Resolving ADHD Diagnosis Confusion
by
Richard Rubin, MD
Clinical Associate
Professor, University of Vermont College of Medicine
Without a diagnosis to guide ADHD treatment, people
become concerned about continuing impairments,
disappointed in lack of direction from
professionals, and frustrated at what to do. Some of
this confusion comes from unrecognized differences
in what constitutes an ADHD diagnosis. The different
types of diagnosis can be defined as 1)
administrative, 2) research,
3) clinical syndrome, and 4) symptomatic.
Administrative guidelines for special education
services may emphasize learning and developmental
disability evaluation, but not address concurrent
ADHD treatment needs, possibly due to limits in
local policies and funding. The failure to diagnose
ADHD may also come from qualifying requirements for
severity and educational interference that are
higher than community treatment standards. Similar
failure to qualify may occur with standardized
testing for college or work accommodations. However,
absence of such administrative diagnosis does not
rule out possible problems needing practitioner
referral for clinical evaluation.
Research diagnosis procedures may produce results
that are contrary to the participant’s expectations.
The protocols usually require more stringent
criteria than clinical practice assessment,
excluding milder degree problems or adults with
unclear childhood history. Research studies also
usually exclude participants with other combined
disorders, leaving the participant with ambiguous
diagnosis information. Someone who does not qualify
as ADHD for a particular study may still have the
diagnosis by community treatment standards.
ADHD clinical syndrome diagnosis by DSM-IV criteria
is the standard for practice. The Diagnostic and
Statistical Manual of the American Psychiatric
Association is accepted by all
medical and mental health specialties. The necessary
criteria are 1) sufficient number of inattention
and/or hyperactivity core symptoms, 2) occurrence in
multiple settings, 3) onset by age seven, 4)
significant impairment, and 5) absence of other
causes. While measuring core ADHD symptoms is
important, treatment should be determined more by
the individual’s impairments, meaning their daily
life difficulties and adverse consequences.
The term symptomatic ADHD has recently been applied
to people who have some significant ADHD
impairments, but do not meet full DSM criteria. The
DSM category “ADHD, Not Otherwise Specified” is used
to describe this situation. At present, the decision
to make a symptomatic disorder diagnosis depends on
the judgment of each doctor and patient.
Parents and ADHD people can recognize they have
several ways to evaluate their problems and meet
their needs, depending on the purpose and procedure.
Inability to obtain conclusions from administrative
testing, as through school programs, does not need
to discourage seeking treatment evaluation and
helping services. Similarly, failure to qualify by
administrative or research criteria does not mean
ADHD disorder is absent. From the practicing
psychologist and physician perspective, we should be
aware of the several forms of ADHD diagnosis to help
each individual best by providing our own methods,
and also know how to advise about other diagnosis
categories and services.
Dr. Rubin practices Child and Adult Psychiatry,
directs The Clinical Study Center in Burlington
Vermont, and serves as Clinical Associate Professor
at the University of Vermont College of Medicine.
