ADHD Diagnostic Criteria Made Easy

Diagnostic Criteria for Attention Deficit Hyperactivity Disorder

The following is a practical summary of the DSM-IV criteria for Attention Deficit Disorder. The actual criteria for "Attention Deficit Hyperactivity Disorder" is available in the DSM-IV manual.

Symptoms of INATTENTION in ADD ADHD

• A lot of people, including his parents, complain that he just doesn't seem to listen when spoken to;
• Because of not sustaining attention, or because of acting like a "space cadet," he doesn't finish his chores or homework;
• He can't keep his mind on what he's doing for very long unless it is very exciting, or very entertaining;
• He doesn't pay close attention to what he's doing, so he makes a lot of careless mistakes. Video games are an exception because they give immediate feedback, they are exciting, and they are fun. Chores and homework are not. The inattention is seen most with homework, chores, and other boring things that you want him to do;
• He's really disorganized. Most commonly seen in spending three hours to finally finish his homework, then losing it at school (it’s in his backpack), or forgetting to turn it in;
• He really tries to avoid doing homework or chores;
• He gets distracted easily, or pays attention to the wrong thing;
• He is often forgetful and has to be reminded to do things often.

Symptoms of IMPULSIVITY in Attention Deficit Hyperactivity Disorder:

• He often blurts out answers in class;
• He can't wait his turn when he is playing games or at school;
• He interrupts others a lot, he just doesn't wait well;
• He tends to do things without thinking about them first;
• He does not consider the consequences of his actions.

Symptoms of HYPERACTIVITY in Attention Deficit Hyperactivity Disorder:

• He has happy hands and feet which fidget and squirm a lot;
• He just can't stay in his seat for very long when he's supposed to at school or the dinner table;
• He may run around too much, or climb on things he's not supposed to;
• Is too loud;
• He is "On the go" as if he is "driven by a motor";
• He talks too much;
• Leaves footprints across the ceiling

Important: At least some of these symptoms must have been seen before the age of seven.

Also Important: At least some of the symptoms are seen both at home and at school.

Also Also Important: These behaviors are really a problem. Not just a little bit, but a lot.

For a diagnosis of Attention Deficit Hyperactivity Disorder, Inattentive Type:

• Six or more from the Inattention list.

For a diagnosis of Attention Deficit Hyperactivity Disorder Impulsive-Hyperactive Type:

• Six or more from the Impulsive or Hyperactive lists.

For a diagnosis of Attention Deficit Hyperactivity Disorder Combined Type:

• Both criteria are met.

WARNING:
Attempt at legal disclaimer. This is just for your information. We want you to know that there are several reasons why a child could have these symptoms besides Attention Deficit Hyperactivity Disorder. For example, thyroid problems, depression, anxiety disorders, hearing problems, and so on. Please do not attempt to "diagnose" your child. Follow the steps in the Diagnosis section. See your doctor. Go to a qualified mental health professional. This web site is no substitute for talking with an expert on ADHD.

ADHD: Steps to a Good Diagnosis

Diagnosing ADHD | the Work-Up

Here are the things that we recommend if you have a child that ought to be looked at for possible Attention Deficit Hyperactivity Disorder:

1. PHYSICAL EXAM - First, there should be an "adequate" physical exam by the child's pediatrician or family practice doctor. This doesn't have to be an extensive, expensive exam, but should be able to rule out possible problems like Mononucleosis, Thyroid problems, lead poisoning (if it is common in your area), and potential attention problems caused by medications, such as allergy medications. Then, with a clean bill of health, we move on to step two. . .
2. EVALUATION FOR ADHD - Get an evaluation for attention deficit hyperactivity disorder. Usually a psychologist or other mental health professional will do this evaluation for ADD ADHD. The evaluation would include at minimum:
   • Parent Interview
   • Parent Rating Scales
   • Teacher Interview if possible
   • Teacher Rating Scales
   • Child Interview
   • Testing with Child

   We look at this process in more detail in the next article.

