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Now, like I mentioned last week, I have a special announcement just for podcast listeners. This is the official rollout of something that I’ve been working on for the past two months.
I’d like to formally invite you to apply for The Testing Psychologist mastermind group. Now, if you don’t know what a mastermind group is, it is a [00:01:00] very focused small group experience where you come together with no more than 7 other testing clinicians who are building or growing practices specifically around assessment.
The group will meet every other week for about 3 months starting March 1st and each person will get at least one hot seat per month. That means that you come in with a problem that you specifically would like support on and for 15 or 20 minutes, the group does nothing but ask questions, support you, give advice, and help guide you through whatever concerns you might be working with. Now, of course, you also get vicarious learning through the other members and you get to participate by offering advice to other folks as well. The group will be facilitated by me and you will have access to a private Facebook group just for group members.
If [00:02:00] that sounds interesting at all, go to thetestingpsychologist.com/mastermind. You can get more information, you can sign up, you can schedule a pre-group application call with me. I hope to see you there.
On to our interview for today.
Today, I’m talking with Dr. Ben Lovett. Dr. Ben Lovett is an associate professor of psychology at the State University of New York (SUNY) at Cortland, where his research focuses on the diagnosis of individuals with ADHD, learning disabilities, and related conditions, as well as the provision of testing accommodations to students with these disorders. He has published over 70 papers on these topics, as well as a full-length book, Testing Accommodations for Students with Disabilities: Research-Based Practice (APA Press). He has served as a consultant to numerous testing agencies and schools on disability and assessment issues, and he is a licensed psychologist in New York.
I hope you enjoy this episode. [00:03:00] I liked talking with Ben. We got into some of the nuances of ADHD assessment, particularly how to diagnose ADHD with the balance of cognitive versus behavioral measures, and how to write reports that are thorough and will come across appropriately to folks who are reviewing those reports and considering implementing accommodations for them.
Without further ado, Dr. Ben Lovett.
Hey everybody, welcome again to another episode of The Testing Psychologist podcast. This is Jeremy Sharp. I hope you’re all doing well.
I’m thrilled today to have a guest on our [00:04:00] podcast. My guest today is Dr. Benjamin Lovett. Dr. Lovett is very well-versed in the field of ADHD and learning disorders across the lifespan. He has written a book with two co-authors, right? Do you have co-authors, Ben?
Dr. Lovett: It’s just myself and Larry Lewandowski.
Dr. Sharp: Okay. Y’all wrote a book recently about accommodations for students and individuals across the lifespan. I’m excited to dive in and learn about some of the stuff that’s in your book, some of your research, and your work these days. Before we do that, though, welcome to the podcast. I’m really glad to have you.
Dr. Lovett: Thanks very much. Very happy to be here.
Dr. Sharp: Good. Thank you so much. I think there’s a lot to dive into, but could you talk a little bit about your training, current [00:05:00] clinical research work, and what you’re up to right now?
Dr. Lovett: Absolutely. I always like to say that testing accommodations were something I did not even know about when I applied to graduate school when I went into school psychology. I don’t think I’d ever heard of them, even through college.
I got to graduate school in 2002, and my advisor, Larry Lewandowski, was interested in testing accommodations issues, and again, I did not know what they were. Quite frankly, when he explained them, they sounded boring. I thought they’re not going to be answering deep questions about human nature. It wasn’t a direct intervention sort of thing. And so I never would have guessed I would wind up writing a book about them. And quite a lot of my life is around testing accommodations right now.
I got very interested in the general field of school psychology growing up. Even in high school, I was interested in childhood aggression, school violence, and things like that. And so, after going to Penn State for my bachelor’s degree in psychology, I went on to Syracuse for [00:06:00] school psychology in particular, and even then, my first few years, I was working on other sorts of things. It wasn’t until my 4th or 5th year that I focused on the assessment of ADHD and learning disabilities and testing accommodations for those sorts of students.
I graduated in 2007, and since then, I’ve mainly been a full-time professor. I worked at a small liberal arts college for several years and now I work at SUNY Cortland at the State University of New York at the Cortland campus. A lot of my work is working with undergraduates as a teacher, but I also conduct empirical research focusing on college students who have ADHD or learning disabilities. I certainly work with them in that capacity.
I also do a lot of consulting for testing agencies and schools on testing accommodations issues. For some agencies, I review individual case files of folks who are documenting a disability and requesting accommodations. A lot of those are for certification licensure exams, but some admissions [00:07:00] tests as well. I also will consult with schools on general testing accommodations policy issues.
