Pay Attention.

Lately, I find myself giving the same speech. It takes me a while to get the language right in explaining difficult concepts about child development, so when I do, I like to make it count and use my new speech whenever possible (apologies to people who attend meetings with me on a regular basis and get to hear me say the same thing). Anyhoo, I think my latest speech/analogy is a fairly decent one, so I will share it with you.

At my school sites, I have been getting a lot of requests for assessment for Attention Deficit Hyperactivity Disorder (ADHD) that sound a little like this: “So and so is inattentive and hyper. Does she have ADHD?” It’s a legitimate question, but it is not an easy answer. As in previous posts, like the one where I went to a Circus School to assess a student for ADHD (true story), ADHD is a complex assessment. Especially if you yourself are distracted by trapeze artists during your “school observation.” But I digress.

My new speech/analogy is:

“Attention is the ‘fatigue’ of the psychology field.”

Here is what I mean by that. I want you to imagine you have fatigue and you go to your doctor and say, “Doc, I have fatigue. Do I have Chronic Fatigue Syndrome?” The doctor (if they are any good, of course) would have to investigate all the potential causes for fatigue before concluding anything. Offhand, (and I’m not that kind of doctor), I can think of about a hojillion reasons for fatigue besides Chronic Fatigue Syndrome: the flu, cancer, pregnancy, working in a school district, depression, hyperthyroidism, hypothyroidism, anemia, seizure disorders, poor sleep…..and it goes on and on. “Fatigue” is a non-specific symptom.

The same is true for attention. Offhand, the “causes” of inattention can be: (um, all medical conditions above), ADHD, difficulties focusing because of a learning disability, anxiety, depression, low IQ, high IQ, autism, social-emotional distraction, situational factors, psychosis…..and it goes on and on. So, when people ask me if I will “test for ADHD”, they are really asking me to test for everything else as well. I enjoy ADHD evaluations. I feel like a detective looking for clues and hitting a bunch of dead ends until I get to the bottom of the inattention symptoms.

That is why it burns my soul just a little bit when I get reports from outside professionals who give one rating scale to the parent, and if it is elevated in attention problems, they get the diagnosis. They don’t interview the teachers, they don’t observe the kid at school, and they don’t rule out the other causes of ADHD-like symptoms. Really, it gives “my people” a bad name to do an incomplete evaluation like that.

Second pet peeve about ADHD evaluations is when a doctor then “prescribes” an IEP or Section 504 plan based on their results, without seeing if the inattention is really having an educational impact that requires special education or accommodations. I have had students with ADHD on the honor roll, earning all As and Bs, and the outside professional recommends an IEP. I always wonder what service they think the kid needs. Then I have a fantasy of calling them up and telling them what psychopharmacological medications to prescribe. Because you know, if they’re going to tell me what to do in my school without knowing what their talking about, surely I can pretend I’m a medical professional and tell them what to do. It’s only fair.

I realize that doctors and outside professionals are only trying to help. But I think that school psychologists are the ones best equipped to assess for ADHD (given they have had training and aren’t super old school psychs who should have retired during the Clinton administration or sooner). In some districts, school psychs are not allowed to assess for ADHD, and in some they are. In some, they do screenings and send the information to a doctor. In my private practice as a clinical psychologist, I do ADHD evaluations all the time. In my role as a school psychologist, it has gone back and forth about whether or not I am allowed to do them, even though I have the training. I feel bad for parents, whose doctor says to go to the school for an evaluation and the school says to go to the doctor. It’s confusing, and then the kids with legitimate issues get bounced between professionals.

I am curious how other school psychologists and districts handle referrals for ADHD. I find that it varies from district to district, school to school, and even by school psychologist comfort level in assessing for ADHD. I would be curious from other school psychologists what your district policy is on how ADHD evaluations are handled in your district. Discuss amongst yourselves…and feel free to try on the fatigue analogy at your next meeting!

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Comments on Pay Attention.

  1. krystie says:

    We frequently joke about "prescribing" a thyroid screening, or a urinalysis, or something right back to the doctors who "prescribe" an IEP…

  2. Stephanie says:

    In our district, if we get a Rx for testing, we hold a referral meeting anyway. The TEAM determines whether or not testing is required. Our regulations have changed and some docs don't get that.

