What Should Parents Look for in a Good Evaluation for ADHD?
Podcast date: February 12, 2020
- What to expect from a good evaluation for ADHD
- Identify which professionals can provide a diagnosis of ADHD
- How a child can qualify for an IEP or a 504 plan at school
- Understand the ADHD diagnosis and the different ways to help children
Sarah Brown: Hi, this is Sarah Brown and you are listening to All Things ADHD. This afternoon. We are here with Harris Finkelstein. Tell us a little bit about yourself.
Harris Finkelstein: Sure. I have been a psychologist for over 30 years. My specialty is attention and learning issues and one of the things I do a lot of is working with parents, families, and schools to evaluate the nature of attention and learning problems and to make some suggestions about what might help.
Sarah Brown: In terms of a behavior plan?
Harris Finkelstein: What I do are comprehensive psychological evaluations. Psychological evaluations really look at children in much greater depth than sometimes we are able to ascertain through simply observing them or asking questions about them.
A good psychological evaluation is able to understand things about how a child thinks, learns, processes, feels in a way that might not always be clear just by simple observation.
Sarah Brown: Right. If I were a parent and you were going to do an evaluation of my child, what would I expect?
Harris Finkelstein: What would likely happen is that I would gather relevant background information first. I want to hear from you about your experiences with your child right now and I would want to hear about your child's development over the years.
I would also want teachers to weigh in. I might give you some questionnaires to give to them. I would like you to fill out some rating scales and teachers to fill out rating scales and I might also visit your child's school with your permission and sit in the classroom and see your child.
I also would want to spend some time talking to your child and asking some of the very same questions. What do you find that you are good at? What kinds of things are harder for you? What do you like? What do you not like? And kind of get the child's perspective about what is going on.
Sarah Brown: How old are the children that you normally work with?
Harris Finkelstein: Well, I work with children anywhere from preschool all the way through medical school.
Sarah Brown: Wow.
Harris Finkelstein: In all cases, I think children have a lot to say, even when I meet with a four-year-old or a five-year-old. They have their viewpoints and opinions about what is going on. My sense often is, after doing this for a very long time, that if you ask the right questions you can basically get a child to tell you what is going on.
Sarah Brown: Right, right. I am a parent; I've sent my child to you. I mean, you have done the assessment. You have talked to the teacher's child. What do I get?
Harris Finkelstein: The crux of the evaluation, what makes an evaluation unique is that then the child is presented with what we would call a series of psychological tests. What I would call to the child, a bunch of activities.
The rationale behind psychological testing is that you are presenting a series of tests that each require the child to think and process in a somewhat different way under standardized conditions. So that when you are looking at a child in a classroom or at home, you are never quite sure. Is it the child? Is it the teacher? Is it the other children? Is it the brothers and sisters?
When you are doing psychological testing, you say the same thing in the same way to the child on each and every occasion and you see what you get back. A good psychological test has a whole set of norms, which are basically the level of responses that typical children have produced to these very same responses. By presenting a whole variety of tasks to the child and seeing how they compare to typical children, you can start to build a profile of their strengths and challenges.
Sarah Brown: Then can I go to the school? I mean, would you be the person that would diagnose my child with ADHD?
Harris Finkelstein: We can think of the test data, sort of the raw material. What I would want to look at is what do these test data tell me? What are the observations that I have made, or teachers or parents made? What do they tell me? What does the history of this problem look like?
My job would be to put all that information together and to come up with a conclusion. The conclusion may be a diagnosis, or it may be something that's more like a description of this child.
This child has these strengths, this child has these challenges. A way that might work with this child is to teach them in a certain way, or respond to them in a certain way, or something that may not work very well at all is to respond to them in a different way.
Sarah Brown: If the data showed that my child had ADHD, would you be the person to diagnose him or do I have to take them back to a medical doctor?
Harris Finkelstein: I would diagnose ADHD. Based on all the information we just talked about, I would make that diagnosis and tell you what type of ADHD or what presentation that was. Now, some school districts might also require a pediatrician to certify that diagnosis. A lot of that depends on regulations, but what I will say is when you have gotten that diagnosis, you've gotten an important piece of information, but you don't have all the information you need.
What you also want to know is based on that diagnosis, what else can I understand about how my child processes his or her world? How do they take in their classroom setting? How do they understand me as a parent? What is it that leads to the behaviors that I have been concerned about? So, it's not just done they, or they don't have the diagnosis, it's way more than that. It is more understanding the nuances of my child's processing.
Sarah Brown: Does this give me different information then if I'd just went to a pediatrician and they said, "Oh, yes, this is a checklist. Your child has ADHD." The information I am getting from you would include more in depth of what I can do to help my child with ADHD.
Harris Finkelstein: The diagnosis based on the checklist is a fine starting point. It is good to know that this is what we are dealing with, but it doesn't give us any information about how to deal with these issues. On the checklist may be things like forgetfulness or dislike of tests that require sustained mental energy, but just because a child has that we do not know what we are going to do about it.
When we do the psychological testing, we look at things like how well does this child sequence? Can they take a task and break it down into three or four steps and accomplish a goal? Well, if they cannot do that, that may be a reason why they are having difficulty organizing. Now we have to work with that underlying process to get them to do better with that.
Sarah Brown: Especially when you hear that saying, "If you see one child with ADHD, you see one child with ADHD," which means, you giving all these tips may be a better way to help your child.
Harris Finkelstein: That's right. There are many, many different presentations and ADHD is just part of this larger picture of how they process. One of the things that we often find in a psychological evaluation is the child may be so hyperactive, so disruptive, or so impulsive in their thinking that they do not demonstrate what they're fully capable of.
