Diagnosis of AD/HD in Adults

By: the National Resource Center on AD/HD

This information and resource sheet will describe:

• the common symptoms of AD/HD in adults
• how professionals evaluate adults for possible AD/HD
• what to expect when consulting a professional for an AD/HD evaluation

Individuals wishing to seek an evaluation for AD/HD should use this information and resource sheet as a set of guidelines for what to expect from the clinician conducting the evaluation.

What is AD/HD?

Attention-Deficit/Hyperactivity Disorder (AD/HD) is a neurobiological condition that affects an estimated 3-7 percent of the population. In most cases, AD/HD is thought to be inherited, and tends to run in some families more than others. AD/HD is a lifespan condition that affects children, adolescents, and adults of all ages. It affects both males and females, and people of all races and cultural backgrounds.

Some common symptoms and problems of living with AD/HD include:

• Poor attention; excessive distractibility
• Physical restlessness or hyperactivity
• Excessive impulsivity; saying or doing things without thinking
• Excessive and chronic procrastination
• Difficulty getting started on tasks
• Difficulty completing tasks
• Frequently losing things
• Poor organization, planning, and time management skills
• Excessive forgetfulness

Not every person with AD/HD displays all of the symptoms, nor does every person with AD/HD experience the symptoms of AD/HD to the same level of severity or impairment. Some people have mild AD/HD, while others have severe AD/HD, resulting in significant impairments. AD/HD can cause problems in school, in jobs and careers, at home, in family and other relationships, and with tasks of daily living.

AD/HD is thought to be a biological condition, most often inherited, that affects certain types of brain functioning. There is no cure for AD/HD. When properly diagnosed and treated, AD/HD can be well managed, leading to increased satisfaction in life and significant improvements in daily functioning. Many individuals with AD/HD lead highly successful and happy lives. An accurate diagnosis is the first step in learning to effectively manage AD/HD.

How is AD/HD diagnosed?

There is no single medical, physical, or genetic test for AD/HD. However, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources. These include AD/HD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information obtained from family members or significant others who know the person well. AD/HD cannot be diagnosed accurately just from brief office observations, or just by talking to the person. The person may not always exhibit the symptoms of AD/HD in the office, and the diagnostician needs to take a thorough history of the individual's life. A diagnosis of AD/HD must include consideration of the possible presence of co-occurring conditions.

Clinical guidelines for diagnosis of AD/HD are provided in the American Psychiatric Association diagnostic manual commonly referred to as the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). These established guidelines are widely used in research and clinical practice. During an evaluation, the clinician will try to determine the extent to which these symptoms apply to the individual now and since childhood. The DSM-IV-TR symptoms for AD/HD are listed below:

Symptoms of Inattention

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
7. Often loses things necessary for tasks or activities
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

Symptoms of Hyperactivity

10. Often fidgets with hands or feet or squirms in seat
11. Often leaves seat in classroom or in other situations in which remaining seated is expected
12. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
13. Often has difficulty playing or engaging in leisure activities quietly
14. Is often "on the go" or often acts as if "driven by a motor"
15. Often talks excessively

Symptoms of Impulsivity

16. Often blurts out answers before questions have been completed
17. Often has difficulty awaiting turn
18. Often interrupts or intrudes on others (e.g. butts into conversations or games)

A diagnosis of AD/HD is determined by the clinician based on the number and severity of symptoms, the duration of symptoms, and the degree to which these symptoms cause impairment in various life domains (e.g. school, work, home). It is possible to meet diagnostic criteria for AD/HD without any symptoms of hyperactivity and impulsivity. The clinician must further determine if these symptoms are caused by other conditions, or are influenced by co-existing conditions.

It is important to note that the presence of significant impairment in at least two major settings of the person's life is central to the diagnosis of AD/HD. Impairment refers to how AD/HD interferes with an individual's life. Examples of impairment include losing a job because of AD/HD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending or failure to pay bills in a timely manner, or getting on academic probation in college due to failing grades. If the individual manifests a number of AD/HD symptoms but does not manifest significant impairment, s/he may not meet the criteria for AD/HD as a clinical disorder.

The DSM-IV TR specifies three major subtypes of AD/HD:

1. Primarily Inattentive Subtype. The individual mainly has difficulties with attention, organization, and follow-through.
2. Primarily Hyperactive/Impulsive. The individual mainly has difficulties with impulse control, restlessness, and self-control.
3. Combined Subtype. The individual has symptoms of inattention, impulsivity, and restlessness.

Internet Self-Rating Scales

There are many Internet sites about AD/HD that offer various types of questionnaires and lists of symptoms. These questionnaires are not standardized or scientifically validated and should never be used to self-diagnose or to diagnose others with AD/HD. A valid diagnosis can only be provided by a qualified, licensed professional.

