Few situations provoke more bewilderment and professional anxiety than the prospect of identifying a student with ADHD. Consider the situation confronting Lakisha Washington, a school psychologist. Lakisha has been practicing in elementary schools for 10 years, and she takes her professional responsibilities with profound seriousness. She has been awarded an EdS degree, is a certified school psychologist in her home state, a member of the National Association of School Psychologists, and she holds NCSP designation. She is a consistent participant in continuing education programs and keeps abreast of practice trends by networking with school psychology colleagues.

While conducting a learning disability evaluation, Lakisha observed first-hand several symptoms of behavioral dysregulation in a fourth-grade, 10-year-old student named Shannon Sales. These included repeated problems staying seated, extreme restlessness, excessive talking, interrupting class with unsolicited comments, answering teachers’ questions without being called on, intruding into classmates’ conversations, and extreme fidgetiness. Review of school records showed mounting problems with work incompletion but only a slight dip in report card marks, most notably in reading. Inattention, only a minor problem in kindergarten and first grade, had reached troublesome levels during second grade. Reading problems intensified through third grade as did difficulty routinely completing assignments. She also lost necessary material, and she recurrently appeared disorganized and forgetful.

Broadband rating scales, which Lakisha’s school district’s policy and her own professionalism mandated as part of every learning disability evaluation, pointed toward clinical-range elevations on an ADHD index. What’s more, the scores were comparably elevated on rating scales completed by both Shannon’s teacher and her parents. When she administered individual achievement tests to Shannon, Lakisha found scant evidence of genuine academic skill deficiencies; repeated curriculum-based measures found the same thing. Not surprisingly, Lakisha had strong suspicion that much of Shannon’s school problems might arise from previously undiagnosed ADHD.

Lakisha’s school district has a crucial principle bearing on this case: “Our school psychologists classify, they do not diagnose.” All district school psychologists grasped that making an ADHD diagnosis is especially taboo. Lakisha concluded that notwithstanding the distinct prospect of ADHD that she was not free to pursue that “diagnosis.” Equally troublesome, even the chance to “classify” seemed constrained. This was because no obvious match existed with any special education category (i.e., those specified under IDEA). Simply put, Lakisha at this point doubted her ability to satisfy criteria for either SLD or ED. Although the IDEA category of Other Health Impairment (OHI) might apply to this student, Lakisha’s home state mandates a medical certification for all OHI cases. Obviously, Lakisha is not a physician (Lakisha’s school district employed no physicians to make such a diagnosis).

Like many U. S. school psychologists, Lakisha senses a way forward, albeit an imperfect one. Lakisha noted that this student received routine care from a well-regarded community pediatrician. Thus, Lakisha’s Child Study Team sought her involvement, hoping for confirmation or disconfirmation of ADHD. Indeed, Shannon’s parents had spoken highly of this pediatrician’s collaborative outlook and her vast medical knowledge, making her input seem all the more straightforward. Without ever mentioning the prospect of ADHD per se, Lakisha floated the idea of involving the pediatrician. Surprisingly, both mother and father seemed puzzled. They said, “If you’re thinking about an attention or hyperactivity problem that might be causing trouble at school, then we prefer you make a judgment yourself. We’re not interested in involving our pediatrician now.”

Before considering Lakisha’s best course of action, let’s take a look at some background facts regarding ADHD diagnosis in schools. Then we will consider several professional practice considerations as well as techniques available for those working in schools. After doing so, charting a course of action for Lakisha will make more sense.

ADHD, a Few General Considerations

According to DSM-5, the yardstick most used by mental health diagnosticians, ADHD requires noteworthy symptoms of either inattention, hyperactivity-impulsivity, or both. ADHD is present only if there is cross-situational impairment and childhood onset. If these facts are even slightly unfamiliar to you, read DSM-5 (American Psychiatric Association, 2013) pages 59 to 66 before going further in this chapter. This chapter offers a few salient points about ADHD, but these are no substitute for reading the relevant pages in DSM-5.

