Let's Talk About How ADHD Is Diagnosed

Here’s the thing: There are no blood tests or scans or any type of online screener to accurately diagnose Attention-Deficit/Hyperactivity Disorder (ADHD). In short, sussing out ADHD is not a quick and easy process. However, with the right know-how, you can navigate this new-to-you world and gather the intel you need to either help your child or yourself move on to the next step: Treatment.

What Exactly Is ADHD?

ADHD is one of the most prevalent neurodevelopmental disorders of childhood, but it can continue well into the adult years. It’s marked by:

• Inattention (wandering off task, loss of focus, disorganization)
• Hyperactivity (being in constant motion)
• Impulsivity (acting or speaking without thinking)

People with ADHD may have one of these signs or symptoms, or a combination; most kids have the type of ADHD that’s a combo of symptoms.

More than 6 million children have been diagnosed with ADHD, according to a 2016 report from the Centers for Disease Control and Prevention (CDC), and roughly 11 million people, or 5 percent of the adult population, have it, too.

Who Diagnoses ADHD?

No teacher can determine if a child has ADHD and, quite frankly, neither can any physician or therapist based on a 15-minute checkup. Instead, a proper ADHD diagnosis involves extensive interviews with the person in question and that person’s parents or other loved ones—and teachers, if applicable. There are checklists, observations, and official questionnaires. There’s a medical evaluation, too.

However, before calling on a trained ADHD expert, know this: Only medical professionals, like physicians and nurse practitioners, can perform a thorough physical evaluation to rule out other possible medical causes of ADHD-like symptoms.

As part of a complete check-up, you or your child should get a vision and hearing test. Your physician may also screen for brain injuries, such as a concussion, and look for an underlying seizure or sleep disorder. In rare cases, individuals with ADHD-like symptoms may have thyroid dysfunction. If this is suspected, a blood panel may be ordered.

At the same time, other conditions can masquerade as—or coexist with—ADHD. These include:

• Developmental delays
• Autistic spectrum disorder
• Learning disabilities
• Anxiety
• Depression
• Trauma
• Bipolar disorder
• Obsessive-compulsive disorder

In fact, according to the American Academy of Pediatrics, the majority of children diagnosed with ADHD also meet the diagnostic criteria for another mental health disorder. These types of issues are normally screened for during the next step of the ADHD diagnosis process: The comprehensive evaluation (also called a comprehensive assessment).

Where Can I Get an Evaluation?

If you suspect that you or your child has ADHD, knowing where to start can be a head-scratcher, but it doesn’t have to be. Simply begin with your primary care provider or your child’s pediatrician. While not all general practitioners or pediatricians are equally qualified—or willing and able—to make the ADHD call; it’s also true that some are. But because of the disparity in capabilities, confirm that the clinician you’re working with has expertise in diagnosing ADHD and is familiar with the many ways symptoms can present.

To find out who’s best to help you or your loved one, ask. Pose questions to your GP or pediatrician like:

• What kind of experience do you have in diagnosing and treating ADHD?
• Are you familiar with other conditions that have overlapping symptoms?
• Have you specifically worked with adults (or children) with ADHD?

Qualified professionals should be 100% game to provide you with ample info about their training and experience. If your clinician isn’t the right fit, ask them for references to local licensed mental health professionals with experience testing and diagnosing ADHD. These can include a:

• Clinical psychologist
• Neuropsychologist
• Psychiatrist
• Clinical social worker

Other ways to find a qualified mental health professional? You can:

• Contact nearby hospitals and university ADHD centers
• Call your insurance company for in-network specialists
• Consult professional directories like the one from CHADD.org (Children and Adults with Attention-Deficit/Hyperactivity Disorder), an organization dedicated to providing info to people with ADHD.

What’s a Comprehensive Evaluation for ADHD?

Instead of lab tests and CT scans, clinicians use a comprehensive evaluation or comprehensive assessment to determine an ADHD diagnosis. Essentially, that’s a fancy way of saying information-gathering.

Although procedures and testing materials may differ from clinician to clinician, a quality evaluation generally takes between 2 to 4 hours. It could, however, take up to 8 hours and may require several appointments, depending on the circumstances.

For instance, an adult evaluation solely for diagnostic purposes will generally be less exhaustive than, say, a child’s evaluation where you’re trying to determine how your kiddo’s ADHD symptoms are affecting his or her learning and whether your child is also dealing with other conditions, like anxiety or a mood disorder.

