NASET ADHD SERIES
ADHD is considered a neurobiological disorder. Only a licensed professional, such as a pediatrician, neuropsychologist, neurologist, or psychiatrist, should make the diagnosis that a child, teen, or adult has ADHD. These professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV-TR) as a guide (APA, 2000).
Over the last 10 years, public awareness about ADHD has led to more children and adults being diagnosed with the disorder. Some people have expressed concern that the condition is being overdiagnosed. The American Medical Association (AMA) took a serious look into these claims. According to AMA’s Special Council Report, however, there is little evidence of widespread overdiagnosis of ADHD or over-prescription of medication for the disorder (Goldman et al., 1998).
Some parents see signs of inattention, hyperactivity, and impulsivity in their toddler long before the child enters school. The child may lose interest in playing a game or watching a TV show, or may run around completely out of control. But because children mature at different rates and are very different in personality, temperament, and energy levels, it’s useful to get an expert’s opinion of whether the behavior is appropriate for the child’s age. Parents can ask their child’s pediatrician, or a child psychologist or psychiatrist, to assess whether their toddler has an attention deficit hyperactivity disorder or is, more likely at this age, just immature or unusually exuberant.
ADHD may be suspected by a parent or caretaker or may go unnoticed until the child runs into problems at school. Given that ADHD tends to affect functioning most strongly in school, sometimes the teacher is the first to recognize that a child is hyperactive or inattentive and may point it out to the parents and/or consult with the school psychologist. Because teachers work with many children, they come to know how “average” children behave in learning situations that require attention and self-control.
However, teachers sometimes fail to notice the needs of children who may be more inattentive and passive yet who are quiet and cooperative, such as those with the predominantly inattentive form of ADHD. In order to be diagnosed with ADHD, children and youth must meet the specific diagnostic criteria set forth in the DSM-IV-TR (see Part 2 of the ADHD Series). These criteria are primarily associated with the main features of the disability: inattention, hyperactivity, and impulsivity.
Symptoms Needed for a Diagnosis of ADHD
For a diagnosis of predominantly inattentive type of ADHD, six or more of the inattention symptoms must be present (see Part 2 of the ADHD Series). For a diagnosis of hyperactive/impulsive type, six or more of the hyperactivity or impulsivity symptoms must be present (see Part 2 of the ADHD Series). For a diagnosis of combined type, six or more symptoms of inattention, plus six or more symptoms of hyperactivity or impulsivity, must be present (see Part 2 of the ADHD Series).
Often
The word often appears before each symptom of inattention, hyperactivity, and impulsivity in the DSM-IV-TR. In order to be considered a symptom of ADHD, a behavior can’t be “a once in a while” problem. Nor can it be a problem that pops up all of a sudden. According to the DSM-IV-TR, the following must be true:
- There must be clear evidence of significant difficulty in two or more settings (e.g., at home, in school, with peers, or at work)
- Symptoms of inattention, hyperactivity, or impulsivity must be present at least six months
- Some of these symptoms have to cause problems before age 7
- The symptoms have to be developmentally inappropriate
Developmentally Inappropriate
“Developmentally inappropriate” is an important point. If you look again at the symptom list for the three main features of ADHD, you will notice that some of these behaviors may be fairly normal at certain ages. For instance, no one expects a two year old to keep track of toys or to stay seated for very long. So, losing things or not being able to stay in a chair for long would not be considered symptoms of ADHD at that age. These same behaviors in a ten year old, however, would be developmentally inappropriate. We don’t expect a ten year old to constantly lose things. We do expect a ten year old to be able to stay seated during a half-hour of class or a family dinner.
Professionals Who Make a Diagnosis of ADHD
Ideally, the diagnosis should be made by a professional in your area with training in ADHD or in the diagnosis of mental disorders. Child psychiatrists and psychologists, developmental/behavioral pediatricians, or behavioral neurologists are those most often trained in differential diagnosis. Clinical social workers may also have such training.
The family can start by talking with the child’s pediatrician or their family doctor. Some pediatricians may do the assessment themselves, but often they refer the family to an appropriate mental health specialist they know and trust.
