What to expect: ADHD assessment

Assessments at the best of times can feel daunting, anxiety-provoking and perhaps overwhelming. We can all possibly feel under the microscope during assessments, which can feel uncomfortable and unsettling, at times. As a qualified ADHD and autism assessor, I am aware of the sensitivities of those attending assessments and have written the following, with the aim to clarify general expectations of ADHD assessments in particular and how you may best prepare.

What is ADHD?

ADHD is one of a group of neurodevelopmental disorders, identified by a consistent pattern of inattention and/or hyperactivity-impulsivity which interferes with functioning or development, as defined by criteria detailed in DSM-5 TR (American Psychiatric Association, 2013) and ICD-11 (World Health Organisation, 2021). DSM-5 TR is a manual compiled by psychiatrists and published in the USA, covering the currently recognised mental health disorders. ICD-11 is the European equivalent of the DSM-5 TR in the USA. Their respective contents can be accessed online.

How is ADHD diagnosed? 

Regarding the assessment and diagnosis of ADHD, there is no medical test that can definitively diagnose ADHD – no blood test, brain scan or known genetic markers. However, the current diagnostic gold standard for ADHD is a multimodal assessment across multiple domains of functioning of the individual, where any issues are identified regarding differential diagnosis. A differential diagnosis involves a systematic approach used by clinicians to identify the most likely cause of a patient's symptoms from a list of potential conditions. It involves considering various possibilities and ruling them out through further investigation, ultimately leading to a correct diagnosis and appropriate treatment plan. 

What happens at an ADHD assessment?

If a child is attending an ADHD assessment, pre-assessment information is gathered via appropriate questionnaires, which can help rule out other possible conditions, apart from ADHD. It is very helpful to gather information from the child’s school and parents, helping to formulate an opinion regarding whether a diagnosis of ADHD is relevant and, if so, which type may predominate, such as inattention or hyperactivity/impulsivity. The clinician would need to meet with the child for perhaps one to one and a half hours to ask the child further questions and to observe their behaviour.

When assessing an adult for ADHD, similar pre-assessment questionnaires can help evidence the likely appropriate diagnosis alongside meeting with the adult to undergo an ADHD questionnaire, addressing possible symptoms in adulthood over the last six months and in childhood from the ages of five to twelve years old.

After a child and adult assessment, the clinician would write a report and make their diagnosis clear. Recommendations for next steps would be made, such as whether therapy would be deemed helpful or other possible pathways to help the child or adult towards an improved quality of life.

DSM-5 criteria for ADHD diagnosis:

ADHD is diagnosable regarding the number of symptoms that are met from two main groups – inattention and hyperactivity/impulsivity. Regarding meeting the criteria for inattention, an individual needs to meet the following criteria:

• An individual may tend frequently to not pay close attention to details or may make careless mistakes I school and/or work.
• Additionally, the person may have difficulty holding attention on tasks or play activities, and/or does not appear to listen when spoken to directly.
• A further indicator of ADHD can be demonstrated when an individual does not follow through on instructions and does not finish schoolwork, chores, or tasks in the workplace.
• An individual may have trouble organising tasks and activities, or avoids, dislikes, or is reluctant to do tasks, requiring mental effort over a long period of time.
• Additionally, the person with potential ADHD tends to frequently lose items necessary for tasks and activities, can be easily distracted and forgetful in daily activities.

Regarding the second group, hyperactivity/impulsivity, the following criteria would need to be met:

• Where the individual fidgets with or taps their hands or feet or, for example, squirms in their seat.
• Individuals with hyperactivity/impulsivity would tend to leave their seats in situations when remaining seated is expected, such as at school or work.
• A further indicator of possible ADHD under the category of hyperactivity/impulsivity is when the person runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Individuals may be unable to play or take part in leisure activities quietly and are “on the go”, acting as if “driven by a motor”.
• People with ADHD tend to talk excessively and can blurt out an answer before a question has been completed. In this way, these individuals have trouble waiting their turn and interrupt or intrude on others.

In order for a diagnosis of ADHD to be met, the symptoms need to have been present prior to age 12 years. Additionally, symptoms need to have been present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). There needs to be clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. Importantly, the symptoms would not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood, anxiety, dissociation, personality, substance intoxication or withdrawal).

How can you best prepare for an ADHD assessment?

It may be helpful to make a few notes regarding when you think your child’s or your ADHD symptoms first emerged and what these were. A series of questions will be asked during the assessment, as indicated previously, and having ready information to share may help you to feel more in control and confident during the process. Since assessments can be quite intensive regarding answering the questions, it may be helpful to sleep and eat well before the assessment and take a bottle of water or other preferred drink with you. You may want a friend or relative to go with you and wait in a nearby café, to support you before and after the assessment.

The main purpose is for you to be yourself and answer the questions as openly and honestly as possible, to facilitate the assessing clinician to reach an accurate diagnosis. You may wish to ask the clinician when the report will be ready and whether this will be shared with you and your view gained on the content, with possible changes made for accuracy. I, for example, work collaboratively with all clients and like to send the ADHD report to them to check that I have represented what they shared with me accurately. Clients often request that I send a copy of the report to their GP, which I am happy to do with consent from the client.

Who receives an ADHD diagnosis?

It has been identified that Black, indigenous and people of colour children are underdiagnosed and undertreated compared to their white counterparts. Additionally, female children are underdiagnosed and undertreated compared to their male counterparts (Shi, Y., et al., 2021). These inequities in diagnoses have been attributed to:

• biases from teachers and clinicians
• related to stigma and structural racism
• linked to funding and policies that affect children. 

Working with a therapist or psychologist can offer personalised support for ADHD. If you’re considering an assessment, don't hesitate to reach out to professionals to see how they may be able to help you.