Diagnosing ADHD

Share it now

ADHD Evaulation and Diagnosis: Getting it Right the First Time

Everyone in a private practice setting who works with ADHD children or adults is going to have their own opinion on how Attention Deficit Hyperactivity Disorder should be diagnosed. Some clinics take the perspective that "more is good," and will recommend a large battery of tests, often costing many thousands of dollars. Other clinics, typically with hurried physicians, will simply give a brief rating scales to the parents and then make a quick diagnosis and prescribe treatment.

Unfortunately neither of these extremes is in the patient's best interest.

Over-Diagnosis of ADHD

The over-diagnosis of Attention Deficit Hyperactivity Disorder is a problem. There are some children who are diagnosed as having ADD ADHD that simply do not have it.

It is not uncommon for someone with the following conditions to be diagnosed as ADHD when they do not have ADHD:

  • depression
  • anxiety
  • specific learning disabilities
  • early onset bi-polar disorder
  • Tourette's Syndrome
  • food allergies
  • head injuries
  • fetal alcohol syndrome
  • dental problems, such as abscessed root canals or mercury toxicity from fillings
  • significant family problems
  • grief or trauma

These differential diagnoses must be considered - and ruled out - before making a diagnosis of ADHD.

This kind of mis-diagnosis is often the result of a diagnostic "work-up" which is too brief and does not take into account the many reasons why a child might be inattentive, impulsive, or over-active.

Under-Diagnosis of ADHD

But over-diagnosis of Attention Deficit Hyperactivity Disorder is not the only problem.

Under-diagnosis of Attention Deficit Hyperactivity Disorder - ADD ADHD - is also a problem. This happens most often in the school setting where the school psychologist writes his report perfectly describing an individual with ADHD, then refuses to use the label "Attention Deficit Hyperactivity Disorder" in his report anywhere.

It also often happens in therapist's offices where the therapist is not familiar with Attention Deficit Hyperactivity Disorder, and only sees the characteristic behaviors as "acting out behaviors" due to family problems, rebelliousness, and so on. Therapists operating entirely from a “Family Systems” orientation are especially at risk for making this mistake.

Some studies suggest that only one out of three people who have Attention Deficit Hyperactivity Disorder will ever get help.

Two out of three people who have ADD ADHD will never receive a diagnosis of ADHD or treatment. They will never really know what it is that's bothered them through their life.

So we have two problems. One is the over-diagnosis of ADHD, and the other is the under-diagnosis of Attention Deficit Disorder.

Read the sections below for more detailed information on testing and diagnosing ADHD.

Douglas Cowan, Psy.D., M.S. is a licensed Marriage and Family Therapist in Tehachapi, CA who has been a skillful counselor to children, teens, and adults helping them to overcome ADHD, find relief for depression or anxiety, and solve other problems in life since 1989. He served on the medical advisory board to the company that makes Attend and Extress from 1997 through 2011, and he is the Editor of the ADHD Information Library online resource. His weekly ADHD Newsletter goes out to 9,500 families. Visit his website at http://DouglasCowan.me for more information on achieving greater health, personal growth, Christ-centered spirituality, stress management, parenting skills, ADHD, working out the stresses of being a care-giver to elderly parents and also being a parent to teenagers, or finding greater meaning in retirement years, Dr. Cowan can be a valuable resource to you.

Douglas Cowan, Psy.D., MFT
27400 Oakflat Dr.
Tehachapi, CA 93561
(661) 972-5953

Share it now

ADHD in the DSM 5 Revision

Share it now

The diagnostic criteria for ADHD, or Attention Deficit Hyperactivity Disorder, has been updated, revised, and slightly changed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). They are hoping to better describe the experience of adults, both men and women, who have ADHD, not just children and adolescents.

This revision is based on nearly two decades of research showing that ADHD, although a condition that starts in childhood, may continue through adulthood for some people. Earlier editions of DSM did not offer appropriate guidance to clinicians in diagnosing adults with the condition. By modifying criteria for adults, DSM-5 aims to ensure that anyone with ADHD can continue to get care over the course of their lives if needed.

Changes to the ADHD Diagnostic Criteria ?

