• Jason Steadman, Psy.D.

Requesting “testing” for ADHD: Helpful tips about what you need to know

Updated: Sep 14

Buckle up, this is going to be a long, but informative “answer” to the question: Do you test for ADHD? The key bullet points are below:

  • “Testing” means the administration and interpretation of specialized tests. Psychologists are usually the only ones trained in interpreting those tests accurately.

  • ADHD doesn’t really need testing to be diagnosed. If diagnosis is all you need, testing isn’t necessary in most cases (though sometimes it can be).

  • ADHD is probably overdiagnosed in our culture, for several complex reasons.

  • “Inattention” means something different to me than it probably does to you.

  • When I do agree to perform testing, especially cognitive testing, the reason is almost never to figure out a diagnosis. Rather, it’s designed to describe how a person thinks and what that means for how they may interact with the world. This is because almost no diagnoses are defined by how a person performs on a cognitive test (though a few – namely intellectual disability, specific learning disorders, and neurocognitive disorders – are).

Introduction to ADHD

Attention-deficit/hyperactivity disorder, ADHD, is a common childhood disorder, occurring in about 5% of children and 2.5% of adults across the world. However, in the U.S. ADHD is far more commonly diagnosed, with, according to CDC data, an overall prevalence of 9.4% in 2016 (6.1 million children ages 2-17). Boys are also far more likely than girls to be diagnosed with ADHD, with 12.9% of boys having the diagnosis, compared to 5.6% of girls. More data from the CDC can be found here: https://www.cdc.gov/ncbddd/adhd/data.html.

ADHD has 3 officially recognized subtypes: combined presentation, predominantly inattentive presentation, and predominantly hyperactive/impulsive presentation. A fourth subtype is widely recognized by experts, though is not currently included in any diagnostic manuals – sluggish cognitive tempo. The three primary subtypes are differentiated by the way symptoms present. ADHD has two clusters of symptoms: inattention and hyperactivity/impulsivity. Each cluster has 9 possible symptoms, and, to qualify for ADHD, a child must demonstrate at least 5 of the 9 symptoms on each cluster. In the combined type, at least 5 symptoms are present on both clusters, whereas in the other types, symptom criteria are met only on one or the other. The clinician also has to ascertain that those symptoms have been present for at least 6 months, are enough to cause real, functional impairment in a child’s daily life, are present in two or more settings, have an onset prior to age 12, and, importantly, are not better explained by another mental or medical disorder, such as a mood disorder, anxiety disorder, neurocognitive disorder, psychotic disorder, dissociative disorder, personality disorder, or substance intoxication or withdrawal.

The fourth type, sluggish cognitive tempo, is pretty different, enough so that some researchers argue it is not really a type of ADHD, but something else altogether. A full review of sluggish cognitive tempo is beyond the scope of this post, but, briefly, sluggish cognitive tempo, has been proposed to be best described by the following symptoms: 1) daydreaming; 2) trouble staying awake/alert; 3) feeling mentally foggy/easily confused; 4) staring a lot; 5) looks/feels spacey, mind is elsewhere; 6) is lethargic; 7) is underactive; 8) is slow-moving/sluggish; 9) doesn’t process questions or explanations accurately; 10) appears drowsy/sleepy; 11) appears apathetic/withdrawn; 12) is lost in thoughts; 13) slow to complete tasks; and 14) lacks initiative/effort fades. Thus, behaviorally, sluggish cognitive tempo can look a lot like the predominantly inattentive type of ADHD. However, if you look more closely, what you see is not someone who lacks focus, but, rather, someone whose mind processes things more slowly, who is unhurried in cognitive tasks, and who seems to be fairly underactive, almost like they are sleepy, even though they really aren’t.

Evaluations or consults for ADHD are easily the most common request I get in my practice, and I have often found that it is useful to share some key information with parents to help inform them about the process, so they can make better decisions about how they want to proceed in seeking an ADHD evaluation. Thus, the reason for this blog is to review that information for parents.

First, I think it is important to note 2 key issues that derive from the first 2 paragraphs above.

1. ADHD is diagnosed more frequently in the U.S. than it is in other countries

2. Inattention and impulsivity are both non-specific symptoms that occur in almost all psychiatric disorders

Why is ADHD diagnosed more frequently in the U.S. and why does that matter?