Regardless, a comprehensive evaluation will consist of certain essential standards and protocols. In brief, these must include all of the below:

• Conducting a thorough diagnostic interview
• Using standardized behavior rating scales for ADHD
• Gathering information from independent sources such as parents, teachers, a spouse or other family members
• Confirming symptoms with the DSM-5 checklist
• Conducting psychological testing if deemed necessary by the clinician

The Diagnostic Interview

This is also called a clinical interview. The clinician inquires about your—or your child’s—medical, developmental, family, social, and academic history. For adults, work experience and current coping strategies will also be covered. To help with this process, it’s a good idea to bring relevant paperwork with you, such as:

• Report cards (even if you’re an adult)
• Copies of any previous psychological testing
• Job evaluations

During the interview, the clinician is looking for answers to key questions like:

• What are your specific symptoms?
• When are symptoms present?
• Do they occur in different situations?
• At what age did symptoms begin?
• To what degree do symptoms interfere with your everyday life?

He or she will also be screening for other disorders that may resemble or go hand-in-hand with ADHD, like depression, anxiety, and substance abuse.

Standardized Behavior Rating Scales

Oftentimes, a diagnostic interview will be combined with questionnaires called standardized behavior rating scales. (This testing can also occur outside of the interview setting.)

Here, you’re tasked with rating certain behaviors on a 3- or 4-point scale ranging from not true to often true, or never or very often. These consistent questions decrease the possibility that another clinician could come up with a different conclusion.

And, for children, rating scales enable scores to be compared with other kids who are the same age and gender, which makes gauging developmental appropriateness easier.

If you’re seeking to have your child or teenager diagnosed, know that the clinician will conduct a separate interview (or a play session) with your kiddo, too. Here, the evaluator can discuss specific ADHD-like behaviors with your child in a kid-friendly way and/or observe your child in real-time.

Interview With VIPs

When a child is evaluated, clinicians will also seek information from the child’s teachers. This data is often collected by way of standardized rating scales (fill-in-the-bubble questionnaires) that teachers complete and mail back. However, it can also be gleaned through a phone interview.

No matter the approach, involving teachers in this process is crucial to assessing a child. After all, teachers observe children for extended periods of time, during both work and social situations. (In certain circumstances, clinicians may also request to observe a child in school or in another natural setting.)

For adults, a clinician generally interviews and/or offers standardized rating scales to someone who knows the grown-up well, such as a significant other, a sibling, or close friend. (Adults with ADHD often under-report their symptoms, so having input from others is vital.)

DSM-5 Symptom Checklists

To properly pinpoint ADHD, physicians, mental health professionals, and other qualified clinicians use the diagnostic standards outlined by the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition, otherwise known as DSM-5. In a nutshell, the DSM-5 is the go-to guide that spells out the criteria for making an ADHD diagnosis.

These standards were most recently updated in 2013, in part, to more accurately diagnose adults affected with ADHD. (Previous editions weren’t completely relevant for determining ADHD in adults.)

That said, there are still weaknesses in the DSM-5 criteria when used with adults. For instance, symptoms of executive functioning deficits, like poor emotional self-control and self-motivation, are indicative of adult ADHD, but are not in the DSM-5. This is another reason why it’s important to seek an evaluation with a clinician who is well-versed in how ADHD presents in children or adults, depending on your needs.

The DSM-5 breaks ADHD into three categories:

• Inattentive
• Hyperactive-impulsive
• Combined

Symptoms pertaining to each category are listed below. ADHD symptoms can change over time, so adults may very well fit different presentations from when they were kids.

Primarily inattentive presentation (ADHD/I) symptoms include:

• Not paying close attention to details; tends to make careless mistakes
• Has difficulty sustaining attention on tasks or activities
• Appears not to listen; “head in the clouds”
• Struggles to follow through with tasks like completing schoolwork, chores, and job duties; may quickly lose focus after starting
• Has a hard time with organizing; poor time management; messy, disorganized work
• Avoids tasks that require sustained mental effort
• Loses things often
• Easily distracted
• Forgets to accomplish everyday tasks, like chores, errands, returning phone calls, or paying bills

Primarily hyperactive-impulsive presentation (ADHD/HI) symptoms include:

• Fidgets with hands or feet; squirms
• Has difficulty staying seated at school or work
• Runs or climbs excessively (children); experiences extreme restlessness (adults)
• Has a hard time waiting or taking turns
• Has difficulty engaging in leisure activities quietly
• Feels or acts as if driven by a motor
• Talks excessively
• Interrupts or intrudes on others (cuts into conversations; takes over activities)
• Blurts out answers before questions are finished

Combined presentation (ADHD/C) Here, an individual meets the criteria for both inattention and hyperactive-impulsive ADHD.

