Diagnosis of ADHD in Adults
Diagnosing ADHD in Adults
You keep losing your keys, feel you can never finish anything at work, or maybe have had a family member say “you might have ADHD.” Whatever the reason, getting a proper diagnosis of ADHD is the first step of getting treatment. It is important to ultimately gaining control over symptoms that wreak havoc in your life, personally and professionally.
Finding a qualified mental health professional
Finding a clinician that is especially familiar with ADHD is key to a good diagnosis. Seeking out hospital and University Centers, gaining referrals from your doctor, or getting suggestions from support group members are all ways to start your search. Don't be discouraged if you have to look outside your home town to find someone that meets these qualifications.
The American Psychiatric Association provides clinical guidelines for the diagnosis of ADHD in theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This manual provides symptoms which the doctor will be looking for in their diagnosis.
The clinician will review the diagnostic criteria and determine if any apply to the individual. They will look at how the symptoms affect the patient’s life. The interview will review the patient’s personal, medical, and psychiatric history from childhood to the present. Patients should also bring up what issues led them to make the decision to have an evaluation.
Interview of a loved one
Often people with ADHD will have holes in their memory or they will downplay symptoms. A significant other such as a partner, sibling, parent, or longtime friend can help fill in these gaps.
Often patients will receive rating scales for themselves and for a loved one or significant other to complete. Rating scales are separate from an in-person interview. They provide information comparing people with ADHD to people without ADHD.
Patients undergoing evaluation for ADHD should also receive a medical examination. Thyroid problems and seizure conditions can cause symptoms that resemble those of ADHD. Physical examinations cannot confirm a diagnosis of ADHD, but they can rule out physical causes of ADHD symptoms.
Screening for co-existing conditions
If a patient is treated for ADHD but the symptoms are not caused by ADHD, the treatment is not going to be successful. Doctors will also look to see if any co-existing conditions exist. Often if the co-existing condition is not treated then the treatment for ADHD will not be as effective.
Many people find that having a diagnosis of ADHD helps them make sense of their life and past decisions. You will want to discuss treatment options with your doctor. Treatment can include lifestyle changes, medication, and therapy, and often includes more than one component.
Although there is no single medical, physical, or genetic test for ADHD, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources. These sources include ADHD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information obtained from family members or significant others who know the person well. Some practitioners will also conduct tests of cognitive ability and academic achievement in order to rule out a possible learning disability. ADHD cannot be diagnosed accurately just from brief office observations or simply by talking to the person. The person may not always exhibit the symptoms of ADHD during the office visit, and the diagnostician needs to take a thorough history of the individual’s life. A diagnosis of ADHD must include consideration of the possible presence of co-occurring conditions.
Clinical guidelines for a diagnosis of ADHD are provided by the American Psychiatric Association in the diagnostic manual Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). These established guidelines are widely used in research and clinical practice. During an evaluation, the clinician will try to determine the extent to which these symptoms currently apply to the adult and if they have been present in childhood. In making the diagnosis, adults should have at least five of the symptoms present. These symptoms can change over time, so adults may fit different presentations from when they were children.
The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.
ADHD predominantly inattentive presentation
- Fails to give close attention to details or makes careless mistakes
- Has difficulty sustaining attention
- Does not appear to listen
- Struggles to follow through with instructions
- Has difficulty with organization
- Avoids or dislikes tasks requiring sustained mental effort
- Loses things
- Is easily distracted
- Is forgetful in daily activities
ADHD predominantly hyperactive-impulsive presentation
- Fidgets with hands or feet or squirms in chair
- Has difficulty remaining seated
- Runs about or climbs excessively in children; extreme restlessness in adults
- Difficulty engaging in activities quietly
- Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
- Talks excessively
- Blurts out answers before questions have been completed
- Difficulty waiting or taking turns
- Interrupts or intrudes upon others
ADHD combined presentation
- The individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.
These symptoms can change over time, so adults may fit different presentations from when they were children.
A diagnosis of ADHD is determined by the clinician based on the number and severity of symptoms, the duration of symptoms and the degree to which these symptoms cause impairment in various areas of life, such as home, school or work; with friends or relatives; or in other activities. It is possible to meet diagnostic criteria for ADHD without any symptoms of hyperactivity and impulsivity. The clinician must further determine if these symptoms are caused by other conditions, or are influenced by co-existing conditions.