ADHD is distinguished by a pattern of behavior that can result in poor performance issues in social, educational, or job settings. As in DSM-IV, symptoms will be divided into two categories of inattention, and hyperactivity and impulsivity. The diagnostic criteria includes behaviors like failure to pay close attention to details, difficulty organizing tasks and activities, excessive talking, fidgeting, or an inability to remain seated in appropriate situations.

It is disappointing that this revision ignores much of the most recent research that would lead to a complete reclassification of ADHD into two new groups:

The first group would be those who display a characteristically sluggish cognitive tempo, daydream, often don't pay attention to what's going on around them, seem to have a cognitive processing disorder, are hypo-active, slow moving, passive, easily confused, prone to errors in accuracy, not impulsive or disruptive.

The second group would be those that are impulsive, hyperactive, move too fast, pay attention to everything around them, lack self-control, over-active, move too fast, don't think before they act, are aware of everything going on around them so that they cannot focus on homework, are not accurate because they work too fast, and can be disruptive to those around them.

And there should be a third group of those with both impulsivity and hyperactivity, paired with oppositional-defiant disorder.

But the DSM 5 pretty much keeps the old way of conceptualizing ADHD for another ten years at least. To be diagnosed with ADHD, children must still have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must have five or more.

While this diagnostic criteria has not changed from DSM-IV, examples have been included to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit. The descriptions will help clinicians better identify typical ADHD symptoms at each stage of patients' lives.

The age of first seeing the problem symptoms has changed. Using DSM-5, several of the individual's ADHD symptoms must be present prior to age 12 years, compared to 7 years as the age of onset in DSM-IV. This change is supported by substantial research over the past twenty years that found no clinical differences between children identified by 7 years versus later in terms of course, severity, outcome, or treatment response.

DSM-5 includes no exclusion criteria for people with autism spectrum disorder, since symptoms of both disorders co-occur. However, ADHD symptoms must not occur exclusively during the course of schizophrenia or another psychotic disorder and must not be better explained by another mental disorder, such as a depressive or bipolar disorder, anxiety disorder, dissociative disorder, personality disorder, or substance intoxication or withdrawal.

Noticing ADHD in Adults : Improved

The ADHD diagnosis in previous editions of DSM was written to help clinicians identify the disorder in children. Almost two decades of research conclusively show that a significant number of individuals diagnosed with ADHD as children continue to experience the disorder as adults. Visit the ADHD Information Library for more about this.

Almost two decades of research conclusively show that a significant number of individuals diagnosed with ADHD as children continue to experience the disorder as adults. The definition of Attention Deficit Disorder (ADHD) has been updated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to more accurately characterize the experience of affected adults. The ADHD diagnosis in previous editions of DSM was written to help clinicians identify the disorder in children. Almost two decades of research conclusively show that a significant number of individuals diagnosed with ADHD as children continue to experience the disorder as adults.

Share it now

ADHD Testing Available in Tehachapi

Share it now


We are now offering ADHD testing with the TOVA test in our Tehachapi - Bear Valley Springs office. Read the full article at http://DouglasCowan.me.

Share it now

ADHD Diagnostic Criteria Made Easy

Share it now

Diagnostic Criteria for Attention Deficit Hyperactivity Disorder

The following is a practical summary of the DSM-IV criteria for Attention Deficit Disorder. The actual criteria for "Attention Deficit Hyperactivity Disorder" is available in the DSM-IV manual.


  • A lot of people, including his parents, complain that he just doesn't seem to listen when spoken to;
  • Because of not sustaining attention, or because of acting like a "space cadet," he doesn't finish his chores or homework;
  • He can't keep his mind on what he's doing for very long unless it is very exciting, or very entertaining;
  • He doesn't pay close attention to what he's doing, so he makes a lot of careless mistakes. Video games are an exception because they give immediate feedback, they are exciting, and they are fun. Chores and homework are not. The inattention is seen most with homework, chores, and other boring things that you want him to do;
  • He's really disorganized. Most commonly seen in spending three hours to finally finish his homework, then losing it at school (it’s in his backpack), or forgetting to turn it in;
  • He really tries to avoid doing homework or chores;
  • He gets distracted easily, or pays attention to the wrong thing;
  • He is often forgetful and has to be reminded to do things often.

Symptoms of IMPULSIVITY in Attention Deficit Hyperactivity Disorder:

  • He often blurts out answers in class;
  • He can't wait his turn when he is playing games or at school;
  • He interrupts others a lot, he just doesn't wait well;
  • He tends to do things without thinking about them first;
  • He does not consider the consequences of his actions.

