Can medical tests reliably determine whether my child has ADHD?

No, ADHD is determined by a clinical diagnosis based on interviews and a child’s personal history from teachers, parents, and others who are involved with the child on a day-to-day basis. Research studies using an electroencephalogram (EEG) to measure brain electrical activity, magnetic resonance imaging (MRI) to assess brain structure, and functional magnetic resonance imaging (fMRI) to measure where things happen in the brain have demonstrated some minor differences between the brains of ADHD children and those without ADHD (Question 9). These differences are found in brain regions we think are important for attention. However, EEG,MRI, and fMRI can not be used to make a diagnosis at this time. The findings are not consistent enough to be useful. Perhaps in the future this will change. In addition, even though research studies suggest neurotransmitter and neuroreceptor differences between children with and without ADHD, no blood tests are available to use to make the diagnosis. Although it is possible that researchers will develop some diagnostic laboratory test that can simplify diagnosis, it is unlikely to happen in the near future. Furthermore, even when we document the gene(s) causing ADHD, having the gene will not necessarily mean having ADHD. The human nervous system is just too complex for a simple onetoone effect. Ultimately, a diagnosis of ADHD relies on the experience and judgment of the physician who examines the child, not medical tests or scans.

I took my child to a doctor who made the diagnosis in 30 minutes. Can doctors really make a diagnosis of ADHD that quickly?

Yes. Although parents may have difficulty understanding this, professionals may be able to make the diagnosis of ADHD quite quickly. First, as qualified professionals, they see many children with the same set of critical characteristics. Similar to diagnosing a medical condition, such as diabetes, a personal history in combination with symptoms may quickly point to the right diagnosis. In fact, a child’s personal history alone is often the most important part of the diagnosis. In addition, if you and your child have provided the doctor with completed questionnaires that point out problems with inattention, hyperactivity, or impulsivity, the diagnosis is often immediately apparent. Very often the history is confirmed by a child’s unruly behavior in the office: however, the key element of the diagnosis is the history, not the inappropriate office behavior.

Whom do I consult to get a proper diagnosis of ADHD?

A number of different kinds of doctors can diagnose ADHD.Which type you choose to examine your child depends in part on your access to subspecialists and in part on the degree of ADHD and the presence of accompanying disorders. A regular pediatrician or a developmental pediatrician (a pediatrician who specializes in learning issues) can generally manage a child with relatively mild ADHD. Both neurologists and psychiatrists diagnose and treat children with ADHD. Often, they see children whose ADHD is complicated by other medical or psychiatric problems. Pediatricians may refer a patient to either a neurologist or a psychiatrist when the diagnosis is unclear or when they feel that adequately managing an affected child is becoming difficult. A psychiatrist might be a particularly good option for a child with comorbid problems involving oppositional behavior, anxiety, or mood. Conversely, a neurologist might be the right choice for a child with comorbid tics, Tourette’s syndrome, or a specific neurological problem (e.g., seizures).

Although psychologists can not prescribe medication, they can diagnose and treat problems associated with ADHD. However, several types of psychologists are available, and their methods of assessment will differ. Clinical psychologists may use techniques similar to those of a psychiatrist. They will interview parents and child, gaining both historical and current information about developmental, academic, social, and emotional issues and other aspects of the child’s behavior. Other psychologists, usually educational psychologists or neuropsychologists, will use more quantitative measurements to make a diagnosis. Besides following the more typical interview procedures, these clinicians will perform several hours of testing to arrive at a diagnosis. Most certainly, significant school difficulties or outstanding social and emotional issues are symptoms that may warrant a more complete assessment by a psychologist, either through the board of education or on a private basis. In this way, a fuller picture of a child’s particular strengths and weaknesses can be obtained.

What are the essential elements of a thorough evaluation to diagnose ADHD?

A thorough evaluation of ADHD requires the recording of a detailed history from parents, a discussion with or observation of the affected child, and some backup evidence from someone outside the home. A qualified doctor can accomplish this at an appointment with you and your child. Although the diagnosis will generally be apparent from a child’s history, an interviewer most likely will ask you, your child, and your child’s teachers to complete appropriate questionnaires.

A detailed history is essential to diagnosing ADHD. It should include information about your child’s birth; illnesses; early language and motor milestones; infant, toddler, and preschool years; educational progress and motivation; homework habits; social interactions and interests; and hobbies and extracurricular activities. A family medical and social history is also important. A detailed history will often include anecdotes that give the doctor a more complete picture of your child’s past and present.