I do some clinical consulting on individual cases too, but right now, I wish I had more time. I don’t have time to be a full-time or even a full-responsibility primary clinician for anyone at the moment, but hoping to eventually get back to that.
Dr. Sharp: Sure. I feel like I hear that from a lot of folks in the academic field. I’ll get back to it sometime.
Dr. Lovett: Exactly. I keep telling myself.
Dr. Sharp: Well, there’s a lot to get into, and that’s interesting to me that you do this consulting for testing agencies. I know that I’m already jumping off-script from your book, but this is interesting.
I think this is something that comes up for me a lot; doing a fair amount of testing for folks who are looking for accommodations on MCAT or the [00:08:00] LSAT or even our local Journeyman’s Plumbers exam, or something like that, we get in this situation, I think you wrote an article about this actually about what constitutes impairment, particularly in bright folks, it’s this idea, I suppose, of bright individuals, above average IQ, let’s say 115, 120, 130, and then they have maybe academic scores in the 100 range or the 96 range, somewhere around there. From your perspective, how would you handle that if you were consulting on a case like that if someone was requesting accommodations for a “learning disorder”?
Dr. Lovett: As consultants, there are a number of psychologists who consult for testing agencies. Some agencies have large panels, others have a few folks who they go to, but generally, there [00:09:00] are three questions that the testing agency asks and the consultant ask when reviewing a file.
One thing is whether or not the client meets the criteria for the disorders that have been diagnosed. For that, we typically would use the DSM. The second question we usually ask is, does the condition or do the conditions if they’re there, do they rise to the level of a disability under ADA; under the Americans with Disabilities Act is typically the law in operation. And then if that’s the case, then we can ask, are these accommodations needed for the exam? I think of things in that stepwise manner.
So in terms of the case you described, you have someone who has a high IQ and average academic skills, the first thing that we should be asking, not just for accommodations planning, but clinically to begin with is, does the person meet the criteria for a learning disability under DSM?
[00:10:00] DSM uses the term specific learning disorder and DSM 5 changed in some important ways from the prior editions of the DSM. So currently the manual is pretty clear that you need to have below-average academic skills. I think the term is substantially and quantifiably below average compared to age expectations.The current DSM does not use intelligence to reference where someone’s academic skills should be. So, if someone’s reading score is 100, then that’s pretty much by definition not substantially and quantifiably below average. So, that would not be a learning disorder, it wouldn’t be a specific learning disorder under DSM 5.
Dr. Sharp: Okay, sounds good. I think that…
A clinician might feel, I’m sorry if I can just go on, a clinician might feel like clinically there’s something going on with the individual if there’s this isolated area of relative weakness compared to other things. And maybe at a neuropsychological level, that’s a meaningful [00:11:00] description of what’s going on, and maybe that’s helpful feedback for the person to have that they can take away from the assessment, but that doesn’t necessarily mean that any disorders are present using the operational guidelines in the DSM.
Dr. Sharp: Okay. I find that that’s a really tough place. For the most part, we’ve done away with that discrepancy model, so to speak, but there’s research, like the stuff from Bruce Pennington and Robin Peterson, there’s some folks that say that the discrepancy criteria is still pretty relevant, especially for folks at the high end of the IQ range. I think that’s where I get stuck.
Dr. Lovett: I think it’s always hard because we expect that someone who has a high IQ should be performing up to that level and everything. I don’t think empirical research validates that assumption, that IQ is some kind of birthright that earns you the [00:12:00] right to achieve at that level.
In the child and adolescent population, there are a lot of good reasons why kids with high IQs will often not have achievement that’s nearly as high. So, achievement is something where you need to be exposed to content and material. You have a kid who has an IQ of 120, but are they going to be exposed to math that’s grades above their grade level so that they can also have a math score that’s 120?
Dr. Sharp: That’s a great question.
Dr. Lovett: Another thing, statistical phenomena like regression to the mean will also explain why you might have an IQ score that’s very high, but an achievement score that’s somewhat lower and close to the average. So there are a lot of reasons why we shouldn’t necessarily assume that the person will have a flat profile.
In the past few years, we’ve seen a number of publications looking at the base rates of low scores on a number of different cognitive and neuropsychological batteries showing that it’s perfectly normal and healthy [00:13:00] populations, folks who don’t have any recognized disabilities, to have 1 or 2 or 3 scores that are even 85 or even lower sometimes.
