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Symptoms of ADHD

If a child or adult has had problems in school, at home, at work, or in social activities for at least six months and if these problems appear to be related to inattention, hyperactivity, or impulsivity, an evaluation for ADHD should be considered. The child or adult should meet the criteria for this condition as published in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM IV) published by the American Psychiatric Association in 1994. Below is a list of the eighteen symptoms found in the DSM IV.

Symptoms of inattention

Symptoms of hyperactivity

Symptoms of impulsivity

The presence of six or more symptoms under the category of inattention or hyperactivity and impulsivity may indicate a problem if they occur frequently, result in impairment, and are not caused by other conditions.

American Academy of Pediatrics Guidelines for Assessment of ADHD

In 2000, the American Academy of Pediatrics (AAP) published guidelines for doing an assessment of ADHD. Among its recommendations were: (1) the primary care clinician should initiate an evaluation of children ages 6 to 12 who present with inattention, hyperactivity, or impulsivity; (2) the diagnosis of ADHD requires that a child meet the DSM IV criteria; (3) the assessment requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset of symptoms, duration of symptoms, and the degree of functional impairment; (4) the assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional); (5) the assessment should include evaluation for associated conditions; and (6) other diagnostic tests are not routinely indicated to establish a diagnosis of ADHD but may be used for the assessment of co-existing conditions (e.g., learning disabilities, mental retardation).

The AAP recommended that specific questionnaires and rating scales that have been developed to assess the behavioral characteristics of ADHD be used in the assessment process. These scales can accurately distinguish between children with and without the diagnosis of ADHD, however, they must be interpreted in the context of the overall evaluation of the child. Furthermore, the AAP recognized that the child’s classroom teacher typically has more information about he child’s behavior than other professionals at the school, and should whenever possible, be contacted to provide information about the child. This information can be obtained through narrative reports (oral or written), questionnaires, or rating scales and any reports should focus on the presence of the core symptoms of ADHD. Furthermore, for children who are educated in their homes by parents, evidence of the presence of core symptoms in settings other than the home should be obtained. When a child spends considerable time in other structured settings (i.e., after-school care) additional information should be sought from professionals in those settings.

Since other psychological and developmental disorders are frequently found to coexist in children who are evaluated for ADHD, the evaluator should consider the possible presence of such coexisting conditions. This may include conditions such as parent-child interaction problems, motor disabilities, speech and language disorders, oppositional disorder, conduct disorder, learning problems, anxiety disorder, depression, etc. The child may be referred to specialists in these areas for more comprehensive assessment.

According to the AAP, other diagnostic tests such as thyroid function tests, brain imaging studies, electroencephalography, and continuous performance tests contribute little to establishing the diagnosis of ADHD

Who is Qualified to Conduct an ADHD Assessment?

While the guidelines discussed earlier are geared for primary care physicians doing an assessment for ADHD, such an assessment may be done by other health professionals. For parents who are seeking an evaluation, it is best to find professionals who are knowledgeable about ADHD and who have experience evaluating and treating those with ADHD. More than one professional is typically involved in the assessment process for ADHD. Physicians, clinical psychologists, school psychologists, clinical social workers, speech-language pathologists, learning specialists, and educators may each play an important role in the ADHD evaluation.

The physician’s role: The physician will start by taking a history. In the case of children or adolescents, both parents should be present to provide the doctor with information. The history may alert the doctor to health problems, which could account for the development of ADHD symptoms. Information about the pregnancy and delivery including maternal health during pregnancy, use of alcohol, smoking, toxemia or eclampsia, postmaturity of the fetus, and extended labor should be reviewed. Detailed information about the early development of the child, educational progress, and behavior at home, at school, and within the community are essential parts of the history. Furthermore, the doctor should collect information about family relationships with particular concern to any stresses on the child, which could affect behavior and performance.

Routine physical examinations of children with ADHD are often normal, nevertheless they are necessary to rule out the unlikely possibility of there being another medical illness, which could cause ADHD-like symptoms. Vision or hearing deficits should be ruled out. The physician should look out for other medical conditions that might predispose the child to ADHD including fragile X syndrome, fetal alcohol syndrome, and phenylketonuria. Although no specific laboratory test is available to diagnose ADHD, the physician may want certain laboratory tests done to determine the overall health of the child or adult. Tests such as chromosome studies, electroencephalograms (EEGs), magnetic resonance imaging (MRI), or computerized axial tomograms (CAT scans) are not to be used routinely for evaluation of ADHD.

Psychiatrists and neurologists, trained in the assessment and treatment of ADHD, may play an important part in identifying this condition as well as other possible related conditions such as learning disabilities, Tourette’s syndrome, pervasive developmental disorder, obsessive compulsive disorder, anxiety disorder, depression, or bipolar disorder.

The psychologist’s role: The clinical or school psychologist administers and interprets psychological and educational tests of cognition, perception, and language development (such as intelligence, attention span, visual-motor skills, memory, impulsivity), as well as tests of achievement and social/emotional adjustment. Results of such tests provide important clues as to whether a person’s difficulties are related to ADHD and/or other problems with learning, behavior, or emotional adjustment. Psychologists and other mental health professionals often integrate data collected from parents and teachers who complete behavior rating scales about the child. Most of the rating scales used to assess ADHD provide standardized scores on a number of factors, usually related to attention span, self-control, learning ability, hyperactivity, aggression, social behavior and anxiety. Remember, there is no test for ADHD. Even though psychological and educational testing can give you a better picture of the person’s strengths and weaknesses, satisfactory performance on these tests does not rule out ADHD.

