Dispelling myths about ADHD Diagnosis
Diagnosis of ADHD is full of myths and misunderstandings. A couple of examples from my personal life:
A family member was told by a professional that in order to figure out if he had ADHD, he had to do a full neuropsych assessment - for $5,000!
An acquaintance was diagnosed with ADHD as a young adolescent. As a freshman in college, he got the correct diagnosis - high-functioning autism. Finally after 6 years of misstarts, he got on the right path.
Given the high stakes in diagnosis and the prevalence of misinformation, here is a FAQ about ADHD diagnosis to bring clarity to the topic:
Q. What kind of professional is qualified to do an ADHD diagnosis?
A. Masters-trained therapists (LCSWs, LMFTs etc.), psychologists, psychiatrists, mental health nurse practitioners, neuropsychologists, and developmental pediatricians are best bets for ADHD (or other mental health) diagnoses. You want somebody who is well-trained in being able to take patient histories, compare them to the criteria in the Diagnostic and Statistical Manual of Mental Health Disorders (Currently DSM-5), and determine if a client has a disorder. Ideally, you would have somebody who does ADHD diagnosis frequently because you are trying to judge clients’ symptoms appropriateness for their “developmental level”, which is hard to decide unless you do this work often.
Primary care providers can also do mental health diagnoses, in theory, but you should definitely inquire about how often they do this kind of work and make sure they are following standard procedures for mental health diagnoses. If they just ask you to fill out a questionnaire like the Vanderbilt or SNAP and in 10 minutes later tell you that you have ADHD, the diagnosis is probably not worth a lot.
Q. What should I expect out of my ADHD diagnosis?
A. At the very least you should expect to be told whether you have ADHD and if it is mild, medium, severe, or sub-clinical (which means you have some of the symptoms but not enough to merit the diagnosis). Many mental health providers will do an ADHD diagnosis as part of a larger mental health diagnosis package so clients can find out not only if they have ADHD but whether they have any co-morbidities (additional diagnoses), the most common for ADHD being anxiety and depression.
Full neuropsychology testing typically goes much deeper, providing insight into brain function like intelligence, memory, processing speed, auditory and visual strengths and weaknesses as well as mental health conditions like ADHD. Neuropsych testing is often a more time-consuming and expensive process and is typically recommended if you are trying to determine if somebody has a learning disability. You may not need it if you are just trying to determine ADHD. Also, if you are working with a therapist, they may have the ability to do some cognitive testing (using a newer class of assessments that have made cognitive testing easier). When calling around about diagnosis services, ask very specifically about what you will learn from the assessment process they use.
Q. What are the most common types of ADHD diagnoses?
A. There are three primary ADHD diagnoses (but #2 is rare):
Predominantly Inattentive Presentation
Predominantly Hyperactive-Impulsive Presentation
Combined Presentation (both hyperactive/impulsive and inattentive)
Q. So what does DSM-V say is required to diagnose ADHD?
A. Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level.
For inattention, the symptom list is:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted.
Is often forgetful in daily activities.
For hyperactive/impulsive, the symptom list is:
Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often “on the go” acting as if “driven by a motor”.
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting their turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).
In addition, the following conditions must be met:
Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
Q. So why can’t I just count up the symptoms and diagnose myself?
A. You can and you might even be right. But it is really hard to rate yourself and even harder to determine if symptoms are inappropriate for developmental level and even that much harder for you to determine if your symptoms could be better explained by another mental disorder. If you try to diagnose yourself using the list, make sure you go to a qualified professional to make sure.
Q. How do I know if the professional doing the diagnosis is following best practices:
A. Diagnosing ADHD is best done by taking a thorough patient history. Neuroimaging is making great strides and gives us data on population groups in larger numbers but is not yet useful for individual diagnoses. So best practices would include:
Asking to fill in ADHD symptom ratings scales (SNAP, Vanderbilt, BAARS, Conners, ASRS etc.). If the clinician is assessing for co-morbid conditions then you should be filling out symptoms rating scales for those conditions (PHQ-9, GAD-7 etc).
Getting another person (family member, teacher, friend, colleague) to fill out symptoms rating scales in order to have a “2nd rater” since it is hard to rate yourself.
Carefully, doing a thorough patient history to understand your symptoms, as well as those from other family members (since ADHD is so heritable). Remember the clinician is trying to determine that the symptoms interfere with, or reduce the quality of, social, school, or work functioning, so they should be asking you about how these symptoms affect you.
Gathering any other information from your life (like school report cards or work reviews) to get information on symptoms.
Q. Is there any new research on the horizon that may change how ADHD is being diagnosed?
A. Dr. Russell Barkley, by many considered to be the foremost expert on ADHD has cited research studies that would suggest a few possibilities:
The number of symptoms for the ADHD diagnoses may be lowered
The requirement that symptoms are present before age 12 may be too restrictive
There is increasing evidence for the existence of a second attention disorder, currently called Sluggish Cognitive Tempo, which is often confused with ADHD, but should be distinct and treated differently.
The stakes are high for getting a diagnosis right. Overdiagnosis exists in some corners but underdiagnosis and misdiagnosis are the bigger problems; I’ve heard the stories of so many people who suffered for years with ADHD symptoms and only got a diagnosis late in life. Resist diagnosing yourself - take the time and spend the money to go to a qualified professional to get diagnosed properly.