Diagnosing ADHD

It's a complex condition, so how do you diagnose it?...
18 May 2021

Interview with 

Tony Lloyd, ADHD Foundation

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For the people who have it, ADHD, attention deficit hyperactivity disorder, can potentially be a tough thing to deal with. But how do they find out they have it in the first place? What does the diagnostic process look like for ADHD? Chris Smith spoke to Tony Lloyd, Chief Executive of the ADHD Foundation...

Tony - Well in children, what we tend to look at is three core characteristics, which are: inattention (poor memory, inability to maintain concentration, forgetfulness, mind wandering), impulsivity, and sometimes, but not always, hyperactivity. Now these are natural characteristics that appear in all children, aren't they? What constitutes a diagnosis of ADHD is when these characteristics appear in a more extreme form. But increasingly clinicians also look at two other things, which are: low emotional resilience, that inclines towards anxiety and depression; and also what we call 'poor executive functioning skills', which is the ability to manage distractibility and maintain focus in terms of organising your thoughts, emotions, and how you might factor all those things in with how you choose to respond to your environment or not. So with children, we use a whole range of rating scales, but increasingly we're using computer-based cognitive functioning tests such as QB tests, which are over 80% reliable. And they tell us about cognitive functioning, whereas the behavioural rating scales tell us about what the observable presentation is, and that can differ according to context. We know that obviously children with ADHD are going to struggle much more in a school classroom than they are playing out on the playground. So context and environment are really important in terms of how we discern how ADHD is actually impacting on the child.

Chris - And what about when someone presents later in their life? We've been hearing about Adam's experience - would you use the same sorts of criteria? Or do you tend to approach this differently in adults?

Tony - No, we approach with the same rigorous criteria. We use QB testing, and my understanding is that it is going to be implemented by NHS England across the country as part of a national strategy within a couple of years, because it provides that quantitative, objective measure of cognitive functioning. I think what we've got to remember here is that ADHD is significantly underdiagnosed in the UK. The World Health Organisation says that prevalence should be in the region of about 5.26%, but we know in the UK that diagnostic rates are well below 3% and that use of medication is actually below 1%. We are seeing an increasing number of adults coming forward now because ADHD is less stigmatised, people have a better understanding of it, it's not some stereotypical idea about 'naughty children', which is incredibly unhelpful. And people don't understand that ADHD also correlates - undiagnosed or unmanaged ADHD - with anxiety, depression, eating disorders, obsessive compulsive disorder, things like that. So we see people presenting with other mental health conditions, and that's when often we arrive at ADHD as an underlying cause.

Chris - And that could be a giveaway. Yes, indeed. Now given how common this is - I mean, 5% is a lot of people - is it actually becoming more common, or are we just better at picking it up? Where previously we may have ignored it, or not put people in a position where it would have manifested itself the way it is. Or is something else changing?

Tony - One - we're much better at picking it up, and there's less stigma attached to it. And also we're seeing research now that's suggesting that every graduate with ADHD is twice as likely to start their own business; that over 30% of business owners have either ADHD or dyslexia or both. I think we need to understand ADHD in the context of a neurodiverse paradigm: where you have dyslexia, which affects approximately one in ten people; autism, approximately one in fifty; dyspraxia, approximately one in twenty; and ADHD, one in 20; but these things rarely travel alone. 

Chris - You mentioned there's a genetic link there. So does this mean if you see a child manifesting this, one perhaps ought to consider the parents as well? Because they may well also have this, and be like Adam and not realise, and may be able to explain some aspects of their lives on the basis of that.

Tony - Yes, ADHD is over 80% genetic - we're certain. We know that traumatic brain injury, which can be caused by premature birth for example, or traumatic birth, or head injury, can be a cause of ADHD. But for the most part it's genetic, so there's usually some family history. But that doesn't mean to say that either or both parents might have ADHD. We do know that there is an increased prevalence of ADHD with parents who conceive children in their late thirties, or an increased prevalence where parents have had children who've been born preterm; but yes, there's usually a family history of some neurodevelopmental condition, whether it's dyslexia, autism spectrum, ADHD, or dyspraxia.

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