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How is ADHD Diagnosed?

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What is ADHD

Deciding whether a person has ADHD is not a single-step task; it requires meticulous evaluation. Many other mental health conditions have symptoms similar to ADHD including anxiety, depression, sleep disorders, and some types of learning disabilities.

What is ADHD?

ADHD stands for Attention Deficit Hyperactivity Disorder. It is a neurodevelopmental condition that usually presents in children. It is characterized by symptoms of inattention, impulsivity, and hyperactivity (1). ADHD has the following presentations:

  • Inattentive ADHD 
  • Hyperactive-impulsive ADHD
  • Combined ADHD (Inattentive-Hyperactive ADHD)

Symptoms of ADHD

The symptoms of ADHD differ depending upon the subtype of the mental health condition. When the symptoms of inattention are present, it is regarded as the predominantly inattentive type of ADHD. The symptoms of inattention are as follows:

  • The person is easily distractible but not hyperactive or impulsive.
  • Tendency to leave tasks unfinished
  • Daydreaming
  • Putting tasks the hold that need mental effort
  • Inability to listen to others
  • Inability to focus on a task
  • Trouble in remembering things
  • Losing things
  • Having a problem organizing things 
  • Inability to follow instructions
  • Making careless mistakes by not paying any attention to details
  • Struggling to focus on tedious tasks

The hyperactive-impulsive symptoms are as follows:

  • Impulsivity
  • Fidgeting
  • Tapping foot
  • Squirming
  • Inability to stay seated
  • Interrupting others when they are talking or doing a task
  • Completing other people’s sentences
  • Talking nonstop in conversations
  • Inability to do quiet tasks
  • Inability to tolerate boredom
  • Reacting quickly without thinking about the consequences
  • Always looking for stimulation and adventures
  • Risk-taking and dangerous behavior
  • Badgering another person when they want something

In combined type, the person experiences inattention and hyperactive symptoms together. 

Causes of ADHD

The exact cause and etiology of ADHD are unknown, but research has concluded that it is an inherited disorder. ADHD symptoms are related to the biological impairment of the brain (2). The factors that increase the risk of development of ADHD and other developmental disorders include the following:

  • Maternal smoking during pregnancy
  • Maternal drinking during pregnancy
  • Premature delivery
  • Low weight at birth

The environmental factors that have an impact on the brain biology are as follows:

  • Toxins 
  • Conflict and stress in the home environment
  • Early childhood trauma 

When to See the Doctor?

In normal life, everyone experiences distractibility and focus issues once in a while. It is completely normal. But when the symptoms start affecting normal activity and interfere with the normal flow of life, it should be evaluated. 

In children, the symptoms are noticed first by parents, teachers, or their primary care providers. Also, if the symptoms are noticed in a child or an adult, the first step is to see any health care professional or your child’s pediatrician depending on accessibility who does a referral to a psychologist. Since the symptoms of ADHD are not hard and fast and similar symptoms are seen in other conditions, it is necessary to get a proper evaluation and diagnosis. 

Other factors that cause inattentiveness in people include

  • Emotional struggles
  • Learning disabilities
  • Anxiety disorder
  • Sleep disorder
  • Depression
  • Brain injury

ADHD Evaluation and Screening

Initial Evaluation:

The beginning of screening includes a general interview to establish whether ADHD is the cause of a person’s emotional, social, behavioral, and academic or schoolwork challenges. For this purpose, the presentation criterion in DSM-5 is used. It determines whether the person has the symptoms that indicate a particular type of ADHD. 

DSM-5 Diagnostic Criteria for ADHD

Healthcare workers use the guidelines provided by the American Psychiatric Association’s DSM-5 criterion (Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition). This standard helps in accurately diagnosing the condition and providing the treatment. 

DSM-5 Criterion is discussed below in short form for the information of readers. Only trained mental health professionals can diagnose ADHD and other mental conditions

People with ADHD show consistent symptoms of inattention, impulsivity, and hyperactivity. 