For a child from ages 4 to 17 to receive a diagnosis of ADHD, he or she must demonstrate six or more symptoms for 6 months or more—and several symptoms need to be present before age 12, according to the DSM-5. (Folks over age 17 need to have 5 or more symptoms during the same timeframe.) In addition, these symptoms must spur significant difficulties in two or more areas in one’s life, like at home, school, work or in social settings.

Are There Other Tests for ADHD?

Because learning or intellectual disabilities commonly coincide with ADHD, many children receive some psychological and intelligence testing, to boot. These tests do not diagnose ADHD directly, but they’re often imperative to the diagnostic process.

On the other hand, tests of a child’s memory and executive functioning are typically not required to make a diagnosis of ADHD. In fact, these types of neuropsychological tests have not been found to improve the diagnostic accuracy of ADHD in children, according to the AAP.

Other tests that have yet to prove essential in the diagnosis of ADHD include:

• Brain imaging scans, such as CAT scans and MRIs
• Electroencephalogram (EEG) or brain-wave tests
• Computer or virtual reality tests (Continuous Performance Tests or CPTs

What About School Evaluations?

School evaluations are important, but their purpose is not to make an ADHD diagnosis. Instead, they can ID issues with inattention, impulsivity or hyperactivity and lead to critical in-school services that can help your child succeed in the classroom, while also perhaps dealing with ADHD.

Moreover, regardless of any outside testing your child may undergo, a school-based evaluation is essential—and required—for your child to access special education services. All public and charter schools (elementary and secondary) are legally obligated to evaluate a student, at no cost to you, if your child’s school has reason to believe your kiddo has ADHD or if you request an evaluation in writing. Once you sign an evaluation consent form, your child’s school has 60 days to conduct an evaluation and determine whether services are appropriate.

What Are the Chances of a “False Positive” or a Misdiagnosis?

The more comprehensive the evaluation is—and the more experience the clinician has—the less likely you are to wind up with a misdiagnosis. At the same time, any evaluation is merely a snapshot of a person at a particular point in time, based on the quality of the information available. Sometimes important data may be withheld or inadvertently forgotten or perhaps additional symptoms come to light after the evaluation.

It’s also important to note that children who are the youngest in their class are 30% more likely to receive an ADHD diagnosis than their slightly older peers in the same grade, a 2018 study in The New England Journal of Medicine indicated. This calls into question whether ADHD-like behaviors reported by teachers and parents are indeed indicative of ADHD or simply the result of an age and maturity gap.

Because of all of the above, re-evaluations are typically recommended every 2 to 3 years for children and adolescents—more often if a child’s symptoms change or if progress stalls. For adults, re-evaluations may be recommended if there are significant changes in symptoms, if additional symptoms emerge, or if you’re simply not making the progress you hoped for even with treatment.

On the flipside of overdiagnosing, there’s failing to diagnose ADHD. That appears to be an issue with Black and Latino children. Black and Latino children who show symptoms of ADHD are diagnosed much less often than white children, a 2016 study in the journal Pediatrics noted. If you or your child is Black or Latino and struggling to get diagnosed, it’s critical to consult a clinician who’s mindful of race-specific norms and is cognizant of implicit bias.

And even though it’s estimated that just about half of all children with ADHD are female, less than 50% are ever referred for an ADHD evaluation. For women and girls, inattentiveness is a more prominent symptom than hyperactivity or impulsivity. That means females tend to be less disruptive, but it’s disruption that often drives the push for an evaluation. Plus, women and girls may develop better coping strategies than males to mask their symptoms, according to a report in The Primary Care Companion for CNS Disorders. In the end, accurate ADHD diagnosis in women and girls requires an understanding of its gender-specific presentation.

Finally, know that getting an ADHD diagnosis doesn’t change who you are, who your child is, or who your loved one is. The diagnosis simply offers you more information about yourself or a person you already love. Reassuringly, you can use that info as a springboard to achieving the success that you know is in reach.