This is perhaps the #1 question I receive about Adult ADHD: How is it diagnosed? To answer it in part, I offer this post, adapted excerpt from my book Is It You, Me, or Adult A.D.D.?.
Maybe you or your loved one will luck out! Maybe you will find an ADHD-competent clinician who can guide you from start to finish. In my long experience, however, those odds are small. That’s why I advise being prepared before making the first appointment.
In my new online training, I extensively cover the Adult ADHD evaluation process. That includes:
- Walking you through the DSM-V official diagnostic criteria, point by point
- An interactive PDF of the full criteria, designed to help you identify the symptoms that resonate most for you—and to provide examples from your youth to now
- How to begin identifying a professional and getting very familiar with the diagnostic criteria
Learn more at Solving Your Adult ADHD Puzzle.
In This Post: Key Points on Getting an ADHD Evaluation
In this post, you’ll find these points related to Adult ADHD diagnosis:
- Guidance from a leading ADHD expert, Thomas E Brown, PhD
- An overview of the Diagnostic and Statistical Manual (DSM) diagnostic criteria for ADHD
- Suggestions for finding mental-health professionals familiar with ADHD
- Links to resources offering more details on the official diagnostic criteria
- A tool for assessing ADHD in women (non-validated but still useful!)
“You Cannot Measure Suffering By Clinical Tests”
That’s a quotation from Thomas E. Brown, PhD, a preeminent ADHD expert.
There is no single test to evaluate for ADHD. That means no
- Computer test
- Fill-in-the-blank test
- Blood test
- Genetic test
The anti-psychiatry fringe element lobs these claims as proof that ADHD does not exist. But, a-hem. Can you measure headaches or backaches with a quiz, a blood test, or a genetic test?
Remember: ADHD symptoms represent an extreme on a range of human behavior. In that regard, ADHD is much like IQ, weight, or height. That’s why the diagnosis is not a cut-and-dried matter.
How does the evaluating professional asses if the person is “over the line” on this continuum? The professional must gauge symptom severity and impairment—that is, areas in which the adult is experiencing true difficulty —and rule out other potential causes.
No More “If It Squirms, You Must Confirm”
In years past, making the ADHD diagnosis was more clear-cut. But that came at great cost. Millions of people fell through the cracks. “ADHD used to be considered a disruptive order of childhood,” Brown explains. “The diagnosis was based on observing overt behavior.”
Today we know that many people, especially adults, have no obvious physical hyperactivity. 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 developing a coexisting condition such as anxiety or depression.
For all these reasons, the Adult ADHD diagnostic process requires at least these three elements:
- Familiarity with ADHD symptoms in adults
- Informed data collection, including a thorough history from birth on, noting physical, psychological, and learning issues, among others
- An ability to listen closely and ask perceptive questions
(A physical exam beforehand should rule out other physical conditions that can affect brain function or limit medication choices.)
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Treating ADHD, Missing the Depression—and Vice-Versa
“Too often, the ADHD is treated and the coexisting condition is ignored, or vice-versa,” Brown 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. That is, having one disorder increases the chances that you’ll have another.
Yet, it is very easy to mistake ADHD for the fallout it creates: looking like “depression” or “anxiety.” Sometimes, those apparent conditions resolve once the ADHD is treated.
For all these reasons, it’s wise to familiarize yourself with the diagnostic process before seeking an evaluation. This is no minor thing, as we learn in Misdiagnosed Until 39: “Best Week of My Life”
Who Can Make the Adult ADHD Diagnosis?
Now that we know a bit about how Adult ADHD is diagnosed, let’s consider the types of professionals who might perform the evaluation:
- Physicians (MD), most often psychiatrists.
- Psychologists (Ph.D. or Psy.D)
- Therapists who hold masters degrees (MCSW, LCSW, MFT, and others)
When Seeking Any Type of ADHD Professional:
- If your family physician cannot make a confident referral, contact the closest university teaching hospital.
- When searching online, note carefully the website’s text. Does the professional list their educational background? What is the professional’s approach to treating ADHD?
