Hi – it’s Dr. Kenny Handelman here with the next edition of your ADHD Audio Newsletter (This is a transcription, please visit The ADHD Doctor to subscribe to the actual newsletter).

Last week we talked about the diagnostic criteria of ADHD coming from the question, “How do you know if you have ADHD?”

This week we’re going to pick up and talk about the assessment of ADHD because I think that this question requires more than one week.

To get the diagnosis you have to see a professional who is experienced in assessing and diagnosing Attention Deficit Hyperactivity Disorder.

First and foremost I want everyone to know there is no test for ADHD.

Brain Scans:

There is no blood test, there is no X-ray, no CT scan, no MRI, no PET scan, SPECT scan or anything.

Let’s go through brain imaging scans for ADHD. There have been research studies that have shown with brain imaging studies like MRI or PET scanning that there are brain differences in ADHD individuals. Now these are important research findings because we know that ADHD is a brain disorder, and these studies confirm that. Even though there are brain differences, having any one individual go for a brain scan would not necessarily show the findings. The reason is that when research studies are done, they show a population effect. In other words if you take 100 children or individuals with ADHD and compare them to 100 age matched controls you would see differences but any one individual may not show that difference. The way I view it is – it is not worth the exposure to radiation for the test unless you want to be part of a research trial.

Psychological Testing and Neuropsycholgical Testing

Psychological testing, or a psychoeducational assessment can be very helpful to look at learning strengths and weaknesses and intelligence. However, it does not diagnose ADHD. It may diagnose a learning disability or developmental delay.

There are some neuropsychological tests that look at aspects of neuropsychological functioning that may be impacted by ADHD, however they do not diagnose ADHD either. A full battery of these tests with a clinical interview may be helpful however there is a high false negative rate; at least 30% if not 50%. Now what is a false negative rate? This means that the result comes out false when it shouldn’t. In other words somebody has ADHD, they go through this testing and this testing shows that they don’t have ADHD. Now if you need a diagnosis of ADHD and you pay a lot of money to get a neuropsychological assessment and it says that there isn’t ADHD, when it is later diagnosed, that may be quite frustrating to you.

Neuropsychological testing may give you very important information which helps to understand what’s going on with the thinking and cognitive processes for the individual but it will not diagnose ADHD.

If there are no tests, how is ADHD actually diagnosed?

Well, we do it the old fashioned way. We ask questions.

ADHD is a clinical diagnosis, meaning it is made based on the clinical assessment (i.e. interview) and all of the information gathered. We do a thorough clinical interview and review all of the symptoms. It’s important to get reports from multiple sources. You’ll remember from last week that we wanted to have symptoms in multiple settings (at least two) – home and school in a child or teen, work in a teen/adult.

How do we get information from the other settings? It may be with an interview in person, a telephone interview, or at the most basic for a busy clinician is checklists from the school and parents for a child, or a spouse/partner for an adult. School report cards can be very helpful – and I generally ask all parents to bring in copies of old report cards, to see if there is a longstanding history. This is also helpful when assessing adults with ADHD. When reviewing report cards, I am looking mainly for comments, not necessarily marks. Report cards in kids with ADHD often say things like: ‘needs to put more effort into completing tasks next term’, or ‘needs to follow through next term’, or ‘although Michael has great social skills, he needs to talk less during class time’, etc. Observation of the individual in their natural environment is very helpful. It is often hard for a doctor to go to school or workplace to observe the behaviour as it is occurring, however this can be very useful information. Sometimes if a behavioural consultant is involved, he/she can do the observation.

The Mental Status Examination:

The mental status examination is an important part of the psychiatric assessment. It is the equivalent of the physical examination in other areas of medicine. The mental status examination is where the psychiatrist (or other clinician) reviews the mental state of the individual insofar as their behaviour, their eye contact, the way they speak, any motor movements noted (i.e. tics), their mood, how they describe their mood, how they interact with the individual, whether there are any thoughts of self harm (i.e. suicidal thoughts) or thoughts or harm to others, whether the individual has good insight into what is going on, whether they appear to have good judgment etc. So, instead of putting a stethoscope to the chest, the psychiatrist (or the psychologist, social worker, etc.) uses the mental status examination to assess the mental functioning. This is another important part of the assessment for ADHD.

After gathering all of the information it’s a matter of reviewing whether the individual meets the criteria of the DSM-IV TR for ADHD.

Next, one assesses for impairment. This means that the symptoms actually interfere with the individual’s functioning and changes their academic, social, and emotional development.

Criticisms of the Diagnosis of ADHD:

Now before we conclude on the issue of diagnosis of ADHD, some people criticize the process and say that it’s not as real as for many other medical conditions. For example if somebody has pneumonia they get an X-ray and it shows the pneumonia. Somebody has a broken bone you get an X-ray and see it. However, for ADHD, you can’t order tests, and so you ‘just talk about it’.

Critics of ADHD suggest that if you’re just talking about it, it must not be a real disorder, and the diagnosis must be ‘wishy-washy’.

The truth is that ADHD is a real disorder, with excellent research to back it up.

Let’s review the diagnostic process in all of medicine. Diagnosis in all areas of medicine boils down to one thing: pattern recognition.

The doctor is looking for a pattern of symptoms that fit together. When these symptoms fit together into a ‘diagnosis’, that is relevant because diagnoses help us to understand the current and future problems, which treatments may help, and what the prognosis may be.

Let’s talk about the diagnosis of pneumonia. Pneumonia isn’t just diagnosed with an X-ray. In fact pneumonia is diagnosed by thorough clinical interview and physical examination. This includes a history of how long the cough has been there, whether there was any fever, chills, sweats at night, etc. Was there colour to the sputum or the phlegm? Now the clinician listens to all this, assesses the patient, listens to their lungs, takes their temperature, their blood pressure etc., and then orders an X-ray. Now you would think this is very straightforward and there is tons of research on which antibiotics work for different pneumonias and how to treat it etc. etc.

Although the diagnosis of pneumonia seems very straight forward, I was amazed in my medical training when I stood in front of Chest X-rays with medical specialists trying to figure out if they truly confirmed the diagnosis. Sometimes the X-rays are very clear, and sometimes they just aren’t. In the end, the decision to treat with antibiotics was made in many cases based on the ‘old fashioned stuff’ – the history and physical examination.

Diagnosing a broken bone should be the most straightforward – you look at the X-rays. Is it broken or not broken? But what about some of the hairline fractures? It can get tricky. The point is that it ultimately comes down to history and physical examination and the clinician’s experience and understanding of the case.

To summarize, ADHD is a diagnosis which is made based on a clinical interview, and the other information gathered. There are no tests for it, however, with a well trained doctor, it is a very reliable diagnosis.

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