"ADHD is generally ignored in medical education," says William Dodson, M.D., author of the forthcoming book What You Wish Your Doctor Knew About ADHD. "Just 5 years ago, 93 percent of adult psychiatry residencies didn’t mention ADHD in four years of training and, amazingly, half of pediatric residencies didn’t mention ADHD. So if you have a physician who has taken the personal time to get up to speed on ADHD, you have found a real gem."
If, on the other hand, your family doctor or general practitioner has not kept pace with ADHD research and understanding, you are not alone — and not without resources.
Bring the following questions with you when interviewing a physician, psychologist, neurologist, or other clinician who you'd like to evaluate and treat symptoms of ADHD in your child or yourself. His or her answers should tell you, without question, whether you’ve found that gem.
1. How many of your pediatric and adult patients have ADHD?
"About 1 in every 5 people who walks into a mental health office is going to have ADHD," says Dr. Dodson. "The problem is that the diagnosis is routinely missed, and that’s because very few physicians have any training whatsoever in ADHD."
In short, ADHD is a specialty. And only specialists with extensive experience evaluating and treating ADHD symptoms — alongside symptoms of commonly co-occurring conditions like depression, anxiety, and oppositional defiant disorder — are equipped to accurately diagnose and address the condition. If your child's doctor is a lovely and proficient pediatrician but is new to ADHD, you need to find a specialist.
"It's unfortunate, in this day and age, that some people go to their family doctor and hear, 'ADHD doesn’t exist for adults,'" says Michelle Novotni, Ph.D., former president and CEO of the Attention Deficit Disorder Association. This myth is simply not true. The National Institutes of Health says that approximately 4% of U.S. adults — that is 14.4 million adults — have a diagnosis of ADHD.
2. How do you evaluate the symptoms of ADHD in children and adults?
For children, the answer is clear: A clinician should use the symptom guidelines outlined in the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition, along with standardized and normative ratings, to diagnose ADHD. Joel Nigg, Ph.D., director of the Attention Project at Oregon Health & Science University, recommends using the Connors Rating Scale, the Child Behavior Checklist, the Strengths and Difficulties Checklist, and the ADHD Rating Scale. "Parents and teachers can complete these and the clinician can score them and determine the probability that a child is in the extreme range compared to the national average," Nigg says.
Unfortunately, the DSM-V guidelines are severely child focused, so a clinician evaluating an adult's symptoms must take the extra step of interviewing family members, friends, and even colleagues. "The accuracy of diagnosis is much, much higher if you have input from two or more informants who have information about symptoms in several settings," Nigg says.
3. How can we be sure it is just ADHD?
"70% of children, adolescents and adults with an ADHD nervous system will have at least one other psychiatric diagnosis; 57% will have two or more," Dodson says, underscoring the prevalence of comorbid conditions existing alongside ADHD.
And then there are all those medical and psychological conditions that mimic ADHD. "These include a history of trauma, mood disorders, developmental delays, and a laundry list of medical and metabolic conditions… like sleep disorders and thyroid disorders," Nigg says.
Your doctor should recognize this, conduct a detailed medical history, and include screening tests for related conditions in his or her thorough ADHD evaluation.
4. What medication and dosage works best for your patients?
This is a trick question.
85 percent of people with ADHD will experience significant benefit from one of the "29 FDA-approved, first-line stimulant formulations for the treatment of ADHD, which are all just different ways of delivering only two molecules: methylphenidate and amphetamine," Dodson says. "Nothing is going to predict which molecule or which dose of a medication will get someone to their optimal level of benefit with no side effects. It has to be determined by trial and error because… the only thing that does determine the right dose is how efficiently the medication is absorbed out of the GI tract, and this is something that changes constantly for children under the age of 16."
5. What medication side effects are acceptable?
Another trick question. No side effect is acceptable.
6. What about treating symptoms with diet and vitamins?
According to Harvard Health Publications, "Traditional research finds no support for radical diets like the Feingold diet — which eliminates nearly all processed foods as well as many fruits and vegetables — for the majority of children with ADHD. And there is no easy way to identify the few children who might benefit from diets that prohibit particular foods."
That said, much research remains to be done and many families report good results with fish oil, iron supplements, and a low-sugar, high-protein diet. Your doctor should be able to recommend diet and supplements that have worked well for other patients, and help you introduce these natural treatments alongside medication and behavior therapy.
7. How often will we meet to evaluate and adjust treatment?
You should see your doctor at least every two to four weeks. When starting a new treatment plan, Dr. Dodson likes to see his patients a few times a week because, as he says, stimulant medications take effect within one hour. So you only need one day to know whether it's working and to make changes.
If you or your child is using medication — with or without behavior therapy or other natural therapies — your doctor should establish and routinely check a monitoring system that collects feedback from multiple sources such as teachers and family members. Your doctor should evaluate improvements in academic/professional and behavioral/social functioning alongside the incidence of side effects when making his or her recommendations for dosing changes.
8. How will you communicate treatment instructions to me?
There is only one right answer here: "I will write them down."
That answer might be obvious for adults with ADHD, but Dr. Dodson also points out that, "There is at least a 50/50 chance that the parent who is accompanying the child to the doctor also has ADHD. That is just the genetics of ADHD. Failure to address that and treat that is the leading cause of treatment failure for children with ADHD."