How ADHD Is Diagnosed

3 Truly Terrible (and Common) Ways to Diagnose ADHD

Too often, doctors diagnose ADHD without considering all of the symptoms and other conditions that may cause them. Here’s what you need to know to avoid a bad ADHD diagnosis for your child or yourself.

Doctor filling out a form to diagnose ADHD in a patient
Doctor filling out form regarding ADHD diagnosis

I worry about the casual way in which many doctors pronounce an ADHD diagnosis. Attention deficit hyperactivity disorder (ADHD) is not easy to diagnose, and doctors who diagnose ADHD too hastily only perpetuate the problems that lead patients to consult them in the first place.

I can’t tell you how many times I’ve been approached by parents who complain that medication “hasn’t helped our child,” or that it “helps, but my child is still struggling in school.” In most cases, the problem isn’t the medication. It’s that the child doesn’t actually have ADHD — or has more than ADHD.

In the past month alone, I’ve started to treat three individuals who were diagnosed with ADHD; two do not have it, and the third has problems beyond ADHD. These cases illustrate the mistakes doctors make when evaluating patients with ADHD-like symptoms.

Mistake #1: Trying medication to “see if it helps.”

Mr. and Mrs. Q. are the parents of eight-year-old Fred. A few months ago, they met with Fred’s third-grade teacher, who expressed concern that Fred was having trouble sitting still in class. As the teacher explained, he often had to intervene to help Fred refocus on his work. “Even then,” he said, “Fred rarely finishes his schoolwork.”

When Fred’s parents shared the teacher’s observations with their pediatrician, she said, “Maybe we should try Ritalin.” After months of trying various doses of that drug, and later Adderall, Fred’s mother contacted me.

In my conversations with Fred and his parents, several themes began to emerge. For one thing, his first- and second-grade teachers had not deemed Fred inattentive or hyperactive. At home, Fred exhibited these behaviors only when he was doing homework; he wasn’t hyperactive or inattentive at other times of day, nor during weekends, holidays, or the summer break.

Clearly, Fred’s symptoms were neither chronic nor pervasive — so the problem couldn’t be ADHD. The pediatrician had jumped from description to treatment without making sure that Fred met the diagnostic criteria.

As I continued to evaluate Fred, I noted that he was struggling with reading. His comprehension was poor, and he retained little of what he read. What’s more, his handwriting was iffy, as were his spelling, grammar, punctuation, and capitalization. I reviewed Fred’s report cards. Sure enough, in first and second grades, teachers termed his reading and writing skills “still developing.” A psycho-educational evaluation confirmed my hunch: Fred has a language-based learning disability. The restless behavior and inattention were the result of frustration he felt over having to cope with this disability.

I took Fred off his meds, and worked with his parents to secure special education services. Guess what? The hyperactivity and inattention disappeared.

Mistake #2: Relying on inconclusive evidence.

Alicia, a single parent, was concerned that her 10-year-old daughter, Marie, had ADHD. Painfully shy, Marie had struggled in school since first grade. Alicia arranged to have Marie evaluated by a psychologist, who told Alicia that her daughter had ADHD. Alicia went to her family doctor, who took one look at the psychologist’s report and started Marie on stimulant medication.

Two years passed. Despite steady use of the medication, Marie continued to have problems in school and with her peers. At this point, with middle school looming, Alicia called me.

I looked over the psychologist’s report. It included several rating scales, completed by Alicia and the psychologist, that seemed “significant” in indicating ADHD. It also included a computerized test (Test of Visual Acuity, or TOVA) that was “suggestive” of ADHD. Yet the psychologist had never taken Marie’s developmental history or even asked Alicia if there was any family medical history that might be contributing to her daughter’s social and academic difficulties. The psychologist had spent only an hour with Marie — not nearly enough time to get a true sense of her “issues.”

I learned that Alicia had separated from her husband when Marie was three and had gotten divorced two years later. The marriage had been stormy long before the separation, and the divorce was acrimonious.

Alicia downplayed the impact that this conflict had on Marie. Yet when I asked Marie about her father’s new wife and her mother’s new boyfriend, she burst into tears. Teachers had noted that Marie’s classroom difficulties were most pronounced on Mondays, and that things got better as the week went on. I learned that Marie stayed with her father every other weekend, and that Alicia’s boyfriend was spending weekends in Marie’s home.

This helped convince me that Marie’s problems stemmed from a mood disorder and a sense of helplessness she felt about her family situation. I recommended that Marie go off medication and start psychotherapy.

Marie’s behaviors did not meet the criteria spelled out in the Diagnostic and Statistical Manual. Her problems were not chronic; they began only after her parents’ marriage began to break up.

What went wrong in this case? Instead of taking a detailed history, the psychologist based his diagnosis solely upon the rating scales and the result of one computerized test. But while scales and tests can confirm the presence of hyperactivity, impulsivity, and/or inattention, they cannot explain what causes such behaviors.

Mistake #3: Failing to consider coexisting conditions.

Virginia, a 40-year-old mother, thought she had ADHD. She was restless, easily distracted, disorganized, and struggling with planning and doing everything she had to do to care for her four children.

When I met with Virginia, she did seem to have a history of chronic and pervasive hyperactivity, inattention, and impulsivity. She recalled being restless and hyperactive since early elementary school. She had always been easily distracted by extraneous sights, sounds, and intrusive thoughts. She tended to interrupt people and to use poor judgment at work, within her marriage, and with friends. I found no other condition that would explain her problems. She must have ADHD.

But that wasn’t the end of my diagnostic workup. When someone has ADHD, there’s a greater than 50 percent chance that he or she will also have a learning disability, anxiety, mood disorder, OCD, or some other neurological disorder. Given this high probability of coexisting conditions, it’s essential to consider additional diagnoses.

And so I learned that reading had always been a problem for Virginia. She told me that the only way to retain what she reads is to read it again and again, while taking notes. She told me that math, spelling, and grammar had always been hard for her. She is perpetually misplacing things, and she can’t get things done on time.

When I asked Virginia if she ever felt anxious, she described a lifetime of panic attacks. She told me she is afraid of closed spaces and cannot use elevators or be in crowded rooms. When I asked about obsessions or compulsive behavior, she could not stop talking about her desire for order. She cleans her home compulsively, and, fearing that others won’t be so conscientious, uses public bathrooms only if absolutely necessary.

Yes, Virginia has ADHD. But she also has dyslexia and suffers from anxiety and OCD. To get better, Virginia needs to be treated for all four conditions.

Knowing that ADHD often runs in families, I asked Virginia about her children. It turned out that her oldest son, a sixth-grader, has always performed poorly in school. Like his mother, he struggles with reading and writing and often feels anxious. I recommended that he be evaluated, as well.

Now you have seen three ways not to be diagnosed with ADHD. I urge you not to accept a hasty diagnosis or one based solely on diagnostic scales or tests. If you or your child is diagnosed with ADHD, make sure the doctor checks for coexisting conditions. Good luck!

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