The diagnosis of ADHD requires that the child have symptoms that interfere in at least two settings. By definition, outside sources are required. Although getting a description directly from a teacher—by questionnaire or in person—is useful, parents’ description of what they have been told about classroom behavior often suffices. Sometimes, teacher questionnaires are useful not only for diagnosis, but to show parents how a teacher rates their child’s attention and behavior in a quantitative, rather than a qualitative or descriptive way (such as they would hear at a parent–teacher conference).

A doctor will also try to obtain a complete “picture” of your child. This may involve performing a physical examination, asking questions about school and outside interests, or asking your child to do some simple tasks (e.g., walking on toes and heels or drawing a picture). The objective is to develop an accurate sense of your child for diagnostic purposes.

Often, when I say no, my child overreacts and is defiant or hostile. Is that common for a child with ADHD?

Not every ADHD child is defiant, hostile, or oppositional. However, some are. A certain amount of defiant and oppositional behavior is normal in children of all ages. Yet, it may be a more common or more prominent issue with ADHD children. These children may interrupt and intrude as well as avoid tasks or directions. They may also deliberately annoy other people and blame others for something they themselves do. In fact, accepting responsibility for their behavior may be quite hard for them. However, you must distinguish their inattention and impulsivity from the disruptive behaviors in truly hostile children. Specific characteristics seen in a child with an oppositional defiant disorder include poor temper control, argumentativeness, spitefulness and vindictiveness (“getting even”), resentfulness and anger, and the tendency to rebel against or refuse adult requests. ADHD children can sometimes be defiant and hostile. But, when your ADHD child routinely becomes disruptive and argumentative, it’s time for a professional consultation to determine whether your child has a comorbid disorder. In other words, such children can have two separate problems that occur at the same time.

Does everyone with attention problems or hyperactivity have ADHD?

No. There are many potential causes for behaviors similar to that seen in ADHD. Children with language disorders who have difficulty understanding and/or expressing themselves can appear inattentive. Their experience may be similar to listening to a foreign language in which words are picked up only here and there. Because they do not always understand what a teacher is saying, such children lose their focus. Consequently, deciding whether a child with language problems also has ADHD can sometimes be difficult. Some children with specific medical problems may also appear to be inattentive. For example, thyroid problems can cause attention difficulties. On the one hand, too little thyroid hormone may cause a child to become inattentive; on the other, too much thyroid hormone may cause hyperactivity. Children with seizures may appear inattentive, but this usually occurs irregularly and only when the seizures are occurring. Children with sleep problems may also appear inattentive because they are so tired during the day. A child with any one of a variety of emotional difficulties may also appear unable to concentrate or may become hyperactive. Children with anxiety or depression sometimes appear preoccupied or distracted. In addition, unlike adults, depressed children may become quite agitated or restless, which can be mistaken for hyperactivity.

As a rule, children with ADHD tend to be distracted by outside stimuli. In contrast, a child with obsessive compulsive disorder or a psychotic illness, for example, may be distracted by internal events, recurring thoughts, and excessive worry. However, a casual observer cannot always tell the difference by the child’s behavior, so it is difficult to correctly identify the source of the problem without careful assessment.

Inattentiveness and hyperactivity also can be side effects of medications. This is particularly common with some of the medications used for treating asthma, particularly theophylline and steroids. Antiseizure medicines can also interfere with attention.

In short, attention problems and hyperactivity are not automatically signs of ADHD, so you should not assume your child has ADHD because you see these behaviors. The child should be assessed by a professional trained to recognize the origins of behavioral problems so that the real cause or causes can be determined.

Do ADHD symptoms in late adolescence put my child at risk for other kinds of problems?

The persistence of ADHD symptoms into adolescence is associated with more academic, behavioral, and social problems. Research indicates that adults with continuing symptoms complete less formal schooling, are employed at the usual rates but have lower-status jobs, and have higher rates of personality disorders. The frequency of substance abuse is higher among adolescents and young adults with continuing ADHD. Coexisting conduct and antisocial personality disorders further increase the risk of substance abuse.

Recent research comparing children who outgrow ADHD to those who remain symptomatic suggests that those with persisting ADHD are more likely to develop other associated illnesses (e.g., conduct and oppositional disorders), which can become increasingly prominent and problematic for these adolescents and young adults. The risk-taking and rule-breaking behavior can also significantly worsen parent–child conflicts.

Among children whose symptoms decrease during adolescence, the outcome is similar to that of non-ADHD individuals regarding occupational achievement, social functioning, and drug and alcohol use, although not academic achievement. Academic issues may remain an affected area even if ADHD disappears.