ADHD Diagnosis: Where to Go and What to Know

Diagnosing ADHD in children, teens or adults is a multi-step process, says board-certified child psychologist Mary V. Solanto, PhD, professor of pediatrics and psychiatry at the Hofstra-Northwell School of Medicine in New York.

Health-care practitioners follow guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (aka DSM-5) to look for patterns of behavior. There is no blood test to determine ADHD. Symptom checklists, rating scales, and other tests are used to look for patterns of behavior that may indicate ADHD.

Information from the person being evaluated, as well as input from family members (parents or spouse) and from teachers, is used when children and teens are being assessed. The input helps determine whether and what types of ADHD symptoms are present, for how long, and the extent to which they are interfering with daily functioning.

Health-care practitioners will rule out mental health conditions such as depression, anxiety, and others that may mimic ADHD. A careful diagnosis should also include an evaluation by your primary care physician to rule out medical conditions that may also mimic ADHD, such as sleep disorders, thyroid disorders, and seizure disorders. In older adults, a practitioner may also determine whether age-related cognitive impairment or dementia is contributing to ADHD-like behavior, says Solanto.

A health-care provider may also check cognitive abilities, to make sure a learning disability isn’t causing disruptive, impulsive, or inattentive behaviors.

The American Psychiatric Association’s clinical guidelines for a diagnosis of ADHD are an important tool for diagnosing ADHD in children, teens, and adults. The criteria also help pinpoint the type of ADHD. There are three: ADHD with predominately inattentive symptoms, with predominately hyperactive-impulsive symptoms, or with combined symptoms. DSM-5 criteria, the organization’s most recent classification of mental disorders, are primarily used by mental health practitioners in the US.

For children and teens up to age 17, the criteria call for having six specific symptoms—and for teens 17 and older and for adults, having five specific symptoms—for at least six months that interfere with play, social life, school, and/or work. Several symptoms should have appeared before age 12, be present in more than one situation (such as at home and at school or work), and are not the result of a different mental health disorder.

Potential Inattention Symptoms

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities

• Often has difficulty sustaining attention in 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

• Often has difficulty organizing tasks and activities

• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

• Often loses things necessary for tasks or activities

• Is often easily distracted by extraneous stimuli

• Is often forgetful in daily activities

Potential Hyperactivity Symptoms

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities

• Often has difficulty sustaining attention in 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

• Often loses things necessary for tasks or activities

• Is often easily distracted by extraneous stimuli

Hyperactivity and Impulsivity (Combined Type) Symptoms

• 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 inappropriate

• 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

Potential Impulsivity Symptoms

• Often blurts out an answer before a question has been completed

• Often has trouble waiting his/her turn

• Often interrupts or intrudes on others

Finding out whether a child has ADHD may begin with a conversation with their pediatrician about the symptoms and behavior that a parent is noticing. The pediatrician may do an evaluation to determine if a child needs a more formal and lengthy evaluation for ADHD. You may also talk with your child’s school about whether she or he would benefit from classroom accommodations (i.e. being allowed more time to take tests) to make learning conditions more optimal and about receiving an evaluation through the school. (Schools that receive federal funding are required to provide ADHD evaluations, according to the non-profit advocacy organization Children and Adults with Attention-Deficit/Hyperactivity Disorder, CHADD.)

An ADHD diagnosis includes an evaluation of a child's or teen’s symptoms of inattention, hyperactivity, and/or impulsivity. Rating scales, symptom checklists, and reports of a child's or teen’s history of behavior from parents and teachers are all used to help determine not only whether symptoms are present but how severe they are and whether they are interfering with daily life.

Parents and teachers may fill out behavior rating scales. Your child’s doctor or a mental health specialist will also spend time with your child, review your family’s health history, administer psychological tests, review school records, screen for learning disabilities, and more.

The American Academy of Pediatrics also recommends that the pediatrician or mental-health practitioner who is evaluating a child or teen for ADHD rule out other conditions that can trigger behavior that looks like ADHD, including emotional or behavioral conditions (such as anxiety, depression, oppositional defiant disorder, conduct disorders, and substance use), developmental conditions (such as learning and language disorders, or autism spectrum disorder), and physical conditions (such as tics and sleep apnea). According to CHADD, a good evaluation also includes vision and hearing tests plus speech and language assessments, if needed, to rule out sensory or neurological issues related to communication that could mimic ADHD.

