ADHD Documentation Guidelines
ADHD Documentation GUidelines
Many conditions (e.g. anxiety, mood problems, learning disorders) share features similar to those of ADHD. At the Center for Counseling and Student Development (CCSD), we believe ADHD is most accurately diagnosed using a combination of clinical information and psychoeducational testing that takes into account the presence or absence of other similar conditions. Therefore, in order to be considered for medication for ADHD by a CCSD psychiatrist, you must provide the documentation described below. The documentation and a psychiatric evaluation by a CCSD psychiatrist inform the clinical decision about prescribing medication.
Credentials of the Diagnosing Professional
The following professionals are generally considered qualified to evaluate and diagnose ADHD. They must have comprehensive training in the differential diagnosis of ADHD and direct experience with an adolescent or adult ADHD population.
- Licensed/certified psychologist or neuropsychologist with training in educational testing.
- Certified school psychologist in the student's school system.
Use of diagnostic terminology indicating an ADHD diagnosis by someone whose training and experience are not in the field is not acceptable.
Requirements for Evaluation Report
Report Contents
The report must be submitted on official letterhead with names, titles, professional credentials, addresses, phone/fax numbers and the date(s) of testing, and it must be signed by the evaluator(s). The specific reporting format is left to the professional, but the required components must be clearly presented and easily discernible. If the report is assembled by a multidisciplinary team, all components of the evaluation including psychological, educational and social reports should be included with the summary report of the group.
Regardless of the format used, the evaluation report must be comprehensive and should include the following elements.
Diagnosis: The ADHD diagnosis must be clearly stated and based on DSM-IV diagnostic criteria. ADHD often occurs in conjunction with other conditions. The report should include what other possible causes of the attention problems were ruled out.
History of the Problem: A history of the presenting attentional symptoms including evidence of ongoing impulsive/hyperactive and/or inattentive behaviors first exhibited in childhood that have significantly impaired functioning over time (to establish the rationale for the diagnosis).
Academic History: A description of auxiliary aids, support services and accommodations, including their effectiveness in mitigating functional impact of the disability.
Psychosocial and Family History: A relevant history and interventions; a history of the presence of absence of ADHD and other relevant educational, learning, physical, and/or psychological difficulties in the family.
Medical/Psychiatric History: A relevant history (including both current and past medications) including possible alternate diagnoses, including medical or psychological disorders that may mimic ADHD.
- Summary: A comprehensive interpretive summary synthesizing the evaluator’s judgment for the diagnosis of ADHD
Diagnostic Battery
Diagnosing professionals are required to use tests that are generally accepted to be the most reliable measure, administered in their entirety, with clear justification of any changes from standard administration. Tests considered appropriate for assessing adolescents and adults should be utilized.
Because ADHD and learning disabilities often co-occur, the diagnostic process should include tests of intelligence, cognition/information processing and academic achievement. The report should state whether any learning disabilities are present or possible.