3. HOW TO FIND AN EXPERT - To find experts on attention deficit hyperactivity disorder in your area you will have to ask around a bit. Ask other parents at your local CHADD chapter. Or call your local Psychiatric Hospital and ask for the Child or Adolescent Unit. Then ask for the "Charge Nurse." Ask the Charge Nurse who the best child psychiatrists, psychologists, and therapists in your town are. They know.
   
   

   Note: Only get counseling or therapy from professionals who have a lot of experience treating attention deficit hyperactivity disorder. Therapists who do not have a lot of experience with ADD ADHD will just take your money and then, out of their lack of understanding, probably blame you, the parents, for the child's ADHD.

Evaluation for ADHD

ADHD Evaluation Process

Here is the process that we believe makes for a good diagnostic evaluation to see if someone has ADHD or not:

PARENT INTERVIEW

When you get an evaluation for attention deficit hyperactivity disorder, there should be a good parent interview. It's absolutely essential that somebody sits down with the parents and spends 45 minutes to an hour with them.

In this interview the psychologist or therapist needs to find out what's going on now, why did the parents pick up the phone and call now instead of last week, and so on. Was there a recent trigger event? A recent trauma? A recent loss? Or is there a problem at school, or a threat from the teacher? What is happening that you had to call for help?

DEVELOPMENTAL HISTORY

A good developmental history must also be taken. Important questions are:

• How did mom do during pregnancy?
• Were there any problems at all during pregnancy?
• Was there any exposure to drugs or alcohol prior to birth?
• When did he learn to walk or crawl?
• How about speech development, any problems?
• Did he have very many ear infections?
• Have there been any head injuries, high fevers, or seizures?

Head injuries and seizures can look just like attention deficit hyperactivity disorder, but aren't. They may require different treatment options.

FAMILY HISTORY

The family trees of Attention Deficit Disorder kids are often very similar. It seems that about 80 percent of the time one can trace the impact of this gene, either the "ADHD" gene or the "Tourettes" gene, as it runs through families causing things like obsessive-compulsiveness, depression, alcoholism, attention disorders or learning disabilities throughout the family.

OTHER CONDITIONS

The clinician must take the time to rule out a long list of other possibilities:

• Is child depressed?
• Does he have anxiety problems?
• Is he hallucinating?
• Is he delusional?
• Is it a head injury?
• Is it a seizure disorder?

PARENT RATING SCALES

Parent rating scales are very good and should be given. The ADD ADHD scales we like best are by Ned Owens out of Texas. Keith Connors has a fine tool that you have probably seen if you are involved with ADHD children at all. It is very important for the parents to fill out these behavior rating scales.

TEACHER RATING SCALES

Ideally the teachers will fill out rating scales also. You want the teacher's input because they see 30, 32, or 35 kids every single class, year in and year out, and they know what is normal behavior and what is not.

Note: One of the things we have noticed is that lately we are having more trouble with the teacher rating scales because the teachers ten years ago, eight years ago, five years ago used to rate the kids pretty reliably compared with the “normal” kids in the class (the non-ADD kids in the class).

But what we are seeing lately is very often the teachers are comparing the child that we want rated against the “worst kid” in the class, who might be totally off the wall. When this happens the rating scale often comes back reporting that the child rated isn't much of a problem at all. We have to give specific directions to the teachers to rate them compared to "normal kids," not against the “worst kids” in the class.

CHILD CLINICAL INTERVIEW

Also, an in-depth clinical interview with the child is essential. This should last 45 minutes to 60 minutes, and should touch on about a dozen different areas with about 100 questions.

This interview is needed to determine the child's reality testing, his degree of maturity, his degree of verbal skills, and so on.

As part of this interview the child should be asked about his world, his relationship with peers, with parents, with school.

Is there some reason that the child can think of that can explain why he cannot focus, concentrate, get his work done, or pay attention?

