Diagnosing Adult ADHD

No physical findings are diagnostic of ADHD, and there are no laboratory studies or electroencephalography (EEG) results that aid in the diagnosis. Neuropsychological testing, including computerized or manual performance tests of attention and impulsivity, may be helpful in assessing a patient’s cognitive strengths and weaknesses but cannot provide a definitive diagnosis of ADHD.  Diagnosis is made by taking a careful psychiatric history, using as much collateral information as is available, such as job evaluations, old report cards and the input of partners and family members. Brain imaging studies (including the test known as a SPECT scan) are not recommended; they are expensive and provide no additional diagnostic benefit.

Many patients with ADHD have long suffered under the impression that they have a “character problem,”  “just need to work harder” or are purposely “self-sabotaging,” when in fact they are working quite hard to try to manage an inherited biologic problem. There are patterns and life stories of inattention, impulsivity and disorganization that have been present since childhood and can only be coherently explained and addressed by the diagnosis of ADHD.

The Adult ADHD Self-Report Scale is a questionnaire developed by the World Health Organization as preliminary screening tool for ADHD.

Adult ADHD Self-Report Scale (ASRS-v1.1)

If a patient has very few of the symptoms on this checklist, it is unlikely that he or she has ADHD.  If a patient does have most of the symptoms on this checklist then ADHD should be considered as a possibility, though a checklist like this can lead to many “false positive” diagnoses, as there are many people who have difficulties with procrastination and distractibility who would not be considered to have ADHD.

The following are some of the issues that can present with symptoms similar to ADHD but are considered to have a different underlying cause:

-Depression, anxiety, learning disabilities, substance abuse, and sleep disorders can all cause significant difficulties with attention and task completion. These situations should generally not be treated with ADHD medications.

-In some cases there can be a mismatch between a person’s talents and their chosen career that can manifest as problems with attention and task completion.  If a person has been reasonably organized, focused and successful throughout their academic and social life, but later in life is in a new career role that is not going well, ADHD should not be considered the most likely cause.  Nearly anyone can be made to seem disorganized if the demands of a job are excessive, as captured by the “Peter Principle.” And some tasks are just going to challenge a person’s attentional capacities. If, for example, a person is finding it difficult to sit and study for many hours at a time for a graduate school examination, this is not necessarily the sign of a disorder; that is a task that was designed to be challenging. There also are many people who consider their attention to be lacking because they see others around them who are more focused. They might be able to work productively for parts of their day, but compare themselves to others who can do so for much longer. It is worthwhile to always strive for improvement, but it is also important to make realistic comparisons and to measure one’s accomplishment against benchmarks other than those who perform at an unusually high level of productivity and efficiency.

-Some people attribute problems with excessive attention to detail (“hyperfocusing”) to ADHD. There is very little research to support this conceptualization. In these cases there is certainly a dysfunction of attention, but it is not usually best explained by a diagnosis of ADHD; the underlying biologic challenge of ADHD is a deficit, rather than surplus of attention. Hyperfocusing is more likely due variously to an obsessive personality style, anxiety, or to one of the many neurocognitive states that can cause difficulties for a person but that have not yet been scientifically categorized. This is not to say that patients with ADHD are unable to focus in all circumstances; there are situations and topics, such as being under deadline pressure or engaging in a highly stimulating activity, during which even someone with impaired attention can bring a high level of a focus to a task. The diagnostic issue is that someone who is frequently impaired by hyperfocus is unlikely to have ADHD.

The diagnosis of ADHD is intended to be used only for patients who have significant impairment from these symptoms. There are many patients who likely have some, but not all, of the genetic makeup that it takes to have the full syndrome of ADHD. They experience some degree of attentional or organizational difficulty, but not so much as to be formally diagnosed with the disorder. In this sense, ADHD is a “spectrum disorder,” whereby there are some people who definitively are considered to have it, others that definitively do not, and many people who are somewhere in the middle on the diagnostic spectrum. In this last group, patients can struggle with certain attention-related areas of their life, and though they don’t technically have ADHD, neither is another problem or disorder a better explanation for the difficulties. It can be conceptualized as essentially a partial, or “sub-syndromal,” case of ADHD.  In these situations treatment with medications is not recommend as a first step in treatment. In these cases cognitive-behavioral therapy, organizational help, or finding ways to alter the working environment may be better treatment plans.

Physicians often see cases of people who do not have a history consistent with ADHD but who have tried someone else’s ADHD medications and were more focused and productive than usual, and the patient wonder if this indicates that they have ADHD. It does not.

As ADHD is currently defined, it affects approximately 4% of the adult population. So one useful way to think about it diagnostically is: if you are wondering if your symptoms are severe enough to be formally diagnosed with ADHD, compare yourself to a group of 25 random adults (not a group of 25 people at a high-performing workplace or academic institution). If your symptoms of inattention and disorganization are not amongst the very worst in the group, then you likely would not warrant a diagnosis of ADHD and medications would not usually be recommended.

The following is a recent podcast discussion regarding diagnosing ADHD:

Click the link below to begin listening

      1. Ritalin Gone Wrong: Roundtable Discussion - Podcast discussion regarding the diagnosis of ADHD

 

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