Help me understand the ADHD Evaluation Process

[Anonymous]

I recently took my DS to his pediatrician to start the process of evaluating for ADHD. I’m not 100% sure if ADHD is the correct direction, it’s just my guess. We were given the Vanderbilt form for his teacher and us to fill out. The pediatrician thinks that DS issues are 50/50 ADHD and anxiety. With that she says the she can prescribe adhd meds and write a note diagnosing DS with adhd to go on file with the school. She tells about the med options and that they could make anxiety worse so it would be trial and error. She also tells us that we can explore therapy but she can’t give us much advice on that and sends us on our way. I am left a little lost. I thought getting an ADHD diagnosis came after a full psych evaluation/testing? I am confused. Should we just go to a psychologist? I thought the pediatrician would give us more guidance. Anyone care to share your experience?

[Anonymous]

There are lots of ways to get evaluated and diagnosed with ADHD. Three typical ones:

1 - pediatrician using Vanderbilt questionnaires and speaking with a parent, and the child (depending on age)
2 - a clinical psychologist who will use Vanderbilt questionnaires, more in-depth family interviews, and some academic and IQ testing
3 - school psychologist who will #2 above but can't 'diagnose' ADHD but rather will say 'child exhibits behaviors and tendencies consistent with an attention disorder' (or something like that)
4 - neuropsychologist who will do all of 2, and usually more in-depth tests.

DCUM has a bias toward #4. I personally think if you have a very clear cut case and no one is concerned about any possible other disorders, any of 1-3 above can work for your kid. But if the kid is borderline, or there is suspicion of anxiety, or a learning disorder, or depression .... I'd seek further formal testing.

ADHD and anxiety are very often comorbid, but often anxiety alone can look like ADHD and vice versa. Assuming you want to pursue medication, I'd want to be as sure as possible you are dealing with the right diagnosis.

[Anonymous]

It has been that ridiculously easy in my experience.

[Anonymous]

Anonymous wrote:There are lots of ways to get evaluated and diagnosed with ADHD. Three typical ones:

1 - pediatrician using Vanderbilt questionnaires and speaking with a parent, and the child (depending on age)
2 - a clinical psychologist who will use Vanderbilt questionnaires, more in-depth family interviews, and some academic and IQ testing
3 - school psychologist who will #2 above but can't 'diagnose' ADHD but rather will say 'child exhibits behaviors and tendencies consistent with an attention disorder' (or something like that)
4 - neuropsychologist who will do all of 2, and usually more in-depth tests.

DCUM has a bias toward #4. I personally think if you have a very clear cut case and no one is concerned about any possible other disorders, any of 1-3 above can work for your kid. But if the kid is borderline, or there is suspicion of anxiety, or a learning disorder, or depression .... I'd seek further formal testing.

ADHD and anxiety are very often comorbid, but often anxiety alone can look like ADHD and vice versa. Assuming you want to pursue medication, I'd want to be as sure as possible you are dealing with the right diagnosis.

We went to a developmental pediatrician at KKI who did 1 & 2. I think the full neurospych is good if you have a complicated case and think you're dealing with a lot more than ADHD. If it seems like run of the mill ADHD, I don't think all of that is necessary.

[Anonymous]

While there is some element of trial and error in choosing adhd and anxiety meds, a child psychiatrist or developmental pediatrician who sees lots of kids with adhd and anxiety will have a better sense of which meds may work better for a particular profile. For a child with both adhd and anxiety, I would not let the pediatrician do med management.

[Anonymous]

You can also go to a psychiatrist, which is what I would do in your situation, as it is possible to treat both ADHD and anxiety but it can be tricky. He/she will use the Vanderbilt forms and do a much longer history and intake process. Also, the psychiatrist is likely to be a much stronger advocate of therapy which is also important, certainly for the anxiety piece. For the ADHD piece, we have found executive function coaching (which some therapists also do) to be more helpful.

[Anonymous]

Anonymous wrote:You can also go to a psychiatrist, which is what I would do in your situation, as it is possible to treat both ADHD and anxiety but it can be tricky. He/she will use the Vanderbilt forms and do a much longer history and intake process. Also, the psychiatrist is likely to be a much stronger advocate of therapy which is also important, certainly for the anxiety piece. For the ADHD piece, we have found executive function coaching (which some therapists also do) to be more helpful.

It depends on the psychiatrist.

The one we contacted told us to go to a clinical psychologist or neuropsychologist for diagnosis and call back if we wanted to pursue medication post-evaluation.

