Diagnosis

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Attention deficit hyperactivity disorder (ADHD) is a complex family of chronic neurobiological disorders that affects learning and behavior. Once thought to affect only children, it is now recognized as a disorder that continues into adulthood and one that presents unique issues for girls and women.

The condition is a serious diagnosis that can have a tremendous impact on your life, work and family. It may require long-term treatment with counseling and medication, so it's important that a health care professional carefully evaluate all symptoms to rule out other conditions that could cause similar symptoms or behaviors.

For instance, stress can cause symptoms similar to those seen in ADHD, such as forgetfulness or feeling overwhelmed and disorganized. However, reactions to stress are usually temporary and subside when stress subsides. Symptoms caused by ADHD are persistent and chronic since childhood or early adolescence.

Although there is a common misconception that ADHD is overdiagnosed, the fact is the condition may actually be under-diagnosed. A major study sponsored by the National Institute of Mental Health found that as many as half the children who qualified for a diagnosis of ADHD across five major U.S. regions had either not been diagnosed or were not being treated appropriately.

The diagnosis itself, however, must be approached very carefully, and shouldn't be done during a routine office visit with a pediatrician or other medical doctor. Improper treatment or a missed ADHD diagnosis can have significant, long-term consequences.

To reach an ADHD diagnosis, health care professionals use diagnostic criteria published by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and consider information from other sources. For example, interviews with the patient, the patient's family and, in the case of children, information provided by caregivers and teachers who see the child on a regular basis can provide a picture of the patient's behavior and learning styles.

Diagnosing and treating adults is challenging. The diagnostic criteria, with their emphasis on school behavior and performance, are really designed to make the diagnosis in children, not adults. Hyperactivity, for instance, tends to diminish by adulthood, although other symptoms, such as inattention, may get worse.

The following informal checklist further describes behaviors in adults that may be the result of ADHD and may require further evaluation:

• I am constantly trying to get organized, but can never seem to get or stay there.

• I often feel that I talk too much or impulsively blurt things out.

• I often feel overwhelmed.

• I make impulsive purchases and decisions.

• I frequently misplace personal items.

• I start one thing but never finish it because I am distracted by something else.

• I am frequently late.

• I am a procrastinator.

• I have struggled with anxiety and/or depression since I was a child.

There are three primary subtypes of ADHD: inattentive type, hyperactivity-impulsive type, or combined type (a combination of inattentive type and hyperactivity-impulsive type). The DSM-IV lists these other signs of ADHD, many of which apply to children in the classroom:

Inattention

Those who are inattentive find it difficult to keep their mind on any one thing and may get bored with a task after only a few minutes. They may, however, give effortless, automatic attention to activities and things they enjoy, like video games. But focusing deliberate, conscious attention on organizing and completing a task or learning something new is difficult.

Hyperactivity-impulsivity

• Hyperactivity: Those who are hyperactive always seem to be in motion and have trouble sitting still. They squirm in their seat or roam around the room. Or they might wiggle their feet, touch everything or noisily tap their pencil. They may be fidgety, or try to do several things at once, bouncing around from one activity to the next. They report an internal sense of restlessness and the need to continually move around.

• Impulsivity: Those who are overly impulsive seem unable to curb or weigh their immediate reactions, thoughts and behaviors before acting. As a result, they may blurt out inappropriate comments or physically attempt something without thinking it through. This could apply to taking tests in school as well as participating in potentially dangerous behaviors. Their impulsivity also makes it hard for them to wait for things they want. This leads to poor frustration tolerance and outbursts.

Not everyone who is overly hyperactive, inattentive or impulsive has an attention disorder. Nor does everyone with ADHD exhibit all behaviors associated with the disorder. It's important to realize that during certain stages of development, it may be normal for children to be inattentive, hyperactive or impulsive, and that these behaviors at these stages don't fit an ADHD profile.

For example, preschoolers typically have lots of energy and run everywhere they go, but that doesn't mean they are hyperactive. And many teenagers go through a phase when they are messy, disorganized and reject authority. This phase doesn't necessarily persist as a lifelong problem with attention, organization and/or impulse control.

Because everyone exhibits some of these behaviors at times, the DSM-IV contains very specific guidelines for determining when the behaviors indicate ADHD. Specific symptoms must appear early in life, often before age seven, and continue for at least six months. In children, they must be much more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person's life, such as school, home, work or social settings. However, it's important to know that the inattentive type of ADHD may not be diagnosed until early adolescence.

So if your or your child's behavior doesn't impair work, friendships or other relationships, you probably won't be diagnosed with ADHD. Nor would a child who seems overly active at school but who functions well elsewhere.

