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  7. Diagnosing ADHD

Diagnosing ADHD

There are two definitive manuals for physicians that contain chapters describing the criteria for diagnosing ADHD. They are known as the DSM and the ICD. Historically, they have had slightly different ways of defining the sub-types or presentations and levels of severity ADHD, but in recent versions (DSM-V and ICD-11) efforts have been made to harmonise the two standards, and in general terms they describe the same disorder as follows:

Symptoms

To receive a diagnosis of ADHD, an individual must display some or all of the following characteristics:

  • Inattention: forgetful, loses interest quickly, doesn’t listen when spoken to
  • Hyperactivity: fidgets, talks excessively, runs about and climbs in inappropriate places, difficulty in engaging in activities quietly
  • Impulsivity: high risk behaviour, doesn’t think about consequences, difficulty in suppressing what they want to say

Challenges and Conditions

Diagnosis can be quite challenging because:

  • There is no physical test for ADHD (such as a blood test)
  • All children may have some problems with self-control
  • Other problems can result in similar behaviour to ADHD
  • Other problems can overlap and hide those of ADHD

In order to compensate for these difficulties, even if all the above symptoms are present, the following conditions must also be met:

  1. Even if diagnosed later, looking back symptoms must have begun before 12 years of age (as of DSM-V).
  2. Symptoms must be noted at school (or work) as well as at home
  3. There must be a definite negative effect on social, school, or work performance (a functional deficit)
  4. The symptoms must not be the result of another disorder or problem

Who can get ADHD?

Attention Deficit Hyperactivity Disorder is a neurobehavioral disorder. The exact cause is not clear, but it is thought to occur due to a combination of genetic and environmental factors, including exposure to toxins early in life. While the primary cause is thought to be genetic, it is possible that environmental factors may cause an underlying genetic predisposition to emerge. These are issues that are still being researched internationally and in Saudi Arabia. What is known for certain is that you cannot contract ADHD through contact with another individual, and it seems pretty clear that you cannot develop ADHD in later life (although you can be diagnosed as an adult, if you didn’t get diagnosed in childhood).

Both boys and girls are affected by ADHD. Although more boys are diagnosed with ADHD than girls, a combination of hyperactivity, impulsivity and inattention are the most prevalent presentation in both genders. For those without all three of these main symptoms, boys with ADHD are more likely than girls to be hyperactive/impulsive (without inattention), while inattention (without hyperactivity and impulsivity) seems to occur in girls more often than it does in boys. Some girls who have all three symptoms also exhibit their hyperactive tendencies differently than the stereotypical disruptiveness of the “hyper boy”. It’s possible that these factors lead to girls with ADHD being overlooked as they do not attract obvious attention with the disruptive behaviour seen most often in boys.

ADHD is estimated to affect 5.9% of school-aged children in Saudi Arabia and the Gulf Region, making it the most common behavioral disorder in children. Adolescents and adults can also have ADHD, even if they were not diagnosed with the disorder when they were younger. It is estimated that one third to one half of children with ADHD will continue to display some or all of their childhood ADHD symptoms as adults. In adolescence and young adulthood, many individuals with a history of childhood ADHD continue to be impaired by the disorder, although they often show reduced hyperactivity and impulsivity while retaining symptoms of inattention.

Who can diagnose ADHD?

ADHD can only be diagnosed by a licensed clinician who interviews the parent or caregiver and/or patient to document criteria for the disorder. It cannot be diagnosed by rating scales alone, neuropsychological tests, or methods for imaging the brain. The diagnosis and management of ADHD is a multi-disciplinary effort and depending on individual requirements the other healthcare professionals may have specific primary or supporting roles to play at different stages of the process.

The diagnosis of ADHD has been criticised as being subjective because it is not based on a biological test. This criticism is unfounded. ADHD meets standard criteria for validity of a mental disorder established by Robins and Guze. The disorder is considered valid because:

  1. well-trained professionals in a variety of settings and cultures agree on its presence or absence using well-defined criteria and
  2. the diagnosis is useful for predicting
    • additional problems the patient may have (e.g., difficulties learning in school);
    • future patient outcomes (e.g., risk for future drug abuse);
    • response to treatment (e.g., medications and psychological treatments); and
    • features that indicate a consistent set of causes for the disorder (e.g., findings from genetics or brain imaging).

Professional associations have endorsed and published guidelines for diagnosing ADHD, including the Saudi ADHD Society which published the Evidence-Based Clinical Practice Guidelines for the Diagnosis and Management of ADHD in Saudi Arabia in 2020.

What tests may be performed?

In addition to evaluation of the above-mentioned criteria through clinical interview, members of the diagnostic team may ask parents to complete one or more standardised questionnaires that help to form a clear picture of a child or adolescent’s behaviour. As there is no direct school involvement in Saudi Arabia, they may also request parents to provide similar questionnaires for their child’s teachers to complete.

Again, depending on the individual, a member of the diagnostic team may recommend additional tests which measure the length and type of mental process or tests of attention and persistence.

In order to exclude the presence of other lookalike disorders or co-existing conditions contributing to the ADHD-like symptoms, various other tests may also be performed.

A number of self-tests are available that can help you form an educated opinion about whether you or your child may have ADHD, but these are simply screening tests, not diagnostic tests, and should be taken only as a first step in deciding whether to consult a professional. Healthcare professionals are trained to recognise the smallest signs and symptoms that cannot be discovered from a generic self-test. They will examine the detailed history of someone suspected to have ADHD in order to eliminate any other possibility. It is important that they are consulted to ensure an accurate diagnosis.

Diagnostic Features

The diagnosis requires:

  1. the presence of developmentally inappropriate levels of hyperactive-impulsive and/or inattentive symptoms for at least 6 months;
  2. symptoms occurring in different settings (e.g., home and school);
  3. symptoms that cause impairments in living;
  4. some of the symptoms and impairments first occurred in early to mid-childhood; and
  5. no other disorder better explains the symptoms.

The clinical presentation of ADHD can be described as primarily inattentive, primarily hyperactive-impulsive, or combined, depending on the nature of their symptoms. Meta-analyses indicate that inattention is more strongly associated with academic impairment, low self-esteem, negative occupational outcomes, and lower overall adaptive functioning. Hyperactive-impulsive symptoms are associated with peer rejection, aggression, risky driving behaviours, and accidental injuries. Patterns of associated disorders also differ between the dimensions.

ADHD impairs the functioning of highly intelligent people, so the disorder can be diagnosed in this group. A population-based birth cohort study of over 5700 children found no significant differences among children with high, average, or low IQ and ADHD in median age at which ADHD criteria were met, rates of learning disorders, psychiatric disorders, and substance abuse, and rates of stimulant treatment.

Many large epidemiologic and clinical studies show that ADHD often co-occurs with other psychiatric disorders, especially depression, bipolar disorder, autism spectrum disorders, anxiety disorders, oppositional defiant disorder, conduct disorder, eating disorders, and substance use disorders. Their presence does not rule out a diagnosis of ADHD.

A meta-analysis comprising 25 studies with over eight million participants found that children and adolescents who are relatively younger than their classmates are more likely to have been diagnosed with ADHD.

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