Assessment and diagnosis

Parents should discuss initial concerns about their child’s behavior with either:

• Their general practitioner (GP)
• Teacher
• In-house educational psychologist or
• Special educational needs coordinator (SENCO).

Ideally, it should be a person that knows the child in question fairly well. A referral can then be made for further investigation and assessment to a consultant psychiatrist or paediatrician (depending on where you are in the world). For a diagnosis to be met, symptoms of hyperactivity/impulsivity and/or inattention must meet the guidelines as set out in the Diagnostic and Statistical Manual for Mental Disorders Volume-5 (DSM-5) or the International Classification for Diseases Volume-10 (ICD-10) [2]. The severity of symptoms should be such that the child experiences difficulties socially, psychologically, educationally and/or occupationally, all of which are assessed by a clinician via interview or direct observation in multiple settings. The symptoms must also be pervasive and manifest in two or more environments including home, school, social or educational. Most clinicians will collect data using various standardized scales such as the Conner’s Parent and Teacher Rating Scales, the Strengths and Difficulties Questionnaire (SDQ) and/or the Child Behaviour Checklist when assessing a child for ADHD [3]. This is in addition to in-depth parent and child interviews and review of school-reports. The diagnostic process is in essence clinical and computerised assessments of attention are seldom used. The clinician will focus on the proportion of inattentive, restless, impulsive and oppositional behaviour which can be attributed to ADHD as opposed to conduct disorder and also weigh up the amount of anger or inattention which may be accountable for other reasons [3].

When considering a diagnosis of ADHD, psychiatrists will carry out a pre-treatment assessment which includes out-ruling the possibility of other factors which may account for the behaviors. This will include assessing for an attachment disorder; anxiety or drug use as potential reasons for over-activity and inattention. The full screening process needs to be thorough and detailed and so a range of areas of the person’s life are examined to ensure that the behaviour cannot be attributed to some other difficulty such as epilepsy, iron deficiency or lead poisoning [4].

The diagnosis therefore of ADHD considers that behaviors are not accounted for by:

• Personal: e.g., difficulties during pregnancy; substance dependence or abuse; term of pregnancy; delivery complicationsand/or admission to neonatal intensive care.
• Medical: e.g., chronic illnesses, trauma, sleep issues.
• Developmental: e.g., social, motor or language difficulties.
• Social: e.g., specific stressors, income/resources, family structure.

In 2008, The National Institute for Health and Clinical Excellence (NICE) published guidelines for the diagnosis and management of children, young people and adults. The publication of the NICE report is especially relevant as it is estimated that only 50% of the most severe ADHD cases are referred and taken up by health-care teams. This is due for a number of reasons including poor detection by schools and general practitioners. The latter group (GP’s) are thought to be especially ill-informed about ADHD and typically only make referrals to experts when there is parental pressure [5].