  3. Lisa says:

    I can swallow everything except the part about an ADHD kid except when you make the leap that an ADHD does not need an IEP if he/she makes the honor roll. The IEP might level the playing field,so that kid has a chance at getting on the honor roll. And maybe that ADHD kid's parents are really working with that child to support him and the teacher so he/she can do well on his tests, homework, projects and help him study for hours daily. And maybe that ADHD kid for the first time in his life actually felt proud about working so hard and getting that little piece of paper that says honor roll. Just sayin…calaspub

  4. Anonymous says:

    You have spoken every concern and pet-peeve of mine. Thank you. The same concerns come out of my mouth on a daily basis. When an outside evaluation "prescribes" an IEP or 504 we have a Child Study Meeting to go over the report and then the team makes the determination if further action is warranted. Many times, this is the first referral from anyone indicating a possible issue. My response to these issues you talk about goes something like this…: "I see your concern but I think it is too early to tell the educational ramifications of these issues. Let's put some things in place first to see if we can't help them, come back together and plan accordingly".

  5. Aimee says:

    I'm at a two day trauma in-service, and symptoms of PTSD can also look like ADHD. Just another confounding variable!

    On topic, I do not do ADHD evaluations in my district. I will discuss a child in terms of "signs" or "symptoms" of ADHD, but won't legally call a child by the label without a diagnosis from an outside provider. Kind of a CMA thing, being that I am untenured!

  6. Dr. Tonya says:

    I share your frustration with doctor prescribed IEP or 504 Plans. Often, on our district's medical form under the section for "implications of medical findings in school setting" a doc will write "none" and then in a space for other they will write in "student needs an IEP." Grrrr! How is that NOT an implication for school? In OK, technically we *can* diagnose ADHD but all evals still require a medical form to rule out other possible causes for the inattention/hyperactivity as you clearly highlighted above. However, many times the doc has not even done an actual eval before coming to the conclusion the child needs an IEP – and once a parent sees that, then they DEMAND an IEP ASAP. Though, even more frustrating (and a topic for a different post, I'm sure) are outside evals that come in from the private sector that say in their summary/recs section that a student will qualify for special education under ED and that the school needs to put in place an IEP. Ummm…last time I checked, eligibility was a TEAM decision made at a school level. But I digress…

  7. Anonymous says:

    In my district, we used to basically do a screening (rating scales, observation, record review, etc.) and then send the info to the doctor in a report. The problem for us was a time/cost-effectiveness issue. I would get between 20-30 referrals a year (our caseloads average around 1000 students) and we would do all that work and maybe 3-5 kids would actually be diagnosed with ADHD. Other parents would take their kids straight to their doctors without that information and come back to school with a diagnosis and new meds without any feedback from school! We finally decided that with RtI caseloads, evaluation paperwork and all the other job responsibilities, that this would be one we would have to let go. I'm happy to help physicians out by collecting information at the school, but it is extremely rare that it's ever requested.

  8. Anonymous says:

    I love your speech and want to share my speech when i get a prescription pad note from the doctor-" While (said doctor)'s input is both welcome and apprexiated medical personnel do not dictate Team decisions". I also had to draw a firm line for ADHD evals bc really, im testing for eligibility for OHI which we cant use without a doctor verification. If i didnt draw the line I would have given a Connors to everyone in my school by now. I explain that to parents up front and we discuss what would be best case by case. We almost always proceed with testing and then the parent decides if they want to follow up with the doctor.

  9. erika says:

    @ Lisa–
    An IEP means specialized instruction. If you are on the honor roll, it is hard to make the case for specialized instruction (ie. IEP). Now what you mentioned might be accommodations, which "level the playing field" and that is a 504 plan. I often have to explain to parents the difference. In Maryland we just had a wonderful spring conference from our school psych association with Dr. Thomas Brown about ADHD. So much of what we knew about ADHD has vastly changed from 2 to 5 years ago!

  10. Anonymous says:

    Just like some of the other replies, we too do a "quick" evaluation (rating scales, observation, record review) that if the parents deem necessary can take to a mental health professional. If I did a full eval for special education on each ADHD inquire I would never get to any other assessments. It is sad but I feel we are working in a field in which cost effectiveness backs up into best practices.

    On the doctors Rx notes….they always give me a chuckle and then later I call the guardians to inform them about an SST meeting at which the doctors note will be discussed.

  11. Anonymous says:

    Just like some of the other replies, we too do a "quick" evaluation (rating scales, observation, record review) that if the parents deem necessary can take to a mental health professional. If I did a full eval for special education on each ADHD inquire I would never get to any other assessments. It is sad but I feel we are working in a field in which cost effectiveness backs up into best practices.

