About ADHD: Assessment, Diagnosis, and Treatment
If you or someone you know is experiencing attention difficulties and/or other issues that impair the ability to focus, attend to tasks, control impulsive behaviour and stay organized, it may be Attention Deficit/Hyperactivity Disorder (ADHD).
In this section you will find a definition of ADHD, guidance on identifying potential symptoms/indicators, information on assessing and diagnosing ADHD, and interventions including medication and behaviour strategies.
You will also find information about related challenges and conditions that may coexist with ADHD.
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neuro-developmental (brain-based) condition. Neurochemical transmitters and their processes in the brain function differently enough that common brain functions are impacted, specifically the brain’s ability to self-regulate and engage executive functioning capabilities.
Executive Functioning (EF) relates to the brain’s ability to plan, focus, and execute goals, and collectively acts much like an “air traffic controller”.
- impulse-control (regulating behaviour)
- overwhelming feelings (regulating emotions)
- difficulties with distraction or over-focusing (regulating attention)
- difficulties with organization (regulating order and time)
Difficulties with EF skills can also present as:
- reduced working memory where there is either not enough available or it is overloaded but both result in forgetting;
- a lack of flexible thinking like understanding someone else’s perspective or easily adapting to unexpected situations;
- challenges with time sensitivity, especially with future-oriented considerations like consequences, impacts and deadlines.
These difficulties must be beyond what would be expected for someone of the same age or developmental level; they are NOT related to intelligence, parenting, food additives or other environmental factors, though ADHD-like symptoms can be the result of brain injury and trauma as well.
ADHD is diagnosed in about 9% of children and about 5% of adults, though this number is increasing due to better awareness and diagnosis. ADHD has a high rate of heredity at about 75% meaning that ADHD tends to run in families.
What Does Executive Functioning Involve?
EF skills essentially involve the following:
- Goal-setting and planning
- Organization and time management
- Flexible use of strategies (a.k.a. cognitive shifting)
- Attention and memory systems that guide learning and performance processes (e.g. working memory)
- Inhibition of impulses
- Emotional control
Common Difficulties with Executive Functioning Skills
Difficulties with these Executive Functioning skills have been identified as major contributors to both academic and social problems and have been highly linked to both ADHD and Learning Disabilities. Some of these problems include:- Holding directions in the mind (particularly complex or multi-step instructions)
- Multi-tasking
- Resisting or delaying impulses (interrupting, impulse buying, physical actions, rushing through tasks, etc.)
- Tending to act in the moment without regard to consequences
- Monitoring how actions affect others
- Setting and working towards goals
- Monitoring work (e.g. checking for errors)
- Starting tasks, despite a level of interest
- Planning, executing, and monitoring projects, assignments or tasks
- Meeting due dates (showing up for appointments, arriving on time, finishing a task on time, etc.)
A major struggle, particularly for those with ADHD, involves self-regulation. Self-regulation can be viewed across three different areas:
- Cognitively: ability to focus on thinking, problem-solving or academic-type tasks
- Behaviourally: ability to control actions
- Emotionally: ability to control emotions
When individuals are dysregulated, they are not able to engage in school, work or relationships consistently and meaningfully.
In the DSM-5, a medical classification system used for diagnosis by professionals, 3 types of ADHD are officially recognized:
- Predominantly Inattentive Presentation. Inattention refers to wandering off task, seeming not to listen, being easily distracted, daydreaming, being disorganized, being forgetful, and losing materials. About 30% of individuals with ADHD only have difficulty with attention.
- Predominantly Hyperactive-Impulsive Presentation. Hyperactivity refers to over-activity, restlessness, fidgeting, talkativeness, and being unable to stay seated. Impulsivity refers to intruding in other people’s activities (e.g. interrupting, blurting out), being unable to wait, and making hasty decisions without thinking about the potential consequences. About 10% of individuals with ADHD only have difficulty with hyperactivity/impulsivity.
- Combined Presentation. The Combined Presentation is the most common, with 50-70% of individuals with ADHD having problems with both inattention and hyperactivity/impulsivity.
- Symptoms affect each person to varying degrees (mild, moderate, and severe).
- Some symptoms can affect an individual more severely than others.
- Symptoms may change from moment to moment and day to day.
- Symptoms can depend on the setting or what the individual is doing.
- Symptoms are often worse when the individual is bored, unsupervised, or doing something difficult.
- Symptoms are often better when the individual is doing something they enjoy, when rewarded immediately, or when closely monitored.
- Symptoms can change over time. For example, in adolescence/young adulthood, hyperactive symptoms are often less obvious than in childhood. However, difficulties with restlessness, inattention, poor planning, and impulsivity can last over the lifetime.
Who Can Diagnose ADHD?
Physicians
As ADHD is a condition that can be medically managed, it is often diagnosed by physicians (family physicians, pediatricians, psychiatrists). Some are more familiar than others on what ADHD is, how to identify it, and how to treat it.
Children: CanReach is a helpful resource to find physicians in different regions of Canada, including the Calgary region, who have specific training in identifying and treating ADHD. A list of pediatricians with specialized training in ADHD can be found on the CanReach website.
Children should see a pediatrician (at any age) to address concerns including assessing delayed milestones, ruling out a medical basis for behavioural or emotional concerns, and/or managing medications. Parents/guardians will need to request a referral to a community pediatrician from their family doctor.
Adults: If you start the process with your family doctor, ask questions to see how knowledgeable the doctor is about ADHD in adults or if a referral to another physician, psychiatrist or neurologist with expertise in ADHD is warranted. Family physicians typically have less expertise in diagnosing and treating ADHD than pediatricians do for treating ADHD in children.