The school’s role: Public schools are required by federal law to evaluate students suspected of having a disability The law (Individuals with Disabilities in Education Act) requires schools to follow specific procedures and standards to perform such evaluations. Frequently, the evaluation process is either initiated by the teacher or the parent. A child study team, made up of school personnel such as the guidance counselor, a learning specialist, the principal or his designee, one or more of the student’s teachers, or others at the school, will meet to discuss the student. As a first step in the assessment process, the child study team will collect information about the student from his parents and teachers. If this information indicates that the student is showing signs of a disability, further assessment may be done by the school psychologist and other school professionals. Assessments should always include information about the student’s current and past classroom performance, academic skill strengths and weaknesses, attention span, and other social, emotional, and behavioral characteristics. Such information can be gathered through teacher interviews, review of cumulative records, analysis of test scores, and direct observation of the student in class. Assessment data enables the school to determine the needs of the student. The student may be eligible for special education and related services or for a 504 Plan that provides accommodations in the regular classroom.

The parents’ role: Having witnessed the child in a variety of situations over a number of years, parents have a unique perspective on the child’s previous development and current adjustment. This information is usually acquired by interview or through questionnaires. The parent also plays an important role in driving the assessment process so that no unnecessary delays occur and that the child receives a thorough assessment by qualified professionals. If there is any doubt that an appropriate assessment was done, the parent should speak to the professionals involved. Get a second opinion if you are unsure of the findings.

The child’s role: An interview with the child offers the clinician an opportunity to observe the child’s behavior first-hand and can yield valuable information about his/her social and emotional adjustment, feelings about him/herself and others, and attitudes about school and other aspects of daily life.

In comparison to young children, adolescents and adults are better able to tell the clinician if they are having problems with attention span, self-control, restlessness, organization, or other difficulties. They can describe the situations in which such problems most often occur and to what degree they impair functioning. Moreover, they can complete self-report rating scales, which yield quantifiable information about difficulties they are experiencing. Observations of the person’s behavior during interviews, such as their level of activity, attentiveness, or compliance, should not be noted as typical of their behavior in other settings. Normal behavior in a one-on-one setting does not diminish the likelihood of the person having ADHD.

Assessment for ADHD in Adults

The lack of consensus as to the criteria for diagnosing ADHD in adults makes assessment particularly challenging. Evaluators of adults should consider history of symptoms in childhood along with current symptoms and levels of impairment. Much, if not all, of this information will come from self-report by the adult being evaluated. The clinician should follow these steps: (1) obtain a developmental history with emphasis on past school performance and evidence of core symptoms of ADHD through development. (attempt to corroborate information obtained by reviewing other sources such as past report cards, spousal reports, parent reports); (2) inquire about the impact of core symptoms of ADHD on current performance in the workplace, in school, and social relationships; (3) assess for the presence of other psychiatric or medical conditions that could cause inattention, hyperactivity, or impulsivity. A number of self-report and other-report ADHD-specific rating scales have been developed to evaluate the presence of ADHD in adults.

After the Assessment

Ideally, assessment data should lead to a thorough understanding of the individual’s strengths and areas of need. If a diagnosis of ADHD and/or other disorders is made, treatment planning should include all areas where interventions are recommended. The physician may discuss appropriate medical interventions with the adolescent and parents. The psychologist or other mental health professionals may discuss counseling, behavior modification, or social and study skills training options. The school may set up classroom interventions to accommodate the adolescent’s areas of need in school or may provide special education or related services. Some or all members of the assessment team may become part of the treatment team, which is responsible for managing the treatment of the individual.

Getting an assessment for ADHD can be a tedious and time-consuming process, especially if the person is in crisis and needs immediate attention. It is advisable to get copies of all the evaluations and treatment recommendations made by the professionals involved. Maintain these records carefully because they may be needed to by other professionals or schools in the future. Coordination of this information and services, whether it be by a parent or a professional on the assessment team, is no easy task, but the outcome is usually well worth the effort.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Academy of Pediatrics. (2000). Clinical practice guidelines: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. J. of the Amer. Acad. of Pediatrics, 105 (5), 1158-1170.

Searight, H. R., Burke, J. M., & Rottnek, F. (2000). Adult ADHD: Evaluation and treatment in family medicine. American Family Physician, Nov. 2000.

Recommended Reading

Barkley, R. A. (2000). Taking Charge of ADHD. Revised Edition. New York: Guilford Press.

DuPaul, G. J., & Stoner, G. (1994). ADHD in the schools. New York: Guilford Press.

Hallowell, E., & Ratey, J. (1994). Driven to Distraction. New York: Pantheon.

Nadeau, K. G., & Quinn, P. (2002). Understanding women with AD/HD. Silver Spring, MD: Advantage Books.

Solden, S. (2002). Journeys through ADDulthood. New York: Walker & Company.

For more information about ADHD go to myADHD.com Library Tools.

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