Dr. Sharp: At least for me, that’s where I think the history comes into play, and it’s so important. Is there an established pattern of weakness in those areas, and, of course, you have to ask about interventions over the years, and all kinds of things?
Dr. Lovett: Absolutely. I think history is definitely underrated. When we’re on the topic of learning disorders, one of the things I would note, we need to have histories that are precise about how poorly did someone do.
Frequently we see histories that say, someone struggled in middle school and I don’t have any reason to doubt that they struggled in middle school, but what does that look like? Is the person doing well? Are they only doing well because of homework assignments and they were failing their exams? We need a lot more detailed information about [00:14:00] what’s going on. Whenever possible, it’s great if clinicians can obtain the objective records to review them, because there are times when folks report histories, and I think it’s an honest recollection, but it’s just not necessarily all that accurate.
Dr. Sharp: I think you’re right. I don’t know if you’re a parent. I’m a parent, and Lord knows that I’ve forgotten what my kids did last month, even those developmental milestones. I’m a child psychologist and I have probably forgotten when our second kid walked.
Dr. Lovett: I’m not a parent but I certainly understand. We all know as psychologists that memory is very fallible. If you ask any general psychologist, they’ll be vaguely aware at least of the work on eyewitness memory, but somehow people think that their memory for retrospective ADHD symptoms from 10 years ago is somehow much better than that. The research doesn’t suggest that.
[00:15:00] Dr. Sharp: Sure. So, how do you get around that? How do you elicit that information from parents when we know what we do about memory and just being busy as a parent and whatnot?Dr. Lovett: It’s a great question. Many parents do save narrative report cards from teachers. For ADHD in particular, those narrative report cards are a gold mine. They can, in my experience, show that someone was truly unusual. Teachers often have very good implicit norms, essentially, because they see so many different kids. So they can say what’s unusual or atypical, at least for that school or that district or that local setting. So if there are any saved report cards, that’s always great.
Another thing is parents’ memories for specific events tend to be, in my mind, more reliable than general overall feelings about a child’s symptoms or behavior. So, if you can recall for me that you [00:16:00] were in the principal’s office several times the past year, meeting with a principal about your son or daughter, to me that’s something that is a more specific recollection and an overall sense that something is unusual. So those things tend to be more helpful and that’s why in general, any history information, the more specific, the better.
So narrative report cards are great for ADHD symptoms. If there are discipline records or something like that, that can be very helpful. But in general, remembering very specific things that occur and occur with frequency can be very helpful, I think. Also, parental recollections of childhood behavior may be superior to the person’s own recollections of what they were like as a child. That’ll depend from case to case, but in general, that may be better.
And that goes to the general point of having someone other than the client provide information about symptoms. That’s more something I think for A DHD than for [00:17:00] learning disabilities. But that’s something I would emphasize if you’re testing young adults. We see a lot of evaluations of ADHD where it’s entirely self-reported.
Dr. Sharp: From a reviewer’s or a consultant’s perspective, what would you suggest for a case where we get a lot of young adults, we’re in a college town, so we have a lot of college students who for whatever reason, we can’t get ahold of their parents or they don’t provide the info for their parents, or they don’t want us to talk to their parents. What would you recommend in cases like that?
Dr. Lovett: The first thing I would recommend, that’s a great question, is to me it has to be a very good reason not to have any contact with third-party informants. If they’re truly unavailable by phone, you can’t mail rating scales or interviews, there’s no way to reach them, in my experience, that’s pretty rare. I think often the [00:18:00] student may want to get things done quickly, and so the third-party informants can add substantial time to the wait for things.
At times, the person may be trying to seek help for what are significant symptoms that they’re having. You may have a referral where a physician wants a psychologist to say whether ADHD is present so that a medication trial can be initiated or something like that. And there’s the sense that it’s emergent and something that can’t wait. We’re in the middle of the semester. I’m doing poorly. I’d like to do better. But I still I’m very hesitant to recommend making a diagnosis without third-party informants if they are at all available. It has to be a pretty good reason to not have any contact.