Children: Once a referral is received, most physicians will request information prior to the first appointment. This information would generally include a detailed family history, diagnostic interview, rating scales, and for children, additional information obtained from school staff/teachers.
Adults: Physicians will likely start with a complete physical and a thorough physical history, family history, and a psychiatric medical history to determine if other conditions, such as anxiety or depression, exist.
For Children: Parents/guardians should prepare the following information for the initial pediatrician appointment:
- report cards
- Individual Program Plans (IPPs)
- prior assessments (e.g., Speech and Language, Occupational Therapy, Psychology, Psycho-educational).
Adults: Gather information about:
- Personal and family medical history
- School history, such as report cards and post-secondary information. They will want to see if there is a pattern to indicate ADHD symptoms by the age of 12 or younger.
If ADHD is diagnosed, a pediatrician, family physician, or psychiatrist would treat and manage any ADHD medication that may be appropriate.
It is important to know that behavioural strategies should also form a part of any treatment plan though physicians would not be responsible for this. It is up to individuals or families to seek out other experts such as psychologists, registered clinical social workers or ADHD coaches for behavioural strategies.
Assessment: There is no cost in Canada for medical assessment of ADHD. Assessments and treatment by a health professional is covered by provincial health care plans in Canada.
Medication: Medication must be paid for by the patient, and is covered by most private health care plans. You will need to check with your health care provider to determine what percentage of the medication they will cover.
Behavioural treatment by professionals other than physicians is paid by the patient and may be covered by private health care plans.
Psychologists
ADHD may also be diagnosed within the context of a psycho-educational assessment. Technically, a psycho-educational assessment is not necessary to diagnose ADHD, as the diagnostic criteria for ADHD are behavioural and psychologists do not prescribe medication to manage ADHD. However, a psycho-educatonal assessment can also provide valuable information about a person’s learning profile that a medical assessment will not provide. You may choose to involve both a physician and a psychologist in the assessment process.
The benefit of involving a psychologist in the assessment is they can do a full psycho-educational assessment to determine if other disorders such as a Learning Disability exist, which is quite common with ADHD. The assessment report will give you a picture of your full learning profile, including your challenges and also your natural strengths and aptitudes.
They can also investigate if other mental health issues co-exist with ADHD, such as anxiety and depression. Psychologists can provide treatment, such as counseling for mental health issues and work on behavioural strategies to manage ADHD symptoms.
A thorough interview with the individual and/or family, questionnaires and observations are often used to diagnose ADHD.
It may be necessary (and beneficial) to also do a psycho-educational assessment, particularly when there may be concerns about underlying learning difficulties. This would be important to fully understand all of the challenges that you or your family member is facing, including ADHD.
Psychologists can be accessed through the school and health systems.
Private psychologists can be searched through the Psychologist Association of Alberta (PAA) website.
The PAA website has a referral list. On this website there are filters you can apply to help to determine their areas of specialty. Be sure to select ADHD, Learning Disabilities, psycho-educational assessment.
Choosing a Service Provider provides suggestions for how to find a psychologist and questions to ask.
Psychological services are not covered through provincial health care plans in Canada. Most private health care plans cover a portion of psychological services including assessments and treatment. Some agencies provide sliding scale rates for psychological services if you qualify. Costs are generally between $100 – $200/hour.
Four Pillars:
ADHD is a complex condition. There are many treatment and interventions available to families, but there are four broad areas supported by research.
There are a lot of misconceptions about ADHD. In order to best support the individual, we need to understand the totality of the impact of ADHD on their life and others. When the individual and others in their life (such as family members, teachers, coaches, employers, colleagues, etc.) learn accurate information about ADHD, they have more insight into the daily struggles, are less likely to assign blame, and are more likely to engage in helpful supports and strategies.
Support System in Place: Because ADHD is complex, the individual will need support from those around them. All of these individuals may benefit from education and training in ways to support the individual: family members, teachers, employers, colleagues, coaches, etc.
Environmental Supports: Providing structure, consistency, predictability, clear expectations and limitations.
Behavioural strategies and tools: Supporting executive function skills like time management and organization, as well as emotional regulation.
Self determination and Self Advocacy
Individuals with ADHD often do not have positive feelings about themselves and do not believe that they can set and achieve goals. Self-determination involves self-knowledge, the ability to plan and act and the ability to learn from experience. It is critical to success in life.
To be an effective self- advocate, the following are important:
- knowing your learning strengths and needs
- knowing how you learn best and what accommodations and supports are most helpful
- being able to communicate your needs to others in a positive way
Stimulant medications have been prescribed for decades and continue to be a first-line treatment. Approximately 70-85% of individuals will respond well to stimulants. There are also non-stimulant medications available for those that do not respond well to stimulants. The adverse effects of medications for ADHD are typically mild and can be addressed by changing the dose or medication.
It is important to note that medications can decrease in effectiveness over time and should be paired with behavioural strategies that can be applied across the lifespan.
A healthy lifestyle can help to manage ADHD symptoms. Ensuring a well-balanced nutritional diet, regular exercise or movement, healthy sleep habits and mental health self-care are important measures that can contribute to well-being and success for individuals with ADHD.
Disclaimer: The Learning Disabilities & ADHD Network does not support, endorse or recommend any specific method, treatment, product, remedial centre, program, or service provider for people with Learning Disabilities or ADHD. It does, however, endeavour to provide impartial and, to the best of our knowledge, factual information for persons with Learning Disabilities and/or ADHD.
