Your Attention Deficit Disorder information source for
Everyone in a private practice setting who works with ADD ADHD children or adults is going to have their own opinion on how Attention Deficit Hyperactivity Disorder - ADD or ADHD - should be diagnosed. Some clinics take the perspective that "more is good," and will recommend a large battery of tests, often costing many thousands of dollars. Other clinics, typically with hurried physicians, will simply give a brief rating scales to the parents and then make a quick diagnosis and prescribe treatment.
Unfortunately neither of these extremes is in the patient's best interest.
There are some children who are diagnosed as having ADD ADHD that do not have it. It is not uncommon for someone with depression, or anxiety, specific learning disabilities, early onset bi-polar disorder, or Tourette's Syndrome, to be diagnosed as Attention Deficit Hyperactivity Disorder. This is often the result of a diagnostic "work-up" which is too brief and does not take into account the many reasons why a child might be inattentive, impulsive, or over-active.
But over-diagnosis of Attention Deficit Hyperactivity Disorder is not the only problem.
This happens most often in the school setting where the school psychologist writes his report perfectly describing an individual with ADD ADHD, then refuses to use the label "Attention Deficit Hyperactivity Disorder" in his report anywhere.
It also often happens in therapist's offices where the therapist is not familiar with Attention Deficit Hyperactivity Disorder, and only sees the characteristic behaviors as "acting out behaviors" due to family problems, rebelliousness, and so on. Therapists operating entirely from a "Family Systems" orientation are especially at risk for making this mistake.
Some studies suggest that only one out of three people who have Attention Deficit Hyperactivity Disorder will ever get help. Two out of three people who have ADD ADHD will never receive a diagnosis or treatment. They will never really know what it is that's bothered them through their life.
So we have two problems. One is the over-diagnosis and the other is the under-diagnosis of Attention Deficit Disorder - ADD ADHD.
The following is a practical summary of the DSM-IV criteria. The actual criteria for Attention Deficit Hyperactivity Disorder is available in the DSM-IV manual. See our detailed explanation of Inattention, Impulsivity, and Hyperactivity here...
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.
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.
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 Important: These behaviors are really a problem. Not just a little bit, but a lot.
Six or more from the Inattention list.
Six or more from the Impulsive or Hyperactive lists.
Both criteria are met.
Attempt at legal disclaimer. This is just for your information. Please be aware 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.
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. . .
Get an evaluation for attention deficit hyperactivity disorder. Usually a psychologist or other mental health professional will do this evaluation for ADD ADHD.
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 probably blame you, the parents, for the child's disorder.
Find experts on attention deficit hyperactivity disorder in your area. Ask around at your local CHADD chapter. Call you local Psychiatric Hospital and ask for the Child or Adolescent Unit. Then ask for the "Charge Nurse." Ask the Charge Nurse who the best psychiatrists and therapists in your town are. They know.
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. 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.
A good developmental history must also be taken. Important questions are:
Then a good family history is great. The family trees of Attention Deficit Disorder kids are often very similar. Look at one and you may say, "Gee, there's no wonder this kid has it," because most of the time, about 80 percent of the time, you can trace the impact of this gene as it runs through families causing things like obsessive-compulsiveness, depression, alcoholism, attention disorders or learning disabilities throughout the family.
The clinician must also know:
Parent rating scales are very good and should be given. The ADD ADHD scales we like are by Ned Owens out of Texas. Keith Connors has a fine tool that you have probably seen if you are involved with attention deficit hyperactivity disorder children at all. It is very important for the parents to fill out these behavior rating scales.
Ideally the teachers will fill them out also. You want the teacher's input because they see 30, 32, or 35 kids every single day, 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. And so the rating scale comes back reporting that the child we want rated isn't much of a problem at all. We have to give directions to the teachers to rate them versus "normal kids," not against the "worst kids" in the class.
Also, an in-depth clinical interview with the child is important. This interview is needed to determine the child's reality testing, his degree of maturity, his degree of verbal skills, and so on. Ask the child if he's hallucinating. Sometimes he is, but he hasn't told anyone. Ask the child if he's anxious. Some kids have tremendous fears, but have not shared them with anyone. There is a lot going on with kids that their parents are not aware of.
Psychological testing as part of an evaluation for Attention Deficit Hyperactivity Disorder - ADD ADHD - can be helpful. We used to give tests such as the WISC-R, an IQ test, the Wide Range Achievement Test (WRAT), and the Bender-Gestalt test, which is a visual motor integration test. Bored already? Well, they are boring things. But they can be helpful. There are certain patterns that one might expect on these tests if the subject had attention deficit hyperactivity disorder of some type.
But it's art, not science at that point. The patterns are not "diagnostic" for Attention Deficit Hyperactivity Disorder - ADD ADHD. It's also important to know if the kid has a real low IQ, or a major learning disability. It could be a clue that there is something else going on instead of attention deficit hyperactivity disorder.
What we find to be very valuable is the Test of Variables of Attention (TOVA).
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 terrific tool, but it should never be given just by itself. It needs to be given in the context of the whole diagnostic workup.
Also, the TOVA can be given with no medication, and then if medication is going to be used down the road, given again with medication in their system. This can tell the clinician if the subject is at the right dosage or not, or how well he responds to that particular dose of that particular medication. The TOVA is a very helpful tool.
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.
Obtaining an EEG from a neurologist is rarely helpful.
EEGs will show differences from non-ADD children. 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 - ADD ADHD - kids have "normal" EEGs. What we mean by "normal" is they don't have big epileptic spikes, or things like that, that a neurologist would say are "abnormal." But when you compare them side by side with a non-ADD kid, they are much different.
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.
Physical Exam - Office Visit
Clinical Interview - Parents (45-60 minutes)
Clinical Interview - Child (45-60 minutes)
Parent and Teacher Rating Scales
Office visit to review information and develop a treatment plan
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. Except for the physician's examination, the cost for this should be about $500-$700.
Continue on to Treatment Options for Attention Deficit Disorder