Diagnosing ADHD in adults is similar to diagnosis in children. The American Psychiatric Association’s DSM-5 criteria for ADHD with predominately inattentiveness, hyperactivity/impulsivity, or mixed ADHD are used.

But an adult’s symptoms will likely look different than a child’s; hyperactivity in a child may be getting out of a classroom seat and running around, while an adult may tap a pen on the table over and over during a meeting, spin around in her chair, or doodle energetically. And for a formal ADHD diagnosis, symptoms should have been present before age 12, which requires that the person being evaluated, or someone close to them, can confirm this part of their medical history.

A thorough evaluation for adult ADHD will include a detailed and comprehensive interview with the person being evaluated, ADHD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information from a spouse or close relative. You may also receive testing to rule out learning disabilities.

The mental health practitioner who is screening you will also look for mental health conditions that can mimic ADHD or may come along with ADHD, such as depression, anxiety, or a psychiatric disorder. You will also need a medical examination, or results from a recent exam, to rule out thyroid conditions, seizure disorders, and other health problems that may mimic ADHD symptoms. You may also need cognitive tests to check for thinking and memory problems due to aging or other factors.

Women with ADHD may have had their condition overlooked earlier in life, says Solanto, a member of CHADD’s professional advisory board. Girls are more likely to have inattentive symptoms with ADHD and to miss out on being evaluated. The under-recognition of ADHD persists into adulthood for women, says Solanto, adding that women, in general, are more likely than men to seek mental-health help, which may lead to help for ADHD. “They can decide for themselves to be evaluated and not depend on parents or teachers,” she says.

A licensed mental health professional or physician—such as a clinical psychologist, psychiatrist, neurologist, family doctor, or clinical social worker with training and experience working with children, teens, or adults with ADHD—can perform an ADHD evaluation. Pediatricians often diagnosis ADHD in children, according to the American Academy of Pediatrics. In fact, a 2015 report from the CDC’s National Center for Health Statistics found that half of all children with an ADHD diagnosis had been evaluated by their family doctor.

ADHD Rating Scales

There are many ADHD rating scales that practitioners may use. These are so-called “narrow band” scales focused on ADHD symptoms in children/teens or in adults. Two commonly used scales are the ADHD Rating Scale V (ADHD-RS-V) for children and the Adult ADHD Self-Report Scale.

Other ADHD scales commonly used in a child's or teen’s ADHD evaluation include the Behavior Assessment Scale (BASC-3), Vanderbilt scales (NICHQ-VADRS), Connors scales (CONNERS-3), and the Swanson, Nolan and Pelham (SNAP) scale. In adults the Conners Adult ADHD Rating Scales (CAARS) and the Wender Utah Rating Scale (WURS) are the most common, according to CHADD.

Your practitioner may choose a certain scale for a specific purpose, such as using the Diagnostic Interview for ADHD in Adults to help with an initial diagnosis, the Swanson, Nolan and Pelham (SNAP-IV) scale to measure how often someone has ADHD symptoms, or the ADHD-RS-V6 for the severity of symptoms. Still other scales may be used to measure improvement or changes in symptoms during treatment.

ADHD Intelligence Tests

Because a learning disability, intelligence level, or cognitive decline can mimic ADHD, practitioners may use intelligence tests during an ADHD evaluation. Specialized intelligence and achievement tests get around some of the problems with conventional IQ tests, such as being timed tests that require sustained concentration to complete, which may be a challenge for a child, teen, or adult with ADHD.

Tests used to measure intelligence and achievement include the Woodcock-Johnson IV, for all ages through adult; the Wechsler Individual Achievement Test, which can be compared to standard IQ tests to spot learning disabilities and can be used to identify academic strengths; and the Wide Range Achievement Test, for children through adults, which measures reading, spelling, and math skills.

