How Is Adult ADHD Diagnosed?

 

How Is Adult ADHD Diagnosed?

How is Adult ADHD diagnosed? 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.?.

In this post, you’ll find these points related to Adult ADHD evaluation and diagnosis:

  1. Guidance from a leading ADHD expert, Thomas E Brown, PhD
  2. An overview of the Diagnostic and Statistical Manual (DSM) diagnostic criteria for ADHD
  3. Suggestions for finding mental-health professionals familiar with ADHD
  4. Links to resources offering more details on the official diagnostic criteria

“You Cannot Measure Suffering By Clinical Tests”

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—and rule out other potential causes.

How Is Adult ADHD Diagnosed?

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 diagnostic process requires:

  1. Familiarity with ADHD symptoms in adults
  2. Informed data collection, and
  3. An ability to listen closely and ask perceptive questions.

(A physical exam beforehand should rule out thyroid disorders and other conditions that can affect brain function or limit medication choices.)

How Is Adult ADHD Diagnosed?

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.
  • Ask about how the professional has developed ADHD expertise and how they approach ADHD treatment. Become familiar with the treatment strategies in my first book .  That way, you can better assess if their responses seem appropriate.
  • I include my work because 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.”

The Diagnostic 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)

Next, 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 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

How Is The Adult ADHD Diagnosis Made?

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:

  1. Parents sometimes provide so much support that it obscures impairments.
  2. 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 not official. So while they might not be used in a formal evaluation, they can help you to better understand the ADHD diagnosis.]

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 and physician Patricia Quinn. 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.

The SADI is available free for personal use at the link above. For professional use, see information at the bottom of the downloaded PDF.

I hope you found this helpful.

If you have helpful advice, please write it in a comment.

Gina Pera

20 thoughts on “How Is Adult ADHD Diagnosed?”

    1. Hi Jerry,

      There is no key for the inventory; this is not a diagnostic instrument.

      As it states on the PDF:

      This scale should not be used for diagnostic purposes. Instead, results should be considered
      as part of a structured interview, and used in conjunction with diagnostic testing when
      evaluating women for possible ADHD.

      best,
      g

  1. OH my gosh, Gina! I’m so glad you wrote this.
    I’m always looking for a shorter explanation of the wheres/hows of getting the diagnosis. Usually I’m referring to Barkley’s books. This will be so much easier for people to read and digest than a whole book.

    1. Hey Liz!

      Thanks for letting me know!

      I was working most of the day on the online training video for that topic (diagnostic criteria and what an evaluation should look like). I kept moaning and groaning…”why is this taking me so long? why am I so slow? why do I take 100 times longer with more effort than I need to?”

      My usual patter while writing books, etc. And my husband says, “Because you do it right.”

      I do try. Thanks!

      g

    2. Liz,
      It would be beneficial if EACH individual member of an ADHD group READ THE WHOLE BOOK written by Gina Pera.
      ** Both of her books. Then read them again.

      Internet groups and others who meet to discuss this diverse disorder do not provide her knowledge, understanding and 20+ years of research. ( IMO)
      Such is the wealth of information Ms Pera has gathered.

  2. My story: I’m 59. A bit over a year ago I was reading a list of ADHD symptoms and said that’s me.

    I asked my primary care physician if he knew of anyone that had a lot of experience with adult ADHD (after having read the book this post came from) and he said sure. That got me an appointment with the mental health gatekeeper that was only interested in whether I was addicted to drugs or alcohol and also hyperactive. Since I have neither of those traits she literally laughed at me. This did not help.

    Jump forward a year and a change of insurance. I asked my primary care doc (different from last year) for help. He gave me a 1 page survey of symptoms, we talked for about 5 minutes, and he said “it looks like you’re not hyperactive but you certainly cover the inattentive side.” He gave me a prescription for Strattera. I was a bit surprised and a bit hesitant, but given my history of having doors slammed in my face I decided to just try it.

    It’s been 3 weeks and I’m on 60mg/day. At first it seemed like a wonder drug but I couldn’t tell if that was more placebo or not. But now I can tell there is a subtle change that is profound.

    I can talk myself into doing things I know I should do. I always thought that the idea of just having a positive attitude and magic will happen was just nonsense. I always felt we’re all lizards deep down inside and our emotions drive everything. What a surprise it was when I could just feel the negativity fall away just because I thought “I shouldn’t be angry about this. What would make me happier?”

    I can now sit and listen to my kids when they come over and not want to just run upstairs. I can also let things go now. I can change directions. Something falls apart and it’s a lot easier to just say okay, time for plan B. What sounds good? What used to absolutely freeze me in place is now a workable problem.

    What I’m going through now is figuring out where I’m at. Or maybe who I am. I’ve hung onto a few ideas of who I am for decades and now I’m thinking that maybe I can just change. Try something new and maybe it will be fun.

    I may never be good at names or learning a new language but the couple of times I’ve failed at something the past few weeks, and then easily tried again in a different manner, has just put a huge smile on my face.