There isn’t total agreement on why ADHD has a higher diagnostic rate in the U.S. compared to other nations. Some argue that we in the U.S. are just better at identifying the symptoms than clinicians in other countries, and while that is technically true, it certainly isn’t because we’re better doctors than doctors in other countries. Rather, our ability to identify ADHD at higher rates derives from a combination of complex factors, including 1) diagnostic bias, 2) misinformed diagnosticians, 3) intolerance of “childhood” in the educational system, and 4) a desire to help frustrated parents/teachers, but being only able to do so if a diagnosis is assigned. Let’s look at each of these below:

Diagnostic bias and misinformed diagnosticians

Especially in the last 35 years or so, our culture has become hyper focused on ADHD. Unlike some of the more “obscure” medical/psychiatric syndromes (take, for example, Rett syndrome[1], cataplexy[2], anosognosia[3]), the general public is highly aware of ADHD, and, as a result, they frequently present to clinics with an already fairly well-developed knowledge of its symptoms. This means that when they present to doctor’s offices, parents and others who believe they have ADHD are more skilled at presenting a narrative that is consistent with the diagnosis. In most cases, this is not done with mal-intent (i.e., most patients are not “faking” or “drug-seeking”). Instead, I only mean that because parents know the basic symptoms of ADHD, they know how to look for them in their children, and they know how to report those to their doctors. On the side of doctors, most pediatricians and primary care doctors are well aware of ADHD, but few have had the training to differentiate true ADHD from other disorders that mimic ADHD, and even fewer have the time in office to interview properly to rule out those other disorders. Furthermore, ADHD is something that many doctors know how to “fix.” We have good medications that work well to improve attention, and they do improve focus and attention, regardless of whether you actually have ADHD. In other words, a person without ADHD can improve focus (at least temporarily) with proper dosing of stimulants. So, prescribers, who have good intentions and really want to help their patients, assign the diagnosis and prescribe the medications.

However, behind the scenes of all of this, there is a clear diagnostic bias for ADHD. ADHD is the “easy” diagnosis to make, because its very name describes the symptoms that are being seen/described. It’s very often the first diagnosis that comes to mind when someone thinks “inattention” and “lack of focus.” But, in reality, inattention and lack of focus are probably the least specific symptoms in all of psychiatry/clinical psychology. Inattention and concentration issues can occur in any problem – anxiety mood problems, and sleep problems are the most common culprits, but inattention happens in pretty much everyone afflicted by a psychiatric problem. Most psychologists (myself included) treat ADHD as a diagnosis that should made only after all other explanations have been ruled out. Rather than being “first” on the list, in my practice, it comes last.

And there is good reason for this from a medical standpoint. Although stimulants and other medications for ADHD are relatively safe (the side effects that occur are usually not serious and will go away when the medication is stopped), they do produce side effects. Stimulants like Ritalin (methylphenidate) and Adderall (amphetamine) are notorious for disrupting three important daily cycles – appetite, sleep, and mood. Stimulants decrease appetite, so weight loss or failure to gain weight are important to monitor. As stimulants, they can also interfere with sleep, especially if taken too late in the day. Lastly, they are addictive medications, and people who take them do build up tolerances and do withdraw from the medications when they wear off. The withdrawals are psychological in this case, most often characterized by irritability and labile (frequently shifting) mood. These addictive properties are why the FDA classifies them as controlled substances. So, we don’t want to give these medications to kids who don’t need them. And furthermore, we especially want to avoid giving them if we think the real root of the problem is a mood or anxiety disorder, because the stimulants, especially when they wear off, can make these problems worse.

At the same time, things get even more complicated because even though mood problems are not part of the diagnostic criteria for ADHD, they are actually really common. Having true ADHD is a lot like being really bored all the time. The ADHD-brain lacks stimulation, which feels pretty boring. Being bored all the time is a really unpleasant feeling, and, after a while, it makes you feel kind of irritable, and you can get pretty moody. So, sometimes, stimulants can actually help with mood. And sometimes you don’t know if they’ll help until you try. And then if the first one you try doesn’t help, you don’t know if the problem is because you’ve got the wrong diagnosis or the wrong medication. It’s very common for people to try many different ADHD medications before finding one that works. And it’s also very common for one that works to eventually not work quite as well as it used to, due to tolerance, as mentioned above (and also due to the fact that these meds are most often taken by kids, and kids get bigger as they age, so they need higher doses). So, just because someone gets moody when they’re on a stimulant doesn’t always mean that they don’t have ADHD. Unfortunately, things are a lot muddier than that.

Still, because of all the above, it is a good idea to get a more thorough evaluation for ADHD before you consider treatment. Things are complicated, and you can get a lot more information from a specialist than you normally will from a typical pediatrics office consult.

Note: There is an exception to that last statement. If your pediatrician knows your child well – perhaps they have seen your child several times a year for the child’s whole life – they have a lot of background information that specialists won’t always have, and they can often use that information to know what things are important to consider in an ADHD evaluation, especially if they’ve had some specialty training in ADHD.

