The Building Blocks of a Good ADHD Diagnosis
A clinical interview. A physical exam. Rating scales and teacher input. Here’s what comprises a good ADHD diagnosis — and what does not.
Attention deficit disorder (ADHD or ADD) is a relatively common diagnosis, but that doesn’t mean it should ever be pronounced lightly. 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. Read on to better understand the standard diagnostic steps — as well as some other “tools” that just aren’t worth your time or money.
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 the other conditions that often go with it. 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. Specialized training — not a degree — is critical to completing this complex task well.
What a Diagnosis Should Comprise
An in-depth, well-rounded ADHD evaluation comprises several components:
DSM-V: 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.
Clinical interview: The provider should first talk extensively with the patient about his or her symptoms in an effort to pinpoint their root causes. The underlying question here is: “Why do you think you (or your child) may have ADHD?” — but in practice, this phase of the evaluation is far more complex than that.
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. 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 does. 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.
Normed rating scales: Most practitioners next use rating scales that have been used on a large number of subjects, some with ADHD and some without. These rating scales ask patients (or their parents) to rate their symptoms in various situations, and help the clinician get a sense of how a person’s symptoms compare to those of other people their age. Respected rating scales include the Connors Scales, BASC, the Brown ADD Scales, or the Barkley scales. Parents and teachers should fill them out for children; adults can fill out their own scales.
Physical exam: 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.
All these puzzle pieces, taken together, help the clinician determine whether an ADHD diagnosis is appropriate. If ADHD is diagnosed, the clinician will follow up with the patient often — particularly if medication is prescribed — in order to assess the efficacy of treatment and to determine if the initial evaluation missed anything.
Learning disability considerations: 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)
What Doesn’t Help
You may have heard about one or more of the following diagnostic “fads,” which are generally not reliably accurate or comprehensive tools for an accurate diagnosis.
Brain imaging: ADHD is not a problem of brain structure, rather, it’s about communication within the networks of the brain. Medical literature is ripe with news of interesting studies on brain scans — including MRIs, PETs, FMRIs, and DTIs — and their provocative results. But people who really know about brain imaging and ADHD will tell you that brain imaging is not a useful diagnostic tool — yet. We are lacking the large number of normative pictures needed to paint an accurate representation of what “normal” looks like at different ages — making the tool’s diagnostic utility a thing of the future, not the present.
Neuropsychological tests: Some patients get referred for expensive — $2,000 to $4,000, usually — packages of neuropsychological tests as part of the ADHD diagnosis process. Unfortunately, I can tell you these tests are generally useless for making an adequate assessment of ADHD. The reason? They are usually given in an office setting and take as many as 8 hours depending on the complexity of the test. They give the tester a snapshot of how that person’s brain might be functioning on that given day, but they don’t communicate a thing about how that person functions in day-to-day life and relationships. Neuropsychological tests are a good way to evaluate brain damage after a traumatic brain injury or a stroke, but they’re not particularly useful for being able to assess and treat ADHD. In fact, the American Academy of Child and Adolescent Psychiatry specifically states that neuropsychological tests are not necessary to evaluate ADHD.
Online “reaction” tests: A wide variety of computerized “attention tests” are available for a fee online. The tests’ creators claim they can determine whether a user has ADHD based on his or her ability to hit a certain key every time a particular target comes on screen — and refrain from hitting it when a different target is shown. In reality, however, these tests are basically boredom tests — and they can be easily manipulated by people who are naturally adept at video games (which many with ADHD are). They very rarely produce false positives, but they often return false negatives, and can miss ADHD in people with quick reaction times or hand-eye coordination.
Genetic testing: 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.
If your physician does any of these things during the diagnostic process, you may want to think very carefully about finding a new doctor:
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.
Thomas E. Brown, Ph.D., is a member of ADDitude’s ADHD Specialist Panel.