ADHD Testing – Attention, Executive Functioning And Memory

What is ADHD Testing?

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by persistent patterns of inattention, impulsivity, and hyperactivity that can affect various areas of a person’s life, including relationships, work, and academic performance. Testing for ADHD is necessary to ensure accurate diagnosis and appropriate intervention, as symptoms may vary widely, and providers need to rule out other conditions with similar features or consider a dual diagnosis. A thorough assessment, often involving clinical interviews, behavioral observations, and standardized tests, helps guide effective treatment strategies tailored to the person’s unique needs.

Recognizing ADHD Symptoms

Individuals with ADHD show a consistent pattern of inattention and/or hyperactivity and impulsivity that interferes with development and their ability to function.[1],[2]

Erin L. George, MA-MFT, says, “Sometimes, especially in adults who weren’t diagnosed as children and have always considered themselves ‘busy’ or easily distracted, ADHD symptoms manifest in ways that aren’t as obvious as they might be in childhood. For example, an adult with ADHD may have a history of car accidents due to being distracted by something on the side of the road. Or they might fall asleep at work due to their difficulties staying focused.”

Fortunately, because of awareness in both parents and educators, more children are diagnosed at a younger age than in the past.

Inattention Symptoms

Six or more inattention symptoms must be present in children up to age 16 and five or more for people aged 17 and older. These symptoms must have been present for at least six months and be inappropriate for the person’s age and level of development:[1],[2]

• Is often forgetful in everyday activities
• Is often easily distracted from the task at hand
• Often loses necessary items like school materials, wallets, books, and keys
• Often avoids or refuses to do tasks that require sustained mental effort, such as homework
• Often struggles with organizing activities and tasks
• Often fails to follow directions or finish a task all the way through
• Often appears to be distracted when spoken to directly
• Often struggles to hold attention for play activities or necessary tasks
• Often makes careless mistakes at work or in their schoolwork

Hyperactivity-Impulsivity Symptoms

Six or more hyperactivity-impulsivity symptoms must be present for children up to the age of 16 or five or more for individuals 17 and older. Likewise, the symptoms must be present for at least six months and interfere with daily functioning: [1],[2]

• Often interrupts others while they’re talking
• Often struggles with waiting their turn
• Often blurts out an answer without thinking it through before the question has been completed
• Often talks excessively
• Often acts as if they’re “on the go”
• Often struggles to participate in activities quietly
• Often climbs or runs in inappropriate situations
• Often leaves their seat when they should be sitting
• Often fidgets or squirms in their seat

Three Presentations of ADHD

Based on the inattention and hyperactivity-impulsivity symptoms, three types of ADHD presentations can occur, including: [1],[2]

• Combined presentation. This includes meeting the criteria for both inattention and hyperactivity-impulsivity.
• Predominantly inattentive presentation. This includes meeting the criteria for inattention only.
• Predominantly hyperactive-impulsive presentation. This includes meeting the criteria for hyperactivity-impulsivity only.

Understanding the ADHD Diagnostic Process

The ADHD diagnosis process involves many important steps and may look something like the following.

• Initial assessment: Begin with an initial evaluation by a primary care physician or pediatrician to discuss concerns and observe the individual’s behavior.
• Medical examination: Conduct a comprehensive medical examination to rule out other potential causes for symptoms and assess overall health.
• Behavioral history: Gather a detailed behavioral history through interviews with the individual, parents (for children), teachers, and other relevant individuals, such as coaches, family members, and therapists, who can provide insight into the person’s behavior across different settings.
• Symptom assessment: Utilize standardized ADHD symptom assessment tools and rating scales to evaluate the presence and severity of symptoms related to inattention, hyperactivity, and impulsivity.
• Rule out other conditions: Exclude other medical, psychological, or environmental factors that may contribute to similar symptoms, ensuring a precise diagnosis.
• Observational assessment: Conduct direct observations of the person’s behavior in different settings.
• ADHD criteria confirmation: Ensure the symptoms align with the diagnostic criteria outlined in the DSM-5.

Another essential part of the ADHD diagnostic process is the multidisciplinary approach, which involves a collaboration between many different treatment professionals, such as:

• Primary care physician or pediatrician
• Psychologist
• Psychiatrist
• Neurologist
• Educational specialists
• Clinical social workers
• Occupational therapists

A comprehensive evaluation involving these professionals ensures a thorough understanding of the individual’s unique profile, leading to an accurate diagnosis and the development of a tailored treatment plan. 

Erin L. George, MA-MFT, says, “Many children with ADHD have a history of what educators might perceive as behavioral concerns when what’s happening is simply a symptom of their ADHD. Something as simple as adding a walk around the school between classes to a student’s IEP plan can be enough to help the child get rid of extra energy so it’s easier to focus in class. Even when education specialists are not included in the diagnosis, it’s helpful to notify the school that a child has ADHD so it is not misunderstood for something else.”

Types of ADHD Tests

Tests of Attention

Testing someone’s ability to pay attention is more complicated than it sounds. Attention is composed of four major components: selective attention (the ability to attend to stimuli while ignoring distractions), sustained attention (the ability to maintain attention over an extended period of time), divided attention (multitasking), and alternating attention (the ability to shift attention from one task to another without losing focus). 

Measuring each facet of attention can be extremely helpful in pinpointing strengths and weaknesses. Tests can also indicate methods for dealing with the identified attention problem. This could range from decisions about mediation to which therapeutic modality to use for an adult hoping to gain skills and better manage their executive functioning challenges.

