Attention-deficit hyperactivity disorder (ADHD) is a condition that develops during childhood and affects 6–10 per cent of children and 2–6 per cent of adults.
People with ADHD may present with predominantly inattentive symptoms, such as difficulty concentrating, predominantly hyperactive and impulsive symptoms, such as speaking or acting without thinking, or a combination of both.
Two individuals with ADHD can have very different symptoms and experiences, making it essential for clinicians diagnosing the condition to have the appropriate knowledge and expertise.
However, our new research found that half of psychologists who assess for ADHD do not follow established diagnostic guidelines or criteria.
This means that less typical presentations of ADHD — including those seen in women and girls, quiet inattentive adults, and high-achieving students — may be overlooked.
How is ADHD diagnosed?
ADHD is currently diagnosed by a psychologist, psychiatrist, or paediatrician, while in Queensland, general practitioners are also authorised to diagnose the condition, with more states and territories expected to follow.
The condition cannot be diagnosed through a blood test or any single measure. Instead, it requires careful consideration of multiple factors and information sources, alongside clinical judgement. Australia’s evidence-based practice guideline for ADHD, released in 2022, sets a clear standard for both assessment and treatment. It recommends that assessments include a comprehensive developmental, mental health, and medical history.
Medical evaluations are necessary to rule out other conditions that may resemble ADHD, such as sensory impairments, thyroid disorders, anaemia, or medication side effects. Clinicians must also take into account the broader social, psychological, and clinical context of the individual’s symptoms. This involves gathering input from multiple settings and sources, such as teachers and family members, rather than relying solely on questionnaires or direct observation.
Diagnosis should align with the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Diseases (ICD). These criteria require that symptoms are inconsistent with the person’s age, begin before the age of 12, and cause impairment across multiple settings, such as home, school, or work.
In practice, a comprehensive ADHD assessment typically involves detailed interviews with the individual and a family member to understand their history and current circumstances, a review of school reports, the use of questionnaires to clarify symptoms, and an investigation into any medical conditions that may be producing similar symptoms.
Our study
Our recent study analysed responses from 322 Australian psychologists involved in diagnosing and treating ADHD through an online questionnaire. The aim was to understand how they conduct assessments, whether their practices align with Australian guidelines, and how well they understand diagnostic criteria.
The study focused on psychologists due to the limited responses from psychiatrists and paediatricians, as well as the larger number of psychologists practising in this field. It relied on anonymous self-reported data, which helped reduce bias by encouraging participation beyond only the most confident clinicians and limiting the tendency to present oneself favourably. However, there remains the possibility that participants may not have accurately recalled their assessment practices or applied the same level of diligence as they would in clinical settings.
What we found
Although three in four psychologists reported that they always follow diagnostic guidelines, and others indicated they follow them at least some of the time, fewer than half actually described assessment practices that aligned with those guidelines. This suggests that individuals seeking an ADHD assessment should not rely solely on a clinician’s assurance and should instead ask detailed questions about the process involved.
While nearly all psychologists reported conducting client interviews and collecting developmental histories, only about three in four carried out a mental health assessment. Fewer than one in three assessed for other medical or psychological conditions, and none reported conducting sensory assessments. These gaps make it more difficult to identify alternative explanations for symptoms or to rule out other potential causes.
Further, when psychologists were asked to identify ADHD diagnostic criteria alongside an unrelated item from specific learning disorder criteria, fewer than one in three correctly identified all ADHD criteria while excluding the unrelated item. This is significant because ADHD does not necessarily involve academic difficulties, even though it is often associated with lower school performance. As a result, individuals who perform well academically but struggle in other areas of life may be overlooked.
Similarly, four in ten clinicians failed to recognise that symptoms must be inconsistent with a person’s age and developmental stage, raising the risk of incorrect diagnoses.
Overall, these inconsistencies increase the likelihood that individuals whose symptoms overlap with conditions such as anxiety, depression, trauma, sleep disorders, thyroid issues, sensory impairments, or learning disorders may either be misdiagnosed or miss out on appropriate support.
What should I look for if I’m seeking an assessment?
If you are concerned about ADHD symptoms in yourself or your child, it is important to consult a general practitioner to discuss available services in your area. Waiting times and costs for assessments can vary considerably, so it is advisable to compare options before proceeding.
For those considering medication, consultation with a paediatrician, psychiatrist, or, in some regions, a general practitioner is necessary, as psychologists are not authorised to prescribe medication.
To ensure a thorough and accurate assessment, individuals should familiarise themselves with established guidelines and ask clinicians about the specific steps involved before booking an evaluation. (The Conversation)