- Is there is a local chapter of CHADD? (Check the CHADD chapter locator.) Attend and talk to members about their experiences with local professionals. Look for names mentioned repeatedly. But also note that some people will deem a professional good simply because they acknowledge that ADHD exists—or they have a friendly demeanor. That doesn’t necessarily mean they have expertise.
- Ask professionals how they have developed ADHD expertise and how they approach ADHD treatment. Become familiar with the treatment strategies in Is It You, Me, or Adult ADHD? . That way, you can better assess if their responses seem appropriate.
- I include my first book because it is among the most comprehensive and accurate on all aspects of Adult ADHD. It serves as a conduit for the best practices and research on ADHD. It contains advice from a “Who’s Who” of ADHD authorities.
- Ask the professional about conference attendance, workshops, continuing education, professional guides relied upon, etc.. You want to hear recognition of leading clinical experts who write and teach. These might include psychologists Russell Barkley, Thomas Brown, Russell Ramsay, Arthur L. Robin, and Kathleen Nadeau, along with physicians Patricia Quinn and Anthony Rostain.
- Always ask about the percentage of patients seen with ADHD. You’re looking for a significant number. When seeking a prescribing psychiatrist, particularly look for appropriate state licensing and “board certified.”
Self-Educate Yourself First
It’s very tempting to believe that “if I just find an expert,” you can turn everything over to that person. That is a very dangerous temptation—and one best avoided.
If all you can ask are close-ended questions (“Do you specialize in ADHD”? with a simple answer of yes or no), then you really have no assurances at all of the person’a capabilities. If you don’t know how the process should go, how treatment should go, you really set yourself at a disadvantage.
When you are solidly self-educated, you can ask open-ended questions, such as:
- What is your process, specifically, for conducting an evaluation?
- Which forms do you use?
- How important is third-party feedback (from a family member who knew you in childhood or from a spouse/partner)?
The Diagnostic Process, in a Nutshell
First, the evaluating professional gathers data from sources that include
- Behavior rating scales (more information Clinical Practice Tools)
- 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)
Next, the clinician also compares client symptoms to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
You can also Click here to view current criteria from DSM-5.
Finally, 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
Changes with the DSM-5 Official Criteria
The previous DSM’s official criteria (DSM-IV-TR) were empirically based and rigorously tested. Yet, they were developed with children in mind, not adults. Therefore, leading ADHD experts considered it problematic in diagnosing adults. Furthermore, the guidelines didn’t reflect recent thinking about when the signs of ADHD first appear.
Moreover, previous guidelines required that impairing symptoms manifest before age seven. Yet, as Brown points out, some signs are not noticeable until middle school or junior high, college, and even later adulthood. Consider two common possibilities:
- Parents sometimes provide so much support that it obscures impairments.
- A highly intelligent child can compensate for many years before “hitting the wall” of unaddressed symptoms.
Yet, with the DSM-5, the criteria moved the age up to 12.
For the nitty-gritty on other changes in the diagnostic criteria, read Changes in the Definition of ADHD in DSM-5: Subtle But Important
[The list of proposed criteria by Barkley and colleagues is included in Is It You Me, or Adult A.D.D.? I find these criteria superior even though unofficial. They can help you to better understand the ADHD diagnosis for adults.]
How Is Adult ADHD Diagnosed in Women?
When it comes to women, ADHD often goes unrecognized.
One reason: The symptoms can manifest differently between the genders.
Moreover, the cyclical nature of female hormones can create a monthly “roller coaster” easily mistaken for other conditions. That means that ADHD is evaluated for diagnosed a little differently for women.
The Women’s ADHD Self-Assessment Symptoms Inventory (SASI) was developed by psychologist Kathleen Nadeau, PhD, and developmental pediatrician Patricia Quinn, MD. They recommend using it as part of a structured interview in conjunction with other diagnostic tools.
It covers traditional ADHD symptoms. But it also goes beyond by measuring difficulties in time management, organization, parenting, life-maintenance activities, hormonal issues, and problem eating patterns.
I hope you found this helpful.
I welcome your comments.