‘Please test him for ADD’

We find it comforting to rely on an X-ray or a blood test to unequivocally establish or refute a diagnosis. But unfortunately, with Attention Deficit Disorder, no such test exists. Not yet, at least. No, the diagnosis rests on the identification of symptoms and signs known to be associated with the condition. So please don’t let anyone tell you that your child needs an EEG (electroencephalogram) – a procedure which records the electrical activity of the brain – in order to diagnose ADHD. And the same goes for the latest fad, the so-called quantitative EEG (known as the ‘qEEG’).

Now, allow me to introduce you to the Diagnostic and Statistical Manual of Mental Disorders, better known as DSMIV (it is now in its fourth edition). Published by the American Psychiatric Association, this is the ‘bible’ of psychiatric disorders. This tome records the diagnostic rules for any condition you care to mention. In the section describing childhood conditions, you will find that the symptoms of ADHD are divided into three clusters. Here are the nine symptoms of the inattentive cluster:

  1. An abnormally short concentration span
  2. A frequent resistance to sustained mental effort, especially with boring or repetitive tasks
  3. Easy distractibility
  4. Marked forgetfulness
  5. A tendency to lose things frequently
  6. Difficulty organising tasks and poor planning
  7. Not listening properly to instructions
  8. A tendency to rush work, giving poor attention to detail and making frequent careless mistakes
  9. Often not completing tasks

And here are the criteria for the Hyperactive and Impulsive clusters:

  1. Constantly on the go, “as if driven by a motor”
  2. Runs about or climbs excessively
  3. Restless, unable to stay seated
  4. Fidgets excessively
  5. Excessively talkative
  6. Plays loudly
  7. Often interrupts or intrudes on others
  8. Cannot wait his or her turn
  9. Blurts out answers before the question is completed

The powers that be have decreed that, in order to qualify for the diagnosis, a child should display at least six of the nine symptoms from the inattentive cluster, or six of the nine hyperactive/impulsive symptoms. There is nothing magical in this particular threshold, and good studies have shown that children with only four or five symptoms may be as impaired as children with seven or eight criteria. So this cut-off is quite arbitrary, and on another planet it might be four or eight. But we have to have some sort of guideline, so six it is.

In assessing these symptoms, apart from questioning the parents and the child, the doctor will engage the child in structured tasks (drawing, puzzle-building, etc) in order to make direct observations. But feedback from the school teacher is crucial in ascertaining how the child is functioning in the classroom. To this end, we use rating scales to assist us. Standardised questionnaires are commonly used for this purpose, such as the Conners or the Copeland scales. They are tabulated checklists, asking for the degree to which the child displays each symptom. But I must stress that questionnaires alone cannot make the diagnosis; they are tools to be supplemented with clinical judgement.

Now, it’s one thing to have these symptoms – even six of them – but quite another to be significantly impaired by them. I tend to be absentminded but I am still able to function reasonably well at work and at home. This is where the concept of functional impairment comes in. In order for us to diagnose a disorder, there has to be, well, disorder. In ADHD, there are three important domains of functioning to think about.

Firstly, ADHD causes children to underperform in the classroom. This is especially important in the early grades, when foundational skills are being learnt. ADHD can affect the brightest children, the slowest, and anyone in between. But whatever the child’s intelligence, it will cause them to underachieve relative to their potential. Some bright children with ADHD seem to cope well enough in primary school when there is enough support in place, from both teachers and parents. If they are not particularly hyperactive, the teacher will not have had any reason to recommend an assessment. These children may only start to struggle in high school, when they are expected to be more organized and to work more independently.

Secondly, this condition often affects the social functioning of the child. This is usually the result of hyperactivity and impulsiveness, affecting how he interacts with his friends, his siblings and authority figures. He often alienates himself from his peers and may be genuinely unaware of why this has happened.

And thirdly, as a consequence of the above, these children are often distressed and demoralized. Their absentmindedness often gets them into trouble with parents and teachers alike. Their academic difficulties frustrate everyone including themselves, and they struggle with rejection from peers.

If an inattentive or hyperactive child is not impaired in any of these areas then it is preferable not to make the diagnosis. After all, we can’t go around diagnosing every absent-minded child with ADHD, now can we?