Knowing the differences in qualifications and services can help the family choose someone who can best meet their needs. There are several types of specialists qualified to diagnose and treat ADHD. Child psychiatrists are doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications. Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on the child’s physician to do medical exams and prescribe medication.
Neurologists, doctors who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional aspects of the disorder. Within each specialty, individual doctors and mental health professionals differ in their experiences with ADHD. So in selecting a specialist, it’s important to find someone with specific training and experience in diagnosing and treating the disorder.
Lab Tests or Specific Medical Exams to DiagnoseADHD
At present, no laboratory test exists to determine if a child has this disorder. ADHD can’t be diagnosed with a urinalysis, blood test, CAT scan, MRI, EEG, PET or SPECT scan, although some of these technologies are used for research purposes.
Formulating an Accurate Diagnosis of ADHD
Diagnosing ADHD is complicated and much like putting together a puzzle. An accurate diagnosis requires an assessment conducted by a well-trained licensed professional (usually a developmental pediatrician, child psychiatrist, or pediatric neurologist). This professional must specialize in ADHD and all other disorders that can have symptoms similar to those found in ADHD. Until the practitioner has collected and evaluated all the necessary information, he or she can only assume that the child might have ADHD.
The ADHD diagnosis is made on the basis of the observable behavioral symptoms previously listed. The symptoms of ADHD must occur in more than one setting. The person doing the evaluation must use multiple sources of information. Since symptoms of ADHD can also be associated with many other conditions, it is problematic when practitioners make a snap diagnosis either because parents said they think their child has ADHD or because he or she has observed the child once. Children with ADHD commonly behave well on the first meeting. Furthermore, personal observation is only one source of information.
Recommended Diagnostic Procedure for AssessingADHD
The American Academy of Pediatrics (2000) recommends that clinicians collect the following information when evaluating a child for ADHD:
1. A thorough medical and family history.
2. A medical examination for general health and neurologic status.
3. A comprehensive interview with the parents, teachers, and child.
4. Standardized behavior rating scales, including ADHD-specific ones completed by parents, teacher(s), and the child when appropriate. (Know that people with
ADHD typically are not great at accurately reporting symptoms of the disorder, because it causes them to have poor insight into their own behavior.)
5. Observation of the child.
6. A variety of psychological tests to measure IQ and social and emotional adjustment. These tests also help to determine the presence of specific learning disabilities, which can co-occur with ADHD.
Once the practitioner completes the evaluation, he or she makes one of three determinations:
1. The child does or does not have ADHD.
2. The child does not have ADHD, but either has another disorder(s) or other factors that have created the difficulties.
3. The child has ADHD and another disorder (called a co-existing condition).
To make the first determination-that the child has or does not have ADHD-the clinician considers his or her findings in relation to the criteria of the DSM-IV-TR mentioned earlier.
To make the second determination-that the child’s difficulties are caused by another disorder or other factors-the professional first considers the disorders that have symptoms similar to ADHD. You should be aware that some mental health disorders have their onset after puberty, but early warning signs, which are very similar to ADHD symptoms, may be present. Thus, it is possible for a diagnosis to change as the child develops and other disorders become more apparent. It is also possible for a child or youth to have more than one disorder, or co-occuring disorders.
Generally, the DSM-IV-TR requires clinicians to rule out ADHD if they see Pervasive Developmental Disorder (PDD), schizophrenia, other psychotic disorders, or if the symptoms are better explained by another disorder. For instance, although not very common, Bipolar Disorder (BPD) can be mistaken for ADHD in early years.
It is also true that major stressful life events can result in temporary symptoms that look like ADHD. Such events could include parental divorce, child abuse, death of a loved one, a move, or a sudden traumatic experience. Under these circumstances, ADHD-like symptoms may arise suddenly and, therefore, would have no long-term history. Remember, ADHD symptoms must exist for at least six months and cause some difficulty before the age of seven. Of course, a child can have ADHD and a stressful event, so such events do not automatically rule out the existence of ADHD.
To make the third determination-that the child has ADHD and a co-existing condition-the assessor must first be aware that ADHD can and often does co-occur with other difficulties, particularly learning disabilities, oppositional defiant disorder, and anxiety. A list of disorders that commonly co-occur with ADHD is provided below. The fact is: Other mental health conditions such as those listed in the box below can be the result of ADHD, in addition to ADHD, or mistaken for ADHD. That is why evaluations need to be conducted by a professional who is trained in a wide variety of child and adolescent disorders. Thorough and correct diagnosis is an essential first step to better treatments.
