This post is in response to Do I "Wiki-Meet" Diagnostic Criteria for ADHD? by David D. Nowell

A recent blog asked for information about how clinicians might go about diagnosing Attention Deficit/Hyperactivity Disorder (ADD). Although I do not consider myself an expert on ADD (my professional expertise centers more on depression, anxiety, suicidal behavior and personality disorders in adults), I do regularly supervise doctoral students in conducting comprehensive assessments for college students who present to our university complaining of ADD-like symptoms and wondering if they should go on medication or if they could receive accommodations. Our assessment is comprehensive, including a semi-structured clinical interview (which I can send if you are interested), assessment of intellectual functioning (WAIS-IV), cognitive ability/processing (WJ-COG), academic achievement (WJ-ACH), and social and emotional functioning (BASC, MMPI-2), and in the case of an ADD referral, we generally give a Conners Self-Report, a Conners Observer Report, and sometimes a Continuous Processing Test.

Here are the five main points that we assess when making a diagnosis of ADD, listed in order of importance.

   1. History of Relevant Symptoms. ADD is defined by the DSM as a developmental cognitive/attention problem and symptoms should be present in several contexts and notable by the age of 7. So, we would expect to see clear evidence of long standing difficulties in the primary symptoms clusters. This is particularly so if the case involves hyperactivity, in that these symptoms are 'highly' visible and often cause overt problems. It is possible to understand that a relatively introverted individual with a high IQ got by in high school without coming to the attention of teachers or parents. Nevertheless, even here, the problems with distractibility, day-dreaming, procrastination, disorganization, etc. should have been evident for awhile. Obviously, a history of being diagnosed or treated for the condition is a strong indicator, although it is crucial to find out how the diagnosis was made. (A check list by a physician is not ideal!) 

    In a related vein, we track the emergence of current symptoms, and question the extent to which they are recent, tied to particular kinds of situations, and we work to rule out other explanations for inattention, like anxiety, low interest, etc. The most common "false" scenario that we see is an individual who is struggling with anxiety and depression regarding identity-relationship-developmental issues, who can't concentrate and believe that they must have ADD. We also see people who take the stimulants without a prescription, find it helps them study, and conclude they must have ADD.   

   2. Self and Observer Report of Symptoms, especially scores on standardized measures, taking into account the individual's motivation. We examine the scores on the BASC, Conners (Self and Other Report) to determine if the symptoms are in the clinical range, examine the profile (what else is elevated?), consider the correspondence between self and other scores, and the objective measures with clinical presentation and narrative. In examining these scores, we do try to take the mindset of the individual in to account (i.e., How motivated are they for the diagnosis? How much have they researched the issue on line? etc).

  3. Cognitive/Academic Profile--We look for variability in performance and low processing speed. There are two primary characteristics that we look for when examining the individual's cognitive/academic profile in considering the presence of ADD. First, one generally expects to see lower processing speed scores and lower academic fluency scores in individuals with ADD (anecdotally, this seems especially true of the inattentive type). Second, one expects to see a more varied profile, particularly on attention related tasks, such as the various working memory tests and following direction tests.

 4. Tests of Sustained Attention/Continuing Performance Tests/Tests of Executive Functioning. We sometimes give additional testing, if the results are ambiguous. Most common, we give the Conner's Continuous Performance Test. We also wills sometimes give the BRIEF, which is a questionnaire that gets at executive functioning.  

 5. Behavioral Observations. The test taking situation is unique and unusual, and thus behaviors such as distractibility, impulsivity, disorganized approach, excessive verbalization, etc. may not be present, but we certainly look carefully to see if they are. We monitor how many breaks the individual needs, if they notice things like the clicking of the clock, if they are fidgety, etc.

   I would be interested in hearing other's thoughts. ADD is all the rage these days and it certainly is not always easy to know where to draw the line on who has it and who does not (if that is even the right way to frame the question). I welcome comments, feedback or suggestions.

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