I explain to the clients that this is something that’s very typical, that it’s not because we’re doubting anything that they say, it’s just that everyone’s going to have a different perspective. For some symptoms, informant reports have been shown to be more accurate than self-reports. And that goes in both directions. There’s [00:19:00] a good deal of research showing that folks with ADHD may under-recognize or underreport their symptoms being unaware of how impairing the symptoms are. So I think there’s quite a lot to be gained in terms of preventing both overdiagnosis and underdiagnosis by getting third-party and foreign reports.
Russell Barkley, the eminent ADHD researcher, had done a great study, it’s now about 15 years old, looking at how if you’re looking at the outcome of child onset ADHD as someone’s getting older and older, you see the rates of symptom endorsements suddenly decline in many prior studies when the person becomes a young adult, and Barkley showed that that was because they switched the informant from the parent to the child. And the child who’s never been so aware of their symptoms as others are doesn’t report all that many. But if you keep the parent as an informant through the 20s, you see higher rates of persistence of ADHD.
[00:20:00]Dr. Sharp: Got you. There are a lot of factors too.Dr. Lovett: If someone truly doesn’t have access to parents, I would also note friends, peers, and significant others can also be very helpful informants. Again, in my experience, it’s pretty rare that someone doesn’t have anyone else in their life who observes them and can see symptoms.
Dr. Sharp: I think you’re right. It’s good to hear you say that because typically we’ll dig around and there’s usually a roommate or a romantic partner or a sibling, somebody who can provide some of that info. But it’s good to hear you say that. I am curious, would you specify specifically in the report then that we were unable to get a hold of parents or a secondary informant just to say, hey, we did our due diligence here?
Dr. Lovett: Absolutely. Anything that shows that the clinician is aware of the issue. To me, I would just [00:21:00] say, as anyone who’s reading a psychological report who themselves has psychology expertise, it makes you trust the clinician’s judgment more; that the clinician is aware of the relevant issues if informants are truly unavailable, but again, how many people don’t have anyone else in their life who observes them? It’s pretty rare.
I understand that some clients, they’re understandably hesitant to ask, say, a boss about ADHD symptoms or something like that. They may be going to such efforts to conceal the symptoms and the impairment to be able to maintain a job or something like that. So, I understand that there are issues, there are reasons why particular informants may not be useful, but it’s very unusual if someone has no family or friends. In many cases of ADHD, we certainly see clinically that the person’s friends are very aware of their symptoms and it’s a source of either joking or sometimes frustration, and the same thing with romantic partners.
[00:22:00] Dr. Sharp: Absolutely.Dr. Lovett: I tend to be very hesitant to endorse diagnoses when there’s no one else who can report the symptoms.
Another thing in addition to third-party reports would be objective records of impairment showing poor functioning. So if you’re preparing to make an initial diagnosis of ADHD and the person has not used medication or other sorts of substantial interventions, we would expect to see life impairment in real-world settings. So, are there any records of that? The person says that they are so distracted that it’s to the point where it’s dangerous for them to drive. Are there records showing the problems that they’ve had with driving?
Dr. Sharp: Right. What I’m taking from all of this, and I guess I probably knew this somewhere in my subconscious, especially in these cases where you’re trying to make a justification for accommodations on these standardized [00:23:00] tests, really precise history, really good examples, documented lifetime impairment, is all very necessary to try to make your case.
Dr. Lovett: I should say, the recommendations I’m making are even more from being a trained clinician and saying to me, that’s what you would want to have to be sure that you’re not making a misdiagnosis. Different testing entities, different testing agencies have, in my experience, different standards for reviewing documentation, and so I certainly can’t say how any particular agency would handle a prior request.
And there are other things that matter a great deal to testing agencies like whether or not someone has a prior history of accommodations. So those things certainly play a large role, but to me, again, making a recommendation to make an accurate clinical diagnosis, ADHD, since we’re using that example, is just not the sort of thing that research supports diagnosing based on a self-report in my view.
[00:24:00] Dr. Sharp: Sure. I could get on board with that. Let’s just go for it. I’m going to ask a question I think that’s probably in a lot of people’s minds, which is, what do you do with kids or, let’s just keep it the kids or teenagers to keep it simple, with those folks who have either all the “behavioral symptoms” of ADHD, but none of the, what we think are cognitive markers or vice versa- they have what I would call, all the cognitive markers, but none of the behavioral symptoms. How would you approach something like that?Dr. Lovett: I tend to view ADHD as more of a behavioral disorder, especially in terms of its functional impact and impairment, but with regard to cognitive markers, I guess the question is really what the operational definition of that is. With regard to ADHD, I tend to think of behavior ratings from multiple [00:25:00] individuals as the most valid way, along with objective history and objective records, as ensuring that the person does meet the criteria and has ADHD.
I tend to not be as positive about say, neuropsychological tests of attention and executive functioning and things like that. So if that’s what you mean by cognitive markers, I wouldn’t view those as being as important. If someone has…
Dr. Sharp: Do you think any of those are important?
Dr. Lovett: Any of those diagnostic tests?
Dr. Sharp: I used the term cognitive markers, so processing speed, working memory, executive functioning measures, continuous performance tests, that’s a can of worms to open, but you get the idea.
Dr. Lovett: No, it’s a great question. To me, I honestly do think of them as more adjunctive in the diagnosis. One of my first jobs in graduate school was coordinating an ADHD clinic, and the director of the clinic, Michael Gordon, had developed a CPT, the Gordon Diagnostic System. And [00:26:00] so I was lucky to train under him. I was surprised that even though we gave the GDS, the Gordon Diagnostic System, and it has some value in terms of diagnosis, Dr. Gordon was always very open and that year, we wrote a review paper on the topic, but compared to other sorts of tools like rating scales, CPTs and other sorts of neuropsychological tests are not as helpful.
Russell Barkley again talked about this. I think in the early 90s he wrote a famous article on what he had called laboratory or analog measures of attention, impulsiveness, and things like that.
When we’re talking about a disorder that has a functional impact on the person’s life, we want measures that are as realistic as possible. And so even though there’s some attractiveness about a measure that looks like it’s pure in a sense that that purity is also a downside, it keeps us from seeing how the person performs in everyday life.
And so [00:27:00] diagnostic measures that are more realistic in terms of the task that they’re asking someone to do have much more of that ecological validity, which for testing accommodations certainly is important because we want to know how you behave in a real-world setting.
We certainly know that many folks who have significant executive functioning problems will nonetheless do well on executive functioning neuropsychological tests. These artificial tests segment executive functioning into a bunch of different areas, the person can handle those, but in actual life where they have to balance this and that coming at them at the same time, there they don’t seem to be too good. Juggling numbers or remembering to press a button when they see one thing and not another is comparatively easy for them.
Dr. Sharp: Got you. So what measures, if you had to recommend any neuropsychological tests or measures, which ones do you feel get at that real-world executive functioning picture?
Dr. Lovett: Compared to rating scales, I can’t think of any that have the same real-world impact. [00:28:00] The ones that I see frequently given, even there, I would think, are more rating scale-type measures like the BRIEF for executive functioning. I certainly see a lot of other executive functioning tests when I review documentation, but are many of them all that realistic?
Again, I can see CPTs and other sorts of measures as adjunctive. I can see them as additional information that may help to confirm a case if it’s a borderline case or to perhaps question that case, but I tend to think that, I don’t know of any tests that are as good, I think, as ratings of behavior from multiple sources. I think that we’re often attracted to the fancy-looking measures, I understand why, and I think there’s a lot of good research on using those measures to do cognitive psychology work, but I don’t know that they’re necessarily as clinically helpful. I don’t think they are compared to other things for [00:29:00] ADHD in particular, I should say.
You mentioned processing speed, for instance. I know a lot of clinicians who make judgments based on performance on the processing speed subtests of a Wechsler IQ scale. I don’t tend to think of simple visual motor speed as especially helpful in judging how well someone’s going to do in the real world. We have research, my research team has published some studies finding that processing speed is not a good predictor of, among other things, how long someone will take to finish a realistic academic test.
Dr. Sharp: Well, I guess that raises the question of then, do we have anything that can predict?
Dr. Lovett: I’m sorry, I didn’t hear you.
Dr. Sharp: Oh, I said, that raises the question of do we have anything that can predict that real-world performance, again, aside from behavior.
Dr. Lovett: Sure. With regard to predicting performance on a realistic academic task or a real-world one, I tend to [00:30:00] recommend, even though there are flaws with the measure in certain ways, I often think for kids who are at least in 9th grade for adolescents, and then up through college, the Nelson-Denny Reading Test is one timed reading comprehension test that a lot of folks put in diagnostic evaluations. And I think that when it’s interpreted properly, it can be very helpful.
