Expert Therapy

Call or email to book an appointment

Do you feel that you have struggled throughout your life with poor concentration, inattention, impulsivity, or getting organized? Have you wondered whether you might have attention deficit/ hyperactivity disorder (ADHD)? Our society has become more aware of ADHD as a condition that affects adults as well as children, and there are many adults who struggle with this disorder. At the same time, other life stressors or mental health conditions can cause similar symptoms. Consider getting an evaluation from a psychiatrist or psychologist who has experience in diagnosing ADHD. Getting an evaluation can help you find the right answer to your struggles and identify the treatment you need to feel better.

Overview:

Approximately 10 million adults have attention-deficit/hyperactivity disorder (ADHD). In early adulthood, ADHD may be associated with depression, mood or conduct disorders and substance abuse. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms.  Many have inconsistent performance at work or in their careers; have difficulties with day-to-day responsibilities; experience relationship problems; and may have chronic feelings of frustration, guilt or blame.

Individuals with ADHD may also have difficulties with maintaining attention, executive function and working memory.  Recently, deficits in executive function have emerged as key factors affecting academic and career success. Executive function is the brain’s ability to prioritize and manage thoughts and actions. This ability permits individuals to consider the long-term consequences of their actions and guide their behavior across time more effectively.  Individuals who have issues with executive functioning may have difficulties completing tasks or may forget important things.

How is ADHD diagnosed?

This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities can also help determine how many children have ADHD, and how public health is impacted by this condition.

Here are the criteria in shortened form. Please note that they are presented just for your information. Only trained healthcare providers can diagnose or treat ADHD.

Need help?

Get information and support from the …………………………….

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development:

  1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    • Often has trouble holding attention on tasks or play activities.
    • Often does not seem to listen when spoken to directly.
    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
    • Often has trouble organizing tasks and activities.
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    • Is often easily distracted
    • Is often forgetful in daily activities.
  2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
    • Often fidgets with or taps hands or feet, or squirms in seat.
    • Often leaves seat in situations when remaining seated is expected.
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    • Often unable to play or take part in leisure activities quietly.
    • Is often “on the go” acting as if “driven by a motor”.
    • Often talks excessively.
    • Often blurts out an answer before a question has been completed.
    • Often has trouble waiting their turn.
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Because symptoms can change over time, the presentation may change over time as well.

Diagnosing  ADHD in Adults:

Although there is no single medical, physical, or genetic test for ADHD, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources. These sources include ADHD 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. Some practitioners will also conduct tests of cognitive ability and academic achievement in order to rule out a possible learning disability. ADHD cannot be diagnosed accurately just from brief office observations or  simply by talking to the person. The person may not always exhibit the symptoms of ADHD during the office visit, and the diagnostician needs to take a thorough history of the individual’s life. A diagnosis of ADHD must include consideration of the possible presence of co-occurring conditions.

Clinical guidelines for a diagnosis of ADHD are provided by the American Psychiatric Association in the diagnostic manual Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 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 currently apply to the adult and if they have been present in childhood. In making the diagnosis, adults should have at least five of the symptoms present. These symptoms can change over time, so adults may fit different presentations from when they were children.

The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.

ADHD predominantly inattentive presentation

ADHD predominantly hyperactive-impulsive presentation

ADHD combined presentation

These symptoms can change over time, so adults may fit different presentations from when they were children.

A diagnosis of ADHD 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 areas of life, such as home, school or work; with friends or relatives; or in other activities. It is possible to meet diagnostic criteria for ADHD 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.

Several of the symptoms must have been present prior to age 12. This generally requires corroboration by a parent or some other informant. 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 ADHD. Impairment refers to how ADHD interferes with an individual’s life. Examples of impairment include losing a job because of ADHD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending, failure to pay bills in a timely manner or being put on academic probation in college due to failing grades. If the individual exhibits a number of ADHD symptoms but they do not cause significant impairment, s/he may not meet the criteria to be diagnosed with ADHD as a clinical disorder.

