Assessment And Diagnosis Of Adult ADHD: Doing It Right

Let’s start here: There is no such thing as new onset ADHD in adulthood. This is because ADHD is a neurodevelopmental disorder with onset beginning in childhood and extending into early adolescence. The diagnosable age range is generally considered to be between 6 and 12. This is important because if you have never-before-diagnosed adults coming to you believing they have ADHD, probably 95 percent of them have something else. People with focusing difficulty, short attention span and distractibility often consult the Web to either become better informed about what’s possibly causing these symptoms or to self-diagnose. But the problem with most Web information regarding these symptoms is it is poorly fleshed out — failing to mention other differentials which are associated with these same symptoms.

Also important: Adults who really have ADHD and went undiagnosed in childhood or adolescence, or were diagnosed and decided not to pursue treatment, will generally report significant impairment in personal, occupational and social functioning. As such, there’s likely to be a paper trail of difficulties, right?

Doing It Right… 

Before doing an adult ADHD assessment, keep in mind that most symptoms are nonspecific and can be present in many other psychiatric disorders — or even present in people without any disorder at all. Positive answers to questions asked can’t confirm the diagnosis, but they can provide clues that may (or may not) prompt a suspicion of ADHD. When an adult patient comes to my office with ADHD-like complaints, the 1st thing I do is assess their motivation.

So Ask… 

  • “Why are you coming in for an evaluation at this age?” “Why now?”
  • “Have there been any major changes in your life recently?”
  • Frequently, there’s a precipitating factor that prompts someone to seek treatment — such as a recent promotion, increased work responsibilities, educational demands, the birth of a child, a new marriage.
  • If a patient comes in and says “I have poor attention,” I’ll ask how long this has been going on.
  • For patients with real ADHD, the most common response is “my whole life.”
  • In my experience, many of them tear up when answering this question.

Additional Questions And Investigation… 

  • “When did your symptoms first start?” If they answer the last year of high school or first year of university, then it’s not ADHD according to criteria.
  • Inquire about education pursuits: “Was school a struggle for you?” “How long did it take to get your degree?” Often you’ll hear it took many years and multiple attempts to earn it.
  • Ask about home life. “What’s your bedroom closet look like?”
  • “How often do you lose important objects, like cellphones or keys?” Many patients will show me that these items are anchored to belts or tied to purses. “This is what I have to do so as to not lose them.”
  • “Are you able to sit still?: “Do you feel an urge to be constantly on the go?” “What’s it like to sit in a meeting at work?” “How about standing in line at a coffee shop or pharmacy?”
  • “Have you had any near misses while driving?” “Car accidents?” “Run red lights?”
  • “Have you lost jobs?”
  • “Have you been formally reprimanded by your supervisor?”
  • The patients I see who again really have ADHD will say, “I can’t drive very well because I just can’t keep my mind focused on the road and I’ve gotten numerous tickets.”
  • “I’ve been fired from several jobs because I sleep in late or I forget.”
  • “I’ve lost relationships because I’m not paying attention and am not fully present.”
  • “My utilities have been cut off because I forget to pay the bill.”

Next Steps… 

Proceed from initial questions to more systematically go through the formal list of ADHD symptoms. Have them fill out the ADHD Rating Scale IV With Adult Prompts in the waiting area — don’t simply read off a list for patients to answer out loud. Then do a review of systems because mood, anxiety and trauma-related disorders are common in patients with ADHD. If a patient describes symptoms of depression, it may be hard to tell whether the poor concentration is due to the depression or the ADHD. So, ask about self-esteem — “I’m down on myself because I can’t accomplish anything,” “I’m a failure.” If most of the patient’s “depressive” symptoms are related to these statements above, think ADHD, because ADHD drives poor self-esteem.

Then… 

Do a good substance abuse history — ask about caffeine usage, energy drinks, nicotine usage as it is possible they are dosing themselves with cigarettes to enhance attention. “What drugs have you tried?” “If you drink, what is your alcoholic beverage of choice?” They may be self-medicating for anxiety. ADHD is highly heritable. “Whom do you suspect has problems with attention in your family?” Finally, screen for pre-existing cardiovascular disease, because if the patient were to be placed on stimulant medication, the drug could aggravate a heart condition.

Be On Alert For Fake Symptoms… 

There’s a webpage named “How to Convince Your Shrink You’ve Got ADHD.” It lists all the questions a psychiatrist is likely to ask, and tells someone how to answer each question to increase the chances of getting a diagnosis and obtaining a prescription for a stimulant.

Treatment Options 

Non-medication strategies such as mindful awareness, yoga and developing an organizational plan are absolutely essential to symptom improvement, as medication cannot carry the load by itself. Two types of stimulants are routinely prescribed:

  • The Ritalin (methlyphenidate) products (MPH)
  • The Dexedrine (amphetamine) products (AMP)

Users may experience some appetite suppression in the beginning but this is not generally persistent. Insomnia can occur, but over time, sleeps improves due to less bedtime rumination.

While it was once thought and taught that ADHD symptoms remitted upon entering adulthood, today we know better… they often don’t, and can be as persistent and intrusive as during childhood.


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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.