If I put them under standardized conditions, I get them to relax, get them to be comfortable with me. We would make it sort of playful and game-like and then I start to see, wow this child can exhibit these capabilities, but maybe only under these certain conditions.
If I can just give you a quick example, sometimes I want to see how well a child can pick up visual details. Sometimes I will have children who are not so good at it, but only can do well if I give them more time to do it. So, they may look very limited in the standard amount of time that is given. If you give them a little more time, they can look better or even actually quite adept at it.
Now we start to see we are working with a child who actually can be quite alert and observant, but if we cut off that process too soon, they will look like they are not noticing very much of anything.
Sarah Brown: Right, right. Oh, that is interesting. That helps you as a parent be able to understand that my child takes longer to do things, but he can do things.
Harris Finkelstein: That's right. Sometimes as parents, we all get into these cycles of we have been there and done that so many times that we almost start to anticipate how the child's going to react. We may not realize if we step out of that paradigm a little bit, maybe approach the child differently. Maybe give them either more time, different conditions, or just talk to them about their process, we might come up with a different result.
Sarah Brown: In terms of qualifying for special services, what do we need from you to qualify for that?
Harris Finkelstein: It's an interesting question. Traditionally, what schools will be looking for is a discrepancy between the child's abilities and their achievement levels. If this is a child who has average ability, but is performing below average in reading, that might qualify them.
The problem with that way of looking at it is, first of all you have excluded all your young children. If I am a first grader, how far behind can I really be? The other problem is what if you have a high ability child and they are reading at an average level, but they really could be capable of a lot more. That also excludes that issue as well.
I like to look at it a little bit differently and I think increasingly school districts are as well. Let us take the fundamental skills that go into reading and look and see how is this child doing with those fundamental skills? If there is a breakdown there that might qualify them for services.
Just to give you a quick example, if a child is struggling with reading decoding, they cannot read the individual words. If it is purely an attention issue, maybe they are just not paying close attention to it and we have to help them with that, but maybe they cannot even hear that the word has all these sounds. If they are looking at the word stop, but they do not hear stop as having four sounds, they think of it as having one sound.
Well then, the letters on the page do not make any sense. Now we have got to intervene on an entirely different level. Even if that child is showing close to average reading skills, that child should qualify for intervention because they are lacking that foundational skill.
Sarah Brown: Right. Is that qualification for IEP or a 504?
Harris Finkelstein: Yes.
Sarah Brown: Wonderful.
Harris Finkelstein: In the case of a child who is really needing a different type of curriculum that maybe teaches in an entirely different way, they may need an IEP that puts them into classrooms that allow that to happen.
Maybe a child that could learn in a more traditional way but needs just a slightly different approach or some modifications or some accommodations, that child might do well with a 504 plan. I think a note to parents, having one of these plans provide safeguards and guarantees to you as a parent that the school will provide these kinds of interventions so that you are not fighting the same battle year to year.
Sarah Brown: Then having this evaluation supports the need for that IEP and your child. It helps your child in the long run.
Harris Finkelstein: In a way, the evaluation is sort of part of that gatekeeping function. If you get a really good evaluation, you then have access to all these services.
What I would say is sometimes when evaluations are not done properly, they do not zero in on what are real issues, but they look as if they are giving a full evaluation. The child comes up looking average and then we have overlooked some real need.
Sarah Brown: Is an evaluation covered by insurance?
Harris Finkelstein: Very often evaluations are not covered by insurance or what they will cover is very limited. There's pressure to keep the evaluation limited in scope.
Even school districts have a lot of children that they have to serve and sometimes the ratios that are set up between how many students each school psychologist, and each school counselor is responsible for sets the stage for these very quick evaluations.
Parents have to be alert to that. It may not be ill intentions from the professionals, but there may be other factors that are causing them to give these more cursory types of evaluations.
Sarah Brown: Got you, got you. Even though you may have to pay for the psychological evaluation, it may be that is where you can get the appropriate information that you need for your child to succeed.
Harris Finkelstein: Well, one option might be to pay for an evaluation that maybe is broader in scope. The other is that maybe a parent can become a more knowledgeable advocate for their child. So that when the child is referred for evaluation in the school, maybe the parent can contact the psychologist and hear them out. So, exactly what are you planning to do? What areas of my child's functioning are you planning to assess? How are you planning to assess them?
A parent doesn't need to know the names of all the tests, but may do better if they just have sort of a sense of what areas need to be assessed and how might the psychologist go about that in the best possible way so that when they hear the information back from the psychologist, they know if they're getting really a comprehensive evaluation.
Sarah Brown: What would your tip be?
Harris Finkelstein: First of all, my tip would be to understand that learning is composed of a variety of different processes and you can get knowledgeable about that pretty quickly through a little bit of reading. For example, learning is composed of a language piece. There is a visual piece. There is a memory piece, which is often forgotten. There is an eye hand coordination piece. There is a sequencing piece and an attention piece. There is probably about eight different functions. One of the things you want to do is to hear that the psychologist is going to look at all those different functions.
The other thing that you also want to make sure is that the psychologist is actually giving testing to the child and not simply collecting rating scales. A quite common limitation in evaluations, particularly in schools, is the rating scales get passed out to parents and teachers and the evaluation so called, will come back as basically a whole bunch of numbers based on rating scales.
Well, that's basically just rehashing observations that people have made already. It does not provide new data. Parents need to be very alert to that. Rating scales are fine, and they should be part of evaluation, but you want the psychologist to engage with your child and develop new data that tell us more about how your child is processing.
Sarah Brown: Well, thank you. I have learned a lot.
Harris Finkelstein: You're welcome.
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