Inattention:

If six symptoms of inattention are present in children below 17 years and five symptoms are present in individuals above or at 17 years for at least six months, then the patient has the inattentive type of ADHD:

  • Fails to provide close attention to details or makes careless mistakes.
  • Has trouble holding attention on tasks
  • Does not listen when spoken to
  • Does not understand and follow instructions and fails to finish work
  • Does not organize activities or tasks
  • Mostly avoids and dislikes tasks that need mental effort for a prolonged period
  • Often loses necessary things like pencils, school materials, wallet, keys.
  • Can be easily distracted.
  • Forgetfulness in daily activities.

Hyperactivity and Impulsivity:

Six or more symptoms of hyperactivity-impulsivity for children up to the age of 17 years, or five or more symptoms of hyperactivity-impulsivity in individuals or adolescents at or above 17 years for at least six months to an extent that it interferes with the normal functioning of life:

  • Often visits and taps hands and feet
  • Squirms in this seat
  • Often runs in situations where it is not appropriate, restlessness.
  • Unable to take part in leisure activities.
  • Is often on the go
  • Talk too much.
  • Blurts out an answer impulsively.
  • Trouble waiting for their turn.
  • Interrupts others when they’re talking or doing something

Conditions:

The following conditions should be met along with the presence of symptoms to diagnose ADHD

  • The symptoms are present before the age of 12
  • Several symptoms are present in more than one setting such as school, at home, or with friends, etc.  
  • The symptoms interfered with the normal functioning of life 
  • The symptoms are not explained by any other mental disorder, such as anxiety disorder, depression, disorder, personality disorder, dissociative disorder, or mood disorder. 
  • The symptoms are consistent and do not appear in an episodic fashion. 

Based on the types of symptoms, the patient is then classified as 

  • Combined presentation: If the symptoms of hyperactivity-impulsivity, and inattention, they present.
  • Predominantly inattentive presentation: If the symptoms of inattention are present, but hyperactivity-impulsivity symptoms are absent.
  • Predominantly hyperactive, impulsive presentation: If enough symptoms of hyperactivity-impulsivity are present, but the symptoms of inattention are absent. 

Rating Scales and Checklists:

Clinicians obtain information from adults, teachers, friends, parents, and others about the symptoms of the patient in various settings through rating scales and checklists. The ADHD-specific rating scales are more accurate in diagnosing children with ADHD, according to the Agency for Healthcare Research and Quality (AHRQ). 

Children and Teenagers Rating Scales:

The rating scales should be filled by more than one important person in the child’s life. For example, his mother, his father, grandparents, daycare provider, or a teacher can fill out the form. It is necessary to have more than one perspective because the behavior of the child is different in different settings, and because of the subjective feelings of the person related to the child. 

The responses to these checklists are not sufficient for diagnosing ADHD, but they form an important part of the evaluation process.

  • Child behavior checklist: It identifies the problematic behavior in adolescents aged from 6 to 18 years. It has a checklist of 120 questions (4).
  • Conners rating scales
  • Vanderbilt ADHD rating scales for parents and teachers containing 45 and 43 questions (6)
  • ADHD rating scale IV which is an 18-item scale. 

Adult Rating Scales

The following scales are used to screen and monitor adults with ADHD. Self-reporting can be subjective; so, it is recommended that significant persons in an adult’s life should also complete the forms. It could be the spouse, the relative, the friend, or the coworker.

  • Adult ADHD Clinical Diagnostic Scale
  • Adult ADHD self-report scale (5)
  • Brown attention, deficit disorder, symptoms, assessment scale for adults
  • ADHD rating scale IV with adult prompts.

Conditions with ADHD-like symptoms

Before diagnosing a patient With ADHD following conditions should be adequately ruled out.

  • Anxiety disorder
  • Depressive disorders.
  • Autism.
  • Epilepsy and seizures.
  • Learning disabilities.
  • Medical conditions that affect the brain like thyroid diseases.
  • Toxicity with lead or lead poisoning
  • Sleep disorders
  • Substance use disorders

What to Expect During an ADHD Screening

If you have an appointment with your mental health, professional, or a clinician regarding ADHD, you should expect the following things during your appointment.

  • You will have to talk in detail about your, or your child’s health, medical history, behavioral attitude, and symptoms.
  • You might have to fill out some questionnaires.
  • Your family members, the teacher of your child, or other relatives might also be asked to fill out some questionnaires.
  • The clinician will perform a general physical exam to rule out other medical conditions.
  • The healthcare providers will spend time with you and your child to observe the behavior.

