ADHD Diagnosis: How is it diagnosed?

The prevalence of attention deficit hyperactivity disorder (ADHD) is steadily increasing across the globe. This neurodevelopmental disorder occurs in both children and adults. Patterns of inattention, hyperactivity, and impulsivity impact every facet of life from school and work to relationships. Receiving an ADHD diagnosis is imperative to managing the symptoms. However, the diagnostic process includes a range of specialized testing. For a mental health professional to confirm attention deficit hyperactivity disorder, they must evaluate through the testing of cognitive skills, intelligence level, behavior scales, and medical tests to rule out other disorders.

What is Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is a mental disorder characterized by inattention, hyperactivity, and impulsivity. An individual with ADHD struggles to focus and pay attention during daily activities. They are overly active and are impulsive—meaning they act without considering the consequences of their actions. Although typically diagnosed in childhood, many adults also suffer from the condition. It is most obvious in school and workplace settings.

There are three types of ADHD:  

1. Inattentive ADHD—The main symptom of inattentive ADHD is inattention, which is characterized by frequent distractions and problems with concentration. Hyperactivity and impulsivity are not as predominant.
2. Hyperactive-Impulsive ADHD—The symptoms of hyperactivity and impulsivity are dominant with inattention being less frequent.  
3. Combined ADHD—The most common type, those with combined ADHD have a combination of symptoms from both categories.

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD)

The symptoms of attention deficit hyperactivity disorder (ADHD) are classified as inattention, hyperactivity, and impulsivity. However, not every individual with an ADHD diagnosis displays them all. The combination of symptoms varies on the type of ADHD.

The symptoms of inattention include:

• Lack of focus—Easily distracted by sights, sounds, and busy environments
• Disorganization—Losing or misplacing belongings
• Poor listening—Does not appear to be listening when spoken to directly
• Problems prioritizing—Time management skills are lacking
• Overlooking details—Making careless mistakes while completing tasks such as homework
• Forgetfulness—Forgetting to do daily tasks like chores, missing appointments, losing or misplacing items necessary for certain tasks
• Delayed information processing—Information processing required to learn is processed slowly in comparison to peers  

The symptoms related to hyperactivity and impulsivity are:

• Excessive talking—Talking constantly
• Talking out of turn—Interrupting conversations, as well as making inappropriate comments
• Restlessness—Squirming, moving, and always “on the go.” Restlessness manifests through fidgeting.
• Easily bored—Dislikes tasks that require long periods of mental effort
• Mood changes—Frequent mood swings and a low frustration tolerance for frustration
• Impatience—Easily bored

Risk Factors For ADHD Diagnosis

There are risk factors that increase the likelihood that someone will develop attention deficit hyperactivity disorder (ADHD). Basic risk factors for an ADHD diagnosis include age, gender, and heredity. Females receive an ADHD diagnoses less often than males. Symptoms tend to originate around 4 to 6 years of age and have a higher chance of occurring in those who have a family member with ADHD or an associated mental disorder.

Maternal factors also influence the potential development of ADHD. Smoking during pregnancy, maternal drug use, exposure to environmental toxins, and a premature birth all impact brain development, which can lead to a child’s ADHD diagnosis.

Who Diagnoses Attention Deficit Hyperactivity Disorder (ADHD)?

DSM-5 Criteria for Attention Deficit Hyperactivity Disorder (ADHD)

For the diagnosis of attention deficit hyperactivity disorder, persistent inattention and hyperactivity and impulsivity must be present. The Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition has proposed a criteria for the diagnosis.