    On the doctors Rx notes….they always give me a chuckle and then later I call the guardians to inform them about an SST meeting at which the doctors note will be discussed.

  12. Jenny says:

    In my district, ADHD is considered a medical diagnosis, and we are not able to give them. I do "behavioral consultations", but try not to advertize that too widely! We are very conservative about qualifying kids with ADHD under OHI, because there are so many! So, only the ones who are severe enough to warrant special education. Also, I have the same fantasies about calling doctors and recommending the amount of Adderall to prescribe! It kills me…

  13. sue says:

    I just have to ask, as a school psychologist and the sister of a pediatrician, how is sending a physician all your behavior rating scales and observations and expecting a medical diagnosis any different than the doctor sending you all the medical records and expecting an IEP? We have to be respectful of each other's professions. It puts each professional in a real bind for the other one to make assumptions about what the other does or what it takes to make/determine a medical diagnosis/educational eligibility.

  14. School Psych in PDX says:

    I frequently find myself asking, "Do you believe this student has a disability?" I do this because, face it, we're all 'helpers' and EVERYONE could use some extra help but that doesn't necessarily mean that they are DISABLED. For instance, when a Kindergarten teacher or parent refers a "wiggly boy" I have to ask what about his behavior leads you to believe that he is disabled. I mean five year old boys can be wiggly. There are developmental 'ranges'. Perhaps that student isn't quite ready for the classroom but does that make him disabled?

  15. Anonymous says:

    It was suggested to me, by the school/district part of the IEP team, that my child be classified as ED for the purpose of obtaining an IEP.

    I disagreed with the label and suggested OHI for ADHD or further testing for autism.

    The staff informed me that the diagnosis for ADHD would have to come from a doctor, they didn't think a diagnosis or change in classification would change the IEP in any way. They reluctantly agreed to look into the possibility of autism and would conduct further testing (ADOS, ADIR).

    I contacted my child's ped and was told that an ADHD evaluation would not be covered by my insurance (nor would any autism testing or treatment) but they gave me a Vanderbilt parent assessment and charged me for the evaluation (they never scored the report either).

    It's tough here (UT) because insurance typically will cover the ADHD meds, but not the evaluation or diagnosis, and schools can't "diagnose" ADHD (at least for an OHI classification.)

    Eventually my child was diagnosed with both high functioning autism and ADHD through the school's evaluation, but we never bothered going back to our ped about it because I wouldn't medicate anyway.

  16. Anonymous says:

    In response to Sue's comment: "I just have to ask, as a school psychologist and the sister of a pediatrician, how is sending a physician all your behavior rating scales and observations and expecting a medical diagnosis any different than the doctor sending you all the medical records and expecting an IEP?"

    The difference is this:

    I don't "expect" a diagnosis; nor do I diagnose ADHD and make treatment recommendations. I simply collect the data, and write a comprehensive, integrated report that the doctor can then use when making diagnostic & treatment decisions.

    Also, I never get "all the medical records" when a doctor requests an IEP. I usually get a prescription pad page that says, "Student has a learning disability, needs IEP". There is no supporting data. There is no integrated report. It is an insult to me, as a professional, that someone who is unqualified to make educational decisions demands services for a child in this way.

  17. John D. Ayer says:

    Nothing better than a post describing how difficult a particular diagnosis is and how many various "tools" there are in the diagnosis "tool box".

    As an engineer, at this point of time in physiology and psychology, I typically think of diagnosis as guess work. Off the record I have had doctors of both persuasions agree with me.

    People have a hierarchy of authority and some parent obviously talked a Doctor (typically higher in that hierarchy than a teacher or school psychologist) into prescribing an individual education plan which the doctor has no expertise or training in the evaluation for or development of.

    I believe you also understand that the inverse is also true, a person unqualified to make a medical diagnosis is unqualified to demand specific medical services.

    Seems I remember teachers, school psychologists and school social workers offering contradictory medical diagnosis and demands for specific medical treatment for my kids.

    Another example, why would a school psychologist have the advanced medical training necessary to interpret "all the medical records".

    Pretty funny, kind of like me asking you (or an MD) to determine why the variability of a manufacturing process is increasing and you telling me "something wore or broke".

    An excellent post.

  18. Anonymous says:

    Thank you so much for another amazing and informative post! As an undergraduate psychology student who is eager to learn more, can you or other readers recommend the best books to read on ADHD?