Symptoms of HYPERACTIVITY in Attention Deficit Hyperactivity Disorder:

  • He has happy hands and feet which fidget and squirm a lot;
  • He just can't stay in his seat for very long when he's supposed to at school or the dinner table;
  • He may run around too much, or climb on things he's not supposed to;
  • Is too loud;
  • He is "On the go" as if he is "driven by a motor";
  • He talks too much;
  • Leaves footprints across the ceiling

Important: At least some of these symptoms must have been seen before the age of seven.

Also Important: At least some of the symptoms are seen both at home and at school.

Also Also Important: These behaviors are really a problem. Not just a little bit, but a lot.

adhd inattentive type

For a diagnosis of Attention Deficit Hyperactivity Disorder, Inattentive Type:

  • Six or more from the Inattention list.

adhd hyperactive

For a diagnosis of Attention Deficit Hyperactivity Disorder Impulsive-Hyperactive Type:

  • Six or more from the Impulsive or Hyperactive lists.

For a diagnosis of Attention Deficit Hyperactivity Disorder Combined Type:

  • Both criteria are met.

Attempt at legal disclaimer. This is just for your information. We want you to know that there are several reasons why a child could have these symptoms besides Attention Deficit Hyperactivity Disorder. For example, thyroid problems, depression, anxiety disorders, hearing problems, and so on. Please do not attempt to "diagnose" your child. Follow the steps in the Diagnosis section. See your doctor. Go to a qualified mental health professional. This web site is no substitute for talking with an expert on ADHD.

Share it now

ADHD Evaluation Process

Share it now

ADHD Evaluation Process

Here is the process that we believe makes for a good diagnostic evaluation to see if someone has ADHD or not:


When you get an evaluation for attention deficit hyperactivity disorder, there should be a good parent interview. It's absolutely essential that somebody sits down with the parents and spends 45 minutes to an hour with them.

In this interview the psychologist or therapist needs to find out what's going on now, why did the parents pick up the phone and call now instead of last week, and so on. Was there a recent trigger event? A recent trauma? A recent loss? Or is there a problem at school, or a threat from the teacher? What is happening that you had to call for help?


A good developmental history must also be taken. Important questions are:

  • How did mom do during pregnancy?
  • Were there any problems at all during pregnancy?
  • Was there any exposure to drugs or alcohol prior to birth?
  • When did he learn to walk or crawl?
  • How about speech development, any problems?
  • Did he have very many ear infections?
  • Have there been any head injuries, high fevers, or seizures?

Head injuries and seizures can look just like attention deficit hyperactivity disorder, but aren't. They may require different treatment options.


The family trees of Attention Deficit Disorder kids are often very similar. It seems that about 80 percent of the time one can trace the impact of this gene, either the "ADHD" gene or the "Tourettes" gene, as it runs through families causing things like obsessive-compulsiveness, depression, alcoholism, attention disorders or learning disabilities throughout the family.


The clinician must take the time to rule out a long list of other possibilities:

  • Is child depressed?
  • Does he have anxiety problems?
  • Is he hallucinating?
  • Is he delusional?
  • Is it a head injury?
  • Is it a seizure disorder?


Parent rating scales are very good and should be given. The ADD ADHD scales we like best are by Ned Owens out of Texas. Keith Connors has a fine tool that you have probably seen if you are involved with ADHD children at all. It is very important for the parents to fill out these behavior rating scales.


Ideally the teachers will fill out rating scales also. You want the teacher's input because they see 30, 32, or 35 kids every single class, year in and year out, and they know what is normal behavior and what is not.

Note: One of the things we have noticed is that lately we are having more trouble with the teacher rating scales because the teachers ten years ago, eight years ago, five years ago used to rate the kids pretty reliably compared with the “normal” kids in the class (the non-ADD kids in the class).

But what we are seeing lately is very often the teachers are comparing the child that we want rated against the “worst kid” in the class, who might be totally off the wall. When this happens the rating scale often comes back reporting that the child rated isn't much of a problem at all. We have to give specific directions to the teachers to rate them compared to "normal kids," not against the “worst kids” in the class.


Also, an in-depth clinical interview with the child is essential. This should last 45 minutes to 60 minutes, and should touch on about a dozen different areas with about 100 questions.

