The Building Blocks of a Good ADHD Diagnosis
Clinical interviews. Physical exams. Rating scales and teacher input. Learn how to get diagnosed with ADHD — and what options don’t reliably help, like SPECT scans and genetic tests.
Attention deficit hyperactivity disorder (ADHD or ADD) is a relatively common diagnosis, but that doesn’t mean it should be diagnosed lightly. An accurate ADHD evaluation includes several standard diagnostic steps and nuanced considerations; other “tools” are unproven and worth neither your time nor your money. The trick is recognizing the difference.
How to Get Diagnosed with ADHD
To get diagnosed with ADHD, you’ll need to be evaluated by a medical professional. An accurate and well-rounded ADHD diagnosis is a complex, multi-step process including a clinical interview, a medical history review, and the completion of normed rating scales by loved ones, educators, and/or colleagues.
Who Can Diagnose ADHD?
Only a medical professional should diagnose ADHD. That might be a pediatrician, a psychologist, a psychiatrist, or an advanced practice registered nurse (APRN). However, keep in mind that one particular certification doesn’t automatically make an individual experienced in diagnosing ADHD and its comorbidities. Most graduates of medical school or nursing school have never received adequate training in recognizing and assessing ADHD; those who are most qualified often sought out additional training themselves. Ask your provider whether they feel comfortable diagnosing ADHD, and what experience they’ve had with it and common comorbid conditions. Specialized training — not a degree — is critical to completing this complex task well.
What an ADHD Diagnosis Should Comprise
An in-depth, well-rounded ADHD evaluation comprises several components:
1. DSM-V for ADHD Diagnosis
A doctor will first want to determine whether the patient has the ADHD symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V). A patient has to have shown at least six of the nine symptoms of inattention and/or hyperactivity and impulsivity prior to age 12. While the DSM-V remains the basis of diagnosis for children, many specialists, myself included, believe it does not adequately address issues of emotional management and executive functions. Most clinicians go beyond the DSM-V in their assessments by conducting an in-depth clinical interview.
[Do I Have ADHD? Take This Test To Find Out]
2. Clinical Interview for ADHD Diagnosis
The most effective way to determine whether a person has ADHD is a well-conducted interview with the individual (and, if possible, with one or two people who know that person well) by a medical or mental health clinician who is familiar with ADHD and with the other medical or psychological disorders that produce similar symptoms. The clinical interview should inquire about:
- The problems that brought the person in for evaluation
- Daily functioning in current school or work, family life, and social relationships, as reported by the patient and others
- Activities the person does for fun
- Self-image as reflected in how the patient thinks others see him
- Current living arrangements
- Family of origin
- Family stress or other stressors over recent years
- Family psychiatric history
- Health, appetite, and physical development, sleep patterns
- Current moods
In short, this phase of the evaluation is far more complex than asking, “Why do you think you (or your child) may have ADHD?”
If the person says, “I have a hard time focusing,” for example, the clinician needs to delve deeper — asking, “When? How do you notice it? When is this difficulty most pronounced? Has this pattern existed most of your life, or is it something that started occurring recently?” If focus troubles are new, for instance, they could point to another condition — mood disorders or learning disabilities are both potential culprits.
[Use This Free Resource: What an ADHD Diagnosis Does (and Does Not) Include]
The clinician’s job is to identify patterns that may point to ADHD or recognize that symptoms actually stem from something else. ADHD is not an “all or nothing” diagnosis; exhibiting some symptoms does not warrant a diagnosis — persistent and problematic symptoms appearing over time in two or more settings do. The clinician must determine, “Are the symptoms impairing the patient’s function in daily life to a degree that it makes sense to treat them?”
The clinical interview helps the clinician understand the individual’s biggest pain points — whether that’s at work, in school, or in personal relationships — and why they’re happening. It should cover:
- Challenges, symptoms
- Strengths, skills
- Family life, day-to-day stressors
- For children: school performance — grades, tests (including standardized test scores and how long they take to complete tests), whether or not they can complete homework on their own or need a parent’s help, etc.
- For adults: work performance — deadlines, productivity, etc.
- General health — including sleep and eating habits
- Family medical history, including other possible instances of ADHD
- Drug use (both prescribed and illicit)
- Previous evaluations (if any) and their results
- Related and comorbid conditions — mood disorders, GAD, and learning disabilities are common in people with ADHD
Very young kids may not participate in a clinical interview because they often can’t fully articulate how they’re feeling or acting, but that is the exception to the rule. Most children can answer a clinician’s questions, and their parents should be interviewed as well — all the way through college, if possible. Adult patients may invite a spouse or close friend to paint a more complete picture of their symptoms and struggles.