The child should be asked if he's anxious. Some kids have tremendous fears, but have not shared them with anyone.

The child should be asked questions that would reveal if the child is depressed.

The child should be asked if he's hallucinating. Sometimes he is, but he hasn't told anyone. A small percentage of children and teens can hear or see things that no one else does for a variety of reasons, some are very serious and some are less so, but the question should be asked.

There is a lot going on with kids that their parents are not aware of, so the kids should be asked.

Psychological Testing for ADHD

Diagnosing ADHD with Psychological Testing

Psychological testing as part of an evaluation for Attention Deficit Hyperactivity Disorder - ADD ADHD - can be helpful.

Tests such as the WISC-R, which is an IQ test, the Wide Range Achievement Test (WRAT), and the Bender-Gestalt test, which is a visual motor integration test, can be helpful within limits.

There are certain patterns of strengths and weaknesses that one might predict to find on these tests if the subject had ADHD. But it's as much art as science. The patterns are not "diagnostic" for Attention Deficit Hyperactivity Disorder. They just may be "consistent" with ADHD.

It's also important as a part of the evaluation to know the subject's IQ level. If the kid has a real low IQ, or a major learning disability shows up, it could be a clue that there is something else going on instead of attention deficit hyperactivity disorder.

So we find these tests helpful, but not specific for ADHD.

TOVA TEST for ADHD

The Test of Variables of Attention (TOVA) is the most helpful test that we found for the diagnosis and treatment of ADHD, but even it is never used in the diagnostic process without the interviews, rating scales, physical exam, or perhaps some other testing. But it is a good tool in the evaluation process.

The TOVA is an extremely boring computer test that requires the kids to respond to a target stimulus by pressing a button, or to not respond when there's a non-target stimulus.

The fact that it is so boring is a work of genius because it helps to differentiate between kids who have trouble with "boring," and kids who do all right with "boring."

The TOVA is really a valuable tool, but it should never be given just by itself. It needs to be given in the context of the whole diagnostic workup.

Getting a TOVA Baseline

TOVA is given with no medication in the diagnostic process. And part of its value is that if medication is considered at some point, the test can be re-administered with a "challenge dose" of medication in their system. This can tell the physician if the subject is a "responder" to that particular medication or not, or how well he responds to that particular dose of that particular ADHD medication.

Clinical Observation for ADHD at School

Clinical observation of the child is very important. If possible, ideally, somebody observes the child in the classroom.

In the real world, we don't know anybody in private practice who can go out in the classroom to observe a child these days, but if a school nurse or school psychologist can go observe them, it can be very, very helpful.

EEG and ADHD

Obtaining an EEG from a neurologist is rarely helpful in the process of diagnosing ADHD.

EEGs will show that there are differences between the brainwave patterns of those with ADHD and those without ADHD. Typically there is excessive slow brainwave activity, particularly in the Theta band (4-7 Hz.).

However, ninety-five percent of all Attention Deficit Hyperactivity Disorder kids have what the neurologist will call "normal" EEGs.

What we mean by "normal" is they don't have big epileptic seizure spikes, or indications of tumors or head injuries, that a neurologist would say are "abnormal."

But when compared side by side with a non-ADD person, the EEGs are much different if the subject has ADHD.

An EEG may be helpful if the child is going to be treated with EEG biofeedback, but in terms of being helpful for a diagnostic work-up, it is rarely helpful.

However, if the parent interview revealed that the child had some potential neurological problem, as seen in sleep walking, or a history of seizures, and so on, then an EEG would be a good idea.

Summary of Diagnostic Evaluation for ADHD

An adequate diagnostic interview, designed to give an accurate diagnosis a very high percentage of the time, while not costing the family thousands of dollars, would look like this:

• Physical Exam - Office Visit
• Clinical Interview - Parents (45-60 minutes)
• Clinical Interview - Child (45-60 minutes)
• TOVA test
• Parent and Teacher Rating Scales
• Office visit to review information and develop a treatment plan
• Other testing if there were still questions to be answered
• Begin Treatment

That's it! If there are further diagnostic questions, then more testing would be required. But in the majority of cases, this is all that is needed to make a highly reliable diagnosis.