1. Inattention – Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
   • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
   • Often has trouble holding attention on tasks or play activities.
   • Often does not seem to listen when spoken to directly.
   • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
   • Often has trouble organizing tasks and activities.
   • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
   • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
   • Is often easily distracted Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity – Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
   • Often fidgets with or taps hands or feet, or squirms in seat.
   • Often leaves seat in situations when remaining seated is expected.
   • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
   • Often unable to play or take part in leisure activities quietly.
   • Is often “on the go” acting as if “driven by a motor”.
   • Often talks excessively.
   • Often blurts out an answer before a question has been completed.
   • Often has trouble waiting his/her turn.
   • Often interrupts or intrudes on others (e.g., butts into conversations or games)

ADHD Diagnosis: Ruling Out Medical and Psychiatric Causes

Studies show more than two-thirds of people with ADHD have comorbid conditions. During an ADHD evaluation, physicians and mental health professionals run a range of tests to rule out other causes for the patient’s symptoms, as well as to confirm any comorbid disorders occurring with ADHD. Physical problems that mimic the symptoms of ADHD are seizure disorders, brain tumors, and thyroid problems. That is why brain imaging and bloodwork are helpful diagnostics.

Other mental conditions have symptoms that resemble those of ADHD. Bipolar disorder, anxiety disorders, oppositional defiant disorder, and depression are easily mistaken for ADHD and if occurring with ADHD, may complicate the diagnostic process. Treating any of the comorbid disorders is crucial to managing ADHD because it enhances ADHD treatment.

ADHD Diagnosis: Behavior Rating Scales

Aside from a physical examination and ruling out other conditions, behavior rating scales access an individual’s behavior to diagnose ADHD. The majority of behavior scales ask a series of questions to inquire about hyperactivity, inattention, and impulsivity in a variety of settings such as school, work, and at home. Each scale is scored based on the answers.

Childhood Behavior Rating Scales

Children and adults are at different stages of development. Professionals evaluating someone for ADHD chooses the behavior scale given on the age and gender of the individual. Below are the most common behavior scales used for children.

Child Behavior Checklist (CBCL)

The Child Behavior Checklist is created for kids ages 6 to 18. It is completed by a parent or legal guardian who spends the most time with the child. They rate statements of a child’s behavior a 0, 1, or 2—with 0 being untrue and 2 often true.

Conners/Wells Adolescent Self-Report Scale of Symptoms (CASS)

The Conners/Wells Adolescent Self-Report Scale of Symptoms is intended for adolescents between the ages of 12 and 17. It is a relatively new scale that includes a parent report, a teacher report, and the adolescent self-report. This gains insight from multiple perspectives rather than relying on parents and teachers alone.

Pelham-IV Questionnaire (SNAP-IV)

The Pelham-IV Questionnaire is a parent-teacher scale to evaluate the behaviors of children. Statements are rated “Not At All,” “Just A Little,” “Quite A Bit,” or “Very Much.” The statements are thorough—investigating the child’s mood to how they act in a classroom setting.

National Institute for Children’s Health Quality (NICHQ) Vanderbilt Assessment Scale

The National Institute for Children’s Health Quality is for children 6 to 12 years old. It is used to monitor the effectiveness of ADHD treatment when taken before and after treatment. The behaviors it accesses the child’s behavior both on and off medication.

Adult Behavior Rating Scales

Adults have ADHD too. The evaluation for an adult with ADHD is more challenging than it is for children. The questionnaires do not access behavior from numerous perspectives like the childhood scales do. However, behavior rating scales remain an essential for an ADHD diagnosis.

Adult ADHD Self-Report Scale

The Adult ADHD Self-Report Scale is for those 18 and older. The scale is designed with a symptom checklist of symptoms predictive of ADHD. The adult places an X in the box for the frequency of each symptom listed.

Adult ADHD Clinical Diagnostic Scale 

The Adult ADHD Clinical Diagnostic Scale is a series of 18 items based on a clinical interview. The scale reflects current adult ADHD symptoms. Research using this scale confirms that the inattentive symptoms of ADHD persist in adulthood, whereas the hyperactive and impulsive ADHD symptoms decrease in severity with age.

Brown Attention-Deficit Disorder Symptom Assessment Scale (BADDS) for Adults

The Brown Attention-Deficit Disorder Symptom Assessment Scale for Adults can be used as a clinical interview or a self-report of the patient. It asks about the frequency of symptoms in the areas of activation, attention, effort, affect, and memory. It also asks about mood, work and school function, and clinical history.

