EMPLOYEE ASSISTANCE PROGRAM (EAP) SUPPORT FOR CHILDREN AND ADOLESCENTS WITH ADHD, BEHAVIORAL AND LEARNING DIFFICULTIES, AND NEURODEVELOPMENTAL CONDITIONS
By Gene Carroccia, Psy.D.
The article “Support for Children and Adolescents with ADHD, Behavioral and Learning Difficulties, and Neurodevelopmental Conditions” was published as the cover story for The Journal of Employee Assistance (JEA), 3rd Quarter, 2022, Vol. 52, No.3. The article link: https://issuu.com/eapa/docs/eapa_journal_202206
Sarah called her company’s employee assistance professional crying, begging for help with her ten-year-old son who is experiencing escalating behavioral and learning difficulties at home and school. He has recently exhibited aggression with students and his siblings, and his teachers are now fearful of him. The child has struggled for years with social and academic issues, as well as persistent anxiety. His pediatrician admitted to being perplexed and has made several referrals, including to a child psychiatrist several years ago, and more recently to a mental health counselor. Yet no improvements resulted. Sarah believes no one has understood her son’s problems. She shared that she is now suffering from crippling depression and work difficulties related to these concerns. The EAP representative is overwhelmed and doesn’t know how to help.
Parents, healthcare providers, and EAPs can become easily confused by complex presentations of child and adolescent neurodevelopmental, behavioral and learning difficulties. Many do not know where to start (Request school testing, psychiatrist examinations, or child therapist sessions?). When not properly addressed, the challenges can escalate, parental mental health may deteriorate and substance misuse can occur, and EA professionals may be repeatedly contacted, or worse not contacted at all. Additionally, with the 2021 declaration of the national emergency in the United States in child and adolescent mental health and the persisting increase of requests for these services, EAPs are being challenged to better understand and support the many children, teens, and families who are suffering and struggling.
One of the most important first steps in effectively treating any presentation is to accurately determine what diagnoses and clinical issues exist so that the most appropriate referrals can be made. However, this does not always occur because neurodevelopmental, behavioral and learning difficulties can result from a number of conditions and can be difficult to diagnose. Often, ADHD, either the predominantly inattentive or the combined inattentive, hyperactive, impulsive presentation, is suspected. ADHD is the most prevalent child and adolescent neurodevelopmental condition. About 9% of children and adolescents in the United States are diagnosed with ADHD. However, effectively diagnosing ADHD can be challenging because inattention, hyperactivity, and impulsivity can result from a large number of diverse conditions. An essential question when considering ADHD is, does it truly exist, and if so, do other conditions occur along with it?
ADHD and Coexisting Conditions
Many do not realize that ADHD is a foundational disorder that frequently occurs with one or more coexisting conditions. About 75% of clinic-referred children with ADHD have one additional disorder, up to 50% have two conditions, and 20% have three or more coexisting disorders. These include medical, sleep, psychological, substance use, trauma, neurodevelopmental, sensory processing, and fetal substance exposure conditions. They can worsen true ADHD or may cause ADHD-like presentations when true ADHD does not exist. When other disorders exist with ADHD, these combinations can magnify ADHD and create more difficulties than ADHD by itself. Often times, these coexisting conditions are not identified and treated because ADHD can mask them. Therefore, they are not recognized as separate disorders and do not receive their own treatment. Clinicians may not identify these other conditions because they do not adequately screen for them, lack effective diagnostic training in ADHD, do not spend enough time in the initial diagnostic phases of treatment, or are simply unaware of them and how they present. When coexisting conditions are not identified and treated, they persist and only partial progress may result, causing families and providers to become frustrated and lose hope. For more information on coexisting conditions in children and teens with ADHD, including some of the most common and a full listing of these conditions, please refer to my article: https://adhdology.com/understanding-coexisting-conditions-in-children-and-teens-with-adhd/
If there is a lack of clarity about what conditions exist and what treatments are needed, diagnostic services or “diagnostics” can be an important step. If a diagnosis is questioned because a thorough evaluation may not have occurred, and/or if parents wonder if other conditions exist, EAP representatives can consider providing referrals for more focused diagnostic services. Diagnostics involve determining what symptoms, disorders, issues and challenges exist in order to obtain the most effective treatments. For those with complex clinical presentations, it can be helpful to obtain diagnostics periodically to review progress, determine current functioning levels, screen for additional conditions that may be new or previously undetected, and receive appropriate treatment recommendations.
While some clinicians use the terms “evaluation” and “assessment” interchangeably, these will be used more specifically here. In the United States, for ADHD diagnostics, parents can obtain either a brief ADHD evaluation or a comprehensive neurodevelopmental assessment. Also in the United States, for children and adolescents with complex presentations or for those with suspected neurodevelopmental disorders (such as autism and learning disorders), a neurodevelopmental assessment from a neuropsychologist can be essential.
ADHD evaluations are typically provided by outpatient psychotherapists (clinical psychologists, licensed professional counselors, clinical social workers, and marriage and family therapists). These often occur during the initial stage of treatment when ADHD is suspected. They should consist of a thorough clinical interview, ADHD and possibly other measures, and perhaps screenings for other conditions (probably a limited range however). Pediatricians, primary care physicians, psychiatrists, and nurse practitioners may provide these. Clinical psychologists are more likely to provide these, but other clinicians who have this training and experience may be effective also. Be aware that when using this term, some clinicians may believe you are referring to neuropsychological testing assessments.
- There are more of these providers, so they are easier to obtain than neurodevelopmental assessments.
- These are less expensive.
- Health insurance often covers these services because they are part of outpatient services.
- ADHD evals can be a first step in obtaining other diagnostic referrals, including neurodevelopmental assessments.
