In honor of ADHD awareness month, this week’s blog focuses on one of the most common reasons for Special Education testing referrals: I want my child tested for ADHD. Many times, parents report they were told by an outside professional (e.g, pediatrician) to have their child evaluated by the school for attention problems. Families also develop concerns based on their child’s behavior at home, behavior during extracurricular activities, academic performance, social concerns, and/or input from the classroom teacher, among others. While families have these concerns, they typically do not know their options for figuring out if their child has ADHD.

Go-to

Attention problems are often a “go-to” explanation for difficulties at school, and even at home. While many children may experience a multitude of problems related to inattention, it is the source of that inattention that needs to be determined. Not all attention problems are attributable to ADHD.

Academic difficulties

When a child’s grades begin to slip or never seem to hit the level that is expected, attention problems are commonly raised as a concern. This is particularly evident at younger ages or when there is no other clear possibility to explain the academic difficulties. However, various interventions and/or evaluations can help determine if the attention problems are possibly attributed to something other than ADHD. For example, if a child cannot see the board or struggles to learn to read, they may look more inattentive than their peers.

Social/emotional/behavioral problems

Attention concerns are often raised for children experiencing social, emotional, and/or behavioral problems at home or school. Examples include: invading personal space of others, lack of volume control (i.e., being unaware you are playing or talking loudly), hyperactivity, impulsivity, needing frequent redirection and/or reminders to stay on task, irritability, aggression, missing directions, becoming upset or excited for no apparent reason, acting out, taking items from peers, fidgeting, and many more. However, all of the aforementioned examples could be attributable to many conditions, not just ADHD. Similarly, not every individual with ADHD displays these traits.

Concerns at home

Parents/guardians often raise concerns about their child’s attentional capacity when problems are noted at home, during extracurricular activities, and/or school. Examples include: not completing a short list of tasks (e.g., completing one or none then becoming distracted), not remembering instructions for homework (or that there was homework), becoming distracted during sports, falling behind on assignments, struggling to sit still, and others.

School resources (RTI, Section 504, Special Education)

1.) RTI

RTI is an acronym for Response to Intervention. RTI is a 3 tiered program that many schools have. It is not governed by any laws or legal framework. It is designed to provide interventions to students within the general education setting. These interventions can be social, emotional, behavioral, and/or academic. If lower tier interventions are shown to be ineffective, more intensive interventions can be implemented at higher tiers. Should all three tiers be ineffective, alternative possibilities are typically considered.

Therefore, if anyone (parents, teachers, counselor) have concerns related to attention, the student’s case can be brought to the RTI committee to discuss possible interventions and/or accommodations. For example, should a student struggle to stay on task, a self-monitoring intervention could be tried. This intervention would involve the student having a timer that went off (e.g., vibrated) at set time intervals and the student would mark whether they were on or off task at all in that interval. Goals should be set for the interventions chosen and data collected to monitor the effectiveness.

Why RTI?

RTI may be a good starting place if the parties involved are unsure of the level of need, how effective various interventions may be, if no interventions have ever been tried, and if it is unclear that attention is the root cause of the student’s difficulties.

RTI is the least restrictive way to try supports for a student. They may receive extra instruction from a specialist but they remain in general education. It is required for schools to try to provide supports in the least restrictive setting before moving to more restrictive environments. However, there are instances where there is enough data to indicate that a more restrictive setting is appropriate.

Why not RTI?

If the child has been receiving interventions and accommodations but not making progress, RTI may not be the best for them. In other words, the data may indicate that RTI has been ineffective and it is time to move to the next level of support. It is also possible that while formal RTI was not implemented, interventions were, and they were not effective so RTI may not be appropriate. If a student has a formal diagnosis (e.g., ADHD) it is best practice to pursue programs backed by legal regulations and laws (e.g., Section 504, Special Education). These laws were put into place to protect individuals with disabilities. It is the safest and most defensible route for schools to pursue, at minimum, a Section 504 plan to document their efforts to level the playing field for students with disabilities.

