Formal diagnostic criteria of ADHD differ depending on what country one resides in. The criteria used most in North and South America is the American Psychiatric Association's Diagnostic and Statistical Manual, 4th ed.(DSM-IV). There is also an updated version designated as DSM-IV-TR (Text Revision). Europe, Asia, and Africa use the International Statistical Classification of Diseases and Related Health Problems (ICD-10, 2006). The American Academy of Pediatrics also issues certain clinical guidelines for diagnosis. Each of these tools organizes the diagnosis in a slightly different manner, but in each there are three major categories of symptoms: (1) hyperactivity, (2) inattention, and (3) problems with conduct.

A child who has six or more of the symptoms in either of two categories--inattention or hyperactivity impulsivity--may be determined to have ADHD. According to DSM-IV, the physician will ascertain if the symptoms have persisted for at least 6 months to a degree that it varies with the development level of the child or adolescent, and if six or more of the following symptoms have been present to the point that the symptom is disruptive and is not appropriate for the developmental level. The diagnosis includes criterion items A, B, C, D, and E:

- Criterion A. Symptoms can be from category 1 or 2.

- Criterion B. The person had some of the symptoms present before age 7. The hyperactive-impulsive or inattentive symptomswere noted to be a problem.

- Criterion C. The person has the symptoms in two or more settings, for example, at school, at home, or at work.

- Criterion D. The person must show significant impairment in social, school, or work settings.

- Criterion E. The symptoms are not related to another mental disorder, such as mood disorder, anxiety disorder, dissociative disorder, or a personality disorder. Also, the symptoms are not part of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.

Based on the above criteria, DSM-IV identifies three types of ADHD that are coded as follows:

- 314.01. Attention-Deficit/Hyperactive Disorder, Combined Type, if both criteria A1 and A2 are met in the past six months

- 314-0. Attention-Deficit/Hyperactive Disorder, Predominantly Inattentive Type, if Criterion A1 is met but not Criterion A2 in the past 6 months

- 314-1. Attention-Deficit/Hyperactive Disorder, Predominantly Hyperactive/Impulsive Type, if criterion A2 is met but not criterion A1 in the past 6 months

The World Health Organization publishes the International Statistical Classification of Diseases and Related Health Problems. The tenth version of the ICD was published in 2006 and is known as ICD-10. The original International Statistical Classification of Diseases and Related Health Problems was adopted in Geneva, Switzerland in 1992. The naming of conditions relating to ADHD is somewhat different from the DSM-IV.

A conduct order is referred to as a ''hyperkinetic conduct disorder.'' Otherwise the disorder is classified as the following:

- Disturbance of activity and attention

- Other hyperkinetic disorders

- Hyperkinetic disorders (HKDs), unspecified or sometimes called hyperkinetic syndrome

The writers of the ICD believe that a person must be hyperactive to be diagnosed with a hyperkinetic disorder. Inattention is considered a separate disorder. According to ICD classification, the prevalence with HKD is 1 to 3 percent.

According to the American Academy of Pediatrics clinical practice guidelines (2001), constitutes the following criteria constitute a reliable diagnosis:

- Using the explicit criteria of DSM-IV. A scale called the Conner's Rating Scale may be used to determine these criteria.

- Obtaining information about the child's symptoms in more than one setting. Parents, teachers, or even the person may provide this history.

- Searching for coexisting conditions that may make this diagnosis more difficult. Use of intelligence and psychological testing may rule out other complicating factors.

Generally concerns about a child's inattention and activity levels are first noted in the context of the school where greater demands for attention and self-discipline are placed on the child. Recognition of ADHD as a disability to be served under existing education laws (Individuals with Disabilities Education Act) and Section 504 of the Rehabilitation Act of 1973 has demanded that schools generate protocols for evaluation. The school has a legal responsibility to provide assessment for students who are suspected of having ADHD.

The Professional Group on Attention and Related Disorders (PGARD) has developed a two-tier approach to evaluate children who appear to have ADHD. The guiding principle is to have many sources of information that can shed light on whether the behavior is affecting educational performance. The two tiers are as follows:

1. Confirm the presence of important characteristics; confirm early onset and duration; rule out other conditions.

2. Determine adverse impact on educational performance; determine impairment of academic performance.

Because some groups accused ADHD of being a fraudulent or benign diagnosis, the American Academy of Pediatrics convened a Committee of Quality Improvement and Subcommittee on Attention-Deficit/Hyperactive Disorder and spurred the development of an International Consensus Statement published in 2002. Researchers and scientists came together to address the validity of this condition and to discuss the importance of diagnosis and treatment to prevent serious harm. In addition, numerous associations have supported its existence.