Who is qualified to diagnose AD/HD?

For adults, an AD/HD diagnostic evaluation should be provided by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor, or other type of physician), or clinical social workers.

Whichever type of professional the individual may choose, it is important to ask about their training and experience in working with adults with AD/HD. Many times the professional's level of knowledge and expertise about adult AD/HD is more important for obtaining an accurate diagnosis and effective treatment plan than the type of professional degree. Qualified professionals are usually willing to provide information about their training and experience with adults with AD/HD. Reluctance to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek out a different professional.

How do I find a professional qualified to diagnose AD/HD?

Ask your personal physician for a referral to a health care professional in your community who is qualified to perform AD/HD evaluations for adults. It may also be helpful to call a university-based hospital, a medical school, or a graduate school in psychology in your area. If there is an AD/HD support group in your area, it may be very helpful to go there and talk with the people attending the group. Chances are that many of them have worked with one or more professionals in your community and can provide information about them.

How do I know if I need an evaluation for AD/HD?

Most adults who seek an evaluation for AD/HD experience significant problems in one or more areas of living. Some of the most common problems include:

• Inconsistent performance in jobs or careers; losing or quitting jobs frequently
• A history of academic and/or career underachievement
• Poor ability to manage day-to-day responsibilities (e.g. completing household chores or maintenance tasks, paying bills, organizing things)
• Relationship problems due to not completing tasks, forgetting important things, or getting upset easily over minor things
• Chronic stress and worry due to failure to accomplish goals and meet responsibilities
• Chronic and intense feelings of frustration, guilt, or blame

A qualified professional can determine if these problems are due to AD/HD, some other cause, or a combination of causes. Although some AD/HD symptoms are evident since early childhood, some individuals may not experience significant problems until later in life. Some very bright and talented individuals, for example, are able to compensate for their AD/HD symptoms and do not experience significant problems until high school, college, or in pursuit of their career. In other cases, parents may have provided a highly protective, structured and supportive environment, minimizing the impact of AD/HD symptoms until the individual has begun to live independently as a young adult.

How should I prepare for the evaluation?

Most people are a little nervous and apprehensive about being evaluated for any type of condition such as AD/HD. This is normal and should not stop anyone from seeking an evaluation if s/he is having significant problems in life and AD/HD is suspected. Unfortunately, some of the common misperceptions about AD/HD (e.g. it only occurs in children, or the person is just looking for an excuse) make many people reluctant to seek help.

Many professionals find it helpful to review old report cards and other school records, dating back to kindergarten or even the preschool years. If such records are available, they should be brought to the first appointment. Copies of reports from any previous psychological testing should also be brought to the appointment. For adults who experience problems in the workplace, job evaluations should be brought for review if available.

Many professionals will ask the individual to complete and return questionnaires before the evaluation, and to identify a significant other who will also participate in parts of the evaluation. Timely completion and return of the questionnaires will expedite the evaluation.

What is a comprehensive evaluation?

Although different clinicians will vary somewhat in their procedures and testing materials, certain protocols are considered essential for a comprehensive evaluation. These include a thorough diagnostic interview, information from independent sources such as the spouse or other family members, DSM-IV symptom checklists, standardized behavior rating scales for AD/HD, and other types of psychometric testing as deemed necessary by the clinician. These are discussed in more detail below.

The Diagnostic Interview: AD/HD Symptoms

The single most important part of a comprehensive AD/HD evaluation is a structured or semi-structured interview, which provides a detailed history of the individual. In a structured or semi-structured interview, the interviewer asks a pre-determined, standardized set of questions, in order to increase reliability and decrease the chances that a different interviewer would come up with different conclusions. This allows the clinician to cover a broad range of topics, discuss relevant issues in more detail, and ask follow up questions while ensuring coverage of the domains of interest. The examiner will review the diagnostic criteria for AD/HD and determine how many of them apply to the individual, both at the present time and since childhood. The interviewer will further determine the extent to which these AD/HD symptoms are interfering with the individual's life.

The Diagnostic Interview: Screening for Other Psychiatric Disorders

The examiner will also conduct a detailed review of other psychiatric disorders that may resemble AD/HD or commonly co-exist with AD/HD. AD/HD rarely occurs alone. In fact, research has shown that many people with AD/HD have one or more co-existing conditions. The most common include depression, anxiety disorders, learning disabilities, and substance use disorders. Many of these conditions mimic some AD/HD symptoms, and may, in fact, be mistaken for AD/HD. A comprehensive evaluation includes some interviewing to screen for co-existing conditions. When one or more co-existing conditions are present along with AD/HD, it is essential that all are diagnosed and treated. Failure to treat co-existing conditions often leads to failure in treating the AD/HD. And, crucially, when the AD/HD symptoms are a secondary consequence of depression, anxiety, or some other psychiatric disorder, failure to detect this will result in incorrectly treating the individual for AD/HD. Other times, treating the AD/HD will eliminate the other disorder and the need to treat it independently of AD/HD.