Am I stuck with RTI?

No, you are not “stuck with RTI” if you try it. Often, parents are only made aware of their child being placed in RTI and are not the ones requesting it. However, parents can request it and have a discussion with the school.

Even though parents are not always the ones requesting RTI for their child, they, as well as school staff, are able to share whether they feel the interventions are effective or not. If RTI does not seem to be working, parents and staff do not have to wait for the child to struggle more before making changes. Campus staff can pursue Section 504 and/or Special Education supports while parents can request an evaluation through Section 504 and/or Special Education.

2.) Section 504

Students can receive support through Section 504 if they have a diagnosis or merely characteristics of ADHD. In other words, a diagnosis is not required. Parents or staff can request/recommend a Section 504 plan. The district would then convene a Section 504 meeting with the campus 504 committee and determine if the student qualified for a Section 504 plan.

Qualification for Section 504

Qualification for a Section 504 plan does not require a formal evaluation the way Special Education does but does need to involve information from a variety of sources. The campus 504 committee must answer 3 questions: 1) does the student have a physical or mental impairment?, 2) What major life activity or bodily function is impacted by the impairment?, and 3) Does the impairment substantially limit a major life activity? If the answer to all 3 questions is “yes,” then the student qualifies for a Section 504 plan.

What does that mean if a student qualifies for a Section 504 plan?

If a student qualifies for a Section 504 plan, the committee will then discuss what accommodations and/or services are needed for the child to have their educational needs met as much as their nondisabled peers. Being found eligible for a Section 504 plan due to attention concerns does not mean the child has been diagnosed with ADHD.

Note

It is important to note that some districts will administer rating scales measuring symptoms of ADHD through general education. This used to be more common and seems to have decreased over time due to needing a range of tools to diagnose ADHD. Even if symptoms are elevated on rating scales, that does not mean the child has been diagnosed with ADHD.

Common accommodations

Common accommodations provided to students with features of ADHD include but are not limited to: preferential seating, extra time, oral administration, reminders to stay on task, individualized structured reminders (i.e., breaking tests up into pieces with paper clips or post-it notes). Students may also receive support from the general education school counselor, whether or not they have a Section 504 plan, to work on skills such as building and maintaining friendships, regulating emotions and behaviors, and learning coping strategies. This support can be listed as a related service on their 504 plan. All accommodations and support should be individualized based on the child’s needs, not merely a list of accommodations typically effective for individuals with ADHD.

Why Section 504?

Parents/guardians often ask why they should pursue or agree to a Section 504 plan for their child. As mentioned previously, it is a good option for parents and schools alike if the child already has a diagnosis (e.g., ADHD).

Section 504 is also a good option if RTI has not been as effective for the student as desired. It is often recommended for students who have not received any intervention rather than going directly to Special Education testing. This provides valuable information on the effectiveness of interventions and accommodations in a less restrictive setting rather than jumping to the most restrictive setting. Many students will not need more support than that which is provided through a Section 504 plan.

3.) Special Education

Parents and staff can pursue a Special Education evaluation for concerns related to ADHD.

How is Special Education different from Section 504?

Special Education provides more than accommodations. Specifically, it includes specially designed instruction. This can be implemented in many forms from inclusion support in classes to social skills instruction in a Special Education classroom and more. It all depends on the individual needs of each student. Conversely, Section 504 does not include specially designed instruction. While Section 504 can include related services, it predominantly involves the provision of accommodations.

OHI

The eligibility category that encompasses ADHD is called Other Health Impairment and is often referred to as OHI. The requirements for eligibility under the educational condition of OHI vary by state. Some, but not all, states require the involvement of a licensed physician that answers 3 questions after indicating the diagnosis of a chronic health condition: does the diagnosis cause the student 1) limited vitality, 2) limited strength, and/or 3) limited alertness.

Texas

In Texas, it is required that the evaluation for OHI involve a licensed physician (MD or DO). A child will not qualify for services if there is no diagnosis and no involvement of a licensed physician.