ADHD is a Neurodevelopmental Disorder

This means that ADHD’s overt manifestations result from presumed brain dysfunction. Although children with ADHD are quite heterogeneous, research appears to have established some basic understanding. Foremost is hypothesized dysfunction in the prefrontal cortex; frontal dysfunction appears as failure of an interrelated set of capabilities referred to as executive function. This means that youngsters with ADHD suffer from poor behavioral inhibition. Because they are poor at inhibiting impulses, youth with ADHD suffer impairments (or at least delays) in development of various executive functions: planning, regulation of emotion, working memory, recapitulation of past events, and internalization of rules. Russell Barkley (2012) in particular argues that these executive failures are the core of ADHD. According to this conceptualization of ADHD, conspicuous symptoms of impulse control and inattention are the mere outward expressions of executive dysfunction. This formulation, however, applies only to individuals with ADHD predominately hyperactive-impulsive type and ADHD combined type.

Critically, ADHD predominately inattentive type is envisioned to arise from different brain dysfunction and to appear as qualitatively different overt behavior. The behavior of children with inattentive type is characterized by daydreaming and sluggish cognitive tempo. They can be summarized as “impersistent-distractible-forgetful” (Smith, Barkley & Shapiro, 2007). Students with predominately inattentive type, however, lack the driven, intrusive, overactive, and impulsive behavior that often characterizes their ADHD hyperactive-impulsive counterparts.

The “developmental” aspect of the neurodevelopmental designation concerns onset and appearance. There is an onset (< 12 years) requirement. Moreover, ADHD is recognized in part by symptoms inconsistent with expectations for one’s age. Accordingly, age-specific standards are needed to help judge if problems controlling impulses and focusing attention are inconsistent with age and global developmental level. There is no secret that 12-year-olds pay better attention than three-year-olds. Equally important, the older group, on average, is superior at formulating plans, processing feedback, holding material in working memory, forestalling unwise actions, and slowing the expression of intense emotions. This means that standards for the behavior and focus of an older group cannot be simple-mindedly imposed on a younger group. Accordingly, everything from classroom observations to parents’ commentaries, to rating scale raw scores must be weigh against the backdrop of a child’s age.

With reflection, this is obvious. Less obvious is the context of each child’s cognitive maturity, his “mental age,” not just his “chronological age.” Twelve-year-olds with high full scale IQs, for example, on average might be expected to appear much like older classmates across a number of neurocognitive dimensions, including impulse control, planning, and sustained attention. In contrast, 12-year-olds with lower full scale IQs, on average, might be expected to appear on these same dimensions much like younger classmates. Researcher affirmed the role of IQ this way, “A moderate-to-strong relationship between general intelligence and neurocognitive functions, such as attention, working memory, and inhibition, has already been established in the literature” (Munkvold, Manger & Lundervold, 2014, p. 120). This line of thinking means that considering students’ developmental level can be important in appraising symptoms of inattention or hyperactivity-impulsivity.

Situational Demands are Particularly Relevant

Any overt behavior is partially about the student and partially about her environment (i.e., the immediate situation in which she finds herself). It’s generally recognized that all students (those with ADHD as well as those without) focus better on interesting activities (and activities they select for themselves) and worse on tedious and effort-intense tasks (and activities imposed by others). There is nothing about the definition of ADHD to make this untrue. Thus, when a parent (often a father) says, “I don’t think my son could have ADHD because he attends so well to video games” nothing has been learned to rule out ADHD. Video games are attention grabbers for many, many people. And in contrast, nearly everyone experiences some sense of boredom confronting a thick stack of uninteresting worksheets. Diagnosticians need to understand that it is perfectly plausible for a student to appear devoid of attention problems in one setting only to appear replete with problems in another setting. The former are often low-attentional-demand situations, the latter are often high-attentional-demand situations.

It is high-attentional demand situations that spread out the distribution of attentional skills. This fact matters when school psychologists observe a student in class. If you want to capture (or rule out) attention problems, watch the student in a setting where it is difficult to pay attention. Compare his success with classmates in the same demanding setting. Empirical data speak to this point. In a meta-analysis Kofler, Raiker, Sarver, Wells and Soto (2016) confirmed that core ADHD symptoms (e.g., hyperactivity) are not ubiquitous among affected children. Rather, they appear differentially depending on executive and working memory demands and level of environmental interestingness.

