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Friday, July 5, 2013

ADHD Diagnosis Guide: How to Make Sure It's Accurate

From ADDitude Magazine

Fall, 2009 Issue

An accurate diagnosis of attention deficit disorder isn’t easy to come by, but it is essential to your good health. Find out where to go, what to expect, and how to prepare for the tests and consultations associated with an ADHD diagnosis.

Warning Signs

You’re worried. Your son’s teacher sent home a note saying that his lack of focus is holding him back in class.

Your daughter phoned a classmate to set up a play date, and was turned down for the third time. The so-called “friend” told your daughter that she’s weird.

Or perhaps you are concerned about your job. You were late to work twice last week, and you frequently miss deadlines and meetings. You won’t be getting the promotion you’ve been after -- in fact, you may be fired.

You’ve wondered for months what’s causing you or your child to come up short -- stresslearning disabilities, a medical condition, or ADHD? You’re tired of wondering. It’s time to find out. You want to get an evaluation.

Congratulations. You are taking an important step in changing your life. But you are plagued by questions: Where do you start? What kind of doctor diagnoses ADHD? How do you know if you’re getting a state-of-the-art evaluation and an accurate ADHD diagnosis? And what should you do after you get it?

Where to Go for an ADHD Diagnosis

To get an ADHD diagnosis, you may start with a routine visit to your primary-care physician, but, chances are, you won’t end it there. As a rule, most general practitioners are not equipped to make the call. One reason is time. It can take several hours of talking, test taking, and analysis of the results to diagnose someone with ADHD. Most general practitioners can’t give you or your child that much attention in a busy practice.

General practitioners sometimes overlook coexisting problems, such as learning disabilities, underlying medical conditions, depression, an anxiety disorder, or substance abuse. Professionals trained in diagnosing ADHD routinely screen for these problems.

How can you find an ADD expert in your area? Five possible approaches should lead to the right help and diagnosis, and a treatment plan that will best manage symptoms:

Ask a school psychologist or guidance counselor for a referral for your child. If you’d prefer to see an outside expert before getting the school involved, move to the next step.

Talk with your internist or your child’s pediatrician. Start the conversation this way: “I’ve noticed these symptoms in myself (or my child), and I’d like an evaluation. Do you know of someone who specializes in diagnosing ADD?” If the doctor says that he can do it, ask about the tests he uses and how long he typically spends making the diagnosis. If the only basis for a diagnosis is a quick interview with you and/or your child, ask for a referral to a specialist.

Contact a medical school near your home. “Call the department of psychiatry and ask, ‘Is there anyone on your staff experienced at working with adults or children with ADD?’” suggests Edward Hallowell, M.D., a psychiatrist with offices in New York City and Boston, and co-author of Superparenting for ADD (Ballantine). “When you get the name of a professional, ask him how many people he has treated. It should be at least a hundred.”

Check with your insurer. Ask if there are experts trained in diagnosing ADD covered by your plan. If not, consider going out of network. Remember that your goal, initially, is to get a thorough, accurate diagnosis. When you have that information, the diagnosing doctor can work with your plan physician to prescribe treatment.


NOTE: Please be aware that, in common with almost all major health insurance companies, Blue Cross Blue Shield of Massachusetts no longer regards ADHD as a covered condition, because it doesn't meet their "medical necessity" criteria. Hence, they will not give prior authorization, or pay benefits, for testing to diagnose or rule out ADHD. This restriction applies to both HMO and PPO plans.


Call your local chapter of the National Alliance on Mental Illness or CHADD, and ask for names of professionals who specialize in ADHD. Another good option: an ADHD support group in your area. Word-of-mouth recommendations are often the best assessment of a professional’s ability.

How Experts Make an ADHD Diagnosis

In making an attention deficit disorder diagnosis, the first thing your doctor will want to determine is whether you or your child has the ADHD symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV).

“The DSM-IV (Note: now, the new DSM-5) remains the basis of the diagnosis, but most clinicians go beyond that in their assessments,” says Hallowell. In addition to reviewing these criteria, doctors will conduct a thorough clinical interview using one standardized ADHD rating scale. A screening test is also often administered to rule out coexisting conditions that are common in people who have ADHD -- learning disorders, anxiety, and mood disorders.

The symptoms listed in the DSM-IV are reviewed periodically. According to the latest DSM-IV guidelines, in order to be diagnosed with ADHD, a patient has to have shown at least six of nine symptoms of inattention and/or hyperactivity/impulsivity prior to age seven. In addition, these symptoms must impair the person’s functioning in more than one setting -- home, school, or work.

Not all doctors subscribe to these criteria. Many professionals point out that some patients have ADHD symptoms that aren’t recognized until later in life, particularly children who are very bright or who have the inattentive form of ADD.