Broad Spectrum Tests

“Broad band” scales go beyond assessing ADHD symptoms and look at other factors such as problems in relationships, academics, trouble with organization and time management, and other mental health or behavioral issues that may be present, such anxiety, depression, or oppositional/conduct problems. Broad band scales include the Child Behavior Checklist (CBCL), Behavior Assessment Scale for Children (BASC), the Brown Attention Deficit Disorder Scales (BADDS), and the Weiss Functional Impairment Rating Scale, which looks at a child's, teen's, or adult’s issues with family, work or school, socializing, and other aspects of life. According to CHADD, it can be used to assess the quality of life of a person who may have ADHD.

Computer Tests

Your health-care practitioner may also use computerized tests in his or her ADHD evaluation. In very basic terms, these tests measure attention, impulsivity, and inattention by asking the test-taker to respond when they see or hear certain things—a specific sound or image of a number or letter, for example—and to ignore others.

Some add a distracting element meant to mimic real-life situations that may affect the focus of a person with ADHD. Examples of computer tests for ADHD include the Test of Variables of Attention (TOVA), the MOXO d-CPT, the IVA: Integrated Visual and Auditory CPT, the QbTest, and the Conners Continuous Performance Test 3rd Edition and Conners Continuous Auditory Test of Attention.

Brain Scans

While researchers are studying a variety of brain-scanning techniques including magnetic resonance imaging (MRI) and SPECT functional neuroimaging to look for differences between the brains of people with and without ADHD, brain scans are not ready for use in diagnosing ADHD, according to the scientists who are studying them.

Some clinics offer brain scanning for ADHD. But the technology’s not ready for prime time, says Solanto: “Brain scan studies do show differences. And this tells us that ADHD is a brain condition, not the result of how you were parented or your environment. That’s important. It’s nobody’s fault. But scanning is not refined enough yet for a correct positive or negative diagnosis of ADHD. It’s not validated for that purpose, though someday it may be.”

There are plenty of online ADHD tests and self-assessment quizzes for ADHD. These may help you think about the symptoms and behaviors you see in yourself or in a loved one, but they are not an accurate way to diagnose the condition or even to decide whether to get evaluated, says L. Eugene (Gene) Arnold, MEd, MD, a board-certified child and adolescent psychiatrist and professor emeritus of Psychiatry and Behavioral Health at The Ohio State University.

“If you are convinced your child has ADHD but it doesn’t show up on a quiz, you should still get a professional evaluation,” he says. “If it does show up, don’t jump to the conclusion it’s ADHD. You still need an evaluation.”

Solanto agrees. “Problems with attention, the hallmark of ADHD, can be due to a whole variety of issues and problems,” she says. “You can’t figure that out on your own. It could be anxiety, depression, or a learning disability. If you think that you or a loved one need an ADHD evaluation, you should get one.”

That said, adults who want to do a quick check could try the World Health Organization’s Adult ADHD Self-Report Scale (ASRS-v1.1). Solanto says it is a scientifically validated screening for ADHD.

Depression, anxiety, or other psychiatric conditions may be mistaken for ADHD, Solanto says. So may some learning disabilities, as well as medical issues including thyroid problems, seizure disorders, and sleep disorders. And children, teens, and adults with ADHD may be able to work around the challenges of the condition and perform at a high level in school or work, essentially hiding or not really recognizing that they’re dealing with the condition until they meet a major challenge, such as moving from elementary to middle school, from high school to college, or into the working world.

“Some people can compensate,” she notes. “That’s why it’s important to have a thorough, good evaluation.”

ADHD may also be overlooked in girls and women because the condition is more likely to have symptoms related to inattentiveness rather than hyperactivity and impulsivity. “Research indicates that females with ADHD that begins in childhood are less likely to be recognized and diagnosed than males,” she says. “They’re not disruptive in the classroom. They’re quiet. They’re encountering insults to their self-esteem, so they may start thinking of themselves as incompetent or unintelligent. And they’re more likely to be socially ignored by their peers.”

A thorough evaluation and accurate diagnosis allows you to get the right treatment for your particular situation. “If you don’t seek an evaluation, the problems will just continue—and you might figure it’s just stress or fatigue,” Solanto says.

An accurate diagnosis will determine whether you need help for depression, anxiety, another mental health condition, or a medical problem like thyroid problems or sleep problems, instead of or along with your ADHD treatment.

“The treatments for anxiety and depression are quite different from the treatments for ADHD,” she notes. “Without clarification on this, you’re not going to get the help you need.”