What Your Doctor Needs to Know About Diagnosing Adult ADHD
Though the medical and scientific communities now agree that ADHD is not strictly a childhood condition, the most widely used diagnostic criteria remain focused on identifying symptoms in children and teens. This means adults may suffer misdiagnosis or no diagnosis at all if they don’t understand nuances of ADHD and it’s overlapping conditions in adulthood. Get started here.
Not long ago, most doctors believed that children outgrew symptoms of ADHD with time. It was considered a pediatric condition. This stems from the fact that ADHD was traditionally linked to hyperactivity, which dims in early adolescence. But we now know that ADHD manifests in three distinct ways, and that some patients never display outwardly hyperactive behavior at all. Thanks to ongoing research, we also know more about the genetic component of ADHD, which suggests that an individual has ADHD for life.
Most adults seeking an evaluation have spent a lifetime learning to compensate for symptoms such as inattention, disorganization, and impulsivity. Because they are bright, creative, and good problem solvers, these undiagnosed individuals find ways to make life work for them — often until mounting family and career responsibilities push them to seek a diagnosis and symptom relief. Dr. William Dodson, a board-certified adult psychiatrist who has specialized in adults with ADHD for the last 23 years, says the average age of diagnosis in his practice is 39.
“[These adults have] been able to find compensations and ways around their ADHD their entire lives,” says Dodson, until their challenges “just overwhelm their ability to cope with their ADHD.” They typically go to the doctor for other conditions they think they may have, like anxiety or a mood disorder.
Common complaints among adults with undiagnosed ADHD include:
- Distractibility and inconsistent focus
- Inability to finish projects
- Tension or restlessness
- Inconsistent performance often perceived as being unreliable
- Motivation not based on importance, but interest and urgency
- Unable to get enough restful sleep
- Poor sense of time
- Intense emotions and sensitivity to criticism
- Unexplained underachievement (not failing, but not achieving what you feel you should be or could be)
- Substance abuse and/or dependence
The standard checklist to determine if a child has ADHD is the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-V). This symptom guide is invalid for adults. An ADHD diagnosis in adulthood emerges only from a careful clinical interview. It’s important that the clinician is a specialist in ADHD, and that he or she takes their time with the evaluation.
“You want to see someone who realizes that there’s a lot of talent embedded in the problems,” suggests Dr. Edward Hallowell, a practicing psychiatrist and founder of the Hallowell Center for Cognitive and Emotional Health. You don’t want to get a diagnosis and walk out feeling like things are all bad, and will be forever.
Any good ADHD diagnosis will begin with a clinical interview to gather your medical history. This is often supplemented with neuropsychological testing, which offers greater insight into strengths and weaknesses, and helps identify co-existing, or comorbid, conditions.
“The part that most family physicians miss out on would be the differential diagnosis,” explains Dr. Michele Novotni, former president and CEO of the national Attention Deficit Disorder Association (ADDA), speaker, best-selling author, psychologist, and coach. “ADHD symptoms can be the result of different mental health issues, such as anxiety or a mood disorder. Any of these conditions can be occurring with ADHD.”
Surveys tell us that most general physicians, even most psychiatrists, undergo absolutely zero training on ADHD. “Ninety-three percent of adult psychiatrists, when asked, report that they’ve never had any ADHD training, either in their residency or in their continuing medical education, whether in children, adolescents, or adults,” says Dodson. It’s no wonder so many struggle to get an accurate ADHD diagnosis in adulthood.
It’s important to see a physician who specializes in ADHD but also has a thorough understanding of its comorbid conditions, and Dr. Dodson underscores this. The emotional sensitivity component of ADHD can look like a mood disorder and/or anxiety, particularly in adults who have lived with ADHD all their lives. If you’re not seeing a clinician who understands the nuances of each related condition, and how they can mimic one another, you may endure a frustrating waste of time and money. A clinician trained in just one of these conditions will see what they’re trained to see, and that often leads to a misdiagnosis of a mood disorder and/or anxiety. Of course, an inaccurate diagnosis leads to ineffective (and in some cases, counterproductive) treatment, which often worsens the problem.
“The best way to find a competent clinician,” Dr. Dodson says, “is to start either with the ADDitude website’s ADHD Directory, or go to a CHADD or NADDA meeting. These are people who are just a couple of years ahead of you and they can tell you who’s good [for adult ADHD] and who’s not.”
Physicians unfamiliar with making a mental health diagnosis should refer patients to either a psychiatrist or psychologist who is trained to diagnose and treat ADHD and its comorbid conditions.
Dr. Russell Barkley is a clinical professor of psychiatry and pediatrics at the Medical University of South Carolina. When adult patients ask him questions about why they should try medication to manage their ADHD, he says he begins his reply with two important words: “Medication works,” he says. “When you find the right medicine, you can experience substantial improvements in your ADHD symptoms.”
The same medications used to treat children who have ADHD are also used to treat adults. Stimulants like Ritalin, Concerta, Vyvanse, or Adderall, comprise the first line of treatment, not the last resort, Dodson says.
“About 80 percent of adults with ADHD have some kind of co-occurring condition that complicates the treatment of their ADHD,” says Novotni. She warns that not treating all of the problems leaves the patient struggling and frustrated.
Debra Brooks was a treatment holdout — at first. Upset about her diagnosis, she says, “for about six weeks, I flailed. I resisted starting medication. But then I remembered what the neurologist who diagnosed me had said: ‘Why did you pay me $1,400 if you didn’t want my advice?'”
After starting a medication regimen, every patient should consider working with an experienced psychologist, psychiatrist, or life coach, says CHADD director Meyer. These professionals can help people with ADHD learn behavioral, time-management, and organizational strategies to enhance their quality of life.
“A coach can give you ways to manage your ADHD symptoms,” Novotni says. “If you’re hyperactive, a coach can suggest ways of channeling your energy — for instance, taking a walk during your coffee break. If you’re impulsive, a coach can teach you ways to delay your responses, so you can think about them.”
“Education of the entire family about what ADHD is — its strengths, its weaknesses, and its treatments — is essential,” concludes Dodson. Understanding of how the ADHD brain works is essential to success.
In addition, Meyer offers these tips for the newly diagnosed:
- Know your legal rights. Having ADHD means you’re protected under two federal laws that apply to individuals with disabilities.
- Seek support by attending meetings of your local chapter of CHADD, a non-profit advocacy and education organization (click “Find local chapters” on CHADD’s home page).
- Don’t feel compelled to tell your boss. “There’s more understanding about ADHD now, but that doesn’t mean that supervisors are happy to learn that one of their employees has the condition,” says Meyer. If, however, you think accommodations — closing your office door, taking more breaks — will help you improve your job performance, you may want to discuss these with your employer.
The bottom line: Adults with ADHD should learn as much as possible about how to make the most of their unique brain wiring. This may include individual or couple’s therapy, support groups, and learning new ways to do things.