A good clinical interview may take 2 to 3 hours, which includes time explaining to the patient what we now understand about ADHD and what it means for them. Many clinicians don’t have the luxury of that time — particularly pediatricians, who only have about 15 minutes for each patient interview. In those cases, a patient may need to return 2 or 3 times in order to convey an adequate amount of information.
3. Normed Rating Scales for ADHD Diagnosis
In addition to the clinical interview, the clinician should use normed ADHD rating scales, such as the Barkley, BASC, Brown, Conners, or BRIEF scales, to gather self-report information from the patient and observer information from parents, teachers, partners, or others who have seen how this individual has functioned over recent months and previously in various aspects of daily life. Psychoeducational testing, with IQ and achievement tests, may also be helpful if a learning disorder is suspected.
The clinician should ask the patient and family and friends what they know about ADHD, and provide a brief description of the condition. The clinician should stop after each section to ask how much each component describes this person during the past six months and before.
In discussing a possible diagnosis, the clinician should explain that each of the symptoms of ADHD is a problem everyone has sometimes. ADHD is not an all-or-nothing matter, like pregnancy. It is more like depression (everyone feels sad and discouraged sometimes), but we do not diagnose a person as clinically depressed unless her symptoms are causing significant impairments in her daily functioning over a significant amount of time.
4. Physical Exam for ADHD Diagnosis
Sometimes, ADHD-like symptoms are caused by internal medical problems such as thyroid conditions or pinworms. A pediatrician or primary care doctor should do a complete physical exam to make sure a medical problem has not been overlooked. A physical exam can also assess whether an individual can safely take ADHD medication.
5. Learning Disability Considerations in an ADHD Diagnosis
The vast majority of children with ADHD have at least one specific learning problem. ADHD and learning disabilities overlap genetically and in terms of functions like working memory. There are various reading, writing, and math evaluations that schools can administer to determine where strengths and weaknesses lie and which accommodations might be helpful:
- Woodcock-Johnson Test of Cognitive Abilities
- Wechsler Individual Achievement Test (WIAT)
- Nelson-Denny Reading Test
- Wechsler Intelligence Scale for Children (WISC-V)
6. Other Comorbid Condition Evaluations in an ADHD Diagnosis
The clinician should explore the possibility of co-occurring problems, such as anxiety, depression, or substance use.
7. Knowledge Gauge for ADHD Diagnosis
The clinician should ask the patient and family and friends what they know about ADHD and provide a brief description of the condition. The clinician should stop after each section to ask how much each component describes this person during the past six months and before.
In discussing a possible diagnosis, the clinician should explain that each of the symptoms of ADHD is a problem everyone has sometimes. ADHD is not an all-or-nothing matter, like pregnancy. It is more like depression (everyone feels sad and discouraged sometimes), but we do not diagnose a person as clinically depressed unless her symptoms are causing significant impairments in her daily functioning over a significant amount of time.
It is also important for the clinician to remind the patient that evaluation for ADHD is an ongoing process. Checking back with the clinician to monitor effectiveness of treatment is essential, especially when medications are prescribed. A clinician should monitor for side effects and determine if the current medication regimen provides adequate coverage at different times of the day (during school classes and at homework time as well as at work).
Patients should be encouraged to contact their prescriber if the medication is causing unwanted side effects or it is not working effectively. In many cases, considerable fine tuning of medication is needed to find the most effective dose for a person.
What Doesn’t Help an ADHD Diagnosis
You may have heard about one or more of the following diagnostic tools, which are not universally accepted by the medical community as reliably accurate or comprehensive. It is my opinion that the following are not accurate tools for an ADHD diagnosis:
1. SPECT Brain Imaging for ADHD Diagnosis
SPECT brain imaging uses radioactive processes to capture 3D images of blood flow in specific areas of the brain over intervals of minutes. It is not painful or damaging to the person. SPECT imaging is good for assessing certain kinds of functioning of the brain or other organs that may have been damaged by injury or disease, but it is not very helpful for assessing ADHD because it reports only how the brain is functioning during the few minutes that the test is being administered. It does not show how an individual’s brain functions in other situations—like school, family activities, or getting along with other people.
2. Computer Games for ADHD Diagnosis
Computer games require a person to respond quickly to particular signals that flash on a screen while avoiding responding to other signals that flash on the screen as decoys. These usually boring games can measure and score how quickly and accurately a person responds to some signals on the computer while trying to ignore others. The computer can compare those scores with scores of others who have taken the same tests, but it does not offer help to know how alert and responsive a person will be when taking in other information, like lessons at college, reading, or interacting with other people when distractions are present and the information one has to respond to, or not, is much more complex.