What Happens After the ADHD Diagnosis?

After the evaluation is done, the healthcare provider will either diagnose you with ADHD or ask for further psychological testing for confirmation. If the clinician diagnosed you with ADHD, he will ask for a follow-up to discuss treatment and therapy. In the cases where the diagnosis of ADHD is not established, the medical health provider will recommend other tests to diagnose the condition. 

What’s Next?

If you’re diagnosed with ADHD, your clinician will discuss comprehensive treatment options with you. According to the CDC, the ADHD treatment plan includes behavior, therapy, medications, and lifestyle modification.

Behavior Therapy

ADHD not only affects the child’s ability to focus but also his interpersonal relationships. The behavior of an ADHD child can be very distressing for the parents and those around him. Behavior therapy helps in reducing and coping with those behaviors. The goal of this therapy is to reinforce positive behavior and eliminate problematic actions. Behavior therapy for ADHD includes

  • Parent training.
  • Behavior therapy with the child
  • Behavioral intervention in the classroom
  • Cognitive behavioral therapy

For children below six years of age, it is recommended to go with behavior therapy to avoid taking any medications. Behavior therapy of parents helps the parents understand how to manage their child and help him in his journey of healing. Parent training and behavior management have worked wonders in ADHD children. Young children have more side effects of medication. 

ADHD Medications

Medications can also help children manage the symptoms from day-to-day life. FDA-approved medications include both stimulants and non-stimulants. 

In children, medications cause side effects. That includes decreased appetite and sleep problems. Some children respond very well to medications, while others do not. Healthcare providers try to avoid medication as much as possible. In the patients who are not responding to behavioral therapy medication becomes necessary.

Advice for Parents

The following suggestions can help your child who is dealing with ADHD.

  • Try to create a routine for your child.
  • Encourage your child to be more organized. Ask him to put his school bag and clothing in the same place.
  • When your child is doing homework or any other activity try to create an environment where there are the least possible distractions. Turn the TV off and make sure that there are no extra noises in that place. 
  • To protect your child from feeling overwhelmed and overstimulated, limit his choices. Just make them choose between one or two things. Do not overcomplicate it. 
  • Listen to your child and make sure that they know that you are listening and understanding.
  • Use positive reinforcement.
  • Instead of yelling, screaming, and spanking try to use rewards to encourage positive behavior, and your child. 
  • For ADHD children, certain conditions are very stressful. Try to help your child by creating positive opportunities for him to apply himself.
  • Make sure that your child is having nutritious food, lots of physical activity, and good quality sleep.

Conclusion

ADHD is a neurodevelopmental disease that cannot be diagnosed by a single medical test, or in a single step. A range of evaluation tests, reading skills, and questionnaires are required to diagnose the condition in children, and in adults. It is important to undergo these evaluations because if accurate diagnosis is not established accurate treatment cannot be given. 

References:

  1. Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2023). Attention Deficit Hyperactivity Disorder. In StatPearls. StatPearls Publishing.
  2. Thapar, A., Cooper, M., Jefferies, R., & Stergiakouli, E. (2012). What causes attention deficit hyperactivity disorder? Archives of disease in childhood, 97(3), 260–265. https://doi.org/10.1136/archdischild-2011-300482
  3. Matte B, Rohde LA, Turner JB, Fisher PW, Shen S, Bau CH, Nigg JT, Grevet EH. Reliability and Validity of Proposed DSM-5 ADHD Symptoms in a Clinical Sample of Adults. J Neuropsychiatry Clin Neurosci. 2015 Summer;27(3):228-36. doi: 10.1176/appi.neuropsych.13060137. Epub 2015 Jun 12. PMID: 26067434.
  4. Achenbach T. Child Behavior Checklist for Ages 6-18. Burlington, VT: ASEBA, University of Vermont. 2001.
  5. Kessler RC, Adler LA, Gruber MJ, Sarawate CA, Spencer T, Van Brunt DL. Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members. International Journal of Methods Psychiatry Research. 2007;16(2):52-65.
  6. Wolraich Ml, Lambert W, Doffing MA, Bickman L, Simmons T, Worley K. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology. 2003;28(8):559-567.