The comprehension part of the Nelson-Denny is a 20-minute-long test with 38 multiple choice items, and about 7 passages, and the passages are taken from actual high school and college level textbooks. So, that is realistic in that sense. And I do think that in the context of other evidence of real-world functioning and valid history and things like that, I think the Nelson-Denny, when it’s properly interpreted, can be very helpful.
The biggest flaw that I would mention with the Nelson-Denny is that it doesn’t have Age norms, right? So for high school kids, Asian grade norms are going to be relatively similar, but for college students, that’s going to be more problematic. A lot of [00:31:00] folks don’t go to college or certainly don’t get college degrees. I think we have to be much more careful in interpreting how someone does it.
Let’s say you’re evaluating a medical student, and so you compare them to the highest norms available, the Spring Grade 16 norms on the Nelson-Denny. I think you have to be very careful about interpreting that as a sign of disability. Someone might do poorly compared to graduating college seniors, but not compared to the general population, which is really what the disability laws are using as a standard. But I think, again, if used properly, it can be very helpful.
I should note while I’m talking up the Nelson-Denny, the reading rate score on the Nelson-Denny is not very good psychometrically, and it’s based on only one minute of silent reading without any check on comprehension, so I tend not to rely on that, but the reading comprehension measure from the Nelson Denny is one that I would recommend using, especially for high school students, as well as for college students when it’s interpreted properly.
Dr. Sharp: Got you. [00:32:00] Well, I feel like we have already packed in a ton of good information at this podcast, but I don’t think we’ve addressed any of the questions that I had written, which is great. I did like that. We’re just running with it. And so I’m already looking forward and hoping that you might be willing to come on again and talk more about your book at some point […] the ADHD one.
Dr. Lovett: Yeah, I’m certainly happy to do. The book, I should say, reviews testing accommodations research generally. Larry Lewandowski and I back in 2012, I think, when we started working on it, we didn’t find any up-to-date compilation of all of the research, along with interpreting that research to guide clinical judgments and judgments by schools. So, we set out to try to make some practical guidance based on all of the science that had been done over the past 10, 20 years, especially.
Dr. Sharp: I can totally get on board that the[00:33:00] the amount of the book that I’ve seen is great. It’s great material and it’s based on science, like you said.
Dr. Lovett: I appreciate it.
Dr. Sharp: And you’re, from talking with you clearly, steeped in the research, which is I think so important here and what we do.
Dr. Lovett: Thanks.
Dr. Sharp: Let me ask you just to continue and maybe wrap up this ADHD thread and how to assess ADHD. It’s been our topic here. What would you say would be your ideal battery for assessing ADHD in an adolescent or a kid at this point?
Dr. Lovett: I think of multimodal assessment in terms of the reports from multiple people, including the child if they’re at least of some age where they’re able to fill out a scale or reflect on things, certainly. But norm-referenced ratings of behavior of symptoms of the core ADHD symptoms that are shown to be substantially [00:34:00] above average, I typically suggest the T-Score of 65 or 93rd percentile, something that’s a standard deviation and a half above the average range, either in inattention, hyperactivity, impulsivity, or both. To me, that’s very good evidence for ADHD when it’s paired with an interview that fleshes out what those symptoms look like in the real world setting and it shows the person is functioning poorly, that they’re impaired by that, that they’re having problems.
So, when you have symptoms that are measured through those rating scales and you have impairment that’s measured by an interview, you have objective historical records that demonstrate that, to me, that’s very strong evidence of ADHD. I don’t know if there’s any need for neuropsychological tests. I tend to be upset. I’ve gone to bat for parents when someone says, a school or some other person says, well, you don’t have an IQ test or something like that.
To me, you want to measure the [00:35:00] defining features of the disorder are not things that happen to be slightly correlated with the disorder. So working memory on average may be impaired in individuals with ADHD, but does that mean that it’s diagnostic of ADHD? Probably not. Folks who have working memory deficits might have them for a variety of reasons other than ADHD. So, I don’t know if that’s…
To me, that’s just an example of something where we often rush to a test, but does that need it? I would say the main purpose of an IQ test would be to rule out if it’s a concern, intellectual disability, borderline intellectual functioning, or something like that, and obviously, in many ADHD evaluations, that’s not even on the radar as a concern. But if it is, I would say that’s very useful, at least perhaps to use a screener.
For many folks who use CPTs or other neuropsychological tests as part of a battery, there’s nothing wrong with that. To me, I would just say that if [00:36:00] the only deficits are shown on those artificial measures, to me, that’s not sufficient for a diagnosis. If we don’t have ratings showing unusual levels of symptoms in real-world settings and consequent impairment, then to me, that’s what I would focus on.
