Both to diagnose ADHD and to rule out a diagnosis of ADHD require skillful history-taking. Let’s keep in mind that ADHD is diagnosed primarily by history and not by neuropsychological testing. On another page on this website, we’ll discuss the role and limitations of neuropsychological testing in patients with ADHD or suspected ADHD. But for now, I’m going to repeat for emphasis:
***ADHD is diagnosed primarily by history***
Also interview the patients’ parents and others who know them well.
This may seem obvious, but, in my experience, mental health clinicians, sometimes fail to systematically interview the parents and/or other family members. Unless the diagnosis of ADHD is clear-cut, interviewing family members and others is important for obtaining a childhood history consistent with a diagnosis of ADHD. Interviewing others who know the patient is also very useful for more recent history of ADHD symptoms, both in terms of getting new information and in verifying and clarifying what the patient told us.
How should we interview family members?
We can either invite the them in to be interviewed in person or speak to them on the phone.
Tip: In both cases, I usually have the patient in the room with me and if I am talking to the family on the phone, I put them on speakerphone. I do this for several reasons:
– It helps to make sure that we are all on the same page
– Any discrepancies between what the patient said and the family members say can be clarified by discussion
– Patients don’t feel that I am talking to the family behind their backs, and
– Interviewing the family is done during billable time rather than on my personal time. 🙂
Learn more about what we are looking for
To take a good history in the limited amount of time available in most clinical settings, we should know in detail about the clinical features of ADHD. If we are familiar in rich detail with how ADHD presents, we will be able to differentiate between cookie-cutter answers (e.g., “I can’t pay attention”) and a description that a person with ADHD will typically give. Unfortunately, most of us, like me, were taught little or nothing about ADHD during our residency training. In the future, I will try to make up for that by writing and lecturing in rich detail about the clinical features of ADHD. For our purpose here, I just want to give a couple of examples of what I mean when I say that we should learn more about what we are looking for.
For example, a typical adult patient with ADHD may say, “I don’t have a problem paying attention if its something I’m interested in. I stay up till 2 or 3 am watching YouTube videos or researching some stupid thing that seems interesting at that time. I know I should stop and go to sleep, but I just can’t stop.” As Andrew Nierenberg noted, the name of the disorder is a misnomer. The problem is not one of attention “deficit,” but of attention “dysregulation.”
By the way, have you heard of the “laugh sign?” I don’t know who first coined the term but it is well known to those with experience in evaluating persons with ADHD. If we ask the patient (and the informant), “Have you (has s/he) had a problem with procrastination?”, the patient or informant doesn’t just say “Yes,” they laugh and say something like, “You have no idea!” or “My family says I’m the Queen of Procrastination.”
While on the topic of procrastination, here’s a very important thing to understand: Persons with ADHD don’t have procrastination, they have paralysis (source unknown). Procrastination is knowing you should be doing something but putting it off because you don’t feel like it. We all do that to varying degrees. Persons with ADHD often do not want to put the thing off but for some reason just can’t get themselves to do it. Often, this is carried to a ridiculous extent and continues even if the person has come to various types of harms due to it (e.g., repeated stress, embarrassment, poor grades, losing jobs, etc.).
Some general principles
Avoid leading questions
Ask for examples
Write down in quotes exactly what the person says
It’s worth it! Sometimes, collecting detailed history from more than one person takes two or even three sessions, but, here is one of the principles of my clinical practice that I believe in very strongly
ANY amount of time spent clarifying the diagnosis is worth it in the long run.
Related Pages
How to screen all your patients for Adult ADHD
Why don’t we screen every patient for adult ADHD?
Stimulants in a person with a history of a substance use disorder?
References
Copyright 2019, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other lay persons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.
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