Supporting Children and Teens with ADHD, Coexisting Conditions, and ADHD-like Conditions
When your child is struggling in school or at home, it’s often hard to determine what are “typical” behaviors or learning struggles and what is beyond what might be considered within the normal range. I asked licensed clinical psychologist and author Dr. Gene Carroccia to share his expertise to help parents determine when and how to seek support.
Question: What are diagnostics? When should a parent consider getting diagnostic services for their child or teen?
Answer: If you have behavioral, learning, or social concerns about your child or teen or if your child’s health care providers are not clear on how to address these concerns, then it may be time to consider getting diagnostic services or “diagnostics.”
Diagnostics can help determine what current disorders exist, answer parents’ questions about their child’s challenges, and provide helpful treatment recommendations. If you have behavioral, learning, or social concerns about your child or teen or if your child’s health care providers are not clear on how to address the concerns, then it may be time to consider getting diagnostic services or “diagnostics.” Also, if your child or adolescent is in treatment but is not progressing, they may have one or more unidentified conditions, and/or the current treatment approach may be ineffective and could need reconsideration. Parents can discuss with their current providers whether their child or adolescent may benefit from new diagnostics and/or new treatment providers. Current providers with longer-term relationships may know their patients well in some ways, but may lack the objectivity and expertise necessary for accurate diagnostics. Therefore, it can be quite helpful to obtain a new diagnostic provider for a fresh perspective and another opinion.
Question: Can other conditions coexist with ADHD? Why is it important to know about these?
Answer: Yes, there are coexisting conditions with ADHD. There are a number of medical, sleep, psychological, neurodevelopmental, trauma, sensory processing, and fetal substance conditions that can coexist with and worsen true ADHD or cause ADHD-like symptoms when ADHD does not really exist. When they do co-occur, these combinations can magnify ADHD to create more complex difficulties than ADHD by itself. This is sometimes called “complex ADHD.” About 75% of clinic-referred children (and 80% or more of adults with ADHD) have at least one additional disorder, up to 50% have two conditions, and 20% have three or more coexisting disorders. Consequently, families should expect other conditions to occur along with ADHD. Some people may have been quickly diagnosed with ADHD without exploring if other conditions exist. When they are not detected and treated, often there is only partial progress, the struggles can continue or increase, and families may become discouraged and drop out of treatment. For those with complex presentations, it can be helpful to periodically obtain diagnostics to review progress, determine current functioning levels, screen for additional conditions that may be new or previously undetected, and receive helpful treatment recommendations. Please refer to my article Understanding Coexisting Conditions in Children and Teens with ADHD for the most common and comprehensive listing of these.
Question: Are diagnostics offered at schools? Are these sufficient?
Answer: It is important for parents to understand the role of public schools with diagnostic services. Most schools focus on addressing learning and behavioral difficulties only at the school. Some parents may misunderstand that their child’s school is fully addressing the disabilities if they have a 504 Plan or Individual Education Program (IEP). The school system is not designed to diagnose or provide comprehensive behavioral health treatment for students. Most schools use different vocabulary to describe learning and behavioral difficulties from clinicians, and most do not diagnose or use clinical language or diagnostic terms. While schools provide evaluations (sometimes called psychoeducational testing) that typically determine if a student qualifies for a 504 or IEP, these should not be confused with clinicians’ diagnostics outside of the school system. Furthermore, school staff may not be permitted to discuss or even recommend outside clinical services because they may be liable for funding these if they are suggested. While federal law allows families to obtain a second opinion if they can prove the school’s evaluation was flawed, most parents do not achieve this because it can be a complicated, long, and often expensive legal process to obtain a school-funded neuropsychological assessment.
Question: So, how do you find a diagnostic provider? I know many parents struggle with this.
Answer: Here are five steps that can assist parents.
STEP 1: Determine the type of diagnostic provider you need. While some clinicians use the terms “evaluation” and “assessment” interchangeably, I prefer to use them more specifically. For ADHD diagnostics, parents can obtain either a brief ADHD evaluation or a more comprehensive neurodevelopmental assessment. These are different and have pros and cons.
ADHD evaluations are typically provided by outpatient psychotherapists (clinical psychologists, licensed professional counselors, clinical social workers, and marriage and family therapists). These usually occur during the initial stage of treatment when ADHD is suspected. They should consist of a thorough clinical interview, ADHD and probably other measures, and perhaps screenings for other conditions (probably a limited range, however). Pediatricians, primary care physicians, psychiatrists, and nurse practitioners may provide these, but often their practices are not designed to provide multiple diagnostic sessions that are needed for ADHD evals. Clinical psychologists are more likely to provide these, but other clinicians who have this training and experience may be effective as well. Be aware that when using this term, some clinicians may believe you are referring to neuropsychological testing or assessments (see below).