  19. Anonymous says:

    I enjoy your posts. One thing that often strikes me in your posts is the differences across state lines. As a clinical psychologist in private practice in GA, I spend most of my time completing very comprehensive neuropsych evaluations on kids. In GA, school psychologists cannot diagnose ADHD; this may be due in part to the fact that GA does not require school psychologists to be licensed. I have to say, in reading your posts, there is a clear difference in your training and understanding of the issues, and the training/understanding of the school psychologists in my area. That being said, I also get my fair share of lousy evals from other private psychologists who have done nothing more than a questionnaire (and often not even a teacher questionnaire). Keep up the good work!

  20. Anonymous says:

    I'm a special education teacher and I agree with much of what you have said. However, I disagree with your blanket statement that a student with ADHD who is on the honor role doesn't need an IEP. There are circumstances where a student with ADHD, especially a bright one who is able to demonstrate academic success with a minimum of effort, could still need an IEP.

    A previous poster mentioned the the possibility of the parent really supporting the student. The student may also be getting specialized instruction in certain study skills that allow him to be successful.

    Also, the student may be bright but because of the impulsivity associated with ADHD and the social skills deficits sometimes associated with ADHD may have trouble with the social/emotional aspects of school and needs the specialized instruction and support in social skills and emotional/behavorial regulation- thus making them eligible for an IEP. I have seen students like this, denied an IEP when younger, because they were academically successful though not socially successful. Some of them were academically successful until they reached a point- usually 4th or 7th or 9th grade, where the workload shifts and they can't keep up because of their organizational deficits and their intelligence isn't enough. Then they wind up on an IEP. Or, the social problems caused by ADHD and left un-remediated within the school setting magnify as the student hits middle and high school, resulting in more complex emotional issues that perhaps could have been avoided or lessened if specialized social skill instruction or social/emotional regulation instruction was given earlier in the student's school career.

  21. Anonymous says:

    School and clinical psychologists can diagnose ADHD here, but we can't qualify a student for SpEd eligibility under OHI without a diagnosis from an MD. So, if I think a student has ADHD and is in need of SpEd services, I'd either have to get an MD's diagnosis OR qualify him under another classification (usually ED), if he meets criteria. This is absurd. On another point, I also love it when the MDs prescribe child-specific paras!

  22. SSW in VA says:

    I have a disagreement with your statement that school psychologists are BEST equipped to diagnose ADHD. First, i do agree that only one source of which to gather information, or one setting of where to observe the child is not sufficant enough to have enough ample information to determine any diagnosis. I also agree that some doctors(primary care physicians) do not conduct a more extensive assessment to give an accurate diagnosis. That is why I prefer that the individual is assessed by a license clinical psychologist.I understand that a complete comprehensive assessment is best, in order to rule out other possible factors.

    I would like to say that ,like you, I have a dual role. i am a School Social Worker and a licensed clinical therapist with my license in clinical social work. Hence,I take offense to the statement that you made.It is a shame that School Social Workers are not given enough credit and are recognized for the rich skill set that we bring to the table.School social workers also have an educational and professional background in clinical services. An added bonus that we possess is that we realize the importance of the child's environmental background, as it can have a major effect on his overall educational, emotional, behavioral, and social development. We also have more of a direct connection with the parent,community, and collaborative agencies.Without our information, many important facets of that child would omitted.Without our information, one cannot even make an "educational" diagnosis of ADHD or Autism (these two can be educationally diagnosed in the state of VA). We understand that a child cannot be defined by a score alone.

    a school psychologist without a supplemental clinical license(which would validate that they have actual extensive clinical experience), and has never done an internship or worked in a clinical setting(the school setting does not count), providing direct clinical services, cannot be more qualified to diagnose ANY psychiatric disorder than a licensed mental health professional.That is what separates them from licensed CLINICAL psychologists.The same applies to a school social worker without a clinical license as well. At my student support team/child study team table, I have more extensive clinical background and training than anyone else that sits with me.This includes the school psy. I have extensive training on how to use the DSM-IV through my LCSW supervision and provision of direct care. I actually can and do clinical assessments, make mental health diagnoses/differential diagnoses(which is an important skill to have to rule out other disorders that have similar symptoms), develop treatment plans, and provide psychotherapy outside of the school setting. If anyone without proper training and credentials attempt to provide any of these services, they would be rendered unethical and in jeopardy of their license.I am not discrediting the school psy's position in the school, but I will not give credit where it isn't due.The reality is, a school psychologist is versed in EDUCATIONAL services . providing counseling services does not make one qualified as a highly qualified clinician or be able to to clinically diagnose. There are masters level home-based counselors that also do that. But someone with my credentials is qualified to clinically supervise these counselors. Just my .02 cents.

