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I recently stumbled upon a quote that struck me: “The essence of verification is the convergence of multiple lines of reasoning at a singular point.” At the time, I thought that it was catchy and might come in handy one day. Then it dawned on me: “That’s exactly the approach that I use to diagnose ADHD.”
ADHD, or attention deficit hyperactivity disorder, is “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” (American Psychiatric Association, Diagnostic and Statistical Manual-5 (DSM-5))
The term has become so common that many people casually describe themselves or someone they know as having ADHD. However, an accurate diagnosis is not a simple process because a multitude of moods and behaviors can mimic ADHD. If misdiagnosed as ADHD, mood and behavior problems can be worsened by inappropriate use of medications most frequently used to treat ADHD.
Over years of testing clergy and religious during evaluation and treatment, I have identified a number of attributes to look for when a diagnosis of ADHD is under consideration. Most people who are accurately diagnosed with ADHD are positive on six or more of these.
1. They meet the DSM-5 criteria, with at least five of the nine characteristics described for either inattentiveness or hyperactivity/impulsivity (e.g., frequently being easily distracted, poor listeners, forgetful, difficulty organizing tasks, fidgety, impatient, excessively talkative, etc.).
They also meet three supplementary criteria: symptoms present as early as age 12, symptoms evident in multiple settings, and symptoms causing clinically significant impairment in interpersonal, academic or occupational functioning. However, an individual reporting he or she has all of these criteria does not mean conclusively that he or she has ADHD.
2. Adults who actually have ADHD are much more consistent in reporting the presence of ADHD-like symptoms across multiple symptom checklists than adults who report having ADHD-like symptoms, but subsequently are found not to have ADHD.
3. Individuals report a positive history of perinatal and/or early development risk factors (e.g., illnesses or injuries during mother’s pregnancy, birth complications such as breech birth, lack of oxygen, prematurity, mother drinking alcohol or smoking during pregnancy, etc.).
4. They are likely to identify one or more relatives as either having ADHD or displaying symptoms that suggests the likely presence of that disorder. ADHD is a highly heritable disorder that tends to run in families. A person with ADHD is likely to have a first-degree relative with ADHD. (van den Berg et al, American Journal of Medical Genetics)
5. They report having, or display, symptoms of psychiatric conditions (e.g., depression, anxiety, bipolar disorder, substance abuse, etc.) that tend to co-occur with ADHD. For example, 33 percent of individuals with ADHD also suffer from depression; 33 percent, anxiety; and 28 percent, impulse control disorder. (Abel, et al, Psychological Medicine)
6. Their histories are positive for medical conditions that tend to co-occur with ADHD, such as sleep apnea, thyroid conditions, restless leg syndrome, irritable bowel syndrome and multiple ear infections during early childhood.
In my experience, untreated sleep apnea can double the number and/or intensity of ADHD symptoms. Treating sleep apnea through consistent use of a CPAP machine has, in some cases, reduced ADHD-like symptoms by 50 percent.
7. Individuals report struggling with numerous problems indicative of executive dysfunction (i.e., with abilities that give organization and order to our actions and behavior, such as planning, prioritizing, initiating, inhibiting, shifting, completing tasks, etc.), even if they perform completely within normal limits on neurocognitive tests that assess executive functions.
8. They frequently display impaired performance on computerized continuous performance tests (CPTs) that assess the vigilance aspect of attention. Individuals with ADHD often demonstrate excessive variability, slower than normal response times and negative attention comparison scores on CPTs. ADHD may cause larger than normal shifts in attention from moment to moment, resulting in the marked fluctuations in response speed.
9. Individuals who know them well, and for a long time, report having observed numerous symptoms suggestive of ADHD.
10. When reflecting on moods and behaviors that were present during their childhood, adults with ADHD typically endorse many more ADHD-related symptoms than adults with no significant psychological or neurological problems and adults with major depression.
The likelihood an individual has ADHD is substantially increased when he or she is positive on six or more of these characteristics. However, other conditions such as major depression, bipolar disorder and sleep apnea, when untreated, can look very much like ADHD. In fact, in some cases, they can be completely indistinguishable. Thus, it is vitally important to identify and adequately treat such conditions, and then reassess for ADHD. If strong evidence of ADHD remains at that point, a firm diagnosis can be made with confidence.
Using multiple lines of reasoning as described above markedly reduces the likelihood of over- or under-diagnosing ADHD.
Gary Thompson, Ph.D., is a psychologist and coordinator of neuropsychological services at Saint Luke Institute.
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