This interview is needed to determine the child's reality testing, his degree of maturity, his degree of verbal skills, and so on.

As part of this interview the child should be asked about his world, his relationship with peers, with parents, with school.

Is there some reason that the child can think of that can explain why he cannot focus, concentrate, get his work done, or pay attention?

The child should be asked if he's anxious. Some kids have tremendous fears, but have not shared them with anyone.

The child should be asked questions that would reveal if the child is depressed.

The child should be asked if he's hallucinating. Sometimes he is, but he hasn't told anyone. A small percentage of children and teens can hear or see things that no one else does for a variety of reasons, some are very serious and some are less so, but the question should be asked.

There is a lot going on with kids that their parents are not aware of, so the kids should be asked.

Share it now

ADHD Over-Diagnosed? Recent Study Says "Yes"

Share it now

Is ADHD Over Diagnosed ? Take a Closer Look

ADHD is not only over diagnosed, but it is often mis-diagnosed, according to a recent study out of Germany. According to this research, many child and adolescent psychiatrists and psychologists in Germany have a picture in their heads of what an "Attention Deficit Hyperactivity Disorder "child or teen looks like, or acts like, and then a child or teen that fits that picture gets the diagnosis. In this process actual diagnostic criteria takes a back seat to “experience” or “heuristics.”

But does this mean that ADHD is being “over diagnosed” because of poor diagnostic criteria, or due to poor diagnostic tools? No. Rather the problem is in the lack of using either diagnostic criteria or diagnostic tools. The reason for “over diagnosis” of Attention Deficit Hyperactivity Disorder is sloppy diagnostic workups by these professionals.

But the study was a little sloppy too. It draws “real world” conclusions from “pretend” or “theoretical” situations. No one examined actual patients or even their charts. So how do they know that in the "real world" that ADHD is being over diagnosed? The answer is that they don't. But they do have a better understanding of the process that busy professionals use in interpreting "case vignettes" that may or may not be Attention Deficit Hyperactivity Disorder.

The study was published in the Journal of Consulting and Clinical Psychology by researchers from Ruhr-Universitat Bochum and University of Basel. The researchers contacted 1,000 professionals who diagnose ADHD as either psychiatrists or psychotherapists in Germany, and nearly 500 responded. They were sent case vignettes which included a set of symptoms and circumstances, and they were asked to offer their theoretical diagnosis. Some of the vignettes met the criteria for ADHD, but most did not (but may have been close).

What the researchers did find is that in the world of looking at vignettes and submitting answers, the psychiatrists and psychologists tended to look for key descriptive words and “prototypical symptoms” to make their decisions. The “prototype” that seemed to be used the most was of a male with symptoms of excessive motor activity, lack of concentration, and impulsiveness. And, yes, these are typical of Attention Deficit Hyperactivity Disorder.

But they could also be caused by other disorders or medical conditions too, from depression to anxiety, thyroid issues, or more.

The research also showed that the same vignette with a male as the subject was “diagnosed” as ADHD more often than with a female as the subject.

While there is much to question in the way that the press, at least, is writing about this study, the researchers do point out some important observations in their conclusions:

  • There isn’t a lot of research into how ADHD is usually diagnosed in the “real world”;
  • A lot more children and teens throughout the US and Europe are being diagnosed with Attention Deficit Hyperactivity Disorder than ever before;
  • More children and teens are being prescribed medications than ever before;
  • And it is very important that therapists, psychologists, and physicians do not just rely on their experience, or intuition, in making a diagnosis of ADHD, but rather that they use that actual Diagnostic Criteria, and use available diagnostic tools such as standardized questionnaires for parents and teachers, CPT tests such as the TOVA or Conners CPT, and other tools as available, to increase the probability of an accurate diagnosis.

See our section of articles on Diagnosing ADHD.

Keywords: Over Diagnosis of ADHD, ADHD Research, Attention Deficit Hyperactivity Disorder

Share it now

Diagnosis and Treatment of ADHD : NIMH statement 2000

Share it now

National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD).

Issue: Feb, 2000


Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem.

Despite progress, ADHD and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.

Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder.

Studies (primarily short-term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer-term studies with drugs and behavioral modalities and their combination.

Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made at present. There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants, and thus the need for improved assessment, treatment, and follow-up.

