When parents consider having their child diagnosed with ADHD, they most commonly ask their pediatrician or physician first. It is very important at this stage to understand the ADHD diagnosis, evaluation processes, and treatment options. While the assessment process varies for preschoolers, middle childhood, adolescence, and adulthood, the basic understanding on how to conduct an evaluation is helpful. The American Academy of Pediatrics (AAP) has established the following recommendations for diagnosing ADHD:
Primary care physicians should evaluate for ADHD in children ages 6-12 if they present with inattention, hyperactivity, academic difficulties, or behavior problems.
Diagnosis should meet DSM 5 criteria for ADHD.
Evidence of impulsive, hyperactive, and/or inattentive symptoms should be gathered directly from parents or guardians. This includes information about the age of onset, degree of functional impairment, and duration of symptoms at home.
Evidence of impulsive, hyperactive, and/or inattentive symptoms should be gathered directly from teachers and school professionals. The presence of coexisting conditions, degree of functional impairment and duration of symptoms at school need to be considered.
The child should also be assessed for other conditions that commonly coexist with ADHD, including learning disorders, oppositional-defiant disorder, sleep problems, and mood/anxiety problems.
Together, these recommendations indicate that ADHD is best diagnosed through a comprehensive evaluation. This evaluation has 6 components:
Screening for the specific symptoms of ADHD by parents/caregivers and teachers/school personnel.
Determining whether symptoms are causing educational, social and/or behavioral impairment at home and at school.
Determining if they meet DSM 5 criteria for ADHD.
Screening for coexisting conditions.
A comprehensive review of patient’s medical history.
A comprehensive physical exam
More information on each component is listed below.
Screening for ADHD Symptoms
While many children demonstrate some inattention, hyperactivity, or impulsivity, these symptoms must appear at a high frequency, be present across multiple settings, and cause impairment in order to warrant a diagnosis of ADHD. The most common way to determine if a child meets this criteria is through the use of parent and teacher report rating scales. Such scales provide an effective and well-validated method of assessing the presence, frequency, and severity of ADHD symptoms. One such measure is the Vanderbilt Parent and Teacher Assessment ADHD rating scales. The Vanderbilt ADHD rating scales are an effective and efficient means of assessing the presence and severity of the child's inattentive and hyperactive/impulsive behaviors. It also screens for coexisting conditions such as: oppositional defiant disorder, conduct disorder, depression, and anxiety. Research has demonstrated that the Vanderbilt ADHD rating scales effectively differentiate children with and without ADHD.
It is important to note here that teachers should also be asked to fill out rating scales. This is because the diagnosis of ADHD requires that symptoms be present in multiple settings (i.e., home, school). Children may behave very differently in different settings. Thus, a child's behavior may be very different in the structured school setting than in the unstructured home setting. Additionally, teachers are often the first to notice behaviors that are characteristic of ADHD (particularly inattentive symptoms), and is often capable of reporting on impairment in terms of academic performance, social interactions, and overall behavior. In some cases, teachers are able to report on a child's school functioning more accurately than parents.
DSM 5 Criteria
The DSM-5 identifies three different "presentations" or types of ADHD that are differentiated by the type of symptoms that are present. The first presentation is ADHD - predominantly inattentive presentation, or what used to the called ADD. Individuals with this type of ADHD do not show the hyperactive symptoms, but instead have difficulties with attention and concentration. Some common symptoms include:
Trouble paying attention and staying on-task
Trouble following rules and instructions
Being easily distracted and confused, daydream often
Trouble finishing homework or classwork
Trouble following complicated or multiple-step directions
Forgetfulness and or being disorganized
The second presentation is ADHD - predominantly hyperactive presentation. Individuals with this diagnosis do not have the inattentive symptoms, but instead have difficulties being overactive, hyperactive, or impulsive. Children with this diagnosis may:
Fidget excessively and have difficulty sitting still
Be constantly in motion, act like they are "driven by a motor"
Have trouble staying in their seats when they need to (i.e., at dinner, school, church, etc.)
Talk too much and interrupt others often
Be very impatient and frequently switch between activities
Act without thinking, have difficulty learning from consequences
Become easily frustrated and bored, and become disruptive when upset
Have trouble taking turns or waiting for things they want
Need a lot of attention, and have trouble playing quietly
Finally, many children are also diagnosed with ADHD - combined presentation. This means that they have symptoms of both inattentive or difficulty concentrating, and overactivity, hyperactivity or impulsivity.
Medical History Review
As previously noted, a comprehensive review of the client's medical history is a core component of an ADHD evaluation. Information that should be reviewed includes:
The presence of the core symptoms of ADHD (impulsivity, hyperactivity and/or inattention) in more than one setting.
Age of onset.
Duration of symptoms.
Degree of functional impairment in more than one setting, including:
Family relationships and behavioral functioning
Independence in activities of daily living
Risky or unsafe behaviors
Presence of coexisting psychiatric or medical conditions that may produce ADHD-like symptoms, including:
Developmental or Cognitive Disorders
Side effects of medications
History of exposure to trauma (abuse, neglect, etc.)
Past medical history including conditions that are associated with an increased risk for developing ADHD. These include: