How is 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.?.
This post (updated from the original posting of 7/9/10) includes:
- 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
“You Cannot Measure a Person’s Suffering in Life by Clinical Tests”
There is no single test to evaluate for ADHD. No computer test. No fill-in- the-blank test. No blood test or genetic test. The anti-psychiatry fringe element lobs these claims as proof that ADHD does not exist.
A-hem, neither can you measure headaches, backaches, or many other maladies with a quiz, a blood test, or a genetic test.
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 the 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—and rule out other potential causes.
No More “If It Squirms, You Must Confirm”
In years past, diagnosing ADHD was more clear-cut. And that came at great cost: 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, 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 as risk factors. (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 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), most often psychiatrists.
- Psychologists (Ph.D. or Psy.D)
- Therapists who hold masters degrees (MCSW, LCSW, MFT, and others)
When seeking a prescribing psychiatrist, it is important to look for appropriate state licensing. For psychiatrists, look for “board certified.”
When seeking any type of ADHD professional:
- If your family physician cannot make a confident referral, contact the closest university teaching hospital.
- Search the Internet, with a close eye toward to the website’s text. Is the professional’s educational background included? What is the professional’s approach to treating ADHD?
- If there is a local chapter of CHADD (check the CHADD chapter locator), attend and talk to members about their experiences with local professionals.
- Ask the professional about conferences attendance, completed workshops with leading ADHD experts, professional guides relied upon, etc.. You want to hear recognition of leading clinical experts who write and teach (e.g. Russell Barkley, PhD, Thomas Brown, PhD, Arthur L. Robin, PhD, Kathleen Nadeau, PhD, Patricia Quinn, MD, and more; I include my work because I serve as a conduit for the best practices and research on ADHD; so read my books to learn about other leading experts).
- Always ask about the percentage of patients seen with ADHD; you’re looking for a significant number.
With other mental-health professionals, also ask about how they have developed ADHD expertise and how they approach ADHD treatment. Become familiar with the treatment strategies in my first book so you can tell if their responses seem appropriate.
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 from DSM-5).
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, but they were developed with children in mind, not adults. Therefore, leading ADHD experts considered it problematic in diagnosing adults, especially with a less than experienced clinician.
Furthermore, the guidelines didn’t reflect recent thinking about when the signs of ADHD first appear.
The previous requirement was 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. Consider two common possibilities:
- Parents sometimes provide so much support that impairments are obscured
- A highly intelligent child can compensate for many years before “hitting the wall” of his or her unaddressed symptoms.
The DSM-5 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.? Personally, I find these criteria superior even though not official.]
A Note about Women with ADHD
ADHD is often missed in women because the symptoms can manifest differently between the genders. Morever, the cyclical nature of female hormones can create a monthly “roller coaster” that can be mistaken for other conditions.
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.
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.