Furthermore, the lack of insurance coverage, preventing the appropriate diagnosis and treatment of ADHD, and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.

Finally, after years of clinical research and experience with ADHD, knowledge about the cause or causes of ADHD remain largely speculative.

Consequently, there are no documented strategies for the prevention of ADHD.

J. Am. Acad. Child Adolesc. Psychiatry, 2000, 39(2):182-193. Key Words: attention-deficit/hyperactivity disorder, diagnosis, treatment, psychostimulants, risks, barriers.

Share it now

Psychological Testing for ADHD

Share it now

Diagnosing ADHD with Psychological Testing

Psychological testing as part of an evaluation for Attention Deficit Hyperactivity Disorder - ADD ADHD - can be helpful.

Tests such as the WISC-R, which is an IQ test, the Wide Range Achievement Test (WRAT), and the Bender-Gestalt test, which is a visual motor integration test, can be helpful within limits.

There are certain patterns of strengths and weaknesses that one might predict to find on these tests if the subject had ADHD. But it's as much art as science. The patterns are not "diagnostic" for Attention Deficit Hyperactivity Disorder. They just may be "consistent" with ADHD.

It's also important as a part of the evaluation to know the subject's IQ level. If the kid has a real low IQ, or a major learning disability shows up, it could be a clue that there is something else going on instead of attention deficit hyperactivity disorder.

So we find these tests helpful, but not specific for ADHD.


The Test of Variables of Attention (TOVA) is the most helpful test that we found for the diagnosis and treatment of ADHD, but even it is never used in the diagnostic process without the interviews, rating scales, physical exam, or perhaps some other testing. But it is a good tool in the evaluation process.

The TOVA is an extremely boring computer test that requires the kids to respond to a target stimulus by pressing a button, or to not respond when there's a non-target stimulus.

The fact that it is so boring is a work of genius because it helps to differentiate between kids who have trouble with "boring," and kids who do all right with "boring."

The TOVA is really a valuable tool, but it should never be given just by itself. It needs to be given in the context of the whole diagnostic workup.

Getting a TOVA Baseline

TOVA is given with no medication in the diagnostic process. And part of its value is that if medication is considered at some point, the test can be re-administered with a "challenge dose" of medication in their system. This can tell the physician if the subject is a "responder" to that particular medication or not, or how well he responds to that particular dose of that particular ADHD medication.

Clinical Observation for ADHD at School

Clinical observation of the child is very important. If possible, ideally, somebody observes the child in the classroom.

In the real world, we don't know anybody in private practice who can go out in the classroom to observe a child these days, but if a school nurse or school psychologist can go observe them, it can be very, very helpful.


Obtaining an EEG from a neurologist is rarely helpful in the process of diagnosing ADHD.

EEGs will show that there are differences between the brainwave patterns of those with ADHD and those without ADHD. Typically there is excessive slow brainwave activity, particularly in the Theta band (4-7 Hz.).

However, ninety-five percent of all Attention Deficit Hyperactivity Disorder kids have what the neurologist will call "normal" EEGs.

What we mean by "normal" is they don't have big epileptic seizure spikes, or indications of tumors or head injuries, that a neurologist would say are "abnormal."

But when compared side by side with a non-ADD person, the EEGs are much different if the subject has ADHD.

An EEG may be helpful if the child is going to be treated with EEG biofeedback, but in terms of being helpful for a diagnostic work-up, it is rarely helpful.

However, if the parent interview revealed that the child had some potential neurological problem, as seen in sleep walking, or a history of seizures, and so on, then an EEG would be a good idea.

Summary of Diagnostic Evaluation for ADHD

An adequate diagnostic interview, designed to give an accurate diagnosis a very high percentage of the time, while not costing the family thousands of dollars, would look like this:

  • Physical Exam - Office Visit
  • Clinical Interview - Parents (45-60 minutes)
  • Clinical Interview - Child (45-60 minutes)
  • TOVA test
  • Parent and Teacher Rating Scales
  • Office visit to review information and develop a treatment plan
  • Other testing if there were still questions to be answered
  • Begin Treatment

That's it! If there are further diagnostic questions, then more testing would be required. But in the majority of cases, this is all that is needed to make a highly reliable diagnosis.