The Centers for Disease Control and Prevention (CDC) believes that only trained health care professionals should make a diagnosis of ADHD. This position is held because the symptoms may be part of other physical conditions, such as hyperthyroidism. Some normal individuals may exhibit some of these conditions from time to time. It is the pervasiveness of the symptoms that keep the person from functioning in school, work, and social relationships that form the strength of the factors in diagnosis.

Neurological diagnosis may also be done by imaging. SPECT scans may investigate areas of underfunction and overfunction. Because there are no lesions in ADHD, the use of EEG, CAT, and MRI and ineffective because they detect abnormalities in the superficial layers or cortex of the brain and do not tap into the deeper layers of the brain. In the late 1980s SPECT and PET scans looked at blood flow and glucose metabolism of different parts of the brain. In 1990 Dr. Alan Zametkin published a landmark study in the New England Journal of Medicine that found individuals with ADHD metabolized glucose at rate 8 percent lower than the control group when taking continuous performance tests that were designed to measure attention and vigilance to stimuli. The decrease in metabolic activity was noticed in the prefrontal and premotor regions of the brain. Also, decreased blood flow was indicated in the frontal lobes and posterior periventricular region of the right hemisphere. The caudate nuclei/striatum were the most consistent areas of under functioning in ADHD individuals. However, presently neuroimaging is not commonly used as a tool for diagnosis because it is very expensive and criteria are not established for diagnosis. It is useful in research and may be developed in the future.

The striatum, frontal lobes, and posterior periventricular regions supposedly underlie aspects of response inhibition, inattention, and incentive learning or sensitivity to reinforcement. These regions are also interconnected with sensory centers. The continuous bombardment shows up in SPECT scans as increased blood flow in regions that receive sight and sound stimuli.

Nash Butros et al. (2005) has proposed a four-step approach for developing diagnostic tests in psychiatry using the electroencephalograph or EEG in ADHD as a test case. The EEG is comprised of four classical frequencies: delta, theta, alpha, and beta. The power of these ranges can be calculated and the relative power in each of the four ranges can be determined. The researchers found a promising increase in EEG theta in ADHD. A metaanalysis for the effect size was conducted and the majority of articles supported the findings that EEG theta had the increased activity. The researchers recommend developing the EEG as a definitive diagnostic test--something that has not been done in the past.

Sattler and Barkley have published some lists for general background questioning that can help with diagnostic assessment. Table 9 is a composite of several lists.

S. K. Katusic et al. (2005) suggests a multistep procedure for case definition and identification in population-based epidemiologic studies of ADHD, which includes the use of school and medical records, a computerized diagnostic index, private psychiatric records, and an combination of DSM-IV-TR questionnaire and clinical records. Because no gold standard for diagnosis of ADHD exists, data from multiple sources and procedures are usually collected in clinical practice.

The diagnosis and evaluation of ADHD actually currently has no reliable objective tests. Because several of the symptoms overlap with other conditions, even a skilled clinician can have difficulty in determining differences. An astute clinician must perform a thorough medical and psychiatric evaluation. Useful tests include urine drug screening, serum thyroid-stimulating hormone, complete blood count, chemistry panel, a and a history of central neurologic illness, infection, or trauma. Many common medications may contribute to psychiatric symptoms. One of the main factors in diagnosis is the presence of chronic ADHD symptoms since childhood, without a major depressive episode. Several other scales have been developed for diagnosis.

Bibliography:

1) Amen, Daniel. 2001. Healing ADD: The breakthrough program that allows you to see and heal the 6 types of ADD. New York: Berkley Books

2) American Psychiatric Association. 2004. Diagnostic and Statistical Manual of the American Psychiatric Association. 4th ed. Arlington, VA: American Psychiatric Association

3) Barkley, R. A. 2002. International Consensus Statement on ADHD. Clinical Child and Family Psychology Review 5(2):89-110

4) Boutros, Nash. 2005. A four-step approach for developing diagnostic tests in psychiatry: EEG in ADHD as a test case. Journal of Neuropsychiatry Clinical Neuroscience 17:455-464

5) Brown, Thomas E. 2005. Attention deficit disorder: The unfocused mind in children and adults. New Haven: Yale University Press

6) Global ADHD Working Group. 2005. Global consensus on ADHD/HKD. European Child Adolescent Psychiatry 14:127-37

7) Gozal, David, and Dennis L. Molfese, eds. 2005. Attention deficit hyperactive disorder: From genes to patients. Totowa, NJ: Humana Press

8) Katusic, S. K. et al. 2005. Case definition in epidemiologic studies of ADHD. Annals of Epidemiology 15:430-37

9) World Health Organization. ''F84 Pervasive Development Disorders.'' International Statistical Classification of Diseases and Related Health Problems. 10th ed. (ICD-10), Geneva, Switzerland, WHO, 2006

10) Zametkin, A. J. et al. 2009. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. New England Journal of Medicine 323:1361-66.

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