Does the involvement of a physician mean I need to put my child on medication?

No, it does not. You do not have to put your child on medication due to the results of a school-based evaluation or the involvement of a licensed physician in the evaluation.

Can my child be tested if they do not have a diagnosis?

Yes, most definitely! A diagnosis is not required for the evaluation to be completed. However, having a diagnosis can speed up the process in states like Texas where a diagnosis is required. In other words, if testing is completed but there is no diagnosis, the child does not qualify until a diagnosis is obtained. If they have a diagnosis and the results of a Special Education evaluation indicate the child meets criteria for OHI, they can qualify immediately at the IEP meeting (ARD in Texas) if the committee agrees to the eligibility.

What is included in the evaluation?

A school psychologist (or LSSP in Texas) is typically involved for initial evaluations of ADHD characteristics. The evaluation typically includes components such as: classroom observations; parent, student, and teacher interviews; completion of rating scales measuring characteristics related to ADHD (e.g., inattention, executive functioning, hyperactivity, impulsivity); developmental history; review of educational, behavioral, and evaluation history; cognitive testing, and academic testing. While other testing may also be completed (e.g., speech and language) it depends on what was requested and the type of evaluation it is (e.g., initial, reevaluation, etc.).

What if the results say ADHD?

If the results of the evaluation indicate enough symptoms to warrant a diagnosis of ADHD as well as an educational need for specially designed instruction through Special Education, the family can take the report to their family practitioner to review. The results of the report do not automatically result in a diagnosis as schools do not diagnose.  If the physician agrees with the results, they may also be willing to complete the OHI form needed for the student to qualify.

What if I don’t have a doctor?

It is not uncommon for families to not have a family physician. Therefore, many times school districts will have resources to connect the family with a physician to obtain the diagnosis of ADHD based on the school evaluation. This is to eliminate barriers to obtaining the diagnosis so that children who need services can obtain them. If you find yourself in this situation, it is worth talking to district staff to see what options you have.

Can my child have ADHD but not qualify for Special Education?

Yes. A student can have symptoms of ADHD, or even a diagnosis, but not have it rise to the level of needing specially designed instruction that can only be provided through Special Education. In other words, it may be best supported by accommodations through a Section 504 plan.

Are schools the only place to have my child evaluated for ADHD?

No, there are many other options. It is up to each family to decide the option that best suits them.

Pediatrician or family practitioner

There are licensed physicians who will administer a rating scale, often the NICHQ Vanderbilt Assessment Scales, to parents and teachers. This rating scale measures symptoms associated with ADHD. It is different from the forms typically utilized by psychologists. If the results surpass the symptom threshold required for diagnosis, the physician can then make the diagnosis of ADHD. Some pediatricians and family practitioners prescribe medication for ADHD as well, but not all will.

Does every pediatrician or family practitioner do this?

No, not every pediatrician or family practitioner will diagnose ADHD. In fact, there are many who will not. In these cases, families are often referred to another outside provider (e.g., psychologist) or to the school to request an evaluation.

Psychiatrist or neurologist

Psychiatrists and neurologists can diagnose ADHD. The way in which they do this varies depending on the doctor and is sometimes done via informal diagnostic interviews. However, it is not uncommon for them to refer out to psychologists for formal evaluation. Psychiatrists and neurologists are two of the types of doctors that can prescribe ADHD medication should the family be considering it. If a family is considering medication, they may choose to go with one of these doctors.

Psychologist

Psychologists, especially clinical and school, are commonly the recipients of referrals for ADHD testing from other providers, including medical doctors. Their evaluations will often contain somewhat similar components to an evaluation completed by a school district. This is particularly true when a school psychologist is involved as they are trained in both school eligibility and clinical diagnostic evaluations. However, in states that require the involvement of a licensed physician to qualify a student under OHI, a psychologist typically does not count. However, their report can be shared with a licensed physician.

Where do all of these providers work?

All of the aforementioned outside providers can work in a variety of settings including, but not limited to: hospitals, clinics, government agencies, evaluation centers, and private practices.