Internet self-rating scales

There are many Internet sites about ADHD that offer various types of questionnaires and lists of symptoms. Most of these questionnaires are not standardized or scientifically validated and should not be used to self-diagnose or to diagnose others with ADHD. A valid diagnosis can only be provided by a qualified, licensed professional.

Who is qualified to diagnose ADHD?

For adults, an ADHD diagnostic evaluation should be conducted 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 is chosen, it is important to ask about their training and experience in working with adults with ADHD. Many times the professional’s level of knowledge and expertise about adult ADHD 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 ADHD. 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 ADHD?

Ask your personal physician for a referral to a health care professional in your community who is qualified to perform ADHD evaluations for adults. It may also be helpful to call a local university-based hospital, a medical school or a graduate school in psychology for recommendations. If there is an ADHD 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. Most insurance plans list professionals by specialty and can assist those who participate in their plans to find a health care professional. Finally, there are many internet sites that list providers of ADHD services, including CHADD’s professional directory.

How do I know if I need an evaluation for ADHD?

Most adults who seek an evaluation for ADHD experience significant problems in one or more areas of living. The following are some of the most common problems:

A qualified professional can determine if these problems are due to ADHD, some other cause or a combination of causes. Although some ADHD 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 ADHD 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 ADHD 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 ADHD. This is normal and should not stop anyone from seeking an evaluation if s/he is having significant problems in life and ADHD is suspected. Unfortunately, some of the common misconceptions about ADHD, such as “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 spouse or other family member who can 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-5 symptom checklists, standardized behavior rating scales for ADHD and other types of psychometric testing as deemed necessary by the clinician. These are discussed in more detail below.

The diagnostic interview: ADHD symptoms

The single most important part of a comprehensive ADHD evaluation is a structured or semi-structured interview, which provides a detailed history of the individual. 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. The clinician covers a broad range of topics, discusses relevant issues in detail and asks follow-up questions to ensure that all areas of interest are covered. The examiner will review the diagnostic criteria for ADHD 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 ADHD symptoms are interfering with the individual’s life.

The diagnostic interview: screening for other psychiatric disorders

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

The examiner is also likely to ask questions about the person’s history of health, development going back to early childhood, academic and work experience, driving history, drug and alcohol abuse, family and/or marital life and social history. The examiner will look for patterns that are typical in individuals with ADHD and also try to determine if factors other than ADHD may be causing symptoms that look like ADHD.

Participation of loved ones

It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, parent or 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 ADHD 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 ADHD profile describing childhood behavior.

Many adults with ADHD may also have a limited awareness of how ADHD-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 ADHD symptoms. This procedure helps the non-ADHD spouse or partner develop an accurate understanding and an empathetic attitude concerning the impact of ADHD symptoms on the relationship, setting the stage for improving the relationship after the diagnostic process has been completed. If it is not possible to interview the loved ones, having them fill out checklists of symptoms is a good alternative.

Many adults with ADHD may feel deeply frustrated and embarrassed by the ongoing problems caused by the disorder. 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 can include one or more standardized behavior rating scales. These questionnaires use research comparing behaviors of people with ADHD to those of people without ADHD. 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.

Additional 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 ADHD directly but can provide important information about ways in which ADHD 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, such as thyroid problems and seizure disorders, can cause symptoms that resemble ADHD symptoms. A medical examination does not confirm ADHD but is extremely important in helping to rule out other conditions or problems.

Concluding the evaluation

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 ADHD 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. Afterward, the clinician will communicate with the individual’s primary care providers, as deemed necessary.

ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 years or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the …………………………

Reference

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.

For more information

Barkley, RA. (2014). Attention-deficit hyperactivity disorder, fourth edition: A handbook for diagnosis and treatment. New York, NY: Guilford Press.

Wolraich, M. & DuPaul, G. (2010). ADHD diagnosis and management: A practical guide for the clinic and the classroom. Baltimore, MD: Brooks Publishing.