Disorders That Commonly Co-Occur With ADHD
Although these behaviors are not in themselves a learning disability, almost one-third of all children with ADHD have learning disabilities (National Institute of Mental Health [NIMH], 1999). Children with ADHD may also experience difficulty in reading, math, and written communication (Anderson, Williams, McGee, & Silva, 1987; Cantwell & Baker, 1991; Dykman, Akerman, & Raney, 1994; Zentall, 1993). Furthermore, ADHD commonly occurs with other conditions. Current literature indicates that approximately 40 60 percent of children with ADHD have at least one coexisting disability (Barkley, 1990a; Jensen, Hinshaw, Kraemer, et al., 2001; Jensen, Martin, & Cantwell, 1997).
Although any disability can coexist with ADHD, certain disabilities seem to be more common than others. These include disruptive behavior disorders, mood disorders, anxiety disorders, tics and Tourette s Syndrome, and learning disabilities (Jensen, et al., 2001). In addition, ADHD affects children differently at different ages. In some cases, children initially identified as having hyperactive-impulsive subtype are subsequently identified as having the combined subtype as their attention problems surface.
Oppositional Defiant Disorder (ODD) – A pattern of negative, hostile, and defiant behavior. Symptoms include frequent loss of temper, arguing (especially with adults), refusal to obey rules, intentionally annoying others, blaming others. The person is angry, resentful, possibly spiteful, and touchy. (Many of these symptoms disappear with ADHD treatments.)
Conduct Disorder (CD) – A pattern of behavior that persistently violates the basic rights of others or society’s rules. Behaviors may include aggression toward people and animals, destruction of property, deceitfulness or theft, or serious rule violations.
Anxiety – Excessive worry that occurs frequently and is difficult to control. Symptoms include feeling restless or on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances.
Depression – A condition marked by trouble concentrating, sleeping, and feelings of dejection and guilt. There are many types of depression. With ADHD you might commonly see dysthymia, which consists of a depressed mood for many days, over or under eating, sleeping too much or too little, low energy, low self-esteem, poor concentration, and feeling hopeless. Other forms of depression may also be present.
Learning Disabilities – Problems with reading, writing, or mathematics. When given standardized tests, the student’s ability or intelligence is substantially higher than his or her achievement. Underachievement is generally considered age-inappropriate. [Note: Children with ADHD frequently have problems with reading fluency and mathematical calculations. ADHD learning problems have to do with attention, memory and executive function difficulties rather than dyslexia, dysgraphia, or dyscalculia, which are learning disabilities. The point here is not to overlook either. Depending on how learning disabilities are defined, between 10-90% of youth with ADHD also have a learning disability (Robin, 1998).]
Parent Options for Having Their Child Evaluated forADHD
When a child is experiencing difficulties that suggest that he or she may have ADHD, parents can take one of two basic paths to evaluation. They can seek the services of an outside professional or clinic, or they can request that their local school district conduct an evaluation.
In pursuing a private evaluation or in selecting a professional to perform an assessment for ADHD, parents should consider the clinician’s training and experience with the disorder, as well as his or her availability to coordinate the various treatment approaches.
Most ADHD parent support groups know clinicians trained to evaluate and treat children with ADHD. Parents may also ask their child’s pediatrician, a community mental health center, a university mental health clinic, or a hospital child evaluation unit.
It is important for parents to realize, however, that the schools have an affirmative obligation to evaluate a child (aged 3 through 21) if school personnel suspect that the child might have ADHD or any other disability that is adversely affecting educational performance. (That means the child must be having difficulties in school. Those difficulties include social, emotional, and behavioral problems, not just academic troubles.) This evaluation is provided free of charge to families and must, by law, involve more than one standardized test or procedure. Thus, if parents suspect that their child has an attentional or hyperactivity problem, or know for certain that their child has ADHD, and his or her educational performance appears to be adversely affected, they should first request that the school system evaluate their child. Be sure to put their request in writing. Their letter should include the date, their name, their child’s name, and the reason(s) they are requesting an evaluation. The letter should state the type of educational difficulties their child is experiencing. They should know to keep a copy of the letter in their file.
