Currently, we’re going through a crisis-of-misdiagnosis in the mental health field. It seems like everyone and their dog is getting diagnosed with ADHD… but unfortunately a lot of these so-called ‘diagnoses’ are false-positives, meaning:
A lot of people who don’t have ADHD are being told that they do have ADHD.
This is happening largely because of money. It is happening because there are a number of healthcare professionals who are trying to ‘cash in’ on the public awareness of ADHD, by doing shoddy, improper ‘assessments,’ and passing them off as valid.
All psychologists should uphold proper practice standards, and it is increasingly important that we communicate openly with the public about these standards. And one of the most important things for the public to know is that:
Any proper ADHD assessment will use multiple different sources of data, and will NOT rely on self-report alone.
In assessing adult ADHD especially, self-report (i.e., your answers to questions about attention, focus and other possible symptoms of ADHD) is very important, and is unquestionably one of the sources of data a good psychologist will consider during your assessment... But it is not the only source of data that must be considered.
Proper ADHD assessment will typically consider at least two or three additional sources of information, most commonly:
- Your report cards from school
- The observations of people who knew you when you were a child—especially parents (or if parents are not available, siblings or other family members)
- Psychometric testing
If these sources collectively show that you have had clear problems with attention, focus, hyperactivity or impulsivity from early life on, then the diagnosis of ADHD may be assigned.
At our clinic, we do many adult ADHD assessments and the psychologists on our team spend a lot of time reviewing report cards. During this process, there are a few things we’re looking at:
- Do the client’s report cards indicate problems with attention and/or hyperactivity and impulsivity from the first years of schooling? Because ADHD is a neurodevelopmental condition, it is present from early childhood (basically, from the beginning). To determine a diagnosis of ADHD, we need to find evidence of ADHD symptoms that existed in early childhood.
- Is there a pattern of comments over time, by multiple different teachers? If a student had, only one teacher who commented on problems with attention, or only one year when these, problems emerged, then this may be a one-off bad year. However, if a student has received, multiple comments from multiple teachers, at different stages, this reflects a clear pattern, over time.
- Were problems reported between ages 5-12? Typically, the first six or seven years of school provide the clearest window into a student’s innate capabilities. Within the first few years, most students want to do well, and many are eager to please adult authority figures like teachers and parents. By the time students hit middle school, some students are more focused on extracurricular interests (dating, sports, hobbies, etc.), and may be become indifferent to their studies, resulting in teachers’ comments about distraction/disengagement. Conversely, many students with ADHD develop behavioural strategies (sometimes called ‘compensatory behaviours’) by the time they reach middle school, which mask their ADHD symptoms. Hence, for a variety of reasons, a student’s performance in elementary school is often the best representation of their possible ADHD symptoms.
- Psychologists are interested in comments, much more than grades. For a bunch of reasons, grades are not a very good representation of a student’s ADHD symptoms. Many individuals with ADHD are creative, smart, and driven—and they are able to use these abilities to get high grades. However, comments about a student’s observed behaviours and study habits, are an invaluable source of information.
- How does the information in report cards align with information from other sources? In determining whether a client has ADHD, or not, the psychologist considers: do the sources of information ‘tell a similar story.’ Of course, there can often be differences between an individual’s perception of their attention and focus, versus the way parents or teachers perceive these traits within the person[1]. However, overall, these sources of information should tell a generally consistent story.
- How do the person’s gender, and other personal characteristics, influence the picture? There is increasing, and much-needed, discussion of how ADHD can appear differently in girls versus boys. There can be very real differences in the gender presentation of many mental health conditions. For instance, we have often found that boys with ADHD may demonstrate more unruly or ‘socially disruptive’ behaviour. By contrast, girls’ ADHD tendencies may manifest in a less socially-intrusive way, for instance in the form of distractibility, disorganization, hyper-verbosity, and flight of ideas (as opposed to overt impulsive behaviour). Similarly, in many population samples girls are more likely to be diagnosed with attentional-dominant ADHD, rather than hyperactive dominant ADHD. However, there is an increasingly widespread myth that girls often ‘camouflage’ or ‘mask’ their ADHD tendencies so strongly that they will not be discernible—this is not often the case. Even for high-masking people, evidence of attention-problems and/or hyperactive/impulsive problems typically will appear in early life data (e.g., parent reports, report cards, etc.), especially data from the first years of school, before children have learned many masking techniques.
In sum, report cards are a very important source of data for ADHD assessment—especially when assessing adults. Of course, they are not the only source of data that a clinical psychologist will consider. But every proper ADHD assessment will include a review of all available report cards. They are an invaluable window into the past, which helps us understand our clients and reach the most well-informed possible diagnostic conclusion!
[1] And sometimes people can become emotionally attached to a particular story. For instance, parents might be emotionally attached to the idea that “there’s no way my child could have ADHD,” or vice-versa. Or a client might be emotionally attached to the idea that “it must be ADHD that’s causing my difficulties.” The best mentality for anyone participating in an assessment is open-mindedness and curiosity. If you don’t get an ADHD diagnosis, this doesn’t mean that your challenges aren’t real and valid. Or if you, or your child does get a diagnosis, that doesn’t mean there’s anything wrong with you, or them.