Intolerance of childhood

The modern U.S. educational system is not designed for children. It was designed, actually, during the industrial revolution (1800s), and it hasn’t changed much since, at least in format and design. The industrial revolution meant that more people needed to learn how to work in factories and with machines. Machines are structured, orderly, predictable, and unchanging. But, they need humans to work them (by building them, operating them, programming them, etc.). So, schools were designed to help humans act more in sync with machines. Humans needed to be able to respond predictably to structure, order, and unchanging work environments. So, schools started to teach children in ways that enhanced their tolerance for such conditions. Unfortunately, surprise surprise, children are not machines. Naturally, in fact, (most) children prefer spontaneity and playfulness. They do not take life seriously, and frivolity and carelessness take precedence over orderliness and predictability. Now, don’t get me wrong, children do need structure and boundaries, and it is our job as adults to help children learn skills they will need to survive in their futures as adults. But, we adults often fail to strike the right balance between teaching these skills and allowing children to be children, especially in the United States (and in some other Western education systems). So, when children go to school and act like children, they get quickly “corrected” to fall back “in line” with expectations. Some teachers and some education systems are less tolerant of childhood than others. Furthermore, some children fall in line less quickly and less readily than others. In an effort to help their children succeed in school and to reduce frustrations, parents often seek help from schools and clinicians to maximize success at school, which, sometimes, may require a diagnosis of ADHD. This brings us to the next section.

Educational and healthcare systems necessitating diagnosis for access to services

In public educational systems, and in many private ones too, children must have a diagnosis to qualify for certain educational accommodations. A diagnosis of ADHD (alone) helps a child qualify for a 504 plan (named after the section of the Federal Code in which the law that describes these rules is listed – section 504), which requires schools to provide reasonable accommodations to maximize a child’s learning. If a child’s predilection to “childhood,” as described above, is getting in the way of their learning at school, then they can qualify for accommodations, but only AFTER a formal diagnosis is made. Very frequently, then, parents present for ADHD evaluations at the request of schools. But here’s the issue. This phenomenon happens much less frequently in schools in other countries, especially in those who have different educational values. Some would see that as a bad thing, with the argument that other countries are “missing” children who struggle to learn, and those children get “left behind.” Others argue that other countries are just more tolerant of childhood frivolity, and, rather than diagnose children, they meet them where they are and educate accordingly, without requiring a diagnosis to make that happen.

The same thing happens in healthcare. I may meet with a child who is having a hard time in school (and/or in other areas of life), and I may have good ideas about how to help them succeed. Some of these ideas may include some coaching of parents and schools, and may involve several follow-up appointments so that such coaching can be done right. At the same time, I have to make a living and have to charge for my appointments. After a while, the cost of appointments adds up, and things can get quickly expensive for families. This is where insurance comes in, to assist with the costs of healthcare. But, for insurance to pay, they need to be given a valid reason for the services, which in this case means a diagnosis must be made. Diagnosis is the verification that insurance needs that a healthcare service is worth paying for. So, to help families afford services, there is a “pressure” to assign a diagnosis in order to conduct business. When the CDC counts diagnoses of ADHD, as in the data cited at the beginning of this blog, they are almost always counting those diagnoses through data submitted by doctors who work within a third-party payor system – that is, doctors whose services are paid for by insurance companies. So, this process of insurance companies requiring doctors to assign diagnoses for payment somewhat artificially boosts the number of kids diagnosed with ADHD – it skews the data. Kids who may be kind of “borderline” may be given the diagnosis just to help them get helpful services. It’s not that the services are unwarranted though – they can help kids regardless of diagnosis. What is unwarranted, in some cases, is the need to make the diagnosis to get helpful services.

So, for these reasons, we end up in the U.S. with somewhat inflated statistics about the rates of ADHD.

What does it mean to be “tested” for ADHD?

Often, parents and psychologists mean very different things when they say “testing” for ADHD. That’s not parents fault. Parents shouldn’t be expected to know what “testing” really means – that’s the job of psychologists. To psychologists, “testing” means something very specific – the administration of some of kind of published test, be it a questionnaire, a survey, an IQ or other cognitive test. Furthermore, “testing” almost always means that the test to be administered requires some sort of specialty expertise to interpret. “Testing” rarely means symptom questionnaires only, because those questionnaires can be interpreted by almost anyone. For example, the Vanderbilt ADHD forms are frequently used in pediatrics office as a means to get multiple ratings about a child’s level of ADHD symptoms. These forms are not “tests,” per se, though, at least not to psychologists. Rather, the Vanderbilt form simply lists the 18 symptoms of ADHD as listed in diagnostic manuals, along with several other items to screen for oppositionality and mood problems, and then asks parents to rate how much those items describe their children. Interpreting Vanderbilt forms is as simple as adding up the items that meet a certain threshold, and then seeing if the total number of items endorsed meets the “cutoffs” for ADHD (that is, 5 or more of the 9 criteria on each of the two ADHD symptom clusters). No specialized training is required to interpret forms like the Vanderbilt.

Thus, although a comprehensive psychological evaluation may include symptom questionnaires, the specialized tests are the ones psychologists are most interested in. Additionally, psychologists are really the only profession that is routinely trained in the interpretation of such tests. Thus, testing, as defined here, is the one thing we can do that really no one else can.

So, when a parent asks a psychologist if they “test” for ADHD, the psychologist may be using a different definition of “testing” than what the parent means. The parent may be looking for more of a consult, rather than true testing. Thus, if you, as a parent, reach out to a psychologist to seek “testing” for ADHD, be prepared for that psychologist to clarify what you really mean and what you’re looking for.