Does anyone else do testing?

Yes, there are other trained professionals that can complete ADHD testing but the ones most commonly utilized for students in conjunction with schools were reviewed.

Things to be aware of

There are many factors that are important to keep in mind when considering having your child evaluated for ADHD.

Young children

It is much harder to diagnose young children (i.e., early elementary or younger) with ADHD due to their age, lack of experience (e.g., socially, academically), maturity, and development. Specifically, they undergo significant change in a short period of time. Young children have higher levels of activity. They have often not experienced the level of demand placed on them in the first few years of education. This is even more so the case for children that did not attend daycare or preschool prior to kindergarten as they have never experienced that type of structure and had limited ability to interact socially in comparison to students who did attend some form of preschool or daycare.

Regardless, all children tend to have a learning curve when adjusting to elementary school because there are significant differences in the level of demand, structure, and length of the school day between preschool and elementary. In addition, there are fewer instruments that measure symptoms in young children. This has improved over time but is still limited in comparison to the tools available for older students.

IQ of young children

Some people believe intellectual ability does not stabilize until age 8. Performance on cognitive assessments can vary significantly up to this age but it can also vary through teenage years. This also results in variability in performance on other measures including rating scales and academic testing. Prior to the stabilization of an individual’s IQ, it is often considered difficult to determine whether the variability in their performance is due to slight delays in development or more.

Young boys

It is particularly difficult to evaluate young boys for ADHD as they take longer than girls to mature and naturally have higher activity levels. Most young boys seem to display some characteristics that could be associated with ADHD (e.g., high levels of activity) but these decrease as they age and mature. However, boys are diagnosed with ADHD more often than girls.

Evaluating young children

However, it is not impossible to diagnose young children with ADHD. It is important that the evaluation consider all components that could be influencing the child’s possible characteristics of ADHD.

Girls

Girls, at any age, can be more difficult to diagnose than boys because they do not always show the same characteristics. For example, they do not always show the same level of hyperactivity. Their inattention is not always marked by behavior problems, which can cause them to blend in. They blend in even more because they often know how to look on task, even if they are not.

Root cause

Regardless of age, it is important to keep in mind any other variables that could be the root cause of symptoms related to ADHD. For example, if a child has an intellectual disability, do their attention problems surpass what would be expected for their intellectual level or are they consistent?

Comorbid condition

It is important that whoever evaluates a child can examine aspects beyond  ADHD alone as ADHD is often comorbid (i.e., co-occurs with) other conditions.

Summary

Yes, schools can evaluate children for ADHD but they do not diagnose ADHD. While schools can evaluate for ADHD, that does not mean that they have to do so. Each evaluation determination is made based on individual student needs. There are many other ways to pursue an evaluation to determine whether your child has ADHD or not. However, there is not one sole test for diagnosing ADHD.

While a variety of providers were discussed in this blog, there are those that specialize in ADHD and/or behavior within each field and those may be the most beneficial. It comes down to who best sees the child for who they are and meets the child’s needs. Parents/guardians have to determine the information they need to best develop a plan for their child and the provider(s) they feel will best meet their needs.

They can pursue:

1. Formal testing
2. Formal testing based solely on rating scales
3. Informal testing through diagnostic interviews

The options are:

1. School-based evaluation which includes formal testing that can result in Special Education eligibility but does not result in a formal diagnosis
2. School administered rating scales (if it is an option on your campus) that do not result in a formal diagnosis
3. Informal or basic rating scale evaluation by a physician or outside provider that can result in a formal diagnosis
4. Having a licensed physician (or whomever your state requires) review an evaluation completed by another professional to complete OHI paperwork
5. Psychological evaluation by a psychologist that includes formal testing, results in a diagnosis, and can assist with determining Special Education eligibility
6. An evaluation by other personnel

Many times, parents will pursue multiple options at once. For example, they may have the school evaluate while also talking with the pediatrician to obtain a formal diagnosis if that is needed for eligibility. It all comes down to what best meets their child’s needs.