Expect Discrepancies among Informants

Distinctive situation-to-situation demands that impact ADHD symptomology may be why raters agree with one another only modestly. What is agreement like? Consider Kennerley and colleagues (2018) who found parent-teacher correlations for ADHD symptoms ranged for among symptoms of Hyperactivity-Impulsivity from .56 to .17. For symptoms of Inattention correlations ranged from .41 to -.03. Overall, parent-teacher ratings were more concordant for Hyperactivity-Impulsivity symptoms than for Inattention symptoms. You are cautioned against assuming that discrepant score indicate that one rater is correct and the other incorrect. Perhaps one rater was in a setting amenable to witnessing one set of symptoms whereas another rater was in a setting lending itself to seeing other symptoms. In light of considerations like these, Smith, Barkley and Shapiro (2007, p. 65) offer the following regarding ADHD diagnosis: “…we recommend that symptoms reported by one source should be tallied; then, the number of additional symptoms identified by the other source should be added to the tally, totaling the number of different items endorsed across both sources.”

A practice like this might work well in clinics where assessment is centered around DSM-5 and its symptom list. This approach, however, at least in the early stages of the assessment process, might not fit with school psychologists who prefer teacher and parent rating scales. But shouldn’t an approach like adding symptoms from several sources be considered when multiple  informants’ ratings are a prime source of information? Perhaps so. Indeed, a longitudinal study of ADHD diagnosis and outcomes seems to verify empirically the wisdom of the assertion made above. Researchers (Shemmassian & Lee, 2016) examined several options for simultaneous consideration of parent ratings and teacher ratings of ADHD. Specifically, they used four algorithms for applying parent ratings of ADHD and teacher ratings of ADHD for predicting gold standard diagnoses as well as academic and social impairment. For our purposes, just two of their methods matter: one entitled the “and algorithm” and the other entitled the “or algorithm.” As you might suspect, in the former approach elevations in both parent and teacher ratings were required to judge ADHD as present. In the latter just one or the other being elevated (not both) was required. The “or algorithm” produced a better balance of sensitivity and specificity regarding accurate diagnoses, plus better prediction of future impairment. The “and algorithm” had poor sensitivity (i.e., just .25); it missed many cases of true ADHD. To be clear, trusting a high parent ADHD rating or a high teacher rating (but not requiring both) worked out best. Thus, school psychologists should be cautious about setting excessive demands for concurrent parent and teacher rating elevations when they are considering ADHD. Don’t reject ADHD as a credible working hypothesis based on a single informant’s non-clinical range score.

Comorbidities are Common

Many students with ADHD (perhaps 2/3) have one or more additional diagnosable mental health conditions. Among the most common are behavior problems (oppositional defiant disorder and conduct disorder), mood disorders, anxiety disorders, SLD, tics and Tourette syndrome (Masi & Gignac, 2015). This is consequential because youth with genuine ADHD may present with problems that seem more akin to the comorbidity than to ADHD. A moody, non-compliant or anxious student may turn out to have ADHD. There are also patterns of comorbidity based on a child’s ADHD type. For example, those students with the predominately inattentive type are more apt to experience anxiety and depressive problems; those with predominately hyperactive/impulsivity type are more apt to present with behavior problems (Barkley, 2013).

The Prospect that ADHD is Outgrown, Empirical Research

Occasionally parents and teachers believe that ADHD represents nothing more worrisome than a circumscribed inability to focus. ADHD is sometimes envisioned to be a minor problem, a trivial one in the overall scheme of factors influencing academic and life success. According to the it’s-just-minor-attention-problem line of thinking, simply tweaking demands to attend or incentivizing sustained attention should go a long way toward making the condition inconsequential (or barely consequential). What’s more, sometimes one hears that ADHD is actually beneficial. It is reasoned that impulsiveness and dysregulation promote spontaneity and risk-taking. After all, aren’t many successful entrepreneurs and scientists like this? Well, what do the data say? How do these lines of thinking hold up to logical and empiricism?

