Attention deficit hyperactivity disorder - Diagnosis

Diagnosis:

Diagnostic Criteria for ADHD in Children

A. Either 1 or 2 should be present:

1. Should have 6 or more of the following symptoms of inattention, persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

• Often fails to give close attention to detail, makes careless mistakes
• Often has difficulty sustaining attention in tasks or play
• Often does not seem to listen when spoken to directly
• Often does not follow through and fails to finish tasks
• Has difficulty organizing tasks and activities
• Avoids or dislikes tasks requiring sustained mental effort
• Often loses things necessary for tasks or activities
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

2. Should have 6 or more of the following symptoms of hyperactivity-impulsivity that lasts for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

• Often fidgets or squirms when sitting
• Has difficulty remaining seated when required to do so
• Often runs about or climbs excessively in inappropriate situations
• Has difficulty playing quietly
• Is often "on the go"
• Often talks excessively
• Often blurts out answers to questions before they have been completed
• Has difficulty waiting for his or her turn
• Often interrupts or intrudes on others

Note: Patients with A1 symptoms are diagnosed with ADHD, predominantly inattentive type. Those with A2 are diagnosed with ADHD, predominantly hyperactive-impulsive type. Those with both A1 and A2 are diagnosed as ADHD, combined-type.

B. Onset of some symptoms before the age of 7. However, children with the inattentive subtype are not often diagnosed until they are above 7 years of age.

C. Symptoms occur in two or more settings. For example, at home and at school.

D. Clear evidence of significant impairment in social or academic functioning.

E. Not caused by a pervasive developmental disorder, schizophrenia, or any other psychotic disorder, and is not better accounted for by another mental disorder, including anxiety or depression.

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. (Text Revision). Washington, DC: 2000.

Factors for Making a Diagnosis

Important factors for making a diagnosis of attention-deficit hyperactivity disorder (ADHD) include:

• Children between ages 6 - 12 should first be evaluated for ADHD if they show symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems in at least two settings. Such behaviors should have been harmful for the child academically or socially for at least 6 months.
• The child should meet the official symptom guidelines.
• A diagnosis requires detailed reports by parents or caregivers. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child.
• Guidelines for primary care doctors emphasize the importance of obtaining direct evidence from the classroom teacher or other school-based professionals about the child's symptoms and their duration, and evidence of functional impairment in the school setting.
• The child should be assessed for accompanying conditions (such as learning difficulties).

Difficulties in Identifying Children with ADHD

No laboratory or imaging tests exist to reliably diagnose ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders. Many doctors believe that the disorder is both over- and underdiagnosed. Diagnosis is difficult for some of the following reasons:

Factors Leading to the Over-Diagnosis of ADHD:

• The popularity of methylphenidate (Ritalin) has encouraged some parents and teachers to pressure doctors into prescribing this standard ADHD drug for children who are aggressive or who have poor grades. Often with careful evaluation many of these children do not meet the criteria for the illness. Children may have other diagnoses, other behavioral or emotional problems, or no problems at all.
• Other factors that may contribute to misdiagnosis include children who are young for their grade and therefore socially and intellectually immature, and social and economic problems such as single parent households.

Factors Leading to the Under-Diagnosis of ADHD:

• Some evidence suggests that girls with ADHD are underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression.
• Doctors may fail to diagnose children with ADHD because they often behave normally in the quiet doctor's office where there are no distractions to trigger symptoms. In addition, doctors may be unfamiliar with how to diagnose the condition.

History of Behavior

The doctor will first require a detailed history of the child's behavior. Doctors will match this against a standardized checklist to define the disorder.

The parents should describe:

• Specific problems, beginning as early as possible, they have encountered during the child's development -- school reports are very helpful
• Sibling relationships
• Recent life changes
• A family history of ADHD
• Eating habits
• Sleep patterns
• Speech and language development
• Any problems during the mother's pregnancy or during delivery
• Any history of medical or physical problems, particularly allergies, chronic ear infections, and hearing difficulties

The health professional will want to know how the parents handle different situations, and may want to observe them interacting with the child.

Physical Examination

The child should also be given a general physical examination to determine if any medical conditions are present. The child should be given a hearing test to rule out hearing abnormalities as a source of behavioral problems.

Screening Tests

Various tests are available to test neurologic, intellectual, and emotional development problems. Most involve learning and problem solving tasks that help define the particular areas that are most disabling. Blood or other laboratory tests are currently recommended only if the doctor suspects lead toxicity or other medical problems.

Drug Trial

Although some doctors use a trial of a psychostimulant (usually Ritalin) to facilitate diagnosis, most doctors strongly recommend against this method of diagnosis, because it is not always accurate. An improvement in symptoms is considered suggestive of ADHD, while in non-ADHD children the stimulant often increases agitation and hyperactivity. Many children and adults without the disorder have a similar response, and such a diagnostic trial may lead to unnecessary prescriptions of this drug.

Diagnosing ADHD in Adults

ADHD in adults always occurs as a continuation of the childhood condition. Adult-onset symptoms are likely due to other factors. Diagnosing adult ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while attention and organizational problems may develop in older people.

A rating scale using four factors may be useful in identifying adults with ADHD:

• Inattention and memory problems. (Examples: losing or forgetting things, being absent-minded, not finishing things, misjudging time, depending on others for order, having trouble getting started, changing jobs or projects in the middle.)
• Hyperactivity and restlessness. (Examples: always being on the go, fidgety, easily bored, taking risks, liking active and fast paced jobs and activities, such as being a sales representative or stockbroker.)
• Impulsivity and emotional instability. (Examples: saying things without thinking first, interrupting others, being annoying to others, easily frustrated, easily angered, having unpredictable moods, driving recklessly, having high relationship and job turnover.)
• Problems with self worth. (Examples: avoids new challenges, appears confident to others but not to oneself.)

Doctors use adult reports of childhood behaviors and experiences when searching for clues for a diagnosis.