Avoiding an ADHD Misdiagnosis: The essential components of an effective ADHD evaluation

Rates of ADHD diagnoses in the US continue to rise steadily, with a newly published study showing that 10% of today’s children and teens are diagnosed with ADHD compared to 6% back in the late 1990s.¹ There are many possible reasons for the sharp increase in diagnoses, including increased awareness about ADHD (especially the inattentive subtype), improved health care access, and more rigid education and testing standards in public schools. These factors all contribute to higher rates of proper diagnoses for kids with ADHD who would have otherwise been missed, and that’s a good thing. Unfortunately, these same factors can also contribute to higher rates of misdiagnoses among kids and teens who are falling behind academically or are struggling to pay attention and follow classroom rules for reasons that are unrelated to ADHD. 

With more and more children and teens being diagnosed with ADHD, it’s more important than ever for parents to insist that their child receive a rigorous diagnostic assessment. A thorough assessment is the only way to minimize the risk of a misdiagnosis and ensure that ADHD is the most appropriate explanation for a child or teen’s symptoms and behavior. Often, ADHD diagnoses are made in the pediatrician’s office after a single visit. If these office visits are too brief and rating scales completed by parents and teachers aren’t included in the assessment process, then the likelihood of a misdiagnosis goes up dramatically. Some pediatricians have a practice that can support the demands of an ADHD diagnostic assessment and have a great deal of experience in this area, but often the most thorough evaluations are conducted by a mental health specialty provider or a developmental pediatrician. When evaluating whether the assessment your child or teen is receiving is as rigorous as it needs to be, look for the following components:

Detailed Interview with Parents
The foundation of a solid ADHD evaluation is a detailed parent interview that assesses the child’s medical history, and social history, as well as his or her history of symptoms of ADHD and other conditions like anxiety and depression. Overall, the goal of this interview is to establish a timeline for the development of ADHD symptoms and behaviors as well as other disorders or situational factors that may also explain a child’s symptoms. At a minimum this interview should take 30-60 minutes.

Detailed Interview with the Child or Adolescent
Older children and adolescents should also be interviewed. Children and teens with ADHD may not have much insight into their ADHD symptoms, but they often have an awareness of anxiety or depression symptoms that may not be as obvious to parents or others around them.

Symptom Rating Scales Completed by Parents and Children or Teens
In addition to diagnostic interviews, rating scales completed by parents and the child (ages 8 and older) or adolescent themselves are a key component of a thorough diagnostic assessment. Rating scales should include questions related to ADHD symptoms as well as symptoms of other disorders. These measures often include normative scales which allow the provider to compare ratings for the child or teen undergoing the evaluation against a large database of scores to see how the child or teen compares to peers of a similar age and gender. This can help determine whether a child’s behavior and symptoms are typical of someone their age or if they have relative weaknesses in certain areas.

Symptom Rating Scales Completed by Teachers
In order to meet diagnostic criteria for ADHD, children and teens must experience impairment at school as well as at home, making teacher reports an essential component of an ADHD assessment. Like the rating scales completed by parents, these measures should include questions about symptoms of anxiety and depression as well as ADHD and should include normative scales that allow for comparisons with same age peers. A measure of academic performance and skills should also be included to help determine whether a learning disorder evaluation is also needed. Ratings should be completed by teachers who have had the child in the classroom for at least 1 month at the time of the evaluation. If a child or teen has multiple teachers, then ideally each teacher should provide ratings, so the evaluator can determine whether a child’s symptoms present differently across classroom subjects and settings.

Report Cards
Past and current year report cards can be extremely helpful in an ADHD evaluation. Report cards include valuable information about a child’s behavior and focus in the classroom over time and can be used to identify the need for a learning disorder evaluation.  

Learning Disorder Evaluation in Kids and Teens with Learning Concerns
In some cases, learning disorder symptoms can look a lot like symptoms of ADHD. When kids and teens struggle to learn new concepts despite having average or above average intelligence, they may have difficulty focusing in class or may act-out behaviorally. If report cards and teacher ratings suggest a history of poor performance in some subject areas but not others (for example, a child or teen receives below average grades in math but receives average or above average grades in other subjects), then a learning disorder evaluation should be completed by the school or by an educational specialist or psychologist.

The process of diagnosing ADHD is complex and participating in the evaluation process can take a great deal of time and effort – but the effort is worth it in the long run when you receive an accurate diagnosis that can be used to identify the best treatments for your child or teen.

 ¹ Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-Year Trends in Diagnosed Attention Deficit/Hyperactivity Disorder Among US Children and Adolescents, 1997-2016. JAMA Network Open. 2018;1(4):e181471. doi:10.1001/jamanetworkopen.2018.1471

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ABOUT DR. MARY ROONEY

Mary Rooney, Ph.D., is a licensed clinical psychologist in the Department of Psychiatry at the University of California San Francisco. Dr Rooney is a researcher and clinician specializing in the evaluation and treatment of ADHD and co-occurring behavioral, anxiety, and mood disorders. A strong advocate for those with attention and behavior problems, Dr. Rooney is committed to developing and providing comprehensive, cutting edge treatments tailored to meet the unique needs of each child and adolescent. Dr. Rooney's clinical interventions and research avenues emphasize working closely with parents and teachers to create supportive, structured home and school environments that enable children and adolescents to reach their full potential. In addition, Dr. Rooney serves as a consultant and ADHD expert to Huntington Learning Centers.

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This website does not provide medical advice, diagnosis, or treatment. The material on this site is provided for educational purposes only.

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