First, consider that across the school years ADHD is associated with  a whole host of problems. A meta-analysis of academic functioning summarizing 74 studies found ADHD/non-ADHD differences averaged .71 standard deviations. This means that, on average, students with ADHD score approximately 10.6 standard score units (assuming a standard deviation of 15) worse than their non-ADHD counterparts (Frazier et al., 2007). Reading performance fared worst. A longitudinal study of more than 2,000 primary grade students demonstrated that ADHD symptoms were correlated with lower reading levels and less growth in both decoding and reading comprehension (Ehm et al. 2016). At the other end of age distribution, high schoolers with ADHD were found to experience lower GPAs, higher rates of course failure, and more remedial class placements that counterparts without ADHD (Kent et al., 2011).  Similarly, high school students with ADHD  ,compared to classmates without ADHD, have been found to be four times more likely to repeat a grade or drop out before graduation (Fried et al., 2016). Interestingly, the drop out statistic held true even after IQ scores and the presence of learning disabilities were accounted for.

Next consider adult indices. Although not all children with ADHD suffer problems that persist into adulthood, a disproportionate number do. This includes adult problems that extend to work, management of personal finances, interpersonal relationships and even responsible driving motor vehicles (Barkley & Fischer, 2011). Klein and colleagues (2012) found elevated risk of adulthood incarceration, substance abuse, and psychiatric diagnoses in the ADHD cohort diagnosed as children. Among young adult females with childhood ADHD, Babinski, Pelham, Molina, Gnagy et al. (2011) and Babinski, Pelham, Molina, Waschbusch et al. (2011) documented impairments in social, occupational, as well as some educational dimensions.

Likewise, it is illogically to assume that ADHD drives success based on scattered anecdotes. When highly successful adults reveal that they have ADHD diagnoses, it’s tempting to surmise that one thing (ADHD) caused the other (success). But if one stops and thinks about it, success is caused by a complex interaction among things like cognitive ability, opportunity, personal drive, social connections plus a big dose of luck. Perhaps for the high achiever with ADHD, the ADHD did not matter—it was insufficient to constrain them. Perhaps their ADHD even sometimes helped a little, such as by promoting risk taking. But it’s a huge logical stretch to assert that ADHD is an advantage. If you want to know if ADHD actually proves advantageous, look at success among 1,000 adults with ADHD and 1,000 without, not anecdotes.

Big Picture

Why does this matter? Although all diagnoses, including, ADHD can be stigmatizing, they can also prove empowering. Understanding, predicting and controlling (improving) behavior is psychology’s prime goal, as argued for since before WW II (Allport, 1940). But too often school psychologists assess a student with obvious symptoms of ADHD and turn a blind eye to the entire notion of ADHD. Either explicitly or implicitly many seem to view ADHD as beyond the borders of their school-based practice. Their boss may have told them not to do so (as likely happened with Lakisha).

How can stakeholders, however, understand the action of an affected student without recognition of his ADHD? How does one make sense of unwanted comments blurted out in class? How does one understand misplaced or forgotten homework assignments? How does one anticipate everyday problems that are likely to appear during adolescence and adulthood of a child who clearly has ADHD but has never been notified of this critical (potentially life altering) fact? Most importantly, how does a school psychologist assure proper educational services (including those entitled under Section 504) and access to empirically documented treatments specific to ADHD? In other words, how can science (and the nomothetic approach) be brought to bear to help this human? The answer is that they cannot. In turn, how does a school psychologist fully satisfy her ethical obligations? The NASP Principles of Professional Ethics says, school psychologists are to “improve the quality of life for students” (NASP, 2020, p. 39). Specifically, how does one meet the obligation to foster improvement when valuable understanding never occurs and worthwhile treatment options are never considered because of a refusal to address the obvious?

Practice Considerations

Who Should Identify ADHD?

Just who is empowered to make ADHD identifications? That question remains largely unresolved and subject to local professional culture, state level regulations, and historical precedent. Nonetheless, various national organizations have spoken. For example, the National Institute of Health (NIH), which is obviously a physician-centric institution, simply calls for a licensed professional. They do not stipulate that the professional is a physician. It is interesting that NIH lists the following as able to establish ADHD’s presence:

• physicians
• psychologists
• social workers

so long as they possess experience in ADHD.  For those who might think that pediatricians are especially skilled ADHD diagnosticians, consider this additional quotation from NIH (2015)….. “some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood brain disorders such as ADHD.”  These statements seem compatible with those of the U. S. Centers for Disease Control: “The diagnosis can be made by a mental health professional, like a psychologist or psychiatrist, or by a primary care provider, like a pediatrician.”

