What Happens in an ADHD Assessment?
I've written a lot about ADHD, but not yet about what an ADHD assessment might comprise, and why. Almost everyone assessing ADHD for children through to adults will be using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In this post, I aim to describe and demystify what is required for an ADHD assessment and discuss the assessment tools that I use in my assessments.
The 18 Symptoms of ADHD
The DSM-5 requires evidence of ongoing issues with inattention and hyperactive or impulsive symptoms. There are nine inattentive and nine hyperactive-impulsive symptoms listed. Adults need to display at least five persistent symptoms from either category (or both) at a high frequency (e.g. "often") over the last six months. The number of symptoms endorsed in each of the two categories determines whether the person has a combined presentation, an inattentive presentation, or a hyperactive-impulsive presentation ADHD. See my other blog post for a description of these presentations.
How I Assess:
Questionnaire: I use the long form of the Conners’ Adult ADHD Rating Scales (CAARS), which are screening questionnaires that can be completed by the client, and by someone who has known them well in the last six months. The CAARS rates for inattentive/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept (self-esteem, self-confidence, and mental health issues). It also provides stricter scores for just the items that meet the inattentive and hyperactive-impulsive symptoms (i.e., no emotional regulation questions or self-esteem issues get a look in), and provides an overall score to show the total number of symptoms and how likely someone is to have different presentations of ADHD.
Interview: I talk to people about symptoms they have noticed in various life settings and the course of these over their life. I do most of this in a telephone screening call to determine if the person is likely to have ADHD. I don't want to assess anyone who is not likely to have ADHD. When I see a person for their assessment I use the DIVA-5, which is a semi-structured clinical interview that is designed to assist in the diagnosis of ADHD in adults. It is based on the criteria for ADHD listed in the DSM-5. The DIVA-5 focuses on the presence of ADHD symptoms in both childhood and adulthood, as well as the impact of these symptoms on various areas of life, such as work, relationships, and daily responsibilities.
Early Signs Before Age 12
The DSM-5 requires that "several" attention or hyperactive/impulsive symptoms should have been present before the age of 12.
How I Assess
Conversations with individuals who knew the person during childhood can be very revealing. Additionally, school reports can be useful. I usually end up talking to a mother, or a father. Sometimes, I talk to a sibling. An older sibling is best since they are more likely to remember their sibling's symptoms below age 12, but I have had to rely on younger siblings on a few occasions, and on same-age friends. Sometimes I need to talk to two or more people. The highest number I have talked to is six people, including two of my client's primary school teachers.
Functional Impairment Across Settings
According to the DSM-5, ADHD symptoms should be present in different areas of life, such as work, study, home, or in social settings.
How I Assess Usually, people are very able to tell me about the ways that symptoms are negatively affecting their lives. This is the reason they are seeking, and are willing to fund an expensive and time-consuming ADHD assessment, after all. Usually, I don't have to ask specific questions about this as they are presented to me in the first screening phone call. The DIVA-5 semi-structured interview does provide some good prompts for assessing impairment across multiple life domains in childhood and adulthood if I have the time and inclination to complete this part.
Not Due to Another Mental Health Issue
Lastly, the DSM-5 specifies that attention or hyperactivity/impulsivity issues should not be better explained by another mental health condition.
How I Assess
This is where the skill of the mental health professional is especially important. A detailed interview with the individual can bring to light mental health conditions that might be causing issues for the person. Some things I expect to be present in most of the people I assess, such as past or current depression or anxiety. Substance abuse issues can be present. And while some consideration is due as to whether these comorbid conditions might be exacerbating symptoms, it's often the case of these issues existing in addition to ADHD. Sometimes these conditions need additional treatment in their own right.
I routinely ask assessment clients to complete the Depression, Anxiety and Stress Scale, since these issues are common in people with ADHD. I use an eating disorders questionnaire when these issues are indicated, and I use two screening tests when autism is a possibility. Other assessors will have additional or different screening questionnaires that they use.
There are some conditions that will affect treatment and need greater consideration. One is bipolar disorder. While bipolar and ADHD can be comorbid, stimulant medication can precipitate manic or psychotic symptoms in a person with bipolar. Anti-psychotics or mood stabilisers may need to be taken before adding a stimulant. For this reason, if I detect possible/likely bipolar in my screening phone call, I do not offer an ADHD assessment, but instead encourage the person to talk to their doctor to get a referral for a bipolar assessment. ADHD in this case must come in second place.
People who have previously experienced psychotic symptoms are also at risk of recurrence due to stimulant meds. Both people with bipolar and past psychosis will likely need to see a private psychiatrist to manage medication (rather than the public health system which manages medications for ADHD in the Canterbury region where I live).
People who are currently using substances may find it more difficult to obtain an assessment, both because of concerns about how the particular substances may alter symptom presentation (think abuse of stimulants or cannabis), and meaning that a person will be unlikely to receive stimulant medication if they are diagnosed.
In Canterbury, where I work, I have had clients who have not been offered stimulants initially because of the level of THC found in a urine drug test. They have had to reduce their use and wait some time to repeat a drug test. I also had a client who was refused stimulants due to a recent history of polysubstance abuse and a longer history of alcohol abuse. But, this does not mean that people are beyond redemption. I have had a client who was given stimulant medication with a prior significant substance abuse history, albeit with several years of sobriety.
What Isn't Required For Diagnosis
It is not required that a person would have met the full criteria for ADHD in childhood had they been assessed. Only "several" symptoms are required.
Neuropsychological testing is not required for a diagnosis of ADHD. This is an expensive and time-consuming step that cannot and should not be used to rule ADHD in or out. This type of assessment may be useful for determining a person's cognitive strengths and weaknesses, or if learning disabilities are also being assessed. See here for an authoritative video summary by ADHD expert Dr Russell Barkley of why neuropsychological testing should not be used for assessment for ADHD.
Personality tests are also not required for an ADHD assessment. They may provide clarity for whether personality factors or disorders are part of the diagnostic mix.
There are some people who have difficulties in providing evidence of childhood symptoms due to school reports not being kept (or being home-schooled), parents having died, or being estranged. It generally becomes harder to provide this information the older the assessment client is due to faded memories, both self-report, and observer-report. When evidence sources cannot be found I generally decline an assessment and suggest the person find a private psychiatrist who may be prepared to consider a diagnosis without this information.
By employing the DSM-5 criteria, using tools like the CAARS and DIVA-5, other mental health screening questionnaires, and insights from school reports and family members, a comprehensive assessment of ADHD in adults can be obtained which will hopefully lead to effective treatment of both ADHD and comorbid issues and lead to an overall better quality of life.