How is ADHD diagnosed?

Though all children show behaviors similar to ADHD from time to time, the child with ADHD has symptom “clusters”—six symptoms of inattention and/or six symptoms of hyperactivity/impulsivity. Before a diagnosis of ADHD can be made, however, it is not enough for the child to have these symptoms—he or she must also meet these conditions:

  • The symptoms must cause problems.
  • The symptoms must cause problems in more than two settings (such as home and school).
  • The symptoms must be present in some form before the child is 12 years old.

If a child shows symptom clusters and also meets these conditions, the doctor may diagnose the following types of ADHD:

  • Combined type (inattentive/hyperactive/impulsive): Children with this type of ADHD have all three groups of symptoms. This is the most common form of ADHD.
  • Predominately hyperactive/impulsive type: Children have both hyperactive and impulsive behavior, but do not have problems with attention.
  • Predominately inattentive type (formerly known as attention deficit disorder, or ADD): Children have difficulties with attention, but are not overly active or impulsive.
  • Other specified/unspecified ADHD: Children have symptoms but do not meet the above conditions for diagnosis.

It is very important to follow three steps when diagnosing ADHD:

  1. Identify the symptoms or behaviors that occur in the natural environment.
  2. Rule out other possible causes of the symptoms.
  3. Identify comorbid conditions (those occurring at the same time as the main symptoms).

A child who has symptoms of ADHD may be able to pay attention in a focused way to activities that he or she finds interesting. For example, children can spend hours in front of a screen playing video games, but they may have trouble finishing even simple homework assignments, or they may throw tantrums and refuse to do chores or school work at home. This affects parent behavior as well, causing parents to yell more often or have to give repeated reminders to prompt the child to do simple tasks (like get ready for school). At such times, parents may know the child is not being oppositional—they just do not follow directions immediately.

Fascination or automatic attention (the kind of attention one uses when doing something interesting) is not a problem for children with ADHD; in fact, it may be very strong in some cases. However, “directed attention” (also known as effortful attention or top-down attention) is far more difficult for a child with ADHD. Tasks that require directed attention are harder to do and require much more effort. This kind of attention is much more readily used up. Because of these conditions, the caregiver must carefully observe the child in a number of different situations to make sure the evaluation is thorough.

Preparing for your ADHD appointment

If you think your child has a problem with attention, hyperactivity, or impulsivity, and it seems that his or her behavior at home and performance at school are being affected, the next step is to have an examination and evaluation.

If the symptoms are affecting your child’s school work, you should request that the school evaluate him or her. When making this request, be as specific as possible about the type of educational or behavioral difficulties your child is having.

Schools are required to evaluate children (age 3 to 21) if they are believed to have a disability that affects their learning. This evaluation is free and must, by law, include appropriate standardized tests.School testing can lead to accommodations in the classroom. The school will not diagnose ADHD, but will take note of the symptoms and will often assign a designation of “Other Health Impaired” (OHI).

If your child is not yet school age, or if his or her problems occur mostly at home, make an appointment with your family doctor or pediatrician (or a caregiver who is familiar with diagnosing ADHD) to discuss the possibility of ADHD. Be sure to give the caregiver or doctor background information about your concerns and the concerns of school personnel or other caregivers. If necessary, the family doctor may suggest you take your child to a professional who specializes in ADHD and other developmental, behavioral, or mental health concerns.

Before the ADHD appointment, parents should fill out and return all the rating scales or medical information forms they received, both broad band (which cover a variety of conditions) and narrow band (which include symptoms associated with ADHD alone). Because there is no one single test for ADHD, information about family history, the child’s medical history, and behavior concerns are important for the doctor or specialist to know in order to complete a full evaluation.

If your child already receives school services from an IEP or 504 Accommodations plan, bring a copy of the IEP/504 to your appointment. This will let the physician or specialist know about the child’s difficulties at school and any testing the school has completed, and will give a picture of the strategies the school already has in place for your child.

The ADHD evaluation

The diagnosis of ADHD will probably be made by a pediatric psychologist or physician (a pediatrician, psychiatrist, or neurologist), with the help of standard guidelines from the American Academy of Pediatrics.

A comprehensive ADHD evaluation includes the following:

  • Broad band and narrow band behavior rating scales completed by at least two observers (for example, parents, teachers, and other caregivers)
  • A medical and family history
  • A physical examination (often included by medical doctors)
  • A detailed interview with the parents and the child
  • Observation of the child
  • Psychological tests to measure the child’s intellectual strengths and weaknesses

If a child is diagnosed with ADHD, it means that not only is he or she easily distracted, but that the distraction is much more noticeable than it is in other children of the same age. Specialists will consider the following when diagnosing ADHD:

  • Are the behaviors more frequent or excessive than in other children of the same age?
  • Did the behaviors begin early in life (before age 12)?
  • Have the behaviors been present for more than six months?
  • Are the behaviors a continuous problem, and not just a response to a temporary situation?
  • Do the behaviors occur in several settings or only in one specific place?
  • Do the behaviors cause problems in at least two areas of a person's life (such as home, school, work, or social settings)?

The specialists will also check to see if other things might be causing behavior that is similar to ADHD. This behavior can often show up in other disorders and situations, such as the following:

  • A sudden life change (such as divorce, death in the family, or moving to a new home)
  • Anxiety
  • Depression
  • Learning disabilities
  • Undetected seizures
  • Medical disorders that affect the functioning of the brain
  • Thyroid disorders
  • Lead toxicity (poisoning)
  • Sleep problems

Understanding the diagnosis of ADHD

After the first appointment, your child’s healthcare provider will collect all the information from the evaluation process, make a diagnosis, and complete a report. The report will sum up the results and give treatment recommendations, including general guidelines for managing your child’s ADHD, and specific strategies and resources tailored to your family’s needs and your child’s strengths and weaknesses.

After diagnosis, recommendations for both behavior therapy and pharmacotherapy (medication) should be discussed with the healthcare provider.

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