Again, the neuropsychological measures can help to confirm borderline cases. They also may provide useful information to give feedback clinically to say it looks as though you’re having particular problems shifting back and forth between things. This might be why you have that trouble in the real world. But to me, that’s a little bit more theoretical, a little bit more speculative than the real-world ratings that we have.
Dr. Sharp: I see what you mean. Well, I’m hearing you loud and clear. It was behavior rating scales, objective history, documented incidents, and reports from teachers.
Dr. Lovett: Yeah, to me, the general rule is, which do you give more weight to? The 4 hours that you spend with [00:37:00] someone, the 2 hours that you spend with someone, even the 8 hours that you spend with someone or the rest of their life? Which is more important? And to me, it’s obvious. It’s the second one. It’s the rest of their life. The information that you can get from the rest of their life. I mean, you’re getting a much larger sample of data than what you’re getting from the few hours that you spend with them.
Dr. Sharp: Let me ask one more question with that. Gosh, I could have 15, 000 more questions, but one more question. I want to be conscious of our time. What do you do then when the rating scales are discrepant, where the teacher is endorsing everything, or the parents are endorsing everything, but they are both not endorsing everything?
Dr. Lovett: It’s always worth going back to the DSM criteria, and we know that the DSM is very clear that the symptoms have to be in multiple settings. When I talk to graduate students, when I do training, I always [00:38:00] say, ADHD is something that you take with you from place to place. If you have problems in one setting, it probably says more about the setting than about whether someone has ADHD.
So the first thing to consider is, and maybe it’s because as a school psychologist, we get a lot of behavioral training, a lot of ABA training, a lot of emphasis in behavior modification, to me, I always think about the environmental circumstances in the setting. If the problems are only present at home, is that because of an impaired parent-child relationship? If the problems are only at school, is that because of some other learning problem or academic issues or even a particular teacher or the rules of that class? I always try to ask more detailed questions to figure out whether or not the standards for behavior in one setting or another are perhaps unusually high or low.
So let’s say, for instance, that the parents are not giving, we’ll say a parent is not giving significant symptom ratings than the teacher is. It could well be that the parent in [00:39:00] that particular home, the standards for behavior are extremely lenient and most parents might have actually rated the person as having symptoms, but in this case, the parent may even be somewhat neglectful or may not spend that much time with the kid so it might be to that point. If the child doesn’t ever need to remember things and can make careless mistakes and there are no consequences, the parent may not rate those things as happening all that frequently.
So I always try to figure out what someone’s standards are for the child’s behavior because I think that matters a lot, but in general, when the symptoms are only present in one setting, that would not meet the criteria for ADHD. And so if the ratings are a valid indicator of whether or not the person is unusual in terms of their symptom levels, then similarly, ratings from one person would not be enough to make a diagnosis accurately.
Dr. Sharp: Sure. Okay. Well, this has been very informative. It, like I said, went a different direction than [00:40:00] I was thinking, but I think this is valuable for a lot of folks.
Dr. Lovett: I appreciate it.
Dr. Sharp: I can already anticipate some of the reactions and comments to the things we’ve talked about, myself included. I think there is a marriage of sorts to a lot of the testing that we do.
Dr. Lovett: I should say, even though I think that for ADHD, real-world history and ratings are more predictive and more helpful than neuropsychological tests, there are lots of other reasons why in a comprehensive evaluation you may want to give those measures. To me, I’m talking about what the core diagnostic criteria are because I’m very focused on whether someone meets those criteria. And then, for the purposes of accommodations, if that’s at issue, do they show an ADA-level disability? So I wouldn’t want to…
I probably have come off somewhat as pooh-poohing formal diagnostic tests and the question is always what their purpose is. For the [00:41:00] purpose of determining if someone meets the ADHD criteria, I would tend to think they’re not as helpful as other things.
Dr. Sharp: Got you. Well, like I said, if you’re open to it, I would love to do a part two where we follow up on some of this and dive into some specific recommendations and accommodations because I think that’s valuable, too.
Dr. Lovett: Certainly.
Dr. Sharp: Well, Ben, thank you so much for coming on and talking with us about this, and like I said, I hope to see you again soon.
Dr. Lovett: I’m very happy to be here.
Dr. Sharp: All right. Thanks. Bye bye.
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