The examiner is also likely to ask questions about the person's health history, developmental history going back to early childhood, academic history, work history, family and marital history, and social history.

Participation of a Significant Other

It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, parent, partner) who knows the person well. This procedure is not to question the person's honesty, but rather to gather additional information. Many adults with AD/HD have a spotty or poor memory of their past, particularly from childhood. They may recall specific details, but forget diagnoses they were given or problems they encountered. Thus, the clinician may request that the individual being evaluated have his or her parents fill out a retrospective AD/HD profile describing childhood behavior.

Many adults with AD/HD may also have a limited awareness of how AD/HD-related behaviors cause problems for them and have impact on others. In the case of married or cohabitating couples, it is to the couple's advantage for the clinician to interview them together when reviewing the AD/HD symptoms. This procedure helps the non-AD/HD spouse or partner develop an accurate understanding and an empathetic attitude concerning the impact of AD/HD symptoms on the relationship, setting the stage for improving the relationship after the diagnostic process has been completed.

Finally, it should be noted that many adults with AD/HD feel deeply frustrated and embarrassed by the ongoing problems caused by their AD/HD. It is very important that the person being evaluated discuss these problems openly and honestly, and not hold back information due to feelings of shame or fear of criticism. The quality of the evaluation, and the accuracy of the diagnosis and treatment recommendations, will be largely determined by the accuracy of the information provided to the examiner.

Standardized Behavior Rating Scales

A comprehensive evaluation includes the administration of one or more standardized behavior rating scales. One of the rating scales may be a checklist of the DSM-IV-TR AD/HD symptoms reviewed earlier in this information and resource sheet. These are questionnaires based on research comparing behaviors of people with AD/HD to those of people without AD/HD. Scores on the rating scales are not considered diagnostic by themselves, but serve as an important source of objective information in the evaluation process. Most clinicians ask the individual undergoing the evaluation and the individual's significant other to complete these rating scales.

Psychometric Testing

Depending on the individual and the problems being addressed, additional psychological, neuropsychological, or learning disabilities testing may be used as needed. These do not diagnose AD/HD directly but can provide important information about ways in which AD/HD affects the individual. The testing can also help determine the presence and effects of co-existing conditions. For example, in order to determine whether the individual has a learning disability, the clinician will usually give a test of intellectual ability as well as a test of academic achievement.

Medical Examination

If the individual being evaluated has not had a recent physical exam (within 6-12 months), a medical examination is recommended to rule out medical causes for symptoms. Some medical conditions (e.g. thyroid problems, seizure disorders) can cause symptoms that resemble AD/HD symptoms. A medical examination does not "rule in" AD/HD, but is extremely important in helping to "rule out" other conditions or problems.

Conclusion

Towards the end of the evaluation the clinician will integrate the information that has been collected through diverse sources, complete a written summary or report and provide the individual and family with diagnostic opinions concerning AD/HD as well as any other psychiatric disorders or learning disabilities that may have been identified during the course of the assessment. The clinician will then review treatment options and assist the individual in planning a course of appropriate medical and psychosocial intervention. Afterwards, the clinician will communicate with the individual's primary care providers, as deemed necessary.

Suggested Reading

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, DC: Author.

Brown, T.E. (Ed.) (2000). Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press.

Goldstein, S., & Teeter Ellison, A. (Eds.) (2002). Clinician's guide to adult AD/HD: Assessment and intervention. New York: Academic Press.

Murphy, K.R., & Gordon, M. (1998). Assessment of adults with AD/HD. In Barkley, R. (Ed.) Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. (pp. 345-369). New York: Guilford Press.

This information & resource sheet was developed for the National Resource Center on AD/HD under CDC grant R04/CCR321831-01-1 by the Attention Deficit Disorder Association. It was approved by CHADD's Professional Advisory Board in May 2003. Permission is hereby granted to reproduce this document in its entirety as long as the NRC name, contact information, and logo are included.

For further information about AD/HD or CHADD, please contact:

National Resource Center on AD/HD
Children and Adults with Attention-Deficit/Hyperactivity Disorder
8181 Professional Place, Suite 150
Landover, MD 20785

800-233-4050
http://www.help4adhd.org/

Please also visit the CHADD Website at http://www.chadd.org/.