https://www.cdc.gov/ncbddd/adhd/diagnosis.html

Critically, because licensing is handled at the state level, local laws may determine who has the right to make ADHD diagnoses. That said, research suggests that school personnel assign ADHD diagnosis in a scant 2.8% of cases. In contrast, more than 50% of the time diagnoses are assigned by primary care physicians, such as pediatricians or family practitioners (see Table 12.1). Non-school-based psychologists (e.g., licensed psychologists in private offices) make diagnostic school-age ADHD determinations in about one in seven cases (see Visser et al., 2015 for more details www.cdc.gov/nchs/data/nhsr/nhsr081.pdf). No wonder Lakisha seems hesitant.

But what about the actual skills school psychologists (like Lakisha) compared to those of typical pediatricians. Based in schools, school psychologists can interview teachers, access facts spanning years of a student’s life (cumulative files), and observe first-hand a student’s actions, including her ability to focus and exert self-control in a setting with ecological validity. None of this is possible in the sterile confines of a physician’s office. A second advantage enjoyed by school psychologists is their relative distribution of time. School psychologists routinely spend large blocks of time assessing children (e.g., several entire mornings on a single student). In contrast, many pediatricians see patients for 15-minute time blocks, with additional time allocated for complex cases or those requiring extended data collection (e.g., ADHD diagnosis). It is implausible that a typical pediatrician would invest as much time in an ADHD evaluation as a typical school psychologist. A third advantage is the focus of professional training. School psychologists earning EdS degrees, for example, spend their entire 3 years of post-graduate training on development, measurement, assessment, behavioral observation, and interviewing. Pediatricians spend a decided minority of their training time on this suite of tasks. It makes sense. Pediatricians primarily must learn about life-threatening illnesses that must never escape detection as well as routine (high-frequency, low-intensity) presenting problems that consume most of their office time. These include ear infections, colds, rashes, diarrhea, immunizations and, occasionally, questions about ADHD. Thus, it’s no surprise when the NASP position statement on Students with Attention Deficit Hyperactivity Disorder says the following, “School psychologists are trained in child psychopathology and behavior assessment practices and have the expertise to evaluate whether students are presenting with ADHD” (NASP, 2018, p. 1).

Are School Psychologists Obliged to Identify ADHD?

To echo Chapter 10, Local Educational Agencies (LEAs), have an obligation to identify all kinds of conditions. The obligation, however, rests with the LEA, not necessarily any one of its specific employees (including a school psychologist). Among the elements of the Individuals with Disabilities Education Act (IDEA) is a provision entitled “Child Find,” which charges all LEA’s to find students with disabilities. Regarding IDEA, this means any of the listed disabilities (e.g., SLD, ED). When this act’s earlier version was up for reauthorization, Congress contemplated changes and thus solicited public input. Many parents and professionals proposed that ADHD be added to the IDEA list of handicapping conditions as a stand-alone category (i.e., assume the same status as SLD or Hearing Impairment). In fact, in 1990 Congress seriously considered adding ADHD to its list of “children with disabilities” (see Wodrich & Davila, 1994, for details). The position of the U.S. Department of Education dating from at least 1992 made it clear that students with ADHD needed to be identified because many of them meet criteria for SLD or ED. Once OHI was added to the listed disabilities in 1993, LEAs’ obligation to identify student with ADHD became even more compelling. This was because ADHD became listed as a candidate medical condition (just like asthma or diabetes) for OHI designation. Indeed, the limited empirical evidence that exists suggests that the OHI category is the common special education route to create eligibility for students with ADHD. Critically, however, IDEA’s Child Find proviso is mandatory, not optional. Furthermore, it is broadly inclusive, not exclusive. Vis-à-vis ADHD, school districts have an “affirmative obligation” to evaluate any child suspected of having LD, ED, or OHI. There is no opt out, such as when a student with ADHD might be eligible under OHI but a school district declines to evaluate her for eligibility. Think back to Lakisha’s situation.