[Anonymous]

We did option #4 described above. I cannot imagine giving my child ADHD medication having only done options 1-3. We weren't sure what was going on so we tested for a lot of things.

[Anonymous]

FWIW, we were using Vanderbilts from school and a developmental ped at KKI, and it was a total fail. My child was slipping through the cracks, and his teachers were not noticing signs of anxiety and ADHD.

Several years later, we moved DS to a new school and won the lottery with some teachers who cared and "saw" him. At their encouragement, we got him to a psychiatrist who could tease it all apart, and my son is doing much better with proper medication and interventions.

I guess my point in chiming in is that there are lots of ways to a diagnosis. But trust your gut. I wish I had.

[Anonymous]

Anonymous wrote:We did option #4 described above. I cannot imagine giving my child ADHD medication having only done options 1-3. We weren't sure what was going on so we tested for a lot of things.

I strongly agree with this. In my experience, the questionnaires are terribly inaccurate. In the three cases I know best, they totally missed my oldest having ADHD (he was later diagnosed with "severe ADHD" but is more on the inattentive side), mis-diagnosed my nephew (no ADHD, testing showed he is dyslexic), caught my younger son (extremely hyperactive... but years after I had been asking teachers for input).

The questionnaires are totally subjective and are based on behaviors. If a child is hyperactive but working really hard, if a child is very bright but struggling with attention challenges, and other situations like this--the person filling out the evaluation might see the child as average. Or if a child presents with hyperactive behavior, the teacher/parent may mark all the boxes, leading to an ADHD diagnosis without any true understanding of what is causing the issues (as in my nephew's case).

It is worth waiting/paying more/seeking out studies or graduate programs--whatever it takes to have a more thorough evaluation done that will actually give you some insight into strengths and weaknesses. All diagnosing is a mix of observation and intuition on part of the evaluator but, ideally, you want to have an expert (pediatricians and teachers are far from that!!!) looking at many different aspects of your child's profile and at least trying to get at the root of the problem.

[Anonymous]

Np here, but thanks for posting this. My son was diagnosed based off interview with me, his behavior in the office(1 hr visit), and asking him questions like repeat these numbers. This was at KK and I’m really not satisfied.

[Anonymous]

ADHD is very over-diagnosed - and your pediatrician's approach shows exactly why.

One fundamental aspect of ADHD is that it compares the child's behavior to other children, and in multiple natural settings. In my opinion, it should never be diagnosed if the child has not been directly observed at home and at school.

I'm also irritated that your doctor did not identify any therapy for you, since therapy is the first line treatment.

[Anonymous]

1 - pediatrician using Vanderbilt questionnaires and speaking with a parent, and the child (depending on age)
2 - a clinical psychologist who will use Vanderbilt questionnaires, more in-depth family interviews, and some academic and IQ testing
3 - school psychologist who will #2 above buIntunivt can't 'diagnose' ADHD but rather will say 'child exhibits behaviors and tendencies consistent with an attention disorder' (or something like that)
4 - neuropsychologist who will do all of 2, and usually more in-depth tests.

We did a variant of option 2 - the psychologist did extensive academic and behavioral testing, and interviewed DS's teachers in addition to his parents (us).

I thought it was useful because it identified some specific executive functioning issues that my son has..

After doing that testing, we went to his pediatrician for medication. But as a caveat, I am already very knowledgeable about ADHD medications, as I have ADHD as well. So I knew what to ask for and knew what the pediatrician was recommending.

DS also has anxiety. We do as well as a stimulant (low dose). If DS did not also have the executive functioning issues, we would not medicate at all, as his ADHD alone is manageable for him.

[Anonymous]

Anonymous wrote:ADHD is very over-diagnosed - and your pediatrician's approach shows exactly why.

One fundamental aspect of ADHD is that it compares the child's behavior to other children, and in multiple natural settings. In my opinion, it should never be diagnosed if the child has not been directly observed at home and at school.

I'm also irritated that your doctor did not identify any therapy for you, since therapy is the first line treatment.

It depends on the age of the child. Therapy and meds together is the recommendation if the child is school age.

[Anonymous]

I was appalled at the process. It was too easy, and no one actually evaluates the CHILD.
Had school eval (inconclusive/enigmatic case) and were told to pursue diagnosis and treatment to qualify for accommodations
First visit to a new pediatrician and walked away with a Dx and Rx for Adderal (child was 5 at the time)
Then went the psych route and all it was a host of adult questionnaires -- no actual evaluation of the child, just reports from people who have interacted with him
So now we're in the queue for the full eval at a children's hospital since we think there's also a learning disability.