognitive activities involving executive functions (EF) and

working memory (Smith et al., 2007). Symptoms of inattention and EF appear to be very


persistent through life course; and ADHD symptoms, rating scales, and DSM-IV-TR criteria

have been found to correlate with EF. The assessment of ADHD might be improved by the

addition of measures of EF (Smith et al., 2007). However, the sensitivity and specificity of

neuropsychological measures has been questioned, and the use of these tests as part of the

assessment process remains controversial (Barkley & Murphy, 2011; Brock & Clinton, 2007).

Barkley and Murphy (2011) suggest that EF are more strongly associated with impairment in

major life activities than tests of EF. Measures of behavioural inhibition, self-regulation, and

executive functions are more discriminating of ADHD than measures of attention or other

psychological constructs (Schwean & McCrimmon, 2008). The full impact of ADHD on a

child’s adaptive functioning requires a longer time span to evaluate, and measures of adaptive

functioning may be useful in capturing the degree of difficulties in daily life (Smith et al., 2007).

Conclusion

The heterogeneous nature of ADHD and additional problems that co-exist with both

types of ADHD make the assessment process a complex and challenging task (Smith et al.,

2007). Evidence-based assessment is critical in promoting a better understanding of the specific

nature of ADHD that goes beyond simple diagnosis of symptoms to facilitate better outcomes for

children affected by this disorder (Schwean & McCrimmon, 2008). The most commonly

recommended assessment processes of ADHD in schools includes parent and teacher interviews

and ratings, observations, and psychological testing to document symptoms, impairments,

strengths and weaknesses, and ongoing assessment of responses to intervention (Brock &

Clinton, 2007; Smith et al., 2007). ADHD symptoms are situation specific and assessment of

ADHD requires information about symptoms, functioning, and impairments from multiple

informants to obtain a full picture of a child’s daily functioning in their environment (Vale &


Tannock, 2010). Cross-informant discrepancies and confounding influences of activity and

setting effects can be untangled through multi-method assessment (Pelham et al., 2005; Smith et

al., 2007). Given the training of school psychologists and their access to these procedures, they

are well positioned to assist in ADHD assessment (Brock & Clinton, 2007). A final task for

school psychologists would be to integrate the data across sources, settings, methods, and

measures by considering the goals of the assessment process (Ricco & Rodriquez, 2007).


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