What makes a good quality Adult ADHD assessment?

Attention Deficit Hyperactivity Disorder (ADHD) was historically considered a childhood condition. It is only in recent history have we acknowledged that the symptoms of ADHD persist into adulthood. This increased public awareness, alongside lockdowns enforced as part of the COVID-19 pandemic, which led to the worsening of symptoms for people with ADHD and increased burden on families, are thought to be some of the reason why there has been a significant increase in people seeking assessment and diagnosis of ADHD.

In keeping with marketplace trends, the increased demand for assessments has led to an increase in supply, as more and more practitioners offer ADHD assessments. However, this has led to reported variations in the quality of assessments provided.

So how do we know if an ADHD practitioner is competent? And what makes a good quality ADHD assessment?

Concerned with the above problem, members of the executive committee of UKAAN (UK Adult ADHD Network), which comprises of distinguished practitioners and researchers in the field of ADHD, have developed the Adult ADHD Quality Assurance Standard (AQAS). This is a quality assurance document that can be found via this link. The following summarises the key points of the AQAS document and is provided to help members of the public understand what makes a good Adult ADHD assessment.

A gold standard assessment

Social media and the Internet is awash with many ADHD ‘self-report tests’. It will come as no surprise that these are insufficient to diagnose a complex condition such as ADHD. The AQAS recommends the following.

• A semi-structured diagnostic interview that explores ADHD symptoms recognised by the Diagnostic Statistical Manual-5 or ICD-11. Certain tools such as the DIVA-5 (used by For-Psych) are recommended as a guide for practitioners.
• The interview should be open-ended and allow the person to freely speak. Tick-box or closed questions that require ‘yes / no’ answer are not sufficient.
• Rating scales or screening assessments can be a helpful starting point, but on their own are not sufficient for diagnosis.
• Examples should be sought of the person’s experience in relation to any identified traits. It is insufficient to say ‘I am impulsive’, a good practitioner will seek varied examples of how you are impulsive.
• The practitioner should screen or consider other neurodevelopmental or psychiatric disorders, as often symptoms can overlap.
• Information should be sought from other sources such as written documentation and / or people who know the person.
• A post-assessment discussion should take place to help the person make sense of findings and begin to think about future symptom management.

At For-Psych we quality assure our assessment process to ensure it meets these requirements.

What information should be in the report?

Every person who undertakes an assessment should receive a report outlining the findings. This is an important document because it helps the person further understand their experience of ADHD. It also becomes an important document if they access future services. Unfortunately, there are varying degrees in report quality. The AQAS recommends the following.

• The quality of the information in the report is more important than the length. However, there is an expectation that certain matters are addressed in the report.
• A summary of sources of information should be included, including any official records and informants.
• The symptoms identified as present and not present should be stated. This is usually depicted in ‘scores’ and should be accompanied with an explanation.
• A summary of any other potential neurodevelopmental or psychological conditions.
• A clear statement as to whether the diagnostic threshold for ADHD has been met.

In addition to this For-Psych make their reports as accessible and jargon-free as possible. We want the report to be a fair reflection of the assessment process, but also a useful aid to help develop a person’s insight into their experience of ADHD. We try to be concise and only provide necessary information. Long-winded reports can be as unhelpful as ‘tick-box’ reports!

How do I know if it is an ADHD trait?

ADHD symptoms are considered to be on a spectrum and can be present to a certain degree within the non-ADHD population. Most members of the general public will identify with at least one of the ADHD traits, so how do we know if it is an ADHD trait and not just something that most people experience? For example, most people will be forgetful at some point in their life, but if the forgetfulness was a daily occurrence at home, work, when socialising, and it caused the person distress and disruption over different periods of their life, then we know this person may be at the higher end of the ‘forgetfulness’ spectrum and there may be an underlying reason (such as ADHD). The key skill for the practitioner is judging the level of impairment. At For-Psych we follow a ‘3 P’s’ rule:

• Is the trait Problematic to the degree that is causes distress or disrupts the person’s life?
• Is the trait Persistent and present over time?
• Is the trait Pervasive and therefore present in different contexts of the person’s life (home, school, work, peers, hobbies)?

Only if the answer is ‘yes’ to these questions the practitioner can be more confident it is an ADHD trait.

How long should an assessment take?

There is no specific guidance on how long an ADHD assessment should take. However sufficient time needs to be allotted to allow all symptoms to be explored and for the person to fully describe their problems. The Royal College of Psychiatrists suggest in their good practice guidelines that two to three hours is reasonable. This seems consistent with what most practitioners report. At For-Psych we assume our assessments take a minimum of three hours and we will offer more time if necessary. We would be sceptical of any assessments that take under two hours.

How do I know if the practitioner is competent?

Psychiatrists, Psychologists and other healthcare professionals can assess and diagnose ADHD. Whilst the profession is important, the level of skill and knowledge of ADHD is also paramount. For example, some psychiatrists could diagnose ADHD, but because it is not their area of expertise they may not feel sufficiently skilled or knowledgeable to do so. The AQAS suggests that the practitioner should have several years of clinical practice and have an understanding of not just ADHD, but also the range of other mental health conditions (to enable differential diagnosis). In addition, the practitioner should be specifically trained to assess for ADHD and must undergo a period of post-training supervision.

At For-Psych our Psychologists are trained by the UK Adult ADHD Network (UKAAN, who authored the AQAS), and they undergo a period of supervised practice after their training to ensure competence. We see the impact that a diagnosis / misdiagnosis / no diagnosis can have and are committed to providing the best assessment and experience possible.