Share it now

RULE OUT Other Possible Causes

Share it now

Mis-diagnosing Children with ADHD

Why does it see that there are so many children today with the diagnosis of Attention Deficit Hyperactivity Disorder – ADD ADHD?

As I get older the answer becomes clearer to me.

The reason there are so many children diagnosed with ADHD today is that physicians, psychologists, therapists, and/or parents, rush to this diagnosis without doing their “due diligence” in the diagnostic process.

In other words, they cut corners and rush to judgment. They make the diagnosis of ADHD too soon in the process simply to save time and effort.

Here is the Road to a Bad Diagnosis:

1. A physician, psychologist, or therapist is well versed in the diagnostic criteria for ADHD.

2. A parent brings in a child for an evaluation because of behaviors at home or at school.

3. The child meets the diagnostic criteria for ADHD.

4. Therefore, the child has ADHD. Simple. Mission accomplished!

But this is absolutely the WRONG WAY to make the diagnosis of Attention Deficit Disorder.

Even according to the diagnostic criteria for ADHD from the Diagnostic and Statistical Manual ( DSM-4 ), just because a child meet all of the criteria for ADHD does NOT mean that he gets the diagnosis.

Rather it is a child who meets all of the diagnostic criteria AFTER an entire series of other possible explanations have been RULED OUT first!

“The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).”

And this is written with the assumption that other medical conditions that might also explain the symptoms have been ruled out.

This step of ruling out a long list of other explanations is ignored in the diagnostic process almost every time!

Before a Diagnosis of ADHD

Before your child is given the diagnosis of Attention Deficit Hyperactivity Disorder, the following long list of medical and mental health possibilities must be RULED OUT.

And by RULED OUT we mean that the physician, psychologist, therapist, and you – the parent, must carefully consider each other possible explanation, and be able to honestly say, out loud, “NO, THAT’S NOT IT.”

Here is out list of other reasons why children can be inattentive, impulsive, hyperactive, show temper, have poor focus, or look like they are ADHD. Each must be considered and RULED OUT:

  • FOOD ALLERGIES – This, in our experience, is the most common alternative cause;
  • HEAD INJURIES – Can be caused lots of ways, from forcep deliveries at birth, to car accidents, to “baby shaking,” to Fetal Alcohol Syndrome or Drug Exposure in utero, to falling out of a crib, to falling and hitting your head, to playing soccer and heading the ball, and many more;
  • BIPOLAR DISORDER or MANIC DEPRESSION – Studies show that 15% of children who are diagnosed as having ADHD actually have early onset Bipolar Disorder. Studies also show that there are as many people born with Bipolar Disorder as there are people born with ADHD. You cannot make a diagnosis of ADHD without ruling out Bipolar Disorder;
  • TOURETTES SYNDROME – Basically ADHD with tics;

Only AFTER each item on this list has been considered, and each has been RULED OUT, can the diagnosis of ADHD be considered.

Results of Cutting Corners

Cutting corners in this important area of making a diagnosis leads to children being put on medications that not only do not have a chance to help them (because they aren’t ADHD), but can actually cause serious problems.

For example, does Stimulant Medication such as Ritalin cause tics?

No. But a child diagnosed with ADHD, who actually has Tourettes Syndrome, and is given stimulant medication, will develop tics because of the stimulant medication.

Are temper outbursts an indication of ADHD?

No. They may occur with ADHD, but they point more toward either head injuries, early onset bipolar disorder, childhood major depression, OCD or anxiety disorders. And if such a mis-diagnosed child is given stimulant medications it may result in explosive temper outbursts, increased anxiety or compulsiveness, or even suicidal thinking.

Symptoms of head injuries, bipolar disorder, tourettes, autism, schizophrenia, anxiety, obsessive compulsive disorder, depression, and post traumatic stress disorder, can all be made WORSE by treating a child for ADHD with stimulant medications.

Please make sure that you get a good diagnosis for ADHD before beginning any stimulant medications. This is where to make the investment of time and money – in the diagnosis.

Share it now

Steps to Take if Your Child Might Have ADHD

Share it now

If you child's teacher has met with you, and suggests that you should have your child evaluated for possible ADHD, here are the steps to take...

Step One: Find an EXPERT, and Get a Righteous DIAGNOSIS

Find a Psychologist, or a Marriage, Family, and Child Therapist, or a Psychiatrist, who has a good working knowledge of Attention Deficit Disorder – ADD ADHD.

