How is ADHD diagnosed? This is how psychologists assess whether a disorder is truly present

The diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) is becoming increasingly common. The CDC recently warned that they have observed an upward trend in national estimates of ADHD diagnoses reported by parents since 1997.

In this era of quick diagnoses, it seems that any restless or daydreaming child who struggles to concentrate has ADHD. However, many of the childhood behaviors that worry parents are not a disorder, but rather part of normal development or a consequence of temporary factors such as stress, insufficient sleep, or even the school environment. Recognizing the difference is key to avoiding over-labeling and over-medicalization.

There is no single, uniform diagnosis of ADHD

In 2021, a meta-analysis conducted at the University of Sydney that included 334 studies concluded that “There is evidence of overdiagnosis and overtreatment of ADHD in children and adolescents.”

While it’s impossible to generalize, clinical practice shows substantial differences in the diagnostic criteria and treatment of ADHD across countries. This explains the variations in incidence.

In fact, a study published in the journal Social History of Medicine revealed that in the United States, for example, there is a high degree of medicalization of ADHD, with medications like methylphenidate being commonly prescribed to children with mild or moderate symptoms. In Sweden and Norway, the diagnostic criteria are more restrictive, and psychoeducational interventions are preferred, while in China, ADHD is only diagnosed when inattention or hyperactivity significantly impacts learning.

Of course, the APA sets the diagnostic criteria for ADHD through its “bible,” the DSM-5. But some countries follow the WHO’s ICD-11, which is more restrictive. And even then, each psychologist or psychiatrist has some leeway in interpreting the cause and severity of the symptoms. This means that two children with similar behaviors can receive different diagnoses depending on where they live, who evaluates them, and how the symptoms are interpreted.

In other words, what is considered ADHD in one country may be seen as expected behavior for their age in another, highlighting a reality that few like to accept: the diagnosis is not always as objective as it seems.

What is the “ideal” process for diagnosing ADHD?

In general, there are specific criteria that must be met for a professional to make a diagnosis of ADHD:

• The child’s behaviors must deviate significantly from the norm and must occur in different contexts; that is, it is not enough for him to be inattentive or hyperactive at school.
• The first symptoms should appear before the age of 7.
• The symptoms must be present consistently for at least 6 consecutive months.

I will never tire of emphasizing that an essential indicator for diagnosing Attention Deficit Hyperactivity Disorder (ADHD) is that the child must exhibit this pattern of inattention in at least two contexts (such as school and home, or with family and friends). For example, a child who is overly active while playing but has no trouble concentrating at school cannot be diagnosed with ADHD. Nor would they meet the criteria if they are inattentive at school but can spend hours playing video games, because in that case, the underlying problem is likely a lack of motivation.

That said, ADHD symptoms almost always begin to appear long before a child starts school. Their inattention, hyperactivity, and impulsivity can be observed whether they are playing, watching television, or at family gatherings.

Once a child consults a psychologist, they will begin to gather information about their behavior to rule out other causes, for example:

• If there has been a sudden change in the child’s life, such as the death of a close relative, a divorce, or the loss of employment by one of the parents
• Presence of seizures
• Learning difficulties or lack of motivation
• Childhood anxiety or depression

Generally, psychologists rule out these factors based on information provided by parents, but in some cases, medical tests will be necessary. This means that diagnosing ADHD usually requires a multidisciplinary team. In fact, differential diagnosis in ADHD is crucial, as the cause could be anything from a sleep disorder to a nutritional deficiency.

The psychologist will perform:

1. Detailed interviews with parents and/or caregivers will explore the child’s development, behavioral history, and attention and hyperactivity patterns. The goal is to identify specific examples of problematic behaviors in different contexts.
2. Interview the child or adolescent. This will assess their perception of their difficulties and how these affect their daily life.
3. Direct observation of behavior, whether in the consultation room or through records at home and school, will allow for firsthand analysis of attention levels, impulsivity, hyperactivity, and self-control.
4. Application of psychometric tests and standardized questionnaires. Generally, the psychologist applies cognitive and neuropsychological tests that measure executive functions, working memory, and inhibitory control to evaluate symptoms, such as the Conners or the SNAP-IV.
5. Gathering information about the environment. The psychologist will also assess family, social, and school factors that may influence children’s behavior. They will use reports from teachers and educators regarding academic performance and classroom behavior.

Only after other problems have been ruled out and a thorough psychological evaluation has been carried out can Attention Deficit Hyperactivity Disorder be diagnosed.

References:

(2024) Facts About ADHD Throughout the Years. In: CDC.

Kazda, L. et. Al. (2021) Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA; 4(4): e215335.

Smith, M. (2017) Hyperactive Around the World? The History of ADHD in Global Perspective. Soc Hist Med; 30(4): 767-787.