- Providers may continue with treatment after the evaluation.
- These are brief and can be less conclusive, particularly with more complex presentations.
- They are less comprehensive and may not provide adequate screenings for other conditions.
- Reports are less likely, but letters from providers may be produced.
To support an effective and more accurate diagnostic process, my article on the 10-step ADHD Evaluation Model can be used to assist EA professionals, parents, educators, and clinicians with information about a comprehensive and evidence-based approach.
Neurodevelopmental assessments (sometimes called neurobehavioral or neuropsychological testing) are more extensive and are provided by neuropsychologists (specialized clinical psychologists) at private practices and larger teaching and university hospital systems. They are necessary when more complex presentations, neurodevelopmental, and/or other conditions may exist. They consist of an extensive clinical interview, a number of measures and psychological tests, considerations of other conditions, conceptualizations of findings, and recommendations.
- These are more comprehensive and definitive than ADHD evaluations.
- Health insurance often covers some or all of these services (depending on the plan).
- These providers are more likely to be familiar with other conditions and to provide screenings for them.
- They include reports that can be shared with other providers and schools.
- There are fewer of these providers.
- Waiting lists often exist.
- They are more expensive.
ADHD evaluations and neurodevelopmental assessments should include screenings for the numerous potential other conditions. However, while this is critical, many clinicians do this minimally or do not do this. Therefore, parents should discuss this with potential diagnostic providers. Additionally, if known conditions currently exist, families and providers should determine if they are being effectively addressed and managed as well.
If certain other conditions are suspected, it can be important to obtain additional diagnostics from non-mental health providers, including:
- Occupational therapy evaluations (for sensory processing and motor coordination conditions)
- Speech-language pathologist evaluations (for speech and language deficits)
- Developmental or behavioral optometrist evaluations (for visual processing deficits)
- Audiologist evaluations (for auditory processing deficits)
- Ears, Nose, and Throat (ENT) physician examinations (to explore sleep apnea, chronic mouth breathing, allergies, and congestion)
- Neurologist examinations (for head injuries, seizures, and tic disorders)
- Medical examinations by pediatricians and primary care physicians (for underlying medical conditions that can worsen ADHD or cause ADHD-like presentations)
- Sleep studies (for mouth breathing, sleep apnea, and other sleep conditions)
The Role of Schools
It is important to understand the more limited and narrower role of schools in the United States regarding diagnostic and treatment services for ADHD and other conditions. The school system is not designed to provide comprehensive behavioral health diagnostics or treatment services. It typically only addresses learning or behavioral difficulties that exist at school. While schools provide evaluations (sometimes called psychoeducational testing) that determines if a student qualifies for a 504 Plan or Individual Education Program (IEP), these should not be confused with clinical diagnostic services outside of the school system. However, while not a replacement for clinical services, EAPs can advocate for parents to explore 504s and IEPs at their child’s school to obtain better support for learning and behavioral challenges.
Five Steps for Finding ADHD & Neurodevelopmental Providers
To address the challenges of how to obtain services, here are five steps for finding an ADHD and neurodevelopmental specialist provider. While most applicable for the United States, these can be helpful for other countries too. EA professionals can use and discuss these steps with parents so they can be more informed and effective in their searches. For more information on each step and list of referral resources in step two below, please read my full article: https://adhdology.com/how-to-find-an-adhd-specialist-provider-in-the-united-states/
- Determine the type of provider that is needed. Are diagnostics necessary as a first step? Or are the conditions clear and now a new treatment provider is required? Is a second opinion about treatment options from a psychiatrist (for medication) or from an experienced psychotherapist needed? Are other non-mental health providers indicated?
- Find appropriate potential providers. Ask primary care physicians and other current health care providers for referrals. Also, speak with health insurance customer service representatives for in-network referrals. Contact state and national professional organizations for local referrals (please refer to the article link above for these).
- Call providers to clarify what services they offer and determine if they may be a good fit.
- At the first session, parents should review their goals and needs with providers.
- If there is not a good match with providers, repeat steps two, three, and four.
Additional Ways EAPs Can Help
Since most EAPs typically do not provide diagnoses or comprehensive assessments, they can provide helpful screenings and referrals to aid families to receive the most appropriate services. To prepare for these specialized referrals, EAPs can locate these providers in their areas. This should include knowing what services these providers offer, their typical waiting list length, and the health insurances they accept. In theory, virtual providers can make access easier, but the need for services has increased, and so has their waiting lists.
EA professionals can also familiarize themselves with the many various possible conditions in children and adolescents that can coexist with true ADHD or cause misdiagnoses from ADHD-like symptoms. Being aware of these presentations can increase the effectiveness of EAPs’ screenings and the referral process. Due to the increasing mental health demands now, EAPs and mental health providers can learn more by reading and attending related trainings.
Furthermore, EA professionals can offer invaluable support to parents of struggling children and adolescents during the referral process and when provider wait lists exist. They can supply realistic information about diagnostic and treatment services to improve clients’ understanding and expectations, as well as address the frustrations and provide encouragement for these parents. EAPs can also address the parents’ own conditions and difficulties, as well as teach stress management and other important skills. Finally, EAPs should be aware that parents of children and teens with ADHD have higher rates of this condition due to the strong genetic link, and may benefit from their own support and referrals.
Dr. Gene Carroccia is a licensed clinical psychologist and Vice President of Behavioral Health at a large healthcare system. He is the author of two books, Treating ADHD/ADD in Children and Adolescents: Solutions for Parents and Clinicians and Evaluating ADHD in Children and Adolescents. To learn more about his books and original articles, visit adhdology.com. Contact him at firstname.lastname@example.org.