RULE OUT Other Possible Causes FIRST

Mis-diagnosing Children with ADHD

Why does it see that there are so many children today with the diagnosis of Attention Deficit Hyperactivity Disorder – ADD ADHD?

As I get older the answer becomes clearer to me.

The reason there are so many children diagnosed with ADHD today is that physicians, psychologists, therapists, and/or parents, rush to this diagnosis without doing their “due diligence” in the diagnostic process.

In other words, they cut corners and rush to judgment. They make the diagnosis of ADHD too soon in the process simply to save time and effort.

Here is the Road to a Bad Diagnosis:

1. A physician, psychologist, or therapist is well versed in the diagnostic criteria for ADHD.

2. A parent brings in a child for an evaluation because of behaviors at home or at school.

3. The child meets the diagnostic criteria for ADHD.

4. Therefore, the child has ADHD. Simple. Mission accomplished!

But this is absolutely the WRONG WAY to make the diagnosis of Attention Deficit Disorder.

Even according to the diagnostic criteria for ADHD from the Diagnostic and Statistical Manual ( DSM-4 ), just because a child meet all of the criteria for ADHD does NOT mean that he gets the diagnosis.

Rather it is a child who meets all of the diagnostic criteria AFTER an entire series of other possible explanations have been RULED OUT first!

“The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).”

And this is written with the assumption that other medical conditions that might also explain the symptoms have been ruled out.

This step of ruling out a long list of other explanations is ignored in the diagnostic process almost every time!

Before a Diagnosis of ADHD

Before your child is given the diagnosis of Attention Deficit Hyperactivity Disorder, the following long list of medical and mental health possibilities must be RULED OUT.

And by RULED OUT we mean that the physician, psychologist, therapist, and you – the parent, must carefully consider each other possible explanation, and be able to honestly say, out loud, “NO, THAT’S NOT IT.”

Here is out list of other reasons why children can be inattentive, impulsive, hyperactive, show temper, have poor focus, or look like they are ADHD. Each must be considered and RULED OUT:

• FOOD ALLERGIES – This, in our experience, is the most common alternative cause;
• ENVIRONMENTAL ALLERGIES
• HEAD INJURIES – Can be caused lots of ways, from forcep deliveries at birth, to car accidents, to “baby shaking,” to Fetal Alcohol Syndrome or Drug Exposure in utero, to falling out of a crib, to falling and hitting your head, to playing soccer and heading the ball, and many more;
• BIPOLAR DISORDER or MANIC DEPRESSION – Studies show that 15% of children who are diagnosed as having ADHD actually have early onset Bipolar Disorder. Studies also show that there are as many people born with Bipolar Disorder as there are people born with ADHD. You cannot make a diagnosis of ADHD without ruling out Bipolar Disorder;
• PERVASIVE DEVELOPMENTAL DISORDER
• TOURETTES SYNDROME – Basically ADHD with tics;
• AUTISM OR ASPERGERS
• SCHIZOPHRENIA
• OTHER PSYCHOTIC DISORDER
• ANXIETY DISORDER
• OBSESSIVE COMPULSIVE DISORDER
• DEPRESSION
• DISSOCIATIVE DISORDER
• CHILD ABUSE OR POST TRAUMATIC STRESS DISORDER
• THYROID PROBLEMS
• MENTAL RETARDATION
• LEAD POISONING OR OTHER HEAVY METAL POISONING

Only AFTER each item on this list has been considered, and each has been RULED OUT, can the diagnosis of ADHD be considered.

Results of Cutting Corners

Cutting corners in this important area of making a diagnosis leads to children being put on medications that not only do not have a chance to help them (because they aren’t ADHD), but can actually cause serious problems.

