Best Practices in the Diagnosis of ADHD

With 11 percent of children diagnosed with ADHD, and more than 60 percent of these children taking a stimulant medication, many parents are understandably concerned about clinicians jumping the gun on an ADHD diagnosis. Dozens of psychiatric conditions can explain bad behavior, difficulty in school, or trouble concentrating. And of course, it's a normal part of childhood to be a bit hyper, unruly, and distracted. Stimulant drugs aren't without side effects, and being labeled with ADHD can alter a child's self-concept, not to mention the way he or she is treated by educators and peers. Before you agree to medicate your child, you need to ensure you have the right diagnosis.

At the Rochester Center for Behavioral Medicine, we have developed a standardized approach to the diagnosis and treatment of AD/HD, which we will explore over the next few blogs. Here, I discuss the key components of proper ADHD diagnosis. Although I explore these best practices from a childhood ADHD perspective, the same best practices should be in place when diagnosing adults.

Exploring Developmental History

ADHD tends to steadily develop over time, not suddenly appear. By taking a developmental history, your doctor can determine whether it's ADHD your child is dealing with, or something related to her development or environment. A child adopted at four from an abusive family, for instance, should be expected to have some attachment difficulties and trouble controlling her emotions. If these issues haven't resolved within a few years, medication might be appropriate, but medicating a child who's just suffered a major loss or trauma is rarely effective—or ethical.

Your doctor will ask about when your child hit major developmental milestones, and explore significant life events. He or she will also check for alternative explanations to the problem. A child with hearing difficulties or poor eye movement coordination will be more distracted than a child without these issues, so it's important to report any and all symptoms—not just those pertaining to mental health or academic success.

To get the best results, your clinician should ask objective questions. Rather than asking you whether your child is “hyper,” for instance, it's better if your doctor asks how often your child has trouble sitting still, since this more objective measure can prevent your frustration and exhaustion from coloring the diagnosis.

Using Psychological Assessments

No doctor would diagnose you with diabetes without first evaluating whether you match the profile of a diabetic. But all too often, doctors hear that a child is inattentive and immediately conclude that he or she has ADHD. Psychological assessments compare your child's symptoms to the diagnostic criteria for ADHD. To get the best results, your doctor should use validated psychological rating scales. These tests are scored using gender and age-appropriate norms, giving a clear picture of where your child’s behavior falls compared to other individuals her age.

Getting Input From Loved Ones

When people who love and know your child provide input on your child's behavior, you're more likely to get an accurate diagnosis. You might find, for instance, that grandma has no trouble getting your daughter to sit still, or that a teacher thinks your child is a gifted student. When loved ones have different opinions of your child's behavior, this can provide insight into better management strategies. It can also help you avoid a misdiagnosis.

Assessing for Other Disorders

In some kids, depression looks a lot like distraction. The panic and fear associated with PTSD can cause hyper behavior, while anxiety disorders may compromise your child's ability to focus. Don't assume your child has ADHD just because he or she is hyper. A good doctor should screen your kid for a host of other common conditions. Don't be surprised if you get multiple diagnoses; it's common for kids with ADHD to get depressed or anxious, and proper treatment requires treating all conditions—not just the most prominent one.

Prioritizing Treatment

The fact that your child has ADHD does not necessarily mean he or she should go on stimulant medication. Good doctors should explore treatment options, prioritizing the most problematic symptoms. Some steps your doctor should take include:

• Addressing lifestyle remedies, such as diet and exercise, may help.
• Offering parenting advice. Children with ADHD respond very well to healthy environments, but tend to flounder in dysfunctional, abusive, or excessively permissive settings.
• Offering insight into which educational accommodations might be appropriate for your child.
• Exploring which symptoms are the most problematic, then offering interventions specifically tailored to those issues.
• Asking about your child's medical history, thereby making it possible to choose the most effective—and safest—medication.
• Starting your child with a low dose of medication, rather than adding multiple drugs at once.

ADHD Essential Reads

Living With and Learning From Inconsistent Behavior in ADHD

ADHD as Dimensional

ADHD is treatable, so if you're not getting the results you want, talk to your clinician or seek a second opinion.