ADHD diagnosis

A diagnosis is the identification and assessment of a physical or mental illness. It aims to find an explanation for a person's problems or difficulties and forms the basis for treatment.

The categorisation of characteristics (classification) is intended to create boundaries. This means that a group of symptoms is attributed to a specific disorder or clinical picture and not to another. As part of the diagnostic process, the relevant information is collected, such as the symptoms and the person's medical history.

It is unclear whether an ADHD diagnosis is always justified

This type of approach is desirably scientific, i.e. systematic, comprehensible and repeatable. However, every person is different and does not always show the same symptoms. In order to define universally valid diagnostic criteria, a long process of observation of the occurrences is necessary.

AD(H)S stands for a non-uniform disorder and overlaps with other clinical pictures. In addition, most people in our society sometimes show AD(H)S symptoms. There is a lack of clarity as to what is meant by AD(H)S; people often ask: «Does it even exist?». If you ask affected families and their children, the answer in most cases is clearly yes.

Professionals who share this opinion use diagnostic criteria and AWMF guidelines (Association of the Scientific Medical Societies in Germany, currently being revised) to narrow down the signs of AD(H)S more precisely. However, it remains unclear whether the diagnosis is justified for every child and how the sharp rise in the number of diagnoses in recent years can be explained.

What is considered conspicuous behaviour depends on cultural norms

Numerous conditions in society have certainly changed, and with them the demands on children. The perception of symptoms in our society may also have changed. Before AD(H)S is diagnosed, most parents are already aware that their child shows problems in areas where their peers do not. However, what is considered conspicuous behaviour depends on cultural norms.

For example, there appear to be fewer AD(H)S diagnoses per year in Ticino compared to French-speaking Switzerland and especially German-speaking Switzerland. According to European statistics, there are fewer children with AD(H)S in Italy than in Germany. The understanding of the norm, i.e. what is considered normal and what is conspicuous, is much broader in some places, as is the tolerance for deviations from this norm.

The reasons for the different numbers of cases should be investigated further. For example, a new research project (see box below) is dedicated to the phenomenon of AD(H)S in all three major language regions of Switzerland and hopes to gain new insights.

In order to be able to diagnose AD(H)S, behavioural problems in the areas of attention, impulsivity and possibly also hyperactivity must already be present at pre-school age and for at least six months.

And these abnormalities must be visible in different areas of life, for example at school and at home. Children can behave very differently at home than they do in the classroom and also with different teachers. This is due to different expectations, the presence of many other children and also the time of day.

Mental and physical disorders must first be ruled out

In line with the multimodal approach, professionals need perceptions and observations from other people in the child's environment in addition to the parents' descriptions in order to make a diagnosis. These are usually the teachers. Additional observations from grandparents or leaders from a (sports) club can supplement the assessment.

Taking the child's developmental history into account is just as much a part of the assessment as obtaining thorough information about the family. Such information is useful as it is assumed that ADHD has a hereditary component. This means that children from a family in which ADHD has already occurred have an increased risk.

However, studies show that only the probability of symptoms increases. However, this means that inheritance is by no means always the case. This means that not every adult affected by ADHD also has a child with ADHD, and not all children with ADHD also have affected parents or relatives.

In addition to carrying out specially developed psychological tests that focus on the child's behaviour and talents, a medical examination should always be carried out.

The first step is to rule out the possibility that concentration and performance problems are actually caused by a reduction in hearing and vision, sleep disorders, metabolic disorders (e.g. thyroid) or deficiency symptoms (e.g. magnesium). It must also be possible to rule out other mental and physical disorders (such as anxiety, depression or autism).

An additional neuropsychological examination allows conclusions to be drawn as to whether and where the child may have functional disorders, for example with regard to working memory or perception. There is still no method for diagnosing AD(H)S on the basis of purely biological characteristics. Imaging techniques such as magnetic resonance imaging (MRI) do reveal which areas of the brain are active and how this activation differs in people with and without AD(H)S.

However, it is not yet possible to diagnose individual patients in this way. However, these imaging techniques are increasingly taking centre stage in research, as is the theory that the cause of AD(H)S is a deficiency of the neurotransmitter dopamine between the nerve cells. With further findings, behaviour-based testing could be supplemented even more reliably with biological indicators in the future.

Medical treatment must always precede diagnosis

Even without physical tests, it is already possible to make an accurate diagnosis for the child. In order to minimise the risk of an incorrect assessment, a careful approach in accordance with the criteria is required. The guidelines, which frame the diagnostic criteria of the DSM-5 and ICD 10 classification systems, leave a lot of room for interpretation and rely on the subjective judgement of the clinician.

This is often criticised and there is a desire for more clarity. However, this room for manoeuvre for the clinician can also be good, so that a diagnosis does not always have to be given if the client would be disadvantaged as a result, or so that a diagnosis can be given if an impairment can be reduced as a result.

However, as all symptoms, such as the three main signs of ADHD, inattention, hyperactivity and impulsivity, are expressed differently in different people, the approach in everyday practice is also a challenge for specialists.

The clarifying specialist should therefore be specialised in the area of children/adolescents and be well versed in AD(H)S. In Switzerland, this applies to people from different disciplines (e.g. paediatricians, psychologists). As part of a holistic assessment, they should work together with other specialists on an interdisciplinary basis wherever possible.

It is important to have a competent specialist at your side who will respond to questions and concerns, take time and accompany the child along the way. Whether a diagnosis is appropriate and in the child's best interests must be carefully assessed in each individual case.

Possible disadvantages such as discrimination or side effects of therapy can only be justified if the child and their family receive support and the child's welfare is thus safeguarded in the long term.