How is ADHD diagnosed?

There are no objective, scientific, diagnostic tests for ADHD. Any clinician who claims there are is either lying or deluded. In reality clinicians can diagnose children with ADHD by relying entirely on third party (usually parent and teacher) reports of children exhibiting childish behaviours including; failing to pay close attention, not finishing school work and chores, disliking homework, running about or climbing excessively, playing loudly and being impatient. In layman’s terms, the diagnostic criteria as so broad as to enable the labelling as ADHD of children who are too active (hyperactive) or inattentive and not active enough (hypoactive).

Every claim about ADHD should be viewed in the light of the diagnostic criteria defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the American Psychiatric Association’s catalogue of mental illness (and it’s earlier version DSM-IV).[1] 

The diagnosis of ADHD is entirely based on reports of a child’s behaviour, as ‘there are no laboratory tests, neurobiological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of Attention Deficit/Hyperactivity Disorder’.[2]  Note: This statement was reworded in DSM5 to state “No biological markers are diagnostic for ADHD”.

Extract from DSM-5: ADHD Diagnostic Criteria[3]

To be diagnosed with ADHD a child should meet six of the criteria below at 1 (Inattentive type/passive ADD) or six at 2 (Hyperactive type ADHD) or six at both 1 and 2 (Combined type ADHD) to an extent that is inconsistent with the child’s developmental level, and has a negative effect on their social and academic activities. For adolescents 17+ and adults five are sufficient.

  1. Inattention

For children aged 16 and younger six or more of the following symptoms should be present for at least 6 months,  (For adolescents 17+ and adults five are sufficient)

  • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities
  • often has difficulty sustaining attention in tasks or play activities
  • often does not seem to listen when spoken to directly
  • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
  • often has difficulty organizing tasks and activities
  • often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  • is often easily distracted by extraneous stimuli
  • is often forgetful in daily activities
  1. Hyperactivity and Impulsivity

For children aged 16 and younger six or more of the following symptoms should be present for at least 6 months, to an extent that is inconsistent with the child’s developmental level, and has a negative effect on their social and academic activities.

  • often fidgets with hands or feet or squirms in seat
  • often leaves seat in classroom or in other situations in which remaining seated is expected
  • often runs about or climbs excessively in situations in which it is inappropriate
  • often unable to play or engage in leisure activities quietly
  • is often “on the go” or often acts as if “driven by a motor”
  • often talks excessively
  • often blurts out answers before questions have been completed
  • often has difficulty awaiting turn
  • often interrupts or intrudes on others (e.g., butts into conversations or games)

The 18 behaviours are, according to ADHD proponents, evidence of a ‘biochemical brain imbalance’, though most children, and many adults, display them to varying degrees in homes, schools and workplaces every day.

What is supposed to distinguish ADHD sufferers from the rest of the population is their level of behavioural impairment or dysfunction. However, how ‘often’ a child ‘fidgets or squirms in their seat’, or ‘interrupts’ or ‘avoids homework’ or ‘fails to remain seated when remaining seated is expected’ or ‘is distracted by external stimuli’ so that they exhibit ‘some impairment’ is not defined in DSM-IV. Like beauty, ‘impairment’ is in the eye of the beholder.

DSM-IV says:

‘Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behaviour, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situation (e.g., the clinician’s office)’.[4]

In other words, ADHD children will behave appropriately and not display ADHD symptoms when they are rewarded, when people pay attention to them (close supervision) and when they are having new experiences. Conversely, ADHD children will be inattentive, easily distracted and display ADHD symptoms when their good behaviour goes unrewarded, no one pays any attention to them, or they are bored.

The diagnosing clinician doesn’t have to observe any of the symptoms, let alone any impairment. He or she may simply base their diagnosis on third party accounts of a child’s behaviour. The child’s parents and teachers usually provide these and are typically asked to fill in a questionnaire detailing if their child always, often, sometimes or never displays behaviour like avoiding homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful.

Parents are not routinely informed of the central role that their evidence plays in their child’s diagnosis. Many are simply fed the line that their child has a ‘biochemical brain imbalance’ – without any supporting evidence other than the observed behaviour of their child – and that this ‘imbalance’ is best treated with what is euphemistically called stimulant medication (but in reality is amphetamine).

One counter argument to this is that all psychiatric disorders, many of which are also treated with medication, are diagnosed using similar behavioural criteria. Pointing out inadequacies in the diagnosis of other psychiatric conditions is a poor defence for the inadequacies of the ADHD diagnostic criteria. However, at least conditions like schizophrenia involve extreme behaviours such as delusions or catatonia.

 

Note: The American Psychiatric Association proposed even broader changes for DSM5 but thankfully backed down in the face of widespread criticism (for details of what they had proposed see The American Psychiatric Association’s DSM5 proposal for ADHD – Making lifelong patients of even more healthy people). 

For more on the absurdity of diagnosing ADHD refer to: 900,000 Canadian Children confirm ADHD is a Birthday Lottery

For a very entertaining perspective on factors contributing to the explosion in the diagnosis of ADHD see http://www.youtube.com/watch?v=zDZFcDGpL4U


[1]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, (DSM-5), (American Psychiatric Association: Washington, D.C., 2013)

[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revised (DSM-IV), (American Psychiatric Association: Washington, D.C., 2000): pp88-89

[3] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, (DSM-5), (American Psychiatric Association: Washington, D.C., 2013)

[4] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revised (DSM-IV), (American Psychiatric Association: Washington, D.C., 2000): pp86-87