Diagnosing an adult is trickier than diagnosing a child. “The DSM-IV criteria are based only on research with children four to 17 years old,” says Thomas E. Brown, Ph.D., assistant clinical professor of psychiatry at Yale University School of Medicine and associate director of the Yale Clinic for Attention and Related Disorders. “As a result, most clinicians bend the criteria when it comes to the age of onset -- recent research has shown that, in some people, symptoms don’t appear until adolescence, when there are greater challenges in self-management -- and the number of symptoms. Clinicians often diagnose adults who have just four or five symptoms, not seven or eight, if they show significant impairment.”

While some doctors use computer programs, such as continuous performance tests (CPTs), to check for attention and impulsivity problems, or brain scans, such as single-photon emission computed tomography (SPECT), to look for abnormalities in the brain, the most reliable evidence for a positive diagnosis, according to most experts, is a patient’s history.

ADHD Diagnosis Step 1: The Consultation

Expect the ADHD diagnosis consultation to take an hour or longer. If your child is being evaluated, the doctor will talk to you and your child, and get feedback through checklists and written information from teachers and other adults who spend a lot of time with your child. Sometimes the doctor’s office will forward these forms to you before the consultation and review them with you at the initial meeting. Other doctors will meet with you first, do the interview, and give you the forms to be filled out before your next appointment.

If you are being evaluated, your doctor will interview you and someone who knows you well -- your spouse, a sibling, your parents. He may or may not use similar checklists designed for identifying symptoms of adult ADHD. The doctor will use the patient interview to determine which, if any, tests might rule out other conditions that may be causing the ADHD symptoms.

“The clinical interview is the core of any evaluation,” says Brown. “The more input from different sources, the better. Many adults come for a consultation alone, but it’s helpful to come with a spouse, sibling, or close friend.”

Many doctors ask people in the patient’s life -- a spouse, parent, or sibling for an adult, or a teacher, coach, or nanny for a child -- to write a few sentences describing the patient. Personal insight often uncovers information that can’t be culled from questionnaires.

Says Hallowell: “A teacher might write, ‘Johnny is sweet, adorable, and cute as a button, but he can’t remember to come in out of the rain. He is disorganized. He speaks out of turn. He needs more discipline.’ It’s what I call the moral diagnosis, but it often reveals a lot about a child who may have ADD. Those one-paragraph narratives give a wide range of input. Checklists don’t.” 

What are doctors hoping to find by evaluating those checklists and narratives and conducting the clinical interview?

Social history. “Describe a typical day in [your life or] your child’s life” is often the first question a doctor will ask to get a sense of how [you or] your child functions -- what usually goes smoothly and what is challenging.

Medical history. Medical problems, ranging from sleep apnea and thyroid conditions to hormone fluctuations and substance abuse, can present symptoms similar to those of ADHD.

Family history. “I ask questions about the immediate family, as well as grandparents, uncles, aunts, and cousins,” says Brown. “I’ll ask things like, ‘Is there anybody who has had trouble paying attention or learning certain subjects, or who was smart but didn’t do well in school -- and did better later? The answers will give me an idea of what’s floating around in the gene pool.”

Strengths and weaknesses. “Every person I’ve seen with ADD can focus well on some activities,” says Brown. “Sometimes it’s sports. Sometimes it’s artistic or mechanical stuff. That , are telltale symptoms of ADD. In the process, I identify strengths I want to protect -- and encourage -- during treatment.”

Education. “Everybody comes in with some information about the condition. Some of it is sophisticated and accurate; the rest is just wrong,” says Brown. “I take 15 or 20 minutes to tell them what I think about ADD, how ideas about the condition have changed, and the latest thinking on managing symptoms.”

By the time the clinical interview is over, most doctors with experience treating people with ADHD will have a good idea of whether you or your child has the condition. Even so, most want to back up their opinion with objective proof from tests.

Most clinical interviews include one or more of the ADHD rating scales, as well as other tests. A proper ADHD evaluation should do two things: determine whether a person has ADHD and rule out or identify other problems -- learning disabilities, auditory processing disorders, anxiety, or mood disorders. Depending on your doctor’s concerns, tests may take from an hour to more than eight hours and may require several appointments.