Most mental health professionals do NOT know much about the disorder, even if they tell you that they do.

How to find the expert:

  • Get some paper and prepare to make a list
  • Ask parents at your local CHADD meeting about the best doctor and the best therapist in your area. These parents have already been down the road that you are on, and they know who is good, and who is a waste of time and money;
  • Then call your local psychiatric hospital. Ask for the "Charge Nurse" at either the Children’s Unit or the Adolescent Unit. Politely ask the charge nurse who the best doctors and therapists for treating Attention Deficit Disorder that they know of are.

You now have some good names on your list.

Call the professionals on the phone and give them a two minute interview. Keep the phone call brief. They are busy people too.

Ask them questions such as:

  • "What percentage of your practice is with Attention Deficit Disorder children or teens?"
  • "How many years experience do you have in treating ADHD individuals?" "How many individuals with ADHD have you worked with?"
  • "How do you do a diagnostic work-up for Attention Deficit Disorder?"
  • "What treatment options are you familiar with in the treatment of ADD ADHD?"

Based on their answers you will know whether or not you will want to work with them.

Prepare yourself for meeting with them. Read this entire ADHD Information Library web site, including the articles and especially the "blog" section with our ADHD newsletter articles, and "up to the minute" ADHD news and information.

Also check out other ADHD sites:

Now you are ready to meet with them, and interview them.

If they seem to know more than you do (after you've spent time at these sites) then that is a good sign. If they seem to know less than you now do, then that is a bad sign. Why pay someone who knows less than you do?

Keep looking and find the Expert.

When you find him or her, do what they recommend -- and pay them what they are worth.


Make sure that you have a thorough assessment done, including at a minimum:

  • parent interview,
  • child interview,
  • parent rating scales,
  • teacher rating scales,
  • and TOVA testing as appropriate.

Medical conditions, such as food allergies, environmental allergies, thyroid problems, head injuries, and more, should be considered and ruled-out.

Mental Health issues, such as bipolar disorder, anxiety disorder, and depression should be considered, and ruled-out.

Emotional issues that could also be causing ADHD - like symptoms must also be ruled-out.

Read through our section on Diagnosing Attention Deficit Disorder - ADD ADHD, and review that information now if needed.

Use your best judgment, and talk with your doctor about these suggestions on getting help for ADHD.

Share it now

Steps to a Good Diagnosis

Share it now

Diagnosing ADHD | Evaluation Diganostic Work-Up

Here are the things that we recommend if you have a child that ought to be looked at for possible Attention Deficit Hyperactivity Disorder:

  1. PHYSICAL EXAM - First, there should be an "adequate" physical exam by the child's pediatrician or family practice doctor. This doesn't have to be an extensive, expensive exam, but should be able to rule out possible problems like Mononucleosis, Thyroid problems, lead poisoning (if it is common in your area), and potential attention problems caused by medications, such as allergy medications. Then, with a clean bill of health, we move on to step two. . .
  2. EVALUATION FOR ADHD - Get an evaluation for attention deficit hyperactivity disorder. Usually a psychologist or other mental health professional will do this evaluation for ADD ADHD. The evaluation would include at minimum:
    • Parent Interview
    • Parent Rating Scales
    • Teacher Interview if possible
    • Teacher Rating Scales
    • Child Interview
    • Testing with Child

    We look at this process in more detail in the next article.

  3. HOW TO FIND AN EXPERT - To find experts on attention deficit hyperactivity disorder in your area you will have to ask around a bit. Ask other parents at your local CHADD chapter. Or call your local Psychiatric Hospital and ask for the Child or Adolescent Unit. Then ask for the "Charge Nurse." Ask the Charge Nurse who the best child psychiatrists, psychologists, and therapists in your town are. They know.

    Note: Only get counseling or therapy from professionals who have a lot of experience treating attention deficit hyperactivity disorder. Therapists who do not have a lot of experience with ADD ADHD will just take your money and then, out of their lack of understanding, probably blame you, the parents, for the child's ADHD.

