The Adult ADHD Diagnosis: How Is It Made?

This is perhaps the #1 question about Adult ADHD. To answer it, in part: I offer this adapted excerpt  from my book, Is It You, Me, or Adult A.D.D.?.

This post includes the current DSM criteria for ADHD as well as the criteria proposed by Dr. Russell Barkley and colleagues for the upcoming DSM revision (you know it’s “not just for kids” when one diagnostic point involves driving!).

Please use the handy links above and below (see the “share” tool) to spread the word about how an evaluation for ADHD should be performed.

The Adult ADHD Diagnose-o-Meter

There is no single test to evaluate for ADHD. No computer test. No fill-in- the-blank test. No blood test or genetic test. These practical facts are commonly wielded by the anti-psychiatry fringe element as proof that ADHD does not exist.  A-hem, just for the record, neither can you measure headaches, backaches, or many other maladies with a quiz, a blood test, or a genetic test.

More importantly, “You also cannot measure a person’s pain or suffering in life by clinical tests,” notes psychologist Thomas E. Brown, assistant clinical professor of psychiatry at the Yale University School of Medicine and associate director of the Yale Clinic for Attention and Related Disorders.

It’s important to remember that ADHD symptoms essentially represent an extreme on a normal continuum of behavior that varies in the population, much like IQ, weight, or height. That’s why its diagnosis is not a cut-and-dried matter. To ascertain if a person is “over the line” on this continuum, the evaluating professional must gauge the severity of the symptoms and impairment.

No More “If It Squirms, You Must Confirm”

In years past, diagnosing ADHD was more clear-cut, but that actually meant that millions of people fell through the cracks. “ADHD used to be considered a disruptive order of childhood, and its diagnosis was based on observing overt behavior,” Brown explains.

Today we know that many people, especially adults, have no obvious physical hyperactivity, and we better understand the subtle nature of ADHD symptoms. “We know that impairments related to Executive Function are largely cognitive, covert, and not easily observed,” he adds. “They are also complex and interactive, and not easily measured.” Furthermore, the longer the patient goes with untreated ADHD, the higher the chances of having a coexisting condition such as anxiety or depression.

For all these reasons, the diagnostic process requires familiarity with ADHD symptoms in adults, informed data collection, and an ability to listen closely and ask perceptive questions. (A physical exam should also be done to rule out thyroid disorders and other conditions that can affect brain function or limit medication choices.)

Treating ADHD But Missing the Depression, etc.—and Vice-Versa

“Too often, the ADHD is treated and the coexisting condition is ignored, or vice-versa,” he says. “The Diagnostic and Statistical Manual, used by professionals to diagnose psychiatric conditions, separately lists more than 200 disorders, but these are not all different trees bearing different fruit.” In fact, these disorders may be linked biochemically as risk factors (that is, having one disorder increases the chances that you’ll have another).

For all these reasons, it’s wise to make sure you understand the diagnostic process, in general terms, before selecting a professional to conduct an evaluation.

Who Conducts the Evaluation for Adult ADHD?

Several types of professionals can evaluate for ADHD, including

• Physicians (MD)
• Psychologists (Ph.D. or Psy.D)
• Therapists who hold masters degrees (MCSW, LCSW, MFT, and others)

It is important to identify a professional who has appropriate state licensing or certification for treating ADHD and who can distinguish ADHD from other physical or psychological disorders (a differential diagnosis).

• If your family physician cannot make a confident referral, contact the closest university teaching hospital.
• If there is a local chapter of CHADD (check here for the chapter locator), attend and talk to members about their experiences with local professionals.
• Always ask the professional about the percentage of patients seen with ADHD; you’re looking for a significant number.

The Process, in a Nutshell

First, the evaluating professional gathers data from sources that include

• behavior rating scales (more information here)
• symptom checklists
• questionnaires completed by the client and, if possible, also by a partner, closer friend, or family member (ADHD symptoms can impair objectivity)
• A detailed life history, including any head injuries (even “minor” ones)

The clinician also compares client symptoms to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (click here to view current criteria).

Brown stresses the importance of asking about the adult client’s abilities in these areas that require executive functioning:

• Holding a job and working productively
• Managing household and finances
• Maintaining stable relationships
• Parenting effectively and consistently
• Sequencing tasks and completing chores
• Driving safely
• Managing one’s health, including getting good sleep, eating well, and avoiding excesses

The Trouble with Current Official Criteria–and a Peek at the Proposed New Criteria

The current DSM’s official criteria are empirically based and rigorously tested, but they were developed with children in mind, not adults. Therefore, leading ADHD experts consider it rather problematic in diagnosing adults, especially with a less than experienced clinician.

Furthermore, the guidelines don’t reflect recent thinking about when the signs of ADHD first appear. The current requirement is that impairing symptoms be apparent before age seven. Yet, as Brown points out, some signs are not noticeable until middle school or junior high, college, and even later adulthood. Then, too, parents can provide so much support that impairments are obscured, or a highly intelligent child can compensate for many years before “hitting the wall” of his or her unaddressed symptoms.

In the works for the upcoming revision to the DSM: New guidelines specifically for Adult ADHD (look for a future blog post on this roiling controversy).

Click here to view the Adult ADHD criteria proposed by psychologist and ADHD researcher Russell Barkley and colleagues, for the next DSM edition, planned for 2011. The team designed these criteria, after intensive research, to reflect adult issues that are distinct from those in children. They are well worth reading, whether or not they are finally accepted in whole or part as the official criteria.

A Note about Women with ADHD

ADHD is often missed in women because the symptoms can manifest differently between the genders. The Women’s ADHD Self-Assessment Symptoms Inventory (SASI) was developed by psychologist Kathleen Nadeau and physician Patricia Quinn for use as part of a structured interview in conjunction with other diagnostic tools. Besides the traditional ADHD symptoms, it measures difficulties in time management, organization, parenting, life-maintenance activities, hormonal issues, and problem eating patterns. It is available for purchase at the link above.

I hope you found this helpful. Please use the handy link below to share on FB, Twitter, and beyond!

Gina Pera