Diagnosis in Adults
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). 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.
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. 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.
How do I know if I need to evaluate a client 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
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.
Providing a comprehensive evaluation
Although procedures and testing materials may vary, 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 part I:
|Standardized set of questions asking about current ADHD symptoms and symptoms during childhood. Includes questions assessing the degree to which symptoms interfere with the client’s life.|
|The diagnostic interview part II:
Screening for other psychiatric disorders
|Standardized set of questions asking about other psychiatric disorders to determine if client has a co-occurring condition or if ADHD symptoms are due to another disorder.|
|Gathering additional information from others||At a minimum having parents, spouses or other relatives complete a checklist about the client’s symptoms of ADHD.|
|Behavior rating scales||Standardized questionnaires that compare the behaviors of people with ADHD to those of people without ADHD.|
|Additional testing||Depending on the client’s responses during the diagnostic interview, additional tests might be needed to provide information about ways in which ADHD affects the individual. It can also help determine the presence and effects of co-occurring conditions.|
|Medical examination||Recommended to rule out medical causes for symptoms.|
To complete the evaluation write a summary or report with the diagnostic opinion concerning ADHD as well as any other psychiatric disorders or learning disabilities that may have been identified during the course of the assessment. From here review treatment options and assist the individual in planning a course of appropriate medical and psychosocial intervention.
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.