3. Genetic Testing for ADHD Diagnosis
Many researchers are studying the genetics of ADHD, and some companies jumping on the bandwagon by creating “genetic tests.” In return for a mailed-in sample of saliva or blood, patients receive a summary of their genetics — including possible vulnerabilities to certain disorders. Unfortunately, these tests focus on just a few genes, whereas a very large number of genes are implicated in the genetic makeup of ADHD. And the fact is: you can’t say if a certain person does or doesn’t have ADHD based on any genetic testing — it simply does not work.
4. Neuropsychological Testing for ADHD Diagnosis
Neuropsychological testing uses a series of puzzles and questions administered over two to four hours by a neuropsychologist to see how quickly and accurately a person can remember lists of words, sentences or numbers or various designs, name colors or words on a series of cards according to specific directions, or insert little pegs into a pegboard with one hand and then with the other. These tests can be helpful for assessing brain damage after a head injury or a stroke, or to evaluate possible dementia.
But these tests do not adequately predict how a person without brain damage is able to respond to normal activities of daily life.
The main problem with these three types of tests is that they try to measure how a person’s brain functions in very brief and very specific situations that do not closely resemble daily life or the complexity of situations in which an adult needs to function every day.
ADHD is not a problem due to a damaged brain. It is a problem that affects a variety of functions of the brain and individual motivations of the person for doing or not doing various tasks. It is not a problem in the brain’s structure. It affects how a person’s executive functions work in a variety of situations.
This is what I call the “central mystery of ADHD”: the fact that virtually all persons who have ADHD are able to exercise their executive functions very well for certain specific tasks or situations that are interesting to them, or when they believe that something they do not want to happen is going to happen if they do not complete some specific action or behavior immediately. An example would be the marketing specialist who can focus extremely well playing video games or cooking a meal at home, but who finds it hard to focus on assignments at work. The question raised by this fact is: “Why can you do it here and now, but not in other situations?” It often appears that this is due to a simple lack of willpower, but it is not. ADHD is actually an inherited problem in the electrochemical signaling of the self-management system of the brain.
How NOT to Diagnose ADHD: More Red Flags
If your physician does any of these things during the diagnostic process, think very carefully about finding a new doctor: (use h2 or h3 subheads below as well)
- Too quick to grab the prescription pad: If you’re seeing a physician or any other clinician who wants to write a prescription for ADHD medication without taking the time to do a full evaluation, that’s trouble. I call these “drive-thru evaluations,” and they are very likely to lead to a mistaken diagnosis.
- Failure to include information from the school: If the patient is a student, it’s very important that the doctor gets a sense of how he or she is functioning in school. This includes reviewing teachers’ completed rating scales, or interviewing educators as part of the clinical interview, if necessary. This takes extra time and effort on the doctor’s part, so many skip it — but it’s vital information.
- Failure to use rating scales: Rating scales are scientifically valid measures of attention and hyperactivity. If your doctor chooses not to use them, he or she will likely base the diagnosis on a personal opinion of your or your child’s symptoms, which can lead to a missed or incorrect diagnosis.
- Too fundamentalist about symptoms: The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) outlines symptoms of both inattentive and hyperactive ADHD and stipulates that patients display six or more symptoms before receiving a diagnosis. But in my view, doctors shouldn’t be too rigid about this. If someone has only five symptoms, but those symptoms are causing him or her significant distress, a medical professional must use clinical judgment to make the best diagnosis possible. If your doctor adheres too strictly to a precise number of symptoms, that’s a red flag.
- Saying, “Don’t worry, it’ll pass!” Some ADHD-like symptoms are normal parts of childhood, and some may resolve with time in certain individuals. But living with untreated ADHD can become very problematic — it often causes people to believe they’re “lazy” or “stupid,” and can lead to dangerous behaviors if left unrecognized. If your doctor dismisses your concerns regarding yourself or your child, trust your gut — if you have challenging symptoms that interfere with your life, you deserve help, and should seek a second opinion.
Following these steps can be helpful for developing and sustaining an effective treatment program for ADHD. You can find more detailed information about diagnosing children and adults with ADHD in my book, Outside the Box: Rethinking ADHD in Children and Adults. (#CommissionsEarned)
Thomas Brown, Ph.D., is a clinical psychologist who served on the clinical faculty of the Yale School of Medicine for 21 years and has published six books on ADHD. He is director of the Brown Clinic for Attention and Related Disorders. He is a member of ADDitude’s ADHD Medical Review Panel.
How To Get Diagnosed with ADHD: Next Steps
- Read: Diagnosing ADHD in Children
- Learn: What Your Doctor Needs to Know About Diagnosing ADHD in Adults
- Utilize: Your Complete ADHD Diagnosis and Testing Guide
SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.
#CommissionsEarned
As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.