Obviously, issues of entitlement (e.g., under IDEA and Section 504) arise when ADHD is considered at school. School psychologists are quite capable of shouldering the LEAs obligation to identify students with ADHD. But individual school psychologists will need to consider their own professional preparation, their personal skill set, authority (based on state-level rules and regulations), and finally directives from their supervisors. They also should know some facts, including the current position of the federal government regarding ADHD in schools (see Illustration 12.1).

How should children with ADHD be identified? Which assessment techniques should be followed? How should things actually be put together? Fortunately, at least two sets of practice guidelines exist–one from the American Academy of Pediatrics and the other from NASP. Both are presented in Table 11.1 The two are surprisingly similar, both advocating use of multiple procedures, consideration of comorbidity, and application (or at least cognizance of) DSM-5 criteria. The school psychology guidelines also correspond closely to the elements you read about in Chapter 2. If we assume that Lakisha decides to conduct an assessment for ADHD, then she could access the standard school psychologist tool kit and simply enter the resulting information in a HR Worksheet. Many times, however, school psychologists start with no clear working hypothesis (ADHD or anything else). Instead, as you have seen, they adopt an opened-end process like the HR approach. But specialized, narrowed consideration of ADHD is a different matter.

When ADHD becomes a prime hypothesis, school psychologists are obviously dealing with a quite specific classification decision (and this process begs for a strongly nomothetic mindset). Thus, ADHD-focused assessments are ripe for possible use of probability nomograms for school psychologist who like to see the probability of ADHD emerge as they work. Consider the position advocated one-quarter of a century ago in an article published in the Journal of School Psychology. “The probability of obtaining a correct diagnosis of children in the general population with behavioral rating scales is affected by two factors: (a) the sensitivity and specificity of the instrument, and (b) the prevalence of ADHD in the population” (Reid & Maag, 1994, p. 342). These authors argue for exactly the Bayesian (probability nomogram) approach to harness the various assessment tools proposed in the NASP practice guidelines. Even if you never use a probability nomogram, knowing how well various tools work to identify ADHD is invaluable. That’s what we turn to now.  At the end of the chapter, we revisit Lakisha and her case.

Base Rate Considerations

The ultimate probability of ADHD hinges to a surprising extent on the base rate of ADHD before any assessment information is even collected. This was detailed in Chapter 2. A few supernaturally motivated school psychologists might collect their own base rate information.  It is interesting (and potentially instructive) that in some settings the verified ADHD base rate is quite high. For example, back in 1990, the base rate was a mammoth .65 for children referred to a clinic for attention problems, high activity levels, or poor school grades (Aylward, Verhulst & Bell, 1990). And, at least one expert (Russell Barkley) has speculated about base rates where you practice, “About half of the children referred to child mental health settings have ADHD. We expect similarly high base rates of ADHD are found in populations referred to school psychologists and similar professionals” (Smith, Barkley & Shapiro, 2007, p. 68, underlining added). This value may seem high to some readers. A more conservative estimate might be between the population prevalence rate (.06) and the estimate by the authors above (.50), perhaps .25 as a rough base rate estimate. Again, collecting your own information would be the best if you find yourself dealing recurrently with questions about ADHD. That said, guessing at base rate is arguably better than completely ignoring the topic.

Information from Background

 ADHD is heritable. Logically then, having a biological relative with ADHD raises a student’s own risk of ADHD. Consider family history and its ability to provide an estimate of a risk, expressed as a ratio (see Chapter 2 for details on calculating risk). When a sibling is affected with ADHD, the risk goes up dramatically. For example, in one study (Chen et al. 2008) the risk ratio was found to be 9.0 (12.7/1.4) when researchers used stringent diagnostic criteria concerning ADHD combined type. In another study (Faraone et al., 2008), the ratio was found to be 4.0 (20.0/5.0) when a broad definition of ADHD was applied. As you would anticipate, either of these values entered into the middle column of a nomogram would boost the pre-test probability upward.