Health care professionals also consider the following questions during an assessment for ADHD:

• Are these behaviors excessive, long-term and pervasive? That is, do they occur more often in you or your child than in others the same age?

• Are they a continuous problem rather than a response to a temporary situation?

• Do the behaviors occur in several settings or only in one specific place?

The health care professional pieces together a profile of behaviors, based on all available information, and then considers:

• Which ADHD-like behavior patterns listed in the DSM-IV are apparent?

• How often and in what situations?

• How long have they been going on?

• How old was the child/adult when the problem(s) started?

• Are the behaviors seriously interfering with friendships, activities or home life?

• Are there any other related problems?

The answers to these questions help identify whether the hyperactivity, impulsivity and inattention are significant and long-standing. If so, you may receive a diagnosis of ADHD.

Other conditions may occur with ADHD, making it more difficult to arrive at a clear diagnosis. Women and girls with ADHD, for example, are more prone to depression than men and boys with ADHD. A serious but treatable mental disorder, depression can disrupt all areas of your life, including mood, sleep, appetite, relationships and the ability to think clearly. If you think you're suffering from depression, it's critical that you get a diagnosis and proper treatment. Left untreated, depression can be life-threatening given the risk of suicide that accompanies the disorder.

Anxiety is another common condition seen in those with ADHD. One-fourth of children with ADHD, for example, feel tremendous worry, tension or uneasiness, even when there's nothing to fear. Because the feelings are scarier, stronger and more frequent than normal fears, they can affect the child's thinking and behavior.

Children with ADHD are also more likely to have learning disabilities (LD) than children without the disorder, or, even if they don't have a full-blown LD, may still have difficulty mastering language or certain academic skills, typically reading and math. ADHD is not in itself a learning disability. But because it can interfere with concentration and attention, it can make it doubly hard for a child to do well in school, creating life-long frustrations.

A very small number of people with ADHD have a rare disorder called Tourette syndrome. People with Tourette syndrome have tics and other involuntary movements like eye blinks or facial twitches they can't control. Some may grimace, shrug, sniff or bark out words. Fortunately, these behaviors can be controlled with medication.

The effects of ADHD extend far beyond the classroom, often wreaking havoc on everything from school budgets to sibling relationships. The CDC reports that the educational cost of ADHD is about three-and-a-half to four billion dollars annually, while health care costs for children with the condition may be more than twice those for children without the disorder. Children with ADHD use more mental health services, have more frequent emergency department visits and higher rates of pedestrian, bicycle and driving accidents than children without ADHD. All of which places extreme stress on their parents.

It doesn't matter if the child with ADHD is male or female; parenting either is equally stressful. Overall, mothers of children with ADHD report significantly higher levels of parenting stress than mothers of children with other chronic disorders, and they're more likely to become depressed.

Parents of children with ADHD are also more likely to experience increased absenteeism and decline in productivity in the workforce than parents of children without the disorder. Of course, this places tremendous strain on marriages. Learning how to manage children with ADHD effectively and consistently is a major component of most treatment plans.

Getting a Diagnosis

Several types of health care professionals are qualified to diagnose and treat ADHD.

For children:

• Child psychiatrists are physicians who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any necessary medications.

• Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on physicians for medical exams and prescriptions.

• Neurologists, physicians who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. They will likely be involved with any brain imaging tests. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional/organizational aspects of the disorder.

• Pediatricians are physicians who have specialized training in treating children's illnesses. Like the family practitioner, pediatricians may or may not have experience with ADHD. Because ADHD is most prevalent in children, it is likely that a pediatrician will have experience in the ADHD screening process and can help rule out (or identify) medical conditions similar to behavior or learning patterns of ADHD. Pediatricians can also provide referrals to local ADHD specialists.

• Developmental and behavioral pediatricians are physicians who specialize in behavior and development in children. Serving as a liaison with primary care physicians and other medical specialists, developmental and behavioral pediatricians serve as key members of a multidisciplinary team. They provide comprehensive developmental, medical and behavioral assessments; education for parents and professionals regarding various medical/developmental diagnoses, and medical management of ADHD and other neurobehavioral disorders.

For adults:

• Psychologists, psychiatrists and neurologists also diagnose and treat ADHD in adults. But not all health care professionals are skilled in identifying or treating ADHD in adults, according to the National Attention Deficit Disorder Association.

Within each specialty, individual health care professionals and mental health professionals differ in their knowledge of and experience with ADHD. So when selecting a health care professional, it's important to find someone with specific training and experience in diagnosing and treating the disorder.