By Dr. Sarah Haas *
The short answer is: Trendy, but ultimately, unnecessary if your goal is to diagnose or treat ADHD.
Many, many years of research have been dedicated to neuropsychological testing in ADHD. Just the phrase "neuropsychological testing" sounds important and necessary, is trendy, and all around sounds daunting! If it sounds daunting, my guess is not many folks are interested in delving into the research to find more out about it. So let me do that for you :)
Q: Isn't ADHD classified as a Neuropsychological Disorder now?
A: Yes. The most recent edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-5), which was published in 2013, classified ADHD as a Neurodevelopmental Disorder. What exactly does this classification mean? It means that people with ADHD often have a hard time acquiring new skills, like body movements, social skills, and/or cognitive skills, and these skills are often related to some issues in the brain. Researchers have known for many, many years that behavior problems that people with ADHD have result from their brain being different. This is not new information.
Q: So if ADHD is a brain thing, wouldn't you test the brain to diagnose ADHD?
A: That definitely sounds logical! If only everything in life were logical....
As long as researchers have found some results showing ADHD to be a brain thing, researchers have been researching the brain and how it is different in people with ADHD versus those without ADHD. Many of these tasks have involved looking at how quickly individuals with ADHD can stop a behavior, can plan ahead, can think flexibly, can be consistent in responses, and so forth. Although they have found lots of cool, geeky, interesting results related to this topic, they haven't found any one, specific brain function that is related to most or all cases of ADHD. This might sound surprising at first, but actually makes sense when you think more about it: there are so many people who meet diagnostic criteria with ADHD who look nothing like each other. Two children with ADHD can have very different symptoms, impairments, and development, but still each meets criteria for ADHD. From this perspective, it makes sense that ADHD may result from different causes. Across lots of studies where many children with ADHD were given a lot of different neuropsychological tasks related to these broad areas of functioning (impulsive behaviors, planning), Nigg and colleagues (2005) found that at most 35% to 50% of children diagnosed with ADHD who exhibited significant levels of impairment with impulsivity and attention, demonstrated poor performance on tasks taping the same neurological function. I think Dr. Russ Barkley, another expert in ADHD, says it the best. He has written an article in the upcoming March 2019 issue of The ADHD Report: "Neuropsychological Testing is Not Useful in the Diagnosis of ADHD: Stop It!"
Q: So...what does that mean that not all people with ADHD show poor performance in a specific neurological function?
A: This means that, at this time, there is no one specific neurological function that underlies all children with ADHD. This means that one person's ADHD may be because they have a hard time stopping impulsive behaviors, whereas another person's ADHD may be because they have low motivation, another person's ADHD may be because they need immediate gratification, and another person's ADHD may be resulting from difficulty adapting to their environment. So if you have your child complete a number of neuropsychological tasks, they may or may not show impairments on them. Not showing impairments on the tasks should not be interpreted as them not having ADHD.
Q: OK, so if we don't know what exactly is causing my or my child's ADHD, doesn't this mean we can't treat it?
A: Absolutely not. Of course, this is true for many things in life. For example, you might not be able to fix a car issue without knowing what is causing it. How does a mechanic know what the cause is of a specific issue with your car? You tell them what is different with the car now (current problem), they look at the different components to the car that can lead to that type of problem and find the piece that is broken or deficient (assessment), they replace that broken or deficient part (change something), and have drive your car home (see if it works). In mental health, therapists use this same model: Tell me what is most problematic for you right now (current problem), look at the different symptoms that can lead to that difficulty (assessment), we discuss if doing something differently would improve that problem (change something), and ask you at our next session if it worked. The difference between the mechanic and the therapist is the ease with which fixing the problem is (replacing a piece versus changing habits).
Q: Does it hurt to get information about my child's neurological functioning?
A: Neuropsychological tasks take time and are often expensive. The information you can get from neuropsychological measures are the same information we can get from talking with parents about the child's behaviors in their every day environment. Not only are they not informative when determining if you or your child has ADHD, they also do not provide any information about what therapy may be most effective for you or your child. Conducting these tasks, which do not help guide diagnosis or treatment, take time away from using your time more effectively by using more informative assessment measures or engaging in effective treatments sooner.
So, as cool as it sounds to feel like you have some tests that get at your child's "neuropsychological functioning", I would strongly encourage you to ask how this information will help you understand you or your child's diagnosis and/or how it will inform treatment decisions.
Barkley, R.A. (2019). Neuropsychological Testing is Not Useful in the Diagnosis of ADHD: Stop It!.
The ADHD Report.
Nigg, J.E., Willcutt, E.G., Doyle, A.E., & Sonuga-Barke, E.J.S. (2005). Casual Heterogeneity in
Attention-Deficit/Hyperactivity Disorder: Do We Need Neuropsychologically Impaired
Subtypes? Biological Psychiatry, 57, 1224-1230.
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