  23. Tim says:

    "a school psychologist without a supplemental clinical license(which would validate that they have actual extensive clinical experience), and has never done an internship or worked in a clinical setting(the school setting does not count), providing direct clinical services, cannot be more qualified to diagnose ANY psychiatric disorder than a licensed mental health professional.That is what separates them from licensed CLINICAL psychologists.The same applies to a school social worker without a clinical license as well. At my student support team/child study team table, I have more extensive clinical background and training than anyone else that sits with me.This includes the school psy. I have extensive training on how to use the DSM-IV through my LCSW supervision and provision of direct care. I actually can and do clinical assessments, make mental health diagnoses/differential diagnoses(which is an important skill to have to rule out other disorders that have similar symptoms), develop treatment plans, and provide psychotherapy outside of the school setting. If anyone without proper training and credentials attempt to provide any of these services, they would be rendered unethical and in jeopardy of their license.I am not discrediting the school psy's position in the school, but I will not give credit where it isn't due.The reality is, a school psychologist is versed in EDUCATIONAL services . providing counseling services does not make one qualified as a highly qualified clinician or be able to to clinically diagnose. There are masters level home-based counselors that also do that. But someone with my credentials is qualified to clinically supervise these counselors. Just my .02 cents."

    Just my .02 but I was with you until you went off the rails in this paragraph. A high percentage of school psychology programs do have a clinical training orientation. In my program for example I worked in school settings BUT also in community mental health agencies, mental hospitals and community clinics while supervised by licensed psychologists. Note I said licensed psychologists not licensed CLINICAL psychologists. As a doctoral level school psychologist I can be licensed in my state (ohio). While I stay within bounds of competence I think it is a generalization and mischaracterization to say that school psychologists are not capable to use the DSM-IV, make differential diagnoses etc. Please do not limit me to just providing EDUCATIONAL services. I also provide a range of clinically oriented services. We have enough people trying to define our role. =)

    You are doing what you say others are doing to school social workers. You are grossly underestimating the training of school psychologists.

  24. Anonymous says:

    As a parent, I appreciate your explanation and acknowledgement that ADHD is not an easy or light diagnosis. However, when educators out and out refuse to discuss how to deal with a child who has not been diagnosed and instead recommend, "See your pediatrician," how is that different than a peditrician sending a parent back to the school with a "perscription" for an IEP? Perhaps that is just the pediatrician's way of letting teachers know that not every child needs to be put on behavior modification drugs.

  25. Anonymous says:

    Help! Our school district use to have a set procedure if a parent came in (without a doctor's note or physician provided rating scales to be completed) and requested rating scales for their doctor. Our director of special ed now says all we have to do is have the parent sign a consent for release of records and we give them ratings scales which are completed by the teachers. We do not score them or send them to the doctors.

    Again, no note or scales are provided by the doctor or clinician.

    Am I wrong to feel just giving rating scales to parent when they ask and sign is unethical?

  26. Matt Berry says:

    First, I fully disagree with your comment that school psychologists are best to assess for AD/HD. Clinical Psychologists and clincal counselors are are trained and experienced in assessment are the best individuals for assessment of AD/HD. As a part of the assessment, most competent clinicians will have input from the school (rather it be school counselors or psychologists or teachers) in form of behavioral observations and behavioral assessments. Upon completion of the clinicians assessment, the report should be provided to the school, in which the school will take this data and the recommendations the clinician provides and uses this to determine the level of services the child needs as well as modifications and accommodations.

    In fact, I never take the diagnosis of any psychiatric disorder (besides ones that are more along the lines of dementia) form physicians, np's, pa's to heart. The majority of them will just give out a dx with limited or no support. The only exception I have are those done by a psychiatrist and developmental pediatrician (that has diagnosed AD/HD or autism, typically they do more evaluations).

  27. Anonymous says:

    Hmmm….feedback from teachers. Well, that would be a good idea if the teachers reported accurately. It's funny when the response on checklists do not match emails or comments on report cards. There's a plan before the making of the plan, don't make it look so bad. Also, for the life of me I will never understand how it is that teachers, who are part of the team vote on whether or not a child should get support, yet the do not know what the scores from an IQ or Acheivement Test mean. How is that appropriate?

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