Neuro-Psychological Testing for Pediatric ADHD

Theresa R. Cerulli, MD: Oftentimes I’m asked if neuropsychological testing is needed to diagnose ADHD [attention-deficit/hyperactivity disorder]. You may be surprised to hear the answer is no. The sensitivity and specificity of being able to rule in or rule out whether the patient has ADHD is in the 65th or so percentile. In other words, neuropsychological testing isn’t great at making this diagnosis, nor is it a required step in doing so. Neuropsychological testing, when we’re doing that, especially with children, it’s important because what you don’t want to miss is what’s often a comorbid learning disability with the ADHD. If you’ve been diagnosed with ADHD, the overlap is 20% of those children will also meet criteria for a learning disability. Dyslexia, for example, is one of the most common. The neuropsych testing is both to see if you can recognize that this child is struggling with inattention, but also because you don’t want to miss what’s a very frequent coexisting learning issue that then may qualify that child for an IEP at school, an individual education plan. The academic accommodations become necessary for that child to do well in the classroom if they are also diagnosed with a learning disability; that step is important to not miss. That’s where the neuropsych testing comes in as most important.

But let me add here that it’s often very hard to access neuropsych testing, and it’s often not covered through insurance. That’s why I want to emphasize neuropsych testing isn’t the gold standard for diagnosing ADHD. If you can’t get it, you can’t get it. What is the gold standard for the diagnosis of ADHD is you, it’s us, it’s the practitioner? The gold standard is that clinical diagnostic interview, the data you are gathering, what you can observe in front of you, what you can gather from the teachers, from the parents; from both parents, obviously, if it’s a family where there’s divorce and the child’s going back and forth between 2 households. From many eyes and observers on the situation, it’s important to collect that information. That’s the gold standard for diagnosing ADHD in addition to obviously meeting with the family and especially the child, what you can directly observe.

In addition, as we’re talking about testing, people mix up what we mean sometimes. Neuropsychological testing is testing and is looking for that ADHD learning disability, the cognitive thumbprints of this child or adult. Now contrast that with rating scales, which sometimes people mix up with testing. Rating scales are not tests but are wonderful adjunctive tools for diagnosing ADHD. They don’t make the diagnosis in and of themselves by any means. The gold standard is still your clinical interview, but the rating scales help guide your interview questions. The rating scales are on ADHD symptomatology, or sometimes they’re functional rating scales like the BSFQ, the Before School Functioning Questionnaire, which looks at things like what is it like getting ready for school in the morning? Is there arguing at home? What’s it like getting through breakfast? These are functional rating scales. Those are wonderful ways to get information and guide your interview, really narrowing in on what it’s like for that family because I’ve said ADHD is such a heterogeneous condition and presents so differently from person to person.

Remember, you may have that child who is a behaviorally dysregulated, oppositional, arguing kind of a kid who’s hyperactive, and can’t even sit through breakfast, let alone remember to organize and pack their backpack and be on time to get on the bus. But you may also have the girl who’s sitting in the back of a classroom, quiet, no behavioral issues whatsoever, extremely well behaved, polite, who is daydreaming through the entire class, but learned to make eye contact with the teacher so it looks like they’re focused, and it looks like there’s no problem at all. That’s also ADHD. It’s just the inattentive type for some of these children.

Transcript edited for clarity.