Evaluation When the Child is a Toddler
If their child is under three years old, and parents suspect that ADHD may be affecting his or her development, they may want to investigate what early intervention services are available in their state through the Part C program of the Individuals with Disabilities Education Act (IDEA).
Since ADHD is a developmental disorder, diagnosing young children requires some special consideration. For instance, toddlers don’t pay attention for long periods of time, so a clinician wouldn’t necessarily find inattention in a toddler a symptom of ADHD. Also, toddlers are more easily frustrated and do shift activities a lot. It’s important that the person doing the diagnosis be very familiar with normal child development in order to determine what behaviors would be inappropriate for that age.
Parents can find out about the availability of early intervention services in their state by contacting the state agency responsible for administering early intervention services, by asking their pediatrician, or by contacting the nursery or child care department in their local hospital.
Preschoolers (children aged 3 through 5) may be eligible for services under Part B of the Individuals with Disabilities Education Act (IDEA). If a child is a preschooler, the parents may wish to contact the State Department of Education or local school district, ask their pediatrician, or talk with local day care providers about how to have their child assessed through their school district’s special education department.
Also, under Head Start regulations, ADHD is considered a chronic or acute health impairment entitling the child to special education services when the child’s inattention, hyperactivity, and impulsivity are developmentally inappropriate, chronic, and displayed in multiple settings, and when the ADHD severely affects performance in normal developmental tasks (for example, in planning and completing activities or following simple directions).
If their child is school-aged (six or older), and the parents suspect that ADHD may be adversely affecting his or her educational performance, they can ask their local school district to conduct an evaluation. With the exception of the physical examination, the assessment can be conducted by school personnel as long as a member of the evaluation group is knowledgeable about assessing ADHD. If not, the district may need to use an outside professional consultant trained in ADHD assessment. This person must know what to look for during child observation, be competent to conduct structured interviews with parents, teacher(s), and child, and know how to administer and interpret behavior rating scales.
Identifying where to go and whom to contact in order to request an evaluation is just the first step. Unfortunately, many parents experience difficulty in the next step-getting the school system to agree to evaluate their child. In the past, some schools have not understood their obligations to serve children who, because of their ADHD, are in need of special education and related services. In 1999, ADHD was specifically listed in the federal regulations of IDEA under the disability category of “other health impairment.”
The inclusion of ADHD in this disability category should help to clarify the school’s obligation to evaluate children who are suspected of having ADHD that is adversely affecting educational performance. However, if the school district does not believe that a child’s educational performance is being adversely affected, it may refuse to evaluate the child. In this case, there are a number of actions parents can take, including pursuing a private evaluation. It is also important to persist with the school, enlisting the assistance of an advocate, if necessary.
Parents can generally find this type of assistance by contacting the Parent Training and Information (PTI) center for their state, the Protection and Advocacy (P&A) agency, or a local parent group.
A school district’s refusal to evaluate a child suspected of having ADHD involves issues that must be addressed on an individual basis. The parents state’s PTI, P&A, or a local parent group will typically be able to provide information on a parent’s legal rights, give specific suggestions on how to proceed, and in many cases offer direct assistance. Parents may also use a special education attorney. For children who are evaluated by the school system, eligibility for special education and related services will be based upon evaluation results and the specific policies of the state. Unfortunately, many parents have found this to be a problematic area as well.
Conclusion
Not everyone who is overly hyperactive, inattentive, or impulsive has ADHD. Since most people sometimes blurt out things they didn’t mean to say, or jump from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD?
Because everyone shows some of these behaviors at times, the diagnosis requires that such behavior be demonstrated to a degree that is inappropriate for the person’s age. The diagnostic guidelines also contain specific requirements for determining when the symptoms indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least 6 months. Above all, the behaviors must create a real handicap in at least two areas of a person’s life such as in the schoolroom, on the playground, at home, in the community, or in social settings. So someone who shows some symptoms but whose schoolwork or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or in the schoolroom? The person’s pattern of behavior is compared against a set of criteria and characteristics of the disorder as listed in the DSM-IV-TR.