- There are more of these providers, so they are easier to obtain than neurodevelopmental assessments.
- These are less expensive.
- Health insurance often covers these services because they are part of outpatient services.
- ADHD evals can be the first step. As a result, providers can suggest other diagnostic referrals, including neurodevelopmental assessments.
- Providers may continue with treatment once these are completed.
- These are less conclusive (particularly with more complex presentations). Therefore, additional diagnostics may be needed.
- Providers are often less comprehensive and may not provide adequate screenings for the many other conditions that may exist.
- Reports are less likely, but letters from providers may be produced.
Neurodevelopmental assessments (sometimes called neurobehavioral or neuropsychological testing) are provided by neuropsychologists who are specialized clinical psychologists (and are not neurologist physicians). They can be offered at private practices and larger teaching and university hospital systems. They are necessary when more complex presentations, other disorders, and neurodevelopmental conditions may exist, such as learning disorders and autism.
- These are more comprehensive and definitive than ADHD evaluations.
- Health insurance may cover some or all of these services (depending on your plan).
- These providers are more likely to be familiar with other conditions and provide screenings to rule in or rule out these other disorders.
- They include reports that can be shared with other providers and schools.
- There are fewer of these providers.
- Waiting lists often exist.
- They are more expensive.
ADHD evaluations and neurodevelopmental assessments should include screenings for the numerous other potential conditions. Although identifying other conditions is critical in diagnostics, many clinicians do this minimally or not at all, particularly those providing only ADHD evaluations. Therefore, parents should discuss this with new potential diagnostic providers. While not ideal, sometimes it can be helpful for parents to use online or other screening tools for different conditions and then share these with providers. Additionally, if known conditions currently exist, families should discuss them with providers to determine if they are being effectively managed.
If certain conditions are suspected, it can be important to obtain additional diagnostics from other non-mental health providers, including:
- Occupational therapy evaluations (for sensory processing and motor coordination conditions)
- Speech-language pathologist evaluations (for speech and language deficits)
- Developmental or behavioral optometrist evaluations (for visual processing deficits)
- Audiologist evaluations (for auditory processing deficits)
- Ears, Nose, and Throat (ENT) physician examinations (to explore sleep apnea, chronic mouth breathing, allergies, and congestion)
- Neurologist examinations (for head injuries, seizures, and tic disorders)
- Medical examinations by pediatricians and primary care physicians (for a number of medical conditions that can cause ADHD-like presentations)
- Sleep studies (for mouth breathing, sleep apnea, and other sleep conditions)
STEP 2: Find potential providers. This can be frustrating because finding available in-network local providers can be difficult. The need for mental health services now has dramatically increased. While virtual services have made it easier to access providers across the state (or even other states), clinicians may have long waiting lists due to the great demand. To help with this process, please refer to my article for a list of potential ADHD and neurodevelopmental diagnostic providers referral resources: How to Find an ADHD Specialist Provider. This is a persistence challenge, and the parents who keep calling, searching, asking as many as possible for referrals, and getting on waiting lists often succeed in obtaining services.
STEP 3: Call providers to determine if they may be the right one. While many may not speak with prospective new patients, some providers will call parents back to discuss their needs to see if they are a good match. However, repeated requests and messages can be helpful. Ask if they provide diagnostics, what percentage of their current patients have ADHD, what is their approach is when diagnosing ADHD, and do they screen for other conditions. Be clear about your current concerns and what you are looking for in a diagnostic provider. If the provider won’t speak to you, try to speak with their office manager or staff.
STEP 4: At the very start of the first session, review your goals and needs. This is particularly critical if you have not been able to previously explore what the provider offers in Step 3.
STEP 5: If you don’t find a good match after starting services, discuss these concerns with the provider and consider repeating Steps 2, 3, and 4.
Question: Any final words on this process?
Answer: Parents who are successful in this quest are often the ones who persist and talk to as many others as possible. Those who keep going and don’t give up are often rewarded with finding the right providers. Reach out to supportive friends and families for help during this journey, if possible. Your child deserves the proper care. Hang in there!
Gene Carroccia, Psy.D. is the author of Treating ADHD/ADD in Children and Adolescents: Solutions for Parents and Clinicians. You can learn more about Gene and his work at www.adhdology.com