ADHD Diagnosis: Testing Cognitive Skills

The term “cognitive” refers to cognition, which pertains to the thinking processes. Therefore, cognitive skills are skills the brain uses to think, read, learn, reason, remember, and pay attention. With emphasis on attention, studies published in the Psychiatry Research Journal show that those with ADHD often have deficits in cognitive skills. To receive an ADHD diagnosis, cognitive skills testing provides a baseline of how extensive the disorder interferes with daily functioning.

Intelligence Tests (IQ)

IQ stands for intellectual quotient. As the name implies, IQ testing measures intelligence. ADHD does not alter one’s intelligence. Some with ADHD have an above average IQ, while others possess an average or low IQ. Although ADHD does not directly impact intelligence, IQ testing is helpful for a clinician to omit potential diagnoses contributing to symptoms of inattention, hyperactivity, and impulsivity. For children with ADHD specifically, IQ testing may determine if their academic struggles are related to ADHD symptoms or if poor academic success is due to an intellectual disability.

Diagnostic Considerations For Children

The diagnostic criteria for an ADHD diagnosis specify children and adolescents 4 and older.  Age is an important consideration because levels of maturity influence behavior. For example, a 2 to 3-year-old may be more rambunctious than a 4 or 5-year-old. The normal behavior for an age group need not be mistaken for hyperactivity of ADHD. Another consideration for ADHD diagnosis in childhood is the setting in which ADHD-like symptoms are evident. In many cases, children do not present with symptoms in a clinical setting. The symptoms become prominent in the classroom or at home. Still, the child’s emotional state should be considered. If the child is unhappy at school or experiencing difficulties at home, it can result in behaviors similar to ADHD.

A Parent’s Role In ADHD Diagnosis

Parents have a role during the diagnostic process and in the management of ADHD in children. If a teacher or mental health professional suspects ADHD, parents are informed of the warning signs. They should observe behaviors that indicate the presence of the disorder. Is the child doing poorly in school? How well does the child interact with siblings and peers? Is there often controversy?

Treatment outcomes are successful when the entire family is involved in its management. Parents of children with ADHD should endure their child or adolescent with ADHD is taking their medications appropriately. Additionally, family therapy is beneficial if ADHD symptoms are impairing relationships.

Diagnostic Considerations For Adults

The symptoms of ADHD evolve. While ADHD is prevalent among children, those children with ADHD do eventually become adults. There are also many individuals who are not diagnosed until adulthood. Professionals attempting to diagnose ADHD in an adult look for a different combination of symptoms.

When diagnosing an adult with ADHD, it is important to note that the hyperactivity so prevalent in childhood improves with age. The disorder is not as obvious in adults like it is for younger children in a structured school setting. Adults with ADHD are not as likely to engage in impulsive, risk-taking behaviors that children do. Instead, adults with ADHD continue to struggle with inattention. They have difficulty concentrating and are forgetful. The disorder interferes with normal executive functions and emotional regulation, which significantly affects adult relationships.

Monitoring Progress After ADHD Diagnosis

ADHD is challenging to live with. There is no cure and the diagnosis does not end with finally determining a cause for the symptoms. Managing ADHD requires a combination of medications, behavioral therapy, and education. Stimulant medications target symptoms of inattention and hyperactivity by balancing neurotransmitters in the brain. Cognitive behavioral therapy attempts to identify and change the thoughts underlying problematic behaviors. Educational services teach the patient and their families about the condition and what they can do for optimal treatment outside of a clinical setting. Once a treatment plan is implemented, monthly follow-ups with a physician are recommended to monitor medication dosing, effectiveness, and possible side effects.

Cheyanne Perry

Cheyanne is currently studying psychology at North Greenville University. As an avid patient advocate living with Ehlers Danlos Syndrome, she is interested in the biological processes that connect physical illness and mental health. In her spare time, she enjoys immersing herself in a good book, creating for her Etsy shop, or writing for her own blog.