Several of the symptoms must have been present prior to age 12. This generally requires corroboration by a parent or some other informant. It is important to note that the presence of significant impairment in at least two major settings of the person’s life is central to the diagnosis of ADHD. Impairment refers to how ADHD interferes with an individual’s life. Examples of impairment include losing a job because of ADHD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending, failure to pay bills in a timely manner or being put on academic probation in college due to failing grades. If the individual exhibits a number of ADHD symptoms but they do not cause significant impairment, s/he may not meet the criteria to be diagnosed with ADHD as a clinical disorder.
Internet self-rating scales
There are many Internet sites about ADHD that offer various types of questionnaires and lists of symptoms. Most of these questionnaires are not standardized or scientifically validated and should not be used to self-diagnose or to diagnose others with ADHD. A valid diagnosis can only be provided by a qualified, licensed professional.
Who is qualified to diagnose ADHD?
For adults, an ADHD diagnostic evaluation should be conducted by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor or other type of physician) or clinical social workers.
Whichever type of professional is chosen, it is important to ask about their training and experience in working with adults with ADHD. Many times the professional’s level of knowledge and expertise about adult ADHD is more important for obtaining an accurate diagnosis and effective treatment plan than the type of professional degree. Qualified professionals are usually willing to provide information about their training and experience with adults with ADHD. Reluctance to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek out a different professional.
How do I find a professional qualified to diagnose ADHD?
Ask your personal physician for a referral to a health care professional in your community who is qualified to perform ADHD evaluations for adults. It may also be helpful to call a local university-based hospital, a medical school or a graduate school in psychology for recommendations. If there is an ADHD support group in your area, it may be very helpful to go there and talk with the people attending the group. Chances are that many of them have worked with one or more professionals in your community and can provide information about them. Most insurance plans list professionals by specialty and can assist those who participate in their plans to find a health care professional. Finally, there are many internet sites that list providers of ADHD services, including CHADD’s professional directory.
How do I know if I need an evaluation for ADHD?
Most adults who seek an evaluation for ADHD experience significant problems in one or more areas of living. The following are some of the most common problems:
- Inconsistent performance in jobs or careers; losing or quitting jobs frequently
- History of academic and/or career underachievement
- Poor ability to manage day-to-day responsibilities, such as completing household chores, maintenance tasks, paying bills or organizing things
- Relationship problems due to not completing tasks
- Forgetting important things or getting upset easily over minor things
- Chronic stress and worry due to failure to accomplish goals and meet responsibilities
- Chronic and intense feelings of frustration, guilt or blame
A qualified professional can determine if these problems are due to ADHD, some other cause or a combination of causes. Although some ADHD symptoms are evident since early childhood, some individuals may not experience significant problems until later in life. Some very bright and talented individuals, for example, are able to compensate for their ADHD symptoms and do not experience significant problems until high school, college or in pursuit of their career. In other cases, parents may have provided a highly protective, structured and supportive environment, minimizing the impact of ADHD symptoms until the individual has begun to live independently as a young adult.
How should I prepare for the evaluation?
Most people are a little nervous and apprehensive about being evaluated for any type of condition such as ADHD. This is normal and should not stop anyone from seeking an evaluation if s/he is having significant problems in life and ADHD is suspected. Unfortunately, some of the common misconceptions about ADHD, such as “it only occurs in children” or “the person is just looking for an excuse,” make many people reluctant to seek help.
Many professionals find it helpful to review old report cards and other school records dating back to kindergarten or even the preschool years. If such records are available, they should be brought to the first appointment. Copies of reports from any previous psychological testing should also be brought to the appointment. For adults who experience problems in the workplace, job evaluations should be brought for review if available.
Many professionals will ask the individual to complete and return questionnaires before the evaluation and to identify a spouse or other family member who can also participate in parts of the evaluation. Timely completion and return of the questionnaires will expedite the evaluation.
What is a comprehensive evaluation?
Although different clinicians will vary somewhat in their procedures and testing materials, certain protocols are considered essential for a comprehensive evaluation. These include a thorough diagnostic interview, information from independent sources such as the spouse or other family members, DSM-5 symptom checklists, standardized behavior rating scales for ADHD and other types of psychometric testing as deemed necessary by the clinician. These are discussed in more detail below.
The diagnostic interview: ADHD symptoms
The single most important part of a comprehensive ADHD evaluation is a structured or semi-structured interview, which provides a detailed history of the individual. The interviewer asks a pre-determined, standardized set of questions in order to increase reliability and decrease the chances that a different interviewer would come up with different conclusions. The clinician covers a broad range of topics, discusses relevant issues in detail and asks follow-up questions to ensure that all areas of interest are covered. The examiner will review the diagnostic criteria for ADHD and determine how many of them apply to the individual, both at the present time and since childhood. The interviewer will further determine the extent to which these ADHD symptoms are interfering with the individual’s life.
