The ADHD Diagnosis and Testing Guide for Patients
A thorough ADHD diagnosis includes symptom tests and interviews, plus a through medical history and evaluations for conditions commonly diagnosed alongside ADD — namely ODD, OCD, anxiety, depression, and autism spectrum disorder. It’s a complicated process — as it should be to ensure accuracy. Here, learn what to expect from start to finish.
How Is ADHD Diagnosed?
Testing alone cannot diagnose symptoms of ADHD. Attention deficit hyperactivity disorder (ADHD or ADD) is a nuanced neurological condition with three distinct sub-types, symptoms that appear along a spectrum of severity, and overlapping comorbid conditions that often complicate diagnosis and treatment. Add to that lingering misinformation and myths in the medical community, and the barriers to an accurate ADHD diagnosis and medical care may seem impossibly high.
Here, we break down the essential information on finding an ADHD specialist and pursuing an accurate diagnosis.
What Are ADHD Signs and Symptoms?
You’re worried. Your son’s teacher sent home a note saying that his lack of focus is holding him back in class.
Your daughter phoned a classmate to set up a play date, and was turned down for the third time. The so-called “friend” told your daughter that she’s weird.
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You are concerned about your job. You were late to work twice last week, and you frequently miss deadlines and meetings. You won’t be getting the promotion you’ve been after — in fact, you may be fired.
You’ve wondered for months what’s causing you or your child to come up short — stress, learning disabilities, a medical condition, or ADHD? You’re tired of wondering. It’s time to find out. You want to get an evaluation — to take an ADHD test.
Congratulations. You are taking an important step in changing your life. But you are plagued by questions: Where do you start? What kind of doctor diagnoses ADHD? How do you know if you’re getting a state-of-the-art evaluation and an accurate diagnosis? And what should you do after you get it? Keep reading for answers to these important first questions.
How Do You Get an ADHD Diagnosis?
An evaluation for ADHD (or ADD) often starts with a routine visit to your primary-care physician, but chances are it won’t end it there. As a rule, most general practitioners are not trained in the idiosyncrasies of ADHD and its overlapping conditions, or not equipped to perform the in-depth evaluation needed. One reason is time. It can take several hours of talking, test taking, and analysis to diagnose someone with ADHD.
In addition, general practitioners sometimes overlook co-existing, or comorbid, conditions with overlapping symptoms, such as learning disabilities, mood disorders, or autism spectrum disorder. Professionals trained in diagnosing ADHD routinely screen for these problems.
Any good ADHD diagnosis will begin with a clinical interview to gather the patient’s medical history. This is often supplemented with neuropsychological testing, which offers greater insight into strengths and weaknesses, and helps identify comorbid conditions.
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How Do You Find an ADHD Specialist?
How can you find an ADHD specialist in your area? Follow these five steps to find the right help and diagnosis, and a treatment plan that will best manage symptoms:
- Ask a school psychologist or guidance counselor for a referral for your child. If you’d prefer to see an outside expert before getting the school involved, move to the next step.
- Talk with your internist or your child’s pediatrician. Start the conversation this way: “I’ve noticed these symptoms in myself (or my child), and I’d like an evaluation. Do you know of someone who specializes in diagnosing ADHD?” If the doctor says that he can do it, ask about the tests he uses and how long he typically spends making the diagnosis. If the only basis for a diagnosis is a quick interview with you and/or your child, ask for a referral to a specialist.
- Contact a medical school near your home. “Call the department of psychiatry and ask, ‘Is there anyone on your staff experienced at working with adults or children with ADHD?’” suggests Edward Hallowell, M.D., a psychiatrist with offices in New York City and Boston, and co-author of Superparenting for ADD. “When you get the name of a professional, ask him how many people he has treated. It should be at least a hundred.”
- Check with your insurer. Ask if there are experts trained in diagnosing ADHD covered by your plan. If not, consider going out of network. Remember that your goal, initially, is to get a thorough, accurate evaluation and diagnosis. When you have that information, the diagnosing doctor can work with your plan’s physician to prescribe treatment.
- Call your local chapter of the National Alliance on Mental Illness or CHADD, and ask for names of professionals who specialize in ADHD. Another good option: an ADHD support group in your area. Word-of-mouth recommendations are often the best assessment of a professional’s ability.
How Do Doctors Diagnose ADHD?
In making an accurate diagnosis, your doctor will first want to determine is whether you or your child has the ADHD symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V)1.
“The DSM-V remains the basis of the diagnosis for children, but most clinicians go beyond that in their assessments,” Hallowell says. In addition to reviewing these criteria, doctors will conduct a thorough clinical interview using one standardized ADHD rating scale. A screening test is also often administered to rule out common coexisting conditions like learning disorders, autism, and mood disorders.
According to the latest DSM-V guidelines, in order to be diagnosed with ADHD, a patient has to have shown at least six of the nine symptoms of inattention and/or hyperactivity/impulsivity prior to age 12. In addition, these symptoms must impair the person’s functioning in more than one setting — home, school, or work.