Risk of ADHD can be gleaned from other background information. Sometimes, for example, school psychologists encounter a student with a prior diagnosis known to predict (raise the risk) of ADHD. In actual practice, diagnoses of comorbid conditions may appear in the paperwork submitted by parents, such as in an evaluation conducted by an outside professional. This is exemplified by the presence of Tourette syndrome, which denotes an estimated risk ratio for ADHD of 5.3. You saw this information already in Chapter 4 (Figure 4.12). Similar findings appear regarding children with diagnosed language disorders. The risk of having ADHD is boosted for children with language disorders about five times based on two studies, both of which are now dated (Beitchman et al., 1986; Reilly, Cunningham, Richards, Elbard & Mahoney, 1999). Like risk ratios associated with family history, information about conditions that predict a risk of co-existing ADHD can be entered into the middle column of an initial nomogram (or permit completion of a second, third, or subsequent nomogram to track changing ADHD probabilities). You are urged to consider these factors whether or not you use nomograms.

You are already generally familiar with broadband rating scales from Chapter 5. But regarding ADHD, it is their potential to accurately classify that counts most. As you have seen, diagnostic likelihood ratios (DLRs) can be used to help classify, as well as to provide a sense about which tools work best (have the largest effect size for proper ADHD identification). DLRs are sometimes found (conveniently) in the test manual or (inconveniently) in post-publication research reports (i.e., published journal articles).

Cultural and Linguistic Considerations, Lakisha and Shannon

You saw earlier the importance of cultural and linguistic considerations regarding all manner of referral questions. This includes deliberate cognizance of parents’ language use and their cultural perspective when collecting background information (Chapter 4) and awareness of language preferences (and potential use of cultural norms when using broadband scales; Chapter 5). These matters should not be disregarded when a referral question concerns ADHD or when ADHD emerges as a working hypothesis. But there’s more. Research shows that although ADHD diagnoses over time grew among all US school children, noteworthy racial disparities also characterize trends. In other words, students from minority groups may not receive ADHD diagnoses (and treatment) at a rate comparable to their European-American counterparts (Morgan, Staff, Hillemeier, Farkas & Maczuga, 2013). A recent, large scale study using several representative samples provides details (Visser et al., 2015). Among fifth graders, 16% of European-American children were diagnosed with ADHD compared to 9% of African-American and just 4% of Latino children. By 10th grade the values for the same three respective groups were 19%, 10% and 4% (Visser et al).

Lakisha and Shannon’s case (with a middle class, African-American, English-only-speaking school psychologist and a middle class, African-American, English-only-speaking family) would seem to impose few cultural and linguistic stumbling blocks. There was, for example, no ethnic incongruence (see Chapter 4 for an explanation). Plus, Shannon’s family possesses resources to access primary medical care (and a pediatrician’s consideration of ADHD) if they had chosen to do so. But that is not always true. What if Lakisha were dealing with an immigrant family from Honduras lacking financial means, access to health care, and basic transportation? Moreover, what if this same family was neither aware of the educational importance of addressing ADHD nor disposed to advocate for an assessment even if such awareness were present? The same might be true for families who are neither African-American nor Hispanic but who are poor.

Although minority membership or SES status may be associated with limited access to health care, it should not constrain access to committed and professional school psychologists. Those school psychologists may help assure essential opportunity to have ADHD identified in schools. Consider the clarion call made by the researchers mentioned above when they published in a pediatric, not a school psychology, journal: “Our findings provide additional support to calls for increasing solicitations by pediatricians, school psychologists, teachers, and other clinicians of concern by minority parents for their children’s learning and behavior, ensuring sensitivity to differing cultural values about disability during well-child visits and referrals, and encouraging symptom recognition and help-seeking behaviors by these parents, and suggest that these efforts by clinicians should be made throughout minority children’s early life course.” (Morgan et al., 2013, p. 91). This statement seems to beg for school psychologists to act assertively “in the best interest of the student.” Those school psychologists may help assure equal opportunity to have ADHD identified in schools. Recognizing that LEA’s, not parents, are obliged to identify all students with ADHD is arguably a first step.

 Summary

Controversy and professional insecurity seem especially common when school psychologists confront the prospect of making an assessment that involves ADHD. Critically, it is now clear that school districts have an obligation to locate and assist students with ADHD. School psychologists are able to assist in this process even though most ADHD identifications now occur out of school. School psychologists’ standard assessment techniques of accessing background information, observing, interviewing, and using multiple rating scales work well when there are questions about ADHD. A structured process such as using the HR Worksheet or probability nomograms can aid the process. Final confirmation by using DSM-5 criteria is a practice compatible with the position of various professional organizations, including the National Association of School Psychologists.