Centers for Disease Control and Prevention (CDC). Attention-Deficit/Hyperactivity Disorder.     www.cdc.gov/ncbddd/adhd/diagnosis.html 

]

Women and Girls

Knowledge of ADHD in women at this time is extremely limited as few studies have been conducted on this population. Women have only recently begun to be diagnosed and treated for ADHD, and today, most of what we know about this population is based on the clinical experience of mental health professionals who have specialized in treating women.

Impact of ADHD in women

ADHD in young girls is often overlooked, the reasons for which remain unclear, and many females are not diagnosed until they are adults. Frequently, a woman comes to recognize her own ADHD after one of her children has received a diagnosis. As she learns more about ADHD, she begins to see many similar patterns in herself.

Some women seek treatment for ADHD because their lives are out of control―their finances may be in chaos; their paperwork and record-keeping are often poorly managed; they may struggle unsuccessfully to keep up with the demands of their jobs; and they may feel even less able to keep up with the daily tasks of meals, laundry and life management. Other women are more successful in hiding their ADHD, struggling valiantly to keep up with increasingly difficult demands by working into the night and spending their free time trying to “get organized.” But whether a woman’s life is clearly in chaos or whether she is able to hide her struggles, she often describes herself as feeling overwhelmed and exhausted.

While research of ADHD in women continues to lag behind that in adult males, many clinicians are finding significant concerns and co-existing conditions in women with ADHD. Compulsive overeating, alcohol abuse and chronic sleep deprivation may be present in women with ADHD.

Women with ADHD often experience dysphoria (unpleasant mood), major depression and anxiety disorders, with rates of depressive and anxiety disorders similar to those in men with ADHD. However, women with ADHD appear to experience more psychological distress and have lower self-image than men with ADHD.

Compared to women without ADHD, women diagnosed with ADHD in adulthood are more likely to have depressive symptoms, are more stressed and anxious, have more external locus of control (tendency to attribute success and difficulties to external factors such as chance), have lower self-esteem and are engaged more in coping strategies that are emotion-oriented (use self-protective measures to reduce stress) than task-oriented (take action to solve problems).

Studies show that ADHD in a family member causes stress for the entire family. However, stress levels may be higher for women than men because they bear more responsibility for home and children. In addition, recent research suggests that husbands of women with ADHD are less tolerant of their spouse’s ADHD patterns than wives of men with ADHD. Chronic stress takes its toll on women with ADHD, affecting them both physically and psychologically. Women who suffer chronic stress like that associated with ADHD are more at risk for diseases related to chronic stress such as fibromyalgia.

Thus, it is becoming increasingly clear that the lack of appropriate identification and treatment of ADHD in women is a significant public health concern.

The challenge of receiving appropriate treatment

ADHD is a condition that affects multiple aspects of mood, cognitive abilities, behaviors, and daily life. Effective treatment for ADHD in adult women may involve a multimodal approach that includes medication, psychotherapy, stress management, as well as ADHD coaching and/or professional organizing.

Even those women fortunate enough to receive an accurate ADHD diagnosis often face the subsequent challenge of finding a professional who can provide appropriate treatment. There are very few clinicians experienced in treating adult ADHD and even fewer who are familiar with the unique issues faced by women with ADHD. As a result, most clinicians use standard psychotherapeutic approaches. Although these approaches can be helpful in providing insight into emotional and interpersonal issues, they do not help a woman with ADHD learn to better manage her ADHD on a daily basis or learn strategies to lead a more productive and satisfying life.

ADHD-focused therapies are being developed to address a broad range of issues including self-esteem, interpersonal and family issues, daily health habits, daily stress level, and life management skills. Such interventions are often referred to as “neurocognitive psychotherapy,” which combines cognitive behavior therapy with cognitive rehabilitation techniques. Cognitive behavior therapy focuses on the psychological issues of ADHD (for example, self-esteem, self-acceptance, self-blame) while the cognitive rehabilitation approach focuses on life management skills for improving cognitive functions (remembering, reasoning, understanding, problem solving, evaluating, and using judgment), learning compensatory strategies, and restructuring the environment.

