Diagnostic Challenge 1: Looking into the Past
The retrospective analysis of ADHD using historical data
Even though someone might not receive an ADHD diagnosis until they are an adult, it is a disorder that begins in childhood. Although it may not have been noticed or identified during childhood, historical evidence must provide confirmation that the symptoms were present prior to age 12.
The diagnostic symptoms for ADHD are the same for children and adults. However, adults do not need as many symptoms as children (five as opposed to six for the relevant subtype of ADHD). Children and adult behavioral symptoms are expressed differently across different developmental age groups. We have previously reviewed behavioral examples of these symptoms for adults. For information about other age groups, please see our companion article about ADHD in children.
The diagnosis of adult ADHD is a complex process. One reason for this complexity is the need to gather accurate historical information. This can prove to be quite tedious and challenging. The length of time between age 12 and an adult's diagnostic assessment is often 15 years or more. Most of us would have trouble accurately recalling life events that long ago. Moreover, school records are rarely stored that long. This makes the assessment process fraught with difficulty as accurate and complete information is necessary for a proper diagnosis.
A further complication is that most clinicians work with either children or adults, but typically not both. Therefore, clinicians who work primarily with adults may be less familiar with the diagnostic indicators of mental and emotional disorders in children. If adult ADHD is suspected, it is especially helpful to try to locate a mental health professional that specializes in Adult ADHD. American Psychological Association offers an excellent psychologist locator system that allows you to search for age groups served. CHADD (the National Resource on ADHD) also has a provider search system that is helpful under the Advanced Search. Please see the Reference and Resource section LINK for more information.
Like the assessment of children, adults benefit from a multi-source assessment. This means information should be gathered from as many valid sources as possible. This may include school records; employment history; and interviews with people familiar with the person being assessed. It is particularly important to be able to interview people who were familiar with the assessed person during childhood. Naturally, parents or other caregivers are a logical choice. However, such persons may be deceased, or estranged, by the time the assessment is performed. This adds another layer of complexity to the assessment process.
To diagnose adult ADHD, clinicians must first verify the presence of ADHD symptoms in childhood. This is done by interviews, questionnaires, and a review of available records. The questionnaires may be given to the adult being assessed; to the parents or other adults who knew the assessed person as a child; and, any other significant adult during that person's childhood. Whenever possible, school records are reviewed.
When reviewing these documents, the clinician is looking for diagnostic clues such as: behavioral problems, poor focus, lack of effort, or underachievement relative to ability. If possible, a clinician might also ask to obtain a developmental history by interviewing the parents or other caregivers of the assessed person. This developmental history provides valuable, detailed information about home, family life, and childhood development. A developmental history consistent with ADHD would include evidence of social, emotional, and other developmental problems. This might include problems with peers; school failures or excessive discipline; and, unusual interventions such as being made to sit in the front of the class, or needing extra time to complete tests, etc. Likewise, unusual disciplinary measures would be evaluated. In the past, shaming techniques were used to discipline underachievement, or non-conformity. These methods have proven to be harmful, not helpful. Keep in mind, these types of childhood events could point to several different childhood disorders. However, a skilled clinician is able to sort it out.
A family history of ADHD is also informative, given the strong genetic component of the disorder. Researchers believe that ADHD is caused by roughly 75% genetic influences (Sarkis, S. 2013). Once again, the clinician is looking for any clues or signs of ADHD symptoms that may be been present during childhood. Since most adults cannot accurately remember childhood details, the information from an adult who knew the assessed person as a child is invaluable.