ADHD Assessments

The way that ADHD is noticed will also change in different settings, which can relate to how well an individual’s areas of need have been recognised and supported. Assessments of neurodivergence and of ADHD need to be sensitive enough to notice these individual differences in order to obtain an accurate and meaningful understanding of each person.

We are aware that the terminology used to describe ADHD can often be stigmatising and unhelpful. ADHD should not be viewed as a disorder, but as a difference that is valued and necessary within our communities. For the purpose of a diagnostic assessment, reference needs to be paid to the thresholds that have been set. However, as a community of clinicians, we strive to provide a neurodivergent affirming service. Our aims are to support individuals to develop compassionate awareness of themselves, to celebrate their strengths, and to support any areas of struggle. With awareness that preferred terminology changes over time, and also between people, we welcome all feedback on individual’s preferences or requirements.

The Diagnostic and Statistical Manual of Disorders (DSM-V) defines ADHD as “a neurodevelopmental condition characterised by a persistent pattern of inattention and/or hyperactivity-impulsivity which interferes with an individual’s functioning or development”. This means that the presence of these attentional differences needs to “reduce the quality of social, academic or occupational functioning” in order that a diagnostic threshold is met.

From a diagnostic point of view, ADHD has been categorised in three main ways.

One subtype is ‘hyperactive/impulsive’ and might be characterised by movement (e.g., fidgeting or tapping); difficulty sitting still; climbing or running when it’s not considered appropriate (in children) or feeling extreme restlessness (in adults); being ‘on the go’ or talking ‘excessively’; difficulty with conversational turn-taking (e.g., ‘blurting out’ or interrupting); difficulty waiting. Impulsivity may mean that someone takes action hastily, without thinking through the possible consequences. This might mean that they’re able to take risks and therefore succeed in a way that others would not, but could also mean that choices are made that cause difficulty or distress in an individual’s life (e.g., at school/work, or within their relationships).

Another subtype is ‘inattentive’ which might be characterised by difficulty giving close attention to tasks and details; struggling to sustain attention on tasks or play; finding it hard to listen when spoken to directly; difficulties following through on instructions or requests; trouble organising tasks and activities; reluctance towards tasks that require sustained mental engagement; often losing items of importance; easily distracted; described as forgetful during daily activities.

The third subtype is ‘combined’, which described a combination of the above two subtypes.

The difficulties and differences noted must be recognised across different settings, have been present for more than 6 months, and be having a detrimental impact on someone’s life in some way. Finally, the difficulties should not be able to be understood by other underlying causes. It may also be that the manifestation of someone’s differences might change over time, e.g., coming across as more hyperactive when younger, but seeming more inattentive as they age.

As previously noted, some of these descriptions can be unhelpful, or seem irrelevant. Often, the way in which someone describes their reality and aspects of their differences is key, which may be one of the reasons why so many people have related to individual accounts of ADHD on social media and recognised themselves in those accounts. For example, a person’s description of how they tend to live in the moment, and struggle to prioritise tasks with a deadline in the future. They might describe ‘needing the threat of an impending deadline’ to feel motivated enough to engage with the task. The difference between someone who struggles with motivation (and is neurotypical) and an individual with ADHD is likely to relate to how pervasive this experience is, and how it shows up in many contexts, regardless of how ‘useful’ or important engaging in the particular task might be to them.

It can also mean that necessary adaptations can be requested in particular environments (e.g., at school/work) in order to facilitate an individual’s coping or access.

This means that more people are seeking assessments in order to understand themselves or their family members and, for some, difficulties are being recognised earlier e.g., in school settings. We are aware that there is a ‘cohort effect’ where lots of adults have remained undiagnosed due to limited awareness when they were younger or at school, and because stereotypes prevailed (e.g., hyperactivity being understood as ‘naughtiness,’ or inattention being understood as ‘daydreaming’), leading to individuals being misunderstood.

From this we can discuss whether it sounds like an ADHD assessment would be useful, or if a different type of assessment might be indicated.

We would ask for questionnaires to be completed to inform this discussion.

If someone chooses to proceed, it would then be important to understand an individual’s history, to ascertain how longstanding the difficulties or differences have been and that they have not developed as a reaction to a life-event (e.g., a trauma, or illness). We would also seek information about their current lifestyle, mental health and social engagement to inform our understanding. To do this, we would use a particular diagnostic tool to guide the questions being asked.

As we need to understand how an individual’s differences or difficulties are noticed by others in other settings, it would also be helpful to talk to someone that has known the individual for a long time (e.g., parent, sibling or family member, long-term friend). Sometimes it can also be helpful to speak with a teacher, or trusted employer, to understand how someone manages in different settings. We would not seek any information without consent.

The individual would be asked to complete an assessment called a QBCheck, which is an online assessment that gives us additional information about attentional differences.

We would then pull all this information together and have a professionals’ meeting to reach an agreement as to whether a diagnostic threshold has been met.

Feedback would then be provided to the individual with recommendations made for any relevant further support.

A full diagnostic report would be written, for the purposes of evidencing the process.

There are therefore direct aspects of the assessment (e.g., talking with the individual) and indirect (e.g., screening questionnaires; gathering information from the individual’s network; liaising with other professionals; report writing in order to document a full and thorough assessment has taken place). The direct aspect of the assessment (e.g., initial discussion; full assessment interview) would take approximately 3 hours.

There is therefore no cure for it, and many people would choose not to change their ADHD even if they were given the choice, as it enables many positive and rewarding qualities and experiences.

‘Treatment’ can involve managing some of the impact of ADHD and could involve psychological therapy and/or medication. Our service does not have access to a psychiatrist, and we cannot therefore prescribe medication. Sometimes, following diagnosis, people seek a psychiatric review with a view to requesting medication, which would need to be sought and paid for separately from this diagnostic assessment. If this happened and medication was continued, a repeat prescription would require another psychiatric review appointment to ensure that the medication is still working as it should, and any other clinical changes are noted.

If someone wanted to move this care into the NHS, it would involve seeking a ‘Shared Care Agreement’ with their GP or local service. Some Commissioning Groups will not currently allow ‘Shared Care Agreements’ following a private assessment. Work is being done by psychiatrists to try and challenge this, and change may be possible in time. However, if you are likely to want medication via the NHS, please discuss local agreements with your GP, in advance of the diagnostic assessment, in order to make an informed decision.

However, a lot of misinformation still exists about neurodivergence. Whilst there are aspects of neurodivergence that are similar between people, no two people will be exactly the same. For this reason, when we assess people, we are careful about not making assumptions, and ensure that we take time to get to know each person, with awareness that ADHD presents differently for people due to gender, identity, culture and the social systems that they were raised within.

In addition to following national guidance as provided by NICE and UKAAN, we have liaised with several other professionals in putting our assessment pathway together, to ensure that we are following best practice and that there is no reason why our assessment outcomes would not be accepted.

If a task is interesting to an individual, sustaining attention may not be difficult for them. However, when a task is deemed taxing or mundane, sustaining attention on it will be very difficult. This can be really hard for an individual when the tasks are necessary for any reason.

Whilst diagnosing ADHD involves focusing on areas of difficulty, it is important to fully recognise that there are many benefits to having ADHD e.g., being able to ‘hyperfocus’ on areas of interest; being creative; being empathic and kind; being able to think ‘outside the box’ which can help to create new ideas, or to problem solve in a way that others could not; being able to be spontaneous; being able to learn through doing things differently.