    I can see walking away from an organization that I’ve spent 20 years with but has really not been that good for me lately. I have to believe that after nearly 60 years of fighting this there are scars and habits I need to learn to recognize. My 15-year-old dog pooped in the house and I got mad. Then I cleaned it up and asked myself why I got mad. That in itself is a big step forward but maybe I can learn to lead with compassion and not anger.

    And who knows, maybe Strattera is not the ideal drug for me (I know caffeine is important and a stimulant is part of what’s happening) but it seems to be a good place to start.

    1. Hi Matt,

      Thanks for sharing your story. I am delighted that you persevered and didn’t let the first abominable “evaluation” discourage you.

      It’s been only a few weeks, and you are noticing lots of progress. That’s fantastic.

      Unless you are independently wealthy or have plenty of other job options, you might want to hold off penning your resignation letter.

      Staying in the job, even if not ideal, a while longer provides one less “moving target”. If you continue to “tweak” your medication, avoiding new variables during that time will give you a better sense of what is the medication and what is the situation.

      Also, the stability can help you to gauge what in the job leaves you dissatisfied vs. an ADHD-fueled tendency toward being dissatisfied. 🙂

      If my first book is still sitting around, you might want to re-read, this time with an eye toward the success strategies. Including CBT-type approaches to revising reactions (as with the dog poop!) and to maximizing medication.

      Good luck and please keep me posted!

      g

    2. Gina, you made an assumption. The organization I’m backing off of is not my job. I’ve volunteered there for nearly 20 years. It was a rut I was in. Afraid to get out because once in a while it made me feel good. Now, maybe there are many things that might be fun.

      One thing I’ve realized is that since I was 17 and learned that if I poured my heart and soul into something I liked that there would be bits of bliss. The ADHD community calls it hyper focus. But the thing I just realized recently is that all wrapped up around the bits of bliss is anxiety, anger when things don’t go right and usually a desire for it to end. In just about anything I do “that I like doing,” camping, travel, designing things, work, cooking, volunteering, maybe even my family, it’s the same pattern. Bits of bliss woven into a big blanket of worry and being upset when things don’t go as expected. This is my roller coaster. And yet, I can’t let go.

      Over the past couple of weeks, when something has gone wrong, my response has been “oh well, what’s plan B?” Five minutes in it hits me. Hey, did I just not have a problem with that? So I’m starting to look at my activities and asking myself if it’s time to let it go or change things up. For my volunteer activity I’m still willing to volunteer, but I’m going to cut it way back and find the thing I enjoy and do well. I still don’t feel like I’ve very organized. I still need lists. I shouldn’t be the guy up front trying to organize 250 people. That’s not fun for me. I’d rather work one on one and do the creative work. The ADHD is not going away but maybe I can learn to enjoy it. That would be sweet.

    3. Yes, Matt. I made an assumption. You wrote “organization” and that to me connotes business. So sue me. 🙂

      g

  3. Pingback: Adult ADHD Diagnosis, "Sleep Issues," and Sex - ADHD Roller Coaster with Gina Pera

  4. This is great information about ADHD in fact. Let the public to drop the idea that ADHD is a “trouble-free” and note that nothing is so easy for a sort like that. It is sincerely clear that parents especially the female side to be so alert and careful about this. It is actually helping and I feel as though it has greatly of assistance for everyone needs to live a long and happy life. Thanks for your truthful and informative post about ADHD!

  5. Thanks for your honest and informative post about ADHD. I find that as an adult with ADHD there is a lot of confusion and ignorance about the topic. Great post.

    1. Thanks so much, Steve.

      It’s sometimes difficult to walk the line, between being open-minded about “alternative” explanations and strategies and being clear about the facts. I just try to do the best I can.

  6. This is great information and I’m sure glad I came across it.

    It drives me crazy how much we are into labels and tests and render labels, and then from those labels, someone with some letters behind their name poses treatment or sentence over you.

    Its good to know that its not so cut and dry to measure and understand which is what I have believed all along…but its still good to find someone in the know reinforce it.

    1. Hi Taylor,

      I’m glad you found this info helpful. Yes, the public often has the idea that ADHD is a “simple” diagnosis or that if you’re impulsive (or distractible or physically active), you have ADHD.

      The one tool I find most helpful when giving presentations on ADHD is …… a cookie cutter. 🙂

      There is nothing cookie-cutter about ADHD — its diagnosis or its treatment strategies. There are only individuals who fit into a syndrome that contains many criteria. Anyone who tells us they have all the answers for people with ADHD is, by definition, selling us a line. Caveat emptor!

      Gina

  7. Thanks for laying out the facts, Gina. I’ve referred quite a few friends to your blog. And your book.

    I just read the New York Times article today (the one that should have promoted your excellent book) and was disgusted that it didn’t.

    Even worse, Tara Parker Pope wrote that Hallowell is a RESEARCHER! Dang, if she got that wrong — and completely missed your book — what else does she get wrong.

    I used to t hink that the New York Times was a decent paper, but this gives me pause. In fact, I smell a rat.

    Hang in there. You’ve always taken the high road and well, nice gals finish last….lol! No, wait. I mean finish lunch. Well, you know I think you’re the best.

    jeff

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