The diagnostic interview: screening for other psychiatric disorders
The examiner will also conduct a detailed review to see if other psychiatric disorders that may resemble ADHD or commonly co-exist with ADHD are present. ADHD rarely occurs alone, and research has shown that more than two-thirds of people with ADHD have one or more co-existing conditions. The most common include depression, anxiety disorders, learning disabilities and substance use disorders. Many of these conditions have symptoms that can mimic ADHD symptoms, and may, in fact, be mistaken for ADHD. A comprehensive evaluation includes screening for co-existing conditions. When one or more co-existing conditions are present along with ADHD, it is essential that all are diagnosed and treated. Failure to treat co-existing conditions often leads to failure in treating the ADHD. And, crucially, when the ADHD symptoms are a secondary consequence of depression, anxiety or some other psychiatric disorder, failure to detect this can result in incorrect treatment of the individual for ADHD. Other times, treating the ADHD will eliminate the other disorder and the need to treat it independently of ADHD.
The examiner is also likely to ask questions about the person’s history of health, development going back to early childhood, academic and work experience, driving history, drug and alcohol abuse, family and/or marital life and social history. The examiner will look for patterns that are typical in individuals with ADHD and also try to determine if factors other than ADHD may be causing symptoms that look like ADHD.
Participation of loved ones
It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, parent or partner) who knows the person well. This procedure is not to question the person’s honesty, but rather to gather additional information. Many adults with ADHD have a spotty or poor memory of their past, particularly from childhood. They may recall specific details but forget diagnoses they were given or problems they encountered. Thus, the clinician may request that the individual being evaluated have his or her parents fill out a retrospective ADHD profile describing childhood behavior.
Many adults with ADHD may also have a limited awareness of how ADHD-related behaviors cause problems for them and have impact on others. In the case of married or cohabitating couples, it is to the couple’s advantage for the clinician to interview them together when reviewing the ADHD symptoms. This procedure helps the non-ADHD spouse or partner develop an accurate understanding and an empathetic attitude concerning the impact of ADHD symptoms on the relationship, setting the stage for improving the relationship after the diagnostic process has been completed. If it is not possible to interview the loved ones, having them fill out checklists of symptoms is a good alternative.
Many adults with ADHD may feel deeply frustrated and embarrassed by the ongoing problems caused by the disorder. It is very important that the person being evaluated discuss these problems openly and honestly and not hold back information due to feelings of shame or fear of criticism. The quality of the evaluation and the accuracy of the diagnosis and treatment recommendations will be largely determined by the accuracy of the information provided to the examiner.
Standardized behavior rating scales
A comprehensive evaluation can include one or more standardized behavior rating scales. These questionnaires use research comparing behaviors of people with ADHD to those of people without ADHD. Scores on the rating scales are not considered diagnostic by themselves but serve as an important source of objective information in the evaluation process. Most clinicians ask the individual undergoing the evaluation and the individual’s significant other to complete these rating scales.
Depending on the individual and the problems being addressed, additional psychological, neuropsychological or learning disabilities testing may be used as needed. These do not diagnose ADHD directly but can provide important information about ways in which ADHD affects the individual. The testing can also help determine the presence and effects of co-existing conditions. For example, in order to determine whether the individual has a learning disability, the clinician will usually give a test of intellectual ability as well as a test of academic achievement.
If the individual being evaluated has not had a recent physical exam (within 6–12 months), a medical examination is recommended to rule out medical causes for symptoms. Some medical conditions, such as thyroid problems and seizure disorders, can cause symptoms that resemble ADHD symptoms. A medical examination does not confirm ADHD but is extremely important in helping to rule out other conditions or problems.
Concluding the evaluation
Towards the end of the evaluation the clinician will integrate the information that has been collected through diverse sources, complete a written summary or report, and provide the individual and family with diagnostic opinions concerning ADHD as well as any other psychiatric disorders or learning disabilities that may have been identified during the course of the assessment. The clinician will then review treatment options and assist the individual in planning a course of appropriate medical and psychosocial intervention. Afterward, the clinician will communicate with the individual’s primary care providers, as deemed necessary.
For more information
Barkley, RA. (2014). Attention-deficit hyperactivity disorder, fourth edition: A handbook for diagnosis and treatment. New York, NY: Guilford Press.
Wolraich, M. & DuPaul, G. (2010). ADHD diagnosis and management: A practical guide for the clinic and the classroom. Baltimore, MD: Brooks Publishing.
Centers for Disease Control and Prevention (CDC). Attention-Deficit/Hyperactivity Disorder. www.cdc.gov/ncbddd/adhd/diagnosis.html