Diagnosing ADHD Takes Time, Insight and Experience

Find out what it takes to make an accurate diagnosis of ADHD in a child.

ADHD cannot be diagnosed and evaluated effectively in the consultation room alone, and it is for this reason that the input of parents and teachers is so important. Rating scales are very useful tools for measuring the extent of the condition, but cannot be used in isolation; a detailed account of the patient's developmental, medical and behavioural history is also necessary. This information, in conjunction with an evaluation of the rating scales and examination makes it is possible to arrive at an accurate diagnosis.

The prospect of having a child with ADHD can be daunting and it is of immense value for parents to be given selected and appropriate literature about the condition and the treatment after the diagnosis has been made, to assist them in understanding and accepting the situation. In the case of an older child, or adult patient, this information should be modified appropriately. To prevent unnecessary stress, the patient should be reassured about the process before the examination.

Prior to the first consultation, teachers and parents complete questionnaires and rating scales. There is often a big difference between the schools' and parents' rating scales. The rating scales are extremely reliable if correctly used. (It is better to use an existing one that has credibility and uniformity, such as the Connor's brief modified rating scale.

To ensure the full co-operation of teachers and parents, questionnaires should not be too elaborate or cumbersome. The parent questionnaire gives information about the family, siblings and marital history, and the child's developmental, medical and behaviour history. The school questionnaire gives information about the academic, social and behavioural history of the child from the school's point of view.

If the patient has been assessed previously, these reports may be useful and should be reviewed.

There is often a world of information to be gained from previous nursery school and school reports. They may suggest poor concentration, restlessness, impulsiveness, aggression, distractibility, poor co-ordination, temperamental behaviour or daydreaming. These reports may also make remarks about underachievement, lack of interest in reading, and heightened interest in subjects like mechanical math, music or art.

Signs and symptoms of ADHD

There are many signs and symptoms to suggest the existence of ADHD and information obtained from the questionnaires will give valuable insight into these, when reviewed in conjunction with the interview and examination.

Prior to nursery school, excessive crying, restlessness, fidgeting, difficult behaviour, colic, food fads, insomnia or restless sleep and frustration are suggestive. Children with ADHD are often late talkers, are sometimes late walkers, and take longer to decide which hand to favour.

At nursery school, colour recognition is often late, but block building is either age-appropriate or advanced; figure drawing is usually immature and lacking in detail, and drawing of geometric shapes may be immature. Language development may also be immature, despite the tendency for ADHD children to be "chatterboxes". Many are left-handed and enuresis is common. In spite of a high IQ, many do not show school readiness at six years of age. Poor concentration, hyperactivity and distractibility are obvious traits of ADHD.

A major concern is that nursery school teachers often see a problem child, consider immaturity, but are reluctant to express their opinion in case they are wrong. A wait-and-see attitude may seem safer for the teacher but it is detrimental to the child. Rating scales from as early as three years of age are very significant and suggestive.

Some children will begin to show a problem only when they start primary school, when auditory concentration becomes important. A child with no impulse control will find it very difficult to sit behind a school desk from eight until one. Poor listening skills, talkativeness, failure to finish tasks and reversal of letters and numbers also feature. It is simply a matter of time before the child becomes the subject of unfair criticism, which leads to disinterest, underachievement, loss of self-esteem ... and unacceptable behaviour. Hyperactivity will become more obvious and, in the inattentive types, daydreaming becomes a major problem.

School reports often reflect better marks in geography, but not in history; better marks in mechanical maths but not in story sums (WHAT DO YOU MEAN BY STORY SUMS?). Word sums which use language/reading to convey the message. Language skills are seldom strong and reading and spelling often presents a problem. Therefore, a disinterest in reading but keenness to play action videos and computer games is hardly surprising.

Older students tend to be better at geometry than algebra. Homework starts to become a "nightmare" ...and real nightmares occur due to stress in the younger child. As underachievement increases and behaviour worsens, the child starts to develop feelings of "nobody loves me". All these problems, if untreated, will continue into high school and are compounded by a growing tendency towards rebellion, disorganisation, depression, delinquency and drug taking. Added to this, a feeling of "I hate everybody" develops and there is a very real risk that the child will become anti social and drop out of school. Adolescent boys tend to show more hyperactivity, while girls display more attention deficit. In neglected cases, it is fairly common for oppositional defiant disorder (ODD) and conduct disorder (CD) to start to manifest.

Consultation

Both parents should attend the first session if possible. After reviewing and discussing submitted information, the parents should be shown a flow chart which illustrates how the evaluation will proceed

Examination

During the first consultation, the patient will be examined for physical features that are indicative of ADHD. The brain and skin are both ectodermal in origin and where there is a genetic, asymmetrical, dysfunctional development of the brain there may also be some unusual development of superficial (skin) organs. There is an increased tendency to have hyperteleorsism (wide nasal bridge) high palate, asymmetrical face, tiny non-dependant earlobes, simian folds in the palms, curved little fingers, webs between second and third toes and unusually wide spaces between the first and second toes and blond electric hair (standing straight up!) . These dysmorphic features are all genetic in origin, are statistically significant but not diagnostic. Checking which hand, foot or eye is favoured will show a greater tendency towards left, mixed or confused laterality in younger patients. There is a natural tendency to use excessive body language such as counting with the fingers. There is also often a mild lack of fine and gross co-ordination, though some ADHD sufferers are superb at sport.

Supplementary testing

IQ, occupational therapy, speech therapy, remedial therapy assessments, EEG, audio testing and eye testing usually are not needed to make a diagnosis of ADHD, but may be required under certain special and unusual circumstances. A simple whisper test and an eye test (illiterate "E") are advisable. Height, weight, blood pressure, pulse and urine testing may be of some value in certain situations but are seldom done routinely.

Correct diagnosis

Vital as it is to make an accurate diagnosis of ADHD, it is equally important not to make a diagnosis where ADHD does not exist. Too many children are either misdiagnosed with ADHD, or miss out altogether on being diagnosed - such tragedies can and must be avoided if these children are to face the future with confidence."

W. J. Levin

About the author: Dr. Billy Levin is a paediatrician with 28 years of experience and authority on ADHD in children and adults. He represented Medical Association on a governmental enquiry into use of Ritalin at Dept. of Health. Dr. Levin has articles published in various teaching, medical and educational journals.

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