To create a uniform process for diagnosing ADHD among school-aged children, the AAP has created a list of standard guidelines for pediatricians to follow in evaluating a child reported to be inattentive, hyperactive, impulsive, underachieving academically, or having behavioral problems.
These guidelines are based on a systematic review of the latest evidence about the prevalence of ADHD, coexisting conditions, and the diagnostic procedures most commonly used. You should expect your child’s pediatrician to follow these recommended steps or a procedure much like them.
The evaluation process will most likely require at least 2 or 3 visits to the doctor, possibly longer sessions with the pediatrician than you may be used to, and the filling out of a number of questionnaires, checklists, and other standard diagnostic tools. Your child’s pediatrician may also ask you to forward questionnaires or ask the teacher to write a brief statement about your child’s behavior and learning in the classroom before your first visit to make the initial interview more productive.
Your child’s pediatrician will start by listening to your observations and experience with your child’s behavior and the difficulties that you have observed him having, along with your explanations of why you think (or do not think) that they may be related to ADHD. In addition to examining written reports from teachers, school counselors, or caregivers, she may ask you to relate what you have been told about your child’s behavior in school and in his other daily settings outside the home. In many cases, parents’ and teachers’ opinions about a child differ significantly. This is all right and not unexpected. Your child’s pediatrician will be prepared for this possibility and will listen carefully to reports from both “camps.” She may ask to speak with other adults in your child’s life (your spouse or partner, former teachers, coaches, or others in your community) to gain a broader impression of the types of problems your child may be experiencing.
Do not be surprised if your child’s pediatrician seems to rely much more on these reports than on her own observation of your child. Children with ADHD do not necessarily exhibit symptoms of the disorder while in the doctor’s office, so she will not expect to see them. (Keep in mind that ADHD, an attentional disorder, usually manifests itself in routine or monotonous situations, and visits to the doctor’s office tend to be stimulating and outside of a child’s usual routines.
Likewise, though she will perform a physical examination, she will not rely on this to indicate whether ADHD is present because there are no physical findings that by themselves verify ADHD, but will look for signs of medical conditions that can be associated with symptoms of ADHD. Your physician will carefully review your child’s and your family’s medical history for ADHD, related disorders, and other medical conditions that can have ADHD-like symptoms. Because ADHD has been shown to run in families, the discovery that you or other relatives have experienced ADHD-specific or similar symptoms may help point the way toward an accurate diagnosis.
Once your child’s pediatrician has collected as much information about your child as you can provide and taken a family medical history, she will move on toward the first of what may be a series of structured questions, checklists, and evaluative procedures to identify his specific problems. She may ask your permission to have your child’s teacher speak to her and complete some rating scales as well. This should be encouraged because the best treatment program will begin from as complete a view of your child as possible in many life settings. Other medical or mental health professionals to whom your child’s pediatrician has referred you may also administer parts of the evaluation.
The AAP advises health professionals to begin with determining whether your child’s behaviors match those considered necessary for making the diagnosis of ADHD. The behaviors comprising the “diagnostic criteria” for ADHD are set out in the manual Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), developed by the American Psychiatric Association. This manual is presently considered the gold standard for professionals who diagnose behavioral and emotional disorders.
The DSM-IV-TR lists 9 typical behaviors that apply to each of 2 subtypes of ADHD: predominantly inattentive type and predominantly hyperactive-impulsive type. A child whose symptoms are significant and match at least 6 of the 9 behaviors described for each subtype is at risk for and may be diagnosed as having that disorder. A child with 6 or more matches in both categories is at risk for and may be eventually diagnosed as having a third subtype of ADHD: combined type.
Children and adolescents can only be diagnosed as having ADHD if
Some of their symptoms were present before the age of 7 years.
The symptoms have been observed to interfere with the child’s functioning in 2 or more major settings, like at child care or at school.
The behaviors significantly impair the child’s ability to function in academic or social situations.
The symptoms cannot be accounted for by another condition, either physical or mental, such as head trauma, physical or sexual abuse, depression, substance abuse, or a major psychological stress in the family or at school.The symptoms have been present for 6 months or more, and are more pronounced than for most children at the same developmental level.
Of course, all children exhibit many of these behaviors some of the time. Still, by considering to what extent such behaviors interfere with the child’s ability to function at home, in school, and in social settings, your child’s pediatrician or other health professionals can begin to arrive at a better idea of whether ADHD is the best explanation for the problems.
As you have learned, it is necessary to differentiate behavior that is age-appropriate from behavior that strongly suggests a full diagnosis of ADHD. As you and your child’s pediatrician consider these detailed descriptions of different types of behavior, you can develop a better idea about whether his behaviors are typical for his age, represent problems that need to be addressed, or signal the likelihood of ADHD. Pediatricians and other experts rely on knowledge about how ADHD-type behaviors are expressed at different ages.
Knowing that your child’s behaviors meet criteria for ADHD does not necessarily pinpoint the areas that cause her the most difficulties in her day-to-day functioning. Yes, using the criteria for making the diagnosis is important, but establishing the ADHD diagnosis is just the first step. A second major aim of an evaluation is to describe the problems caused by the ADHD behaviors specifically enough that they can be translated into a treatment plan. Your pediatrician will ask specific questions of you and your child to determine “functional impairment”—that is, the condition’s impact on her day-to-day life. The functional impairments associated with ADHD include difficulties interacting positively with family members; keeping friendships; problems with social skills, academic achievement, and following household rules; issues regarding self-esteem and self-perception; and problems with accidental injuries. Your pediatrician’s recommendations for a treatment program for your child will depend to a large extent on these functional difficulties, and they will become the main “targets” for treatment.
As you and your child’s pediatrician work through these detailed descriptions of different types of behavior, your child’s problem areas should become increasingly clear. Some of these may fall out of the usual difficulties expected as a result of ADHD alone. Pediatricians, parents, teachers, and other members of a child’s support team must thoroughly consider other environmental, situational, and emotional factors that may be influencing or causing these behaviors.