Medication management in women with ADHD

Medication issues are often more complicated for women with ADHD than for men. Any medication approach needs to take into consideration all aspects of the woman’s life, including the treatment of coexisting conditions. Women with ADHD are more likely to suffer from coexisting anxiety and/or depression as well as a range of other conditions including learning disabilities. Since alcohol and drug use disorders are common in women with ADHD and may be present at an early age, a careful history of substance use is important.

Medication may be further complicated by hormone fluctuations across the menstrual cycle and across the lifespan (e.g., puberty, perimenopause, and menopause) with an increase in ADHD symptoms whenever estrogen levels fall. In some cases, hormone replacement may need to be integrated into the medication regimen used to treat ADHD.

For more information on medication management in adults with ADHD, see Medication Management.

Other treatment approaches

Women with ADHD may benefit from one or more of the following treatment approaches:

  1. Parent training. In most families, the primary parent is the mother. Mothers are expected to be the household and family manager—roles that require focus, organization and planning, as well as the ability to juggle multiple responsibilities. ADHD, however, typically interferes with these abilities, making the job of mother much more difficult for women with ADHD.

Furthermore, because ADHD is hereditary, a woman with ADHD is more likely than a woman without the disorder to have a child with ADHD, further increasing her parenting challenges. Women may need training in parenting and household management geared toward adults with ADHD. The evidence-based parent management programs found to be effective in children with ADHD are also recommended for parents with ADHD. However, research on these parent training approaches has indicated that parent training may be less effective if the mother has high levels of ADHD symptoms. Thus, it may be necessary to incorporate adult ADHD life management strategies into parent training programs for mothers with ADHD.

  1. Group therapy. Social problems for females with ADHD develop early and appear to increase with age. Women with ADHD have greater self-esteem problems than men with ADHD, and often feel shame when comparing themselves to women without ADHD. Because many women with ADHD feel shame and rejection, psychotherapy groups specifically designed for women with ADHD may provide a therapeutic experience―a place where they can feel understood and accepted by other women and a safe place to begin their journey toward accepting themselves more and learning to better manage their lives.
  2. ADHD coaching.ADHD coaching, a new profession, has developed in response to the need among some adults with ADHD for structure, support and focus. Coaching often takes place by telephone or e-mail. For more information on coaching, see Coaching.
  3. Professional organizing. As contemporary lives have become increasingly complicated, the organizer profession has grown to meet the demand. Women with ADHD typically struggle with very high levels of disorganization in many areas of their lives. Some women are able to maintain organization at work, but at the expense of an organized home. For others, disorganization is widespread, which increases the challenges and difficulties of ADHD. A professional organizer can provide hands-on assistance in sorting, discarding, filing, and storing items in a home or office, helping to set up systems that are easier to maintain. For more information on organization, see Organizing and Time Management.
  4. Career guidance. Just as women with ADHD may need specific guidance as a parent with ADHD, they may also greatly benefit from career guidance, which can help them take advantage of their strengths and minimize the impact of ADHD on workplace performance. Many professional and office jobs involve the very tasks and responsibilities that are most challenging for a person with ADHD, including paying attention to detail, scheduling, paperwork, and maintaining an organized workspace. Sometimes a career or job change is necessary to reduce the intense daily stress often experienced in the workplace by most individuals with ADHD. A career counselor who is familiar with ADHD can provide very valuable guidance. For more information, see Workplace Issues.

Ways that women with ADHD can help themselves

It is helpful for a women with ADHD to work initially with a professional to develop better life and stress management strategies. However, the following strategies can be used at home, without the guidance of a therapist, coach or organizer to reduce the impact of ADHD:

Individuals with ADHD have different needs and challenges, depending on their gender, age and environment. Unrecognized and untreated, ADHD may have substantial mental health and education implications. It is important that women with ADHD receive an accurate diagnosis that addresses both symptoms and other important issues with functioning and impairment, which will help determine appropriate treatment and strategies for the individual woman with ADHD.