There is no Test for ADHD: Diagnosis Starts Here

6-15-15 Wiley, James HS

“I got tested and I’m ADHD.”

Whenever I hear people say that, I want to correct them. Twice!

First, the language of that sentence stigmatizes people with ADHD. I want to say to them, “No, you’re not ADHD.  You have ADHD. You are a person!  You have talents, interests, a unique personality that all make you who you are, and that’s much more important than a diagnosis! ADHD is a neuro-genetic disorder that affects you, but never let it define who you are!”  

Second, as a pediatrician who specializes on working with children with ADHD, I want to scream from the rooftops: there is no test for ADHD!

There is No Test for ADHD

This comes as a particular surprise to parents who have spent thousands of dollars for Psychoeducational testing or Neuropsychological testing, both of which are commonly referred to as ADHD testing (explained very well by psychologist Andy Gothard, PsyD in his article “9 Key Things to Know about Psychoeducational Evaluations.”)

Although this testing is considered essential by some, it is not recommended as part of an INITIAL evaluation for ADHD by either The American Academy of Pediatrics or The American Academy of Child and Adolescent Psychiatry.

Psychologists and educators do this testing to look for learning disabilities, processing and working memory issues, and psychological conditions that can mimic ADHD or occur right along side it.  One way to look at it is testing for everything except ADHD!  

How do you “test for” ADHD?

ADHD diagnosis is made not by this or any other type of testing, but by meeting the five criteria for the disorder in the Diagnostic Statistical Manual, 5th Edition.  The DSM 5 is the rule-book used by clinicians to establish diagnoses for ADHD and other mental health disorders.

The first course of action to test for ADHD is to find a clinical psychologist, educator or physician who knows ADHD well, and then let him or her get to know your child well enough to determine if the DSM 5 Criteria are met.  The degree or specialty of the professional is not as important as his/her working knowledge of ADHD and the other conditions that mimic and co-occur with it.

The ADHD diagnostic criteria are:

A. 6/9 inattentive symptoms and or 6/9 impulsive/hyperactive symptoms that have been present for   at least 6 months
 and occur more often than age appropriate
B. Symptoms starting before age 12
C. Symptoms occur in two or more environments (e.g. home, school, socially, other activities)
D. Symptoms clearly interfere with or reduce the quality of academic, social or occupational function
E.  Symptoms are not better explained by another diagnosis

Here are some guidelines for assessing whether, based on the criteria above, your child qualifies for a diagnosis of ADHD.

A. Evaluating Symptoms
It is important that an evaluation be performed by someone looking at the whole child, including his/her home and school environments – someone with a thorough enough knowledge of ADHD to take into account the potential pitfalls of Rating Forms.

Rating Forms are a tool often given to teachers and parents to evaluate the presence of symptoms. When rating forms are consistent and every one is on the same page, they can be quite helpful in determining the number and frequency of ADHD symptoms.

However, scores on rating forms can vary widely, and they are inherently subjective and prone to bias, a particular challenge since variable performance is a hallmark of ADHD! For example:

  • Parents and teachers who are frustrated with a child’s behavior may overstate symptoms
  • Parents and teachers in denial or biased against ADHD may understate symptoms
  • Sometimes parents don’t even agree on the child’s symptoms, or how often they occur
  • Most children have 2 to 6 teachers in a day, and parents often have different roles with their children, so there is frequently quite a bit of variation between observers:
    • The teacher of a child’s favorite subject may experience very different behavior from the teacher of a child’s least favorite subject, who experiences that child as disinterested, apathetic or lazy.  
    • A non-custodial parent may give a very different rating form from the parent who has to make sure homework gets done every night!

Like IQ and achievement scores, Rating Forms can be both helpful or misleading, so a well-informed professional is important.

B and C. When Symptoms Occur

When symptoms occur, Criteria B and C above are more straightforward to evaluate.  It is important to note, however, that while the patient should have some of the eighteen symptoms by age 12, they may not be causing impairment by that age. Many bright kids with good supports at home and school can make it through to high school, or even college or graduate school, before symptoms become impairing enough to interfere with or reduce their quality of life.

D. When Symptoms Interfere with or Reduce the Quality of Life

Impairment of function is another criterion that is subjective and requires a well-informed examiner to define.  Patients making good grades or receiving advanced degrees are often told they don’t have ADHD because they are successful.  Not necessarily true!  

What is the cost of those good grades?  What is the stress level on the individual and family?  How would the grades look if the patient’s parents backed off to usual parental supervision, instead of managing every detail of the child’s school performance?

In addition, school is only one measure of impairment.  How are the child’s executive function, time management, and emotional/social functioning?  Are there excessive accidents or safety issues arising out of inattention and impulsive behavior?

E. Not Better Explained by Something Else (Process of Elimination Diagnosis)

The list of things that can look like ADHD is long. To make diagnosis more complicated, these disorders can be the primary cause of the patient’s symptoms INSTEAD of ADHD, or they can occur right along WITH ADHD.  

The best examples are dyslexia and anxiety.  

Dyslexic kids often have many of the same processing and executive function problems that inattentive kids have. Very few of them will pay attention in school, for example, because every time they look at their paper it looks like a foreign language. But while dyslexia can be misdiagnosed as ADHD, many dyslexics HAVE ADHD, too!  

Similarly, Anxiety disorders cause problems with attention because when the brain is processing anxious or obsessive thoughts, it is really hard to simultaneously pay attention to the math teacher. Anxiety can also cause irritability and fatigue that can look very much like impulsive behaviors. Like dyslexia, anxiety can mimic ADHD, or show up along side it.  

Other examples of diagnoses that can seem to copy-cat or occur with ADHD include: sleep disorders, depression, PTSD and Autism.

What’s a Parent to Do?

Careful consideration of the DSM 5 is the key to sorting out a proper diagnosis of ADHD. But the process needs to allow time to consider all of the patient’s symptoms, not just the inattentive, hyperactive and impulsive ones.   

Like most chronic disorders of childhood, ADHD diagnosis is best made by carefully listening to the patient’s history, rather than performing tests. Like blood tests and X-rays can be helpful for confirming and monitoring other chronic illnesses of childhood, traditional Psychoeducational or Neuropsychological testing can be helpful, especially when the history suggests additional information is indicated. But in most cases, it’s not the first place to start.

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