Share it now

TOVA Test Useful in Diagnosis of ADHD

Share it now

Diagnostic Issues and Attention Deficit Hyperactivity Disorder – ADD ADHD

Clinical utility of the test of variables of attention (TOVA) in the diagnosis of attention-deficit/hyperactivity disorder

Journal of Clinical Psychology
Volume 54, Issue 4, 1998. Pages: 461-476
Published Online: 6 Dec 1998

Ability of the Test of Variables of Attention (TOVA) to distinguish between referred children with attention-deficit/hyperactivity disorder (ADHD) and other (OTHER) clinical diagnoses were studied.

The ADHD group differed from the OTHER group on TOVA variables and most measures from the Revised Conners Teacher Rating Scale (RCTRS) and ADD-H Comprehensive Teacher's Rating Scale (ACTeRS).

The criteria of any one TOVA variable > 1.5 standard deviations from age and sex adjusted means correctly identified 80% of the sample with attention deficit disorders and 72% of the sample without attention deficit disorder.

Cases misclassified by teacher ratings were often correctly classified by the TOVA and conversely. The TOVA makes a unique and important contribution to diagnostic evaluations.

J Clin Psychol 54: 461-476, 1998.


TOVA Test Useful in Diagnosis of ADHD

Share it now

Diagnosis Question from a Parent

Share it now

I recently received this letter from a parent which touches on all of the issues involved in the diagnosis of childhood behavior disorders such as ADHD. Look at all of the issues involved: divorced parents, lifestyle of one of the parents, mood swings, inattention, tics, meds that don't work, and more. My heart goes out to this dad and his child:

I have a 9 yr old son who was diagnosed with ADHD about 4-5 years ago, and ever sense then I'm not sure where my son has gone. He's lost weight, doesn't eat and has a pretty bad mood swing once in a while and the only action by his care provider is to change his medication time after time after time. He's been on countless combination's of drugs and none seem to work. My son's school told us they ranked him in 9th percentile in terms on attention span, I would hope after being on drugs for more than 4 years that are suppose to help his attention span that number would at least be 70-80%.

My questions are simple...

Could a hectic home life with his mother (lots of boyfriends, being moved from place to place, moms constant fights with b/f, not getting the attention he needs basically) be confused with a child having ADHD?

He is currently on Vyvanse..Is it normal that he has constant ticks?

And is there an age at which doctors take a wait and see approach before giving meds, because the child may just be young and unruly?

Here was my response to this father:

Dear Dad,

It sounds like a difficult situation, as the school is involved, a doc is involved, custody is involved, boyfriends, and etc. It can be very difficult to figure out what is ADHD, depression, anxiety, tourette syndrome, a head injury, fetal alcohol syndrome, chaos at home, or what... There are lots of things that can cause the attention problems in school.

Certainly "mood swings" can be from ADHD, or early on-set bipolar disorder, or childhood depression, or anxiety disorders, or OCD, or just being "fed up" with things. Weight loss is likely from the medications, as stimulants reduce appetite.

The tics are most likely from tourettes syndrome (the genetics of ADHD and TS are very close, and they are often confused diagnostically, as are ADHD and early onset bipolar disorder). Some experts think that the medications can cause the tics, and there is some evidence for this, but it is just as likely to see a child diagosed as ADHD, and treated for ADHD, but has TS instead.

Fetal Alcohol Syndrome or Drug Exposure in utero can cause little head injuries during development that can look like more extreme cases of ADHD (mood, temper, inattention, etc) but they don't respond to meds as well as "true" genetic ADHD kids do.

You might just consider going back to get a new diagnosis from someone who can differentiate between the possibilities listed above. This diagnosis might include using a Tova test or similar, both without medication, and then a challenge test with medication. But without a diagnosis that you can be confident in it is hard to 100% support treatment, especially if it doesn't seem to be working.

I guess you should also rule out food allergies, which would set him off whether on the meds or not, or "environmental" allergies that would do the same to him.

You probably know that I like Attend and Extress for ADHD treatment, but when several medications have already failed to get desired results it makes me suspicious of the diagnosis. But you might try some Extress in addition to the Vyvanse, just to calm the mood. It can be taken with the Vyvanse. Here's a link with more information on Extress from the manufacturer's site: http://www.vaxa.com/26462/index.cfm?page=631.cfm

Here are some links that might help:

Things that look like ADHD but are not -

ADHD Tests and Diagnosis -

ADHD Diet Recommendations -

Hope this helps at least a little.

Doug Cowan

Share it now