“If You Finished College, Then You Can’t Have ADHD”

Are you pretty sure you might have ADHD but others say no way? Read this for guidance.

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Many adults eventually diagnosed with ADHD recall facing rebukes like the one in the title of this post when they first voiced the possibility that they had ADHD. This, after finally working up the courage to reach out for help, and probably having silently struggled for way too long.

Other such misguided ADHD brush-offs include, “You’re too smart to have ADHD,” “If you got into graduate school (or med school or law school, etc.), then you don’t have ADHD,” “You’re too successful to have ADHD," or “Everyone struggles with what you’re describing. You just need to deal with it.” This sampling does not even include questioning the validity of ADHD or commonplace accusations that the person is drug-seeking.

How ADHD difficulties operate behind the scenes

The main problems with such categorical snubbing of ADHD are that it is not supported by research^1,2 and it interferes with gaining an understanding of someone’s struggles that might not be apparent to observers, such as a student who hands in assignments on time or an employee who is insightful in meetings, both of whom by all accounts seem on top of things. Upon deeper inquiry, though, the student needs their parents sitting with them to be able to get through assignments (or they cheat out of desperation); the worker sacrifices family time and probably sleep, devoting inordinate time and effort outside of work to complete projects, which are still submitted late. In both cases, the work product is of high quality, but the processes required to complete it sap overall well-being and are unsustainable. Impairments eventually become visible but much later, perhaps only after an academic suspension or a formal performance improvement plan.

The need for thorough evaluations

To be fair to those who might doubt the possibility of ADHD in seemingly well-functioning adults, ADHD is difficult to make out and differentiate from other difficulties. Alternative explanations might seem more plausible at first, such as depression or anxiety, especially among behavioral health providers better trained to notice them and not trained to assess for ADHD.

In fact, ADHD-like difficulties might not stem from ADHD. The recommendation for a thorough evaluation for adult ADHD includes the fact that such evaluations are comprehensive and include assessment for other factors that could cause “attention problems” and other ADHD-like symptoms.

This discussion begs the question of what indeed constitutes an adequate evaluation for adult ADHD. There are highly competent ADHD assessment approaches, but an empirically-driven review provides a useful guide for competent, first-time evaluations of adult ADHD.³

• Structured diagnostic interview. A systematic review of each of the 18 symptoms of ADHD and other diagnostic criteria for ADHD (as defined by the DSM-5) is recommended to adequately establish their number, severity, and onset of symptoms, which helps differentiate issues such as “poor concentration” that also are symptoms of other conditions. The systematic reviews assess both current symptoms of ADHD and retrospective accounts of childhood onset of them.
• Informant ratings. Self-report questionnaires of childhood and adult ADHD symptoms are fixtures of the evaluation process. Such questionnaires often include other-ratings to be completed by individuals who know the person undergoing the evaluation to get their impressions, too. These observer-ratings both help consider evidence counter to ADHD, and pick up items that an individual with ADHD might miss or under-report. Symptoms on such scales are “endorsed” when rated as either “moderate” or “severe” or as occurring “very much” or “often/daily,” reflecting the uppermost end of the severity ratings.
• Impose “or rule." Discrepancies between self- and other-reports are managed with the “or rule”: If either the self-report or informant-report indicates the presence of a symptom, then it is counted in the overall tabulation. The disparities usually reflect symptom expression in different settings, such as an adult with ADHD noticing distractibility more at work than their partner sees at home.
• Establish impairment. Impairment is a necessary criterion for a diagnosis of any sort. There are standardized impairment ratings scales that provide objective, standardized documentation. Other examples of common ADHD concerns include poor work evaluations or underperformance, poor grades or academic probation, or relationship and family discord from the effects of ADHD.
• Assess symptom settings and timeline. Structured diagnostic interviews also assess the age-of-onset of at least “several” symptoms of ADHD and their relative persistence over time. The DSM-5 age-of-onset is symptom emergence by age 12 and present in at least two life domains (school, family, or peer relationships). The age-of-onset also helps differentiation from other possible conditions and onset and presence of conditions existing alongside ADHD.
• Rule out alternatives. Structured interviews and questionnaires are used to assess other DSM-5 diagnostic explanations for ADHD-like difficulties. This rule-out process can include medical referrals to assess for conditions that might cause ADHD-like symptoms, such as Lyme disease or sleep disorders.
• Finalize diagnosis. If supported by the evaluation data, a final diagnosis of ADHD includes a presentation designation: predominantly inattentive, predominantly hyperactive-impulsive, or combined presentation. Severity level is also rated (mild, moderate, or severe). For unclear cases in which the full criteria could not be established but for which there are prominent features of ADHD without a better explanation, the designation of Other Specified ADHD is used.

Co-existing diagnoses are documented alongside ADHD. When a diagnosis of ADHD is not supported, the diagnosis that better explains the symptoms is documented.

An adult ADHD evaluation helps trained clinicians assess suspected ADHD. The empirically-informed elements of this evaluation are as important for identifying previously undiagnosed ADHD as they are for clarity of diagnosis and treatment options when the issue is not ADHD. Either way, people can get validation and direction in terms of treatments and supports that help them get control of their lives and improve their well-being.