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. It should be noted that a mother's description of her child's behavior is a very accurate and reliable guide for diagnosing ADHD. 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 experts believe that the disorder is both over- and underdiagnosed. Diagnosis of attention-deficit hyperactivity disorder is difficult for some of the following reasons:

Factors Leading to the Over-Diagnosis of ADHD:

• The popularity 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 testing 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 many girls with ADHD may go 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. The inattentive subtype, in any case, may first show up in older children and adolescents.
• 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.
• In spite of the fact that there seems to be no differences in response to treatment among population groups, African-American, Hispanic, and Asian children with ADHD are half as likely to be diagnosed and treated as Caucasian children. By high school, the racial disparity increases to the level that the medication rate for blacks is one-fifth of that for whites.

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 the following:

• 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 experts 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.