ATTENTION DEFICIT DISORDER – DIAGNOSTIC EVALUATION
Direct testing & observation is much better than checklists or questionnaires…
No one test or assessment is universally accepted as the “right” or “best” way to diagnose ADD. Whether done by a team or an individual, regardless of which type of professional(s) are involved, two fundamentally different approaches can be taken to the evaluation process: subjective vs. objective. In practice this means using history, questionnaires, & “rating scales” (subjective) vs. doing direct testing/observation (objective). The former approach has unfortunately become very popular, almost to the point of being an accepted “standard”, during the past decade. “Standardized” questionnaires have the advantages of being easy to use & interpret, even for relatively unsophisticated evaluators. They really are not the best way to go about ADD diagnosis, however. Questionnaires and history, by the very nature of the information they obtain, do not really get at the question of WHY mentioned in the previous section. They focus on WHAT instead. In so doing, they tend towards systematic OVER-DIAGNOSIS. They fail to differentiate the child who is inattentive for non-neurologic reasons.
Direct testing and observation of a child by an experienced clinician who knows not only ADD, but psychological disorders and learning problems as well, is a far better way to diagnose this disorder. Critics of this approach will say that no test is really designed to measure attention. True enough. However, an experienced clinician can observe and make judgments, not only about the quality of a child’s attention, but also about the likely CAUSES of any inattention displayed during almost any task that requires some. It almost doesn’t matter which specific test they use! It can be an extended neurologic or developmental exam (for the pediatrician or neurologist), a cognitive or IQ test (for the psychologist), or an individual achievement test (for the education professional). The experience, judgment, and observational powers of the examiner matter more in this context than the specific items on the test. This fact makes many people uncomfortable nowadays (especially school staffs and managed care organizations), because it suggests an acceptance of non-reproducibility. It says that who gives the test is more important than which test is given – a true idea quite out of step with the times.
Critics of direct testing as a way to diagnose ADD also point out that all children attend better in 1:1 testing situations. Also true. However, children with ADD still don’t attend as well in such situations as they should, or as well as children without ADD typically do. This is key, because in the 1:1 testing situation the child with true ADD cannot completely suppress his difficulty, or hide it from the examiner, precisely because it is neurologically based. In contrast, very often a child whose inattention is due to other factors (emotional, learning, etc.) will have no trouble at all in the 1:1 setting because the setting substantially ameliorates the problem. This strongly suggests a non-neurologic origin for the inattentive symptoms.
Finally, no discussion of diagnostic methods would be complete without mentioning the future. The future lies neither with questionnaires nor in 1:1 “tests”. Like all neuropsychiatric conditions, ADD is based on differences in brain chemistry and brain anatomy. We are starting to understand these things, and it is reasonable to expect that within another generation we will have physical tests, similar to CT scans or blood tests, which can reliably identify ADD. Then and only then can we expect the current controversy about how to diagnose (and define) this disorder to begin to cool down.