Common tests used in diagnosing ADHD include:
  • ADHD rating scales. These questionnaires can identify specific symptoms of ADHD that may not emerge in the clinical interview. Answers to the questions can reveal how well a person functions at school, home, or work. The scales are specifically formatted for children, adolescents, and adults. “ADHD rating scales have their pluses and minuses, and doctors go with the ones they feel most comfortable using,” says Patricia Quinn, M.D., director of the National Center for Girls and Women with ADHD. “I recommend using at least two scales that gauge both ADHD and other symptoms.”
  • Intelligence tests are a standard part of most thorough evaluations because they not only measure IQ but can also detect certain learning disabilities common in people with ADHD.
  • Broad-spectrum scales screen for social, emotional, and psychiatric problems, and they may be ordered if the doctor suspects a patient has anxiety, obsessive-compulsive disorder, or another condition in addition to ADHD.
  • Tests of specific abilities -- language development, vocabulary, memory recall, motor skills -- may also be recommended to screen for learning disabilities or other processing problems. The doctor may decide which tests to do based, in part, on which kinds of tasks you or your child find easy or difficult.
  • Computer tests are becoming popular because patients enjoy taking them, and because they can screen for attention and impulsivity problems, which are common in people with ADHD. These “continuous performance tests” (CPT) challenge the patient to sustain attention. A series of visual targets appear on the screen, and the user responds to prompts while the computer measures his ability to stay on task. In practice, some experts have found that these tests are better at identifying impulsive symptoms and less successful at flagging symptoms of inattention.
  • Brain scans. Neuro-imaging procedures, such as positron emission tomography (PET) scans, SPECT scans, and magnetic resonance imaging (MRIs), have long been used in research studies of ADHD. But their use in diagnosing ADHD has not yet been proved. They have revealed, though, that certain parts of the brain are smaller in volume in people who have ADHD than in people who don’t have the condition.

“You do not need a brain scan to be diagnosed with ADD, and they are not the standard of care,” says Hallowell. “Scans are not a cost-effective way of spending your health-care money, and they don’t contribute much to the diagnosis of ADD. But it seems that patients love seeing a picture of their brain, and the scans can often help them own the diagnosis.”

ADHD Diagnosis Step 3: Learning How to Manage Symptoms

After the clinical interview and the recommended tests are completed, most doctors will call you into the office to go over the results of your ADHD evaluation. This is the best time to ask the doctor questions. When you leave that appointment, the doctor should have formulated an action plan to manage symptoms. It should include:
  • A list of accommodations for work (or school) that will help you (or your child) perform well.
  • A plan for follow-up therapy with a psychologist, therapist, ADD coach, or another expert.
  • Recommendations for ADHD medication, if considered appropriate
  • A schedule of follow-up appointments with the diagnosing physician or your primary-care doctor to see how well the treatment plan is working.

“After the psychologist finished evaluating my son -- a process that included eight hours of testing -- she met with me to discuss his strengths and weaknesses, and handed me a list of accommodations that would help him at school,” says Joanna Thomas, of Lubbock, Texas, whose son, Ryan, now age 10, was diagnosed with ADHD at age seven.

“Every year since the initial evaluation, I discussed the list of accommodations with his new teacher. I have also used it to write an introductory letter to the teachers that focuses on his strengths. Having that diagnosis meant everything to me. It gave me the tools I needed to help him at home and in working with his teachers.”

“An accurate diagnosis is good news,” says Hallowell, “because things can only get better. When you learn how to manage ADD, it can become an asset in your life. I tell patients, ‘You’ve got a Ferrari engine for a brain, and you’re lucky, because you’re going to win a lot of races. The only problem is, you have bicycle brakes.’ The point is that someone with ADD is on the way to being a champion, not a loser. And with the correct diagnosis and treatment, 100 percent of ADDers can improve their lives.”

Five Common Diagnosis Mistakes

Not taking enough time. A thorough evaluation for ADHD can’t be done in a 15-minute visit. Rushed visits raise the likelihood that you or your child will bemisdiagnosed, or that the doctor will miss a secondary diagnosis that may be important to treat.

Diagnosing the symptoms, not the underlying problem. “Physicians sometimes misdiagnose secondary symptoms as the person’s primary problem, without looking for coexisting ADHD,” says Patricia Quinn, M.D., director of the National Center for Girls and Women with ADHD. In many cases, when the ADHD is treated, the secondary symptoms -- depression or anxiety -- also improve.

Thinking that academic failure is intrinsic to ADHD. Many children with ADHD do well at school because they work hard, and teachers and doctors will not suspect they have the condition.

Thinking that a high IQ means your child doesn’t have ADHD. Your child may score well on an IQ test, but her grades are mediocre and teachers “diagnose” her as being lazy or undisciplined. An evaluation by an outside psychologist may indicate that she has ADHD and/or a learning disorder.

Sticking with a doctor you don’t like. If you don’t feel a positive connection with your doctor -- if he doesn’t seem to respond to you as a person or if he reprimands you for asking too many questions -- you won’t have confidence in his diagnosis and the ADHD treatment won’t go well.

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