Not all doctors subscribe to these criteria. Many professionals point out that some patients’ ADHD symptoms aren’t recognized until later in life — this particularly true for twice-exceptional individuals, women and girls, or those who have the inattentive form of ADHD.
Diagnosing an adult is trickier than diagnosing a child. The DSM-V symptom guide is really invalid for adults; almost all of its criteria is geared toward diagnosing children. An ADHD diagnosis in adulthood emerges only from a careful clinical interview conducted by a specialist in ADHD who takes his or her time with the evaluation.
“The DSM-V criteria are based only on research with children four to 17 years old,” says Thomas E. Brown, Ph.D., Yale-trained clinical psychologist. “As a result, most clinicians bend the criteria when it comes to the age of onset — recent research has shown that, in some people, symptoms don’t appear until adolescence, when there are greater challenges in self-management. Clinicians also may diagnose adults who have just four or five symptoms, not seven or eight, if they show significant impairment.”
Some doctors use computer programs, such as continuous performance tests (CPTs), to check for attention and impulsivity problems. Others use brain scans, such as single-photon emission computed tomography (SPECT), to look for abnormalities in the brain. But the most reliable evidence for a positive diagnosis, according to most experts, is found in a patient’s history.
ADHD Diagnosis Step 1: The Consultation
Expect the ADHD diagnosis consultation to take an hour or longer. If your child is being evaluated, the doctor will talk to you and your child, and get feedback through checklists and written information from teachers and other adults who spend a lot of time with your child. Sometimes the doctor’s office will forward these forms to you before the consultation and review them with you at the initial meeting. Other doctors will meet with you first, do the interview, and give you the forms to be filled out before your next appointment.
If you are being evaluated, your doctor will interview you and someone who knows you well — your spouse, a sibling, or your parents. She may or may not use similar checklists designed to identify symptoms of adult ADHD. The doctor will use the patient interview to determine which, if any, tests might rule out other conditions that may be causing symptoms.
“The clinical interview is the core of any evaluation,” Brown says. “The more input from different sources, the better. Many adults come for a consultation alone, but it’s helpful to come with a spouse, sibling, or close friend.”
Many doctors ask people in the patient’s life — a spouse, parent, or sibling for an adult; or a teacher, coach, or nanny for a child — to write a few sentences describing the patient. Personal insight often uncovers information that can’t be culled from questionnaires.
Says Hallowell: “A teacher might write, ‘Johnny is sweet, adorable, and cute as a button, but he can’t remember to come in out of the rain. He is disorganized. He speaks out of turn. He needs more discipline.’ It’s what I call the moral diagnosis, but it often reveals a lot about a child who may have ADHD. Those one-paragraph narratives give a wide range of input. Checklists don’t.”
What are doctors hoping to find by evaluating those checklists and narratives and conducting the clinical interview? These five things:
Social history. “Describe a typical day in [your life or] your child’s life” is often the first question a doctor will ask to get a sense of how [you or] your child functions. This reflects what usually goes smoothly and what is challenging in everyday life.
Medical history. Medical problems, ranging from sleep apnea and thyroid conditions to hormone fluctuations and substance abuse, can present symptoms similar to those of ADHD.
Family history. “I ask questions about the immediate family, as well as grandparents, uncles, aunts, and cousins,” says Brown. “I’ll ask things like, ‘Is there anybody who has had trouble paying attention or learning certain subjects, or who was smart but didn’t do well in school — and did better later? The answers will give me an idea of what’s floating around in the gene pool.”
Strengths and weaknesses. “Every person I’ve seen with ADHD can focus well on some activities,” Brown says. “Sometimes it’s sports. Sometimes it’s artistic or mechanical stuff. Those are telltale symptoms of ADHD. In the process, I identify strengths I want to protect and encourage during treatment.”
Education. “Everybody comes in with some information about the condition. Some of it is sophisticated and accurate; the rest is just wrong,” Brown says. “I take 15 or 20 minutes to tell them what I think about ADHD, how ideas about the condition have changed, and the latest thinking on managing symptoms.”
By the time the clinical interview is over, most doctors with experience treating people with ADHD will have a good idea of whether you or your child has the condition. Even so, most will want to back up their opinion with objective proof from tests.
ADHD Diagnosis Step 2: ADHD Tests
Most clinical interviews include completing one or more of the ADHD rating scales, as well as other ADHD tests. A proper ADHD test should do two things: determine whether a person has ADHD and rule out or identify other problems — learning disabilities, autism, auditory processing disorders, or mood disorders. Depending on your doctor’s concerns, tests may take from an hour to more than eight hours and may require several appointments.
Common tests used in diagnosing ADHD include:
ADHD rating scales. These questionnaires can identify specific symptoms of ADHD that may not emerge in the clinical interview. Answers to the questions can reveal how well a person functions at school, home, or work. The scales are specifically formatted for children, adolescents, and adults. “ADHD rating scales have their pluses and minuses, and doctors go with the ones they feel most comfortable using,” says Patricia Quinn, M.D., cofounder of the National Center for Girls and Women with ADHD. “I recommend using at least two scales that gauge both ADHD and other symptoms.”