For example, does Stimulant Medication such as Ritalin cause tics?

No. But a child diagnosed with ADHD, who actually has Tourettes Syndrome, and is given stimulant medication, will develop tics because of the stimulant medication.

Are temper outbursts an indication of ADHD?

No. They may occur with ADHD, but they point more toward either head injuries, early onset bipolar disorder, childhood major depression, OCD or anxiety disorders. And if such a mis-diagnosed child is given stimulant medications it may result in explosive temper outbursts, increased anxiety or compulsiveness, or even suicidal thinking.

Symptoms of head injuries, bipolar disorder, tourettes, autism, schizophrenia, anxiety, obsessive compulsive disorder, depression, and post traumatic stress disorder, can all be made WORSE by treating a child for ADHD with stimulant medications.

Please make sure that you get a good diagnosis for ADHD before beginning any stimulant medications. This is where to make the investment of time and money – in the diagnosis.

Steps to Take if Your Child Might Have ADHD

If you child's teacher has met with you, and suggests that you should have your child evaluated for possible ADHD, here are the steps to take...

Step One: Find an EXPERT, and Get a Righteous DIAGNOSIS

Find a Psychologist, or a Marriage, Family, and Child Therapist, or a Psychiatrist, who has a good working knowledge of Attention Deficit Disorder – ADD ADHD.

Most mental health professionals do NOT know much about the disorder, even if they tell you that they do.

How to find the expert:

• Get some paper and prepare to make a list
• Ask parents at your local CHADD meeting about the best doctor and the best therapist in your area. These parents have already been down the road that you are on, and they know who is good, and who is a waste of time and money;
• Then call your local psychiatric hospital. Ask for the "Charge Nurse" at either the Children’s Unit or the Adolescent Unit. Politely ask the charge nurse who the best doctors and therapists for treating Attention Deficit Disorder that they know of are.

You now have some good names on your list.

Call the professionals on the phone and give them a two minute interview. Keep the phone call brief. They are busy people too.

Ask them questions such as:

• "What percentage of your practice is with Attention Deficit Disorder children or teens?"
• "How many years experience do you have in treating ADHD individuals?" "How many individuals with ADHD have you worked with?"
• "How do you do a diagnostic work-up for Attention Deficit Disorder?"
• "What treatment options are you familiar with in the treatment of ADD ADHD?"

Based on their answers you will know whether or not you will want to work with them.

Prepare yourself for meeting with them. Read this entire ADHD Information Library web site, including the articles and especially the "blog" section with our ADHD newsletter articles, and "up to the minute" ADHD news and information.

Also check out other ADHD sites:

• ADD101.com for basic information on Attention Deficit Disorder;
• ADDinSchool.com with 500 classroom interventions to help children and teens with ADHD succeed in school;
• the ADD Links Project with hundreds of links to ADHD and related sites;
• ADD-Products.com for the results of our studies showing the effectiveness of Attend vs. Ritalin.

Now you are ready to meet with them, and interview them.

If they seem to know more than you do (after you've spent time at these sites) then that is a good sign. If they seem to know less than you now do, then that is a bad sign. Why pay someone who knows less than you do?

Keep looking and find the Expert.

When you find him or her, do what they recommend -- and pay them what they are worth.

ASSESSMENT

Make sure that you have a thorough assessment done, including at a minimum:

• parent interview,
• child interview,
• parent rating scales,
• teacher rating scales,
• and TOVA testing as appropriate.

Medical conditions, such as food allergies, environmental allergies, thyroid problems, head injuries, and more, should be considered and ruled-out.

Mental Health issues, such as bipolar disorder, anxiety disorder, and depression should be considered, and ruled-out.

Emotional issues that could also be causing ADHD - like symptoms must also be ruled-out.

Read through our section on Diagnosing Attention Deficit Disorder - ADD ADHD, and review that information now if needed.

Use your best judgment, and talk with your doctor about these suggestions on getting help for ADHD.