Continuous Performance Tests (CPTs)

Continuous Performance Tests (CPTs) are computer-based tasks (often called Target-Focused Tests) that test attention, including sustained attention over time. 

Providers may use CPTs in conjunction with clinical information to make a diagnosis. In general, CPTs provide an objective method for assessing attention deficits that is not subject to the personal biases that can occur with more subjective assessment techniques, such as self-report questionnaires (i.e., someone may not have an accurate interpretation of their attentional difficulties).

These tests are suitable for various age groups, from children to adults.

Conners CPT II Continuous Performance Test II Version 5 for Windows

This is a computerized test used for people suspected of having attention problems. The computer immediately delivers results following the brief 14-minute administration. Administrators instruct subjects to press the space bar immediately following the appearance of a specific letter on the screen.

Conners Kiddie CPT V.5

The K-CPT is designed for children 4 to 5 years of age. The process involves quick flashes of familiar objects to which the child must respond. This version is similar to the Conners’ CPT II but contains key differences for this younger population. 

For example, the test takes half the time to complete, and it uses pictures of objects rather than letters on the computer screen to avoid letter recognition problems common in this age group.

Brown Attention-Deficit Disorder Scales

Brown ADD Scales assess executive functions associated with ADHD, including organizational skills and working memory. This test provides insight into specific cognitive aspects affected by ADHD, assisting in a more nuanced diagnosis and treatment planning. It is typically used for adolescents and adults but not children.

Integrated Visual and Auditory Continuous Performance Test (IVA)

This test combines visual images and sounds to assess impulsivity, inattention, and hyperactivity in individuals from 5 years of age through adulthood. Clients are instructed to click the mouse when they see or hear a “1” but not when they see or hear a “2.” Test scores also provide information about stamina, consistency, speed, attention, focus, motivation, and problems with learning.

Tests of Variable Attention (TOVA)

TOVA is a computerized test that can measure impulsivity, vigilance, and deterioration of attention over time. 

TOVA can screen for ADHD, as well as predict and monitor medication effects. It takes about 22 minutes to complete and does not require the use of language, right-left discrimination, or letter or number recognition. These qualities make it useful for people of various ages and skill levels.

Trail-Making Test A&B

The Trail-Making Test evaluates visual-motor speed and task-switching skills by assessing someone’s ability to follow a simple number sequence (Trails A) and a more complex sequence of alternating numbers and letters (Trails B). Scores are compared to age-, education-, and gender-based information to determine whether someone’s performance is impaired.

Attentional Capacity Test (ACT)

This test evaluates the child’s selective attention ability. Test results can indicate critical areas of treatment focus.

Kagan Matching Familiar Figures Test (MFFT)

The Matching Familiar Figures Test is used to measure someone’s tendency toward reflection versus impulsivity when solving problems. Reflection is the ability to consider alternative options when faced with a complex decision, typically resulting in a correct or successful course of action. In contrast, impulsivity is choosing quickly without weighing options or consequences. Impulsivity often results in errors and is a poor problem-solving style. Each item on the MFFT consists of a picture of a common object and six other similar pictures, only one of which is identical to the standard. Five of the pictures differ slightly from the original. The subject is asked to choose the picture that identically matches the standard.

Executive Functioning

Executive functions, also known as higher-order functions, include problem-solving abilities (i.e., reasoning, planning, and organization), flexibility in thinking, and the ability to integrate feedback from others. These abilities are primarily associated with the frontal lobe area of the brain. Tests that evaluate executive functioning attempt to determine the child’s ability to manage life tasks and school assignments that involve higher-order cognitive abilities.

Wisconsin Card Sort Test (WCST)

The Wisconsin Card Sort Test is an objective neuropsychological test that assesses frontal lobe functions, visual skills, and working memory (i.e., the ability to hold information in your mind while making a decision about it). The WCST takes about 20 minutes to complete. The administrator presents four cards to the subject with the instruction that there is a strategy (e.g., sort by color) for sorting the cards (the actual strategy is not described). The subject is asked to determine the sorting strategy by a process of trial and error. Across the test, the sorting strategy shifts without explicit warning to the subject. Individuals with frontal lobe damage often make perseverative errors (i.e., they repeat themselves by continuing to sort cards using the same rule that worked in the first series, even though the strategy has changed to a new one).

Memory Tests

Memory tests can measure both short- and long-term memory skills. The primary goals of memory tests are to evaluate the student’s current level of functioning in the areas of visual and auditory memory (i.e., memory for things that you see and hear), delayed memory (i.e., memory across time), distractibility (i.e., the ability to concentrate on things to be remembered), and retrieval from memory. Individuals with ADHD tend to perform more accurately in areas that do not require sustained focus or concentration. The person’s pattern of responses can be very useful in identifying strengths and weaknesses and specific problem areas and determining the types of interventions needed to address any identified deficits.

California Verbal Learning Test

The California Verbal Learning Test-Children’s Version (CVLT-C) assesses the strategies and processes that children between 5 and 16 use in learning and recalling verbal material. The CVLT-C can help diagnose and treat memory impairments related to mild or severe learning disabilities, attention-deficit disorders, and other neurological and/or psychiatric problems. The test measures levels of total recall and recognition (i.e., remembering whether you heard a word previously), rate of learning verbal material, strategies employed to remember material, serial-position effects (i.e., whether someone tends to remember words that come first or last in a list), consistency, degree of vulnerability to interference (i.e., can the person screen out irrelevant material), and short-term and long-term retention.