Intelligence tests are a standard part of most thorough evaluations because they not only measure IQ but can also detect certain learning disabilities common in people with ADHD.
Broad-spectrum scales screen for social, emotional, and psychiatric problems, and they may be ordered if the doctor suspects that a patient has a mood disorder, obsessive-compulsive disorder, or another condition in addition to ADHD.
Tests of specific abilities — such as language development, vocabulary, memory recall, motor skills — may also be recommended to screen for learning disabilities or other processing problems. The doctor may decide which tests to do based, in part, on which kinds of tasks you or your child find easy or difficult.
Computer tests are becoming popular because patients enjoy taking them, and because they can screen for attention and impulsivity problems, which are common in people with ADHD. These “continuous performance tests” (CPT) challenge the patient to sustain attention. A series of visual targets appear on the screen, and the user responds to prompts while the computer measures his ability to stay on task. In practice, some experts have found that these tests are better at identifying impulsive symptoms and less successful at flagging symptoms of inattention.
Brain scans. Neuro-imaging procedures, such as positron emission tomography (PET) scans, SPECT scans, and magnetic resonance imaging (MRIs), have long been used in research studies of ADHD. But their use in diagnosing ADHD has not yet been validated with conclusive scientific research. They have revealed, though, that certain parts of the brain appear different in people who have ADHD than in people who don’t have the condition.
“You do not need a brain scan to be diagnosed with ADHD, and they are not the standard of care,” Hallowell says. “Scans are not a cost-effective way of spending your healthcare money, and they don’t contribute much to the diagnosis of ADHD. But it seems that patients love seeing a picture of their brain, and the scans can often help them own the diagnosis.”
The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters clearly state that scans and computerized continuous performance testing should not be done because they do not give either diagnostic or clinically useful information and they expose the patient to very significant levels of ionizing radiation2.
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ADHD Diagnosis Step 3: Learning How to Manage Symptoms
After the clinical interview and the recommended tests are completed, most doctors will call you into the office to go over the results of your ADHD evaluation. This is the best time to ask the doctor questions. When you leave that appointment, the doctor should have formulated an action plan to manage symptoms. It should include:
- A list of accommodations for work (or school) that will help you (or your child) perform well
- A plan for follow-up therapy with a psychologist, therapist, ADHD coach, or another expert
- Recommendations for ADHD medication, if considered appropriate
- A schedule of follow-up appointments with the diagnosing physician or your primary-care doctor to see how well the treatment plan is working
“After the psychologist finished evaluating my son — a process that included eight hours of testing — she met with me to discuss his strengths and weaknesses, and handed me a list of accommodations that would help him at school,” says Joanna Thomas, of Lubbock, Texas, whose son, Ryan was diagnosed with ADHD at age seven. “Every year since the initial evaluation, I discussed the list of accommodations with his new teacher. I have also used it to write an introductory letter to the teachers that focuses on his strengths. Having that diagnosis meant everything to me. It gave me the tools I needed to help him at home and in working with his teachers.”
“An accurate diagnosis is good news,” Hallowell says, “because things can only get better. When you learn how to manage ADHD, it can become an asset in your life. I tell patients, ‘You’ve got a Ferrari engine for a brain, and you’re lucky, because you’re going to win a lot of races. The only problem is, you have bicycle brakes.’ The point is that someone with ADHD is on the way to being a champion, not a loser. And with the correct diagnosis and treatment, 100 percent of those with ADHD can improve their lives.”
What Are Common ADHD Diagnosis Mistakes?
The following are a few common ways in which an evaluation for ADHD may go awry or arrive at a false conclusion.
Not taking enough time. A thorough evaluation for ADHD can’t be done in a 15-minute visit. Rushed visits raise the likelihood that you or your child will be misdiagnosed, or that the doctor will miss a secondary diagnosis that may be important to treat.
Diagnosing the symptoms, not the underlying problem. “Physicians sometimes misdiagnose secondary symptoms as the person’s primary problem, without looking for coexisting ADHD,” says Patricia Quinn, M.D., cofounder of the National Center for Girls and Women with ADHD. In many cases, when the ADHD is treated, the secondary symptoms also improve. For example, a physician may focus on only the mood dysregulation symptoms intrinsic to ADHD, and make a mood disorder diagnosis that totally misses other underlying ADHD symptoms.
Thinking that academic failure is intrinsic to ADHD. Many children with ADHD do well at school because they work hard, and teachers and doctors will not suspect they have the condition.
Thinking that a high IQ means your child doesn’t have ADHD. Your child may score well on an IQ test, but her grades are mediocre and teachers “diagnose” her as being lazy or undisciplined. An evaluation by an outside psychologist may indicate that she has ADHD and/or a learning disorder.
Sticking with a doctor you don’t like. If you don’t feel a positive connection with your doctor —if he doesn’t seem to respond to you as a person or if he reprimands you for asking too many questions — you won’t have confidence in his diagnosis and ADHD treatment won’t go well.
