How to Identify ADHD in Your Clinical Practice

Our understanding of attention-deficit/hyperactivity disorder (ADHD) has evolved significantly since symptoms were first identified around the 18th century (Abdelnour et al., 2022).



Now, we define ADHD as a neurodevelopmental disorder occurring in most cultures and impacting 5% of children and 2.5% of adults (American Psychiatric Association, 2013).



Yet, there is evidence that mental health professionals are still operating from an outdated understanding of the disorder.



The notion that ADHD is a diagnosis reserved for hyperactive, fidgety boys prevails. But research demonstrates that ADHD can present differently in adults, women, minorities, and even gifted individuals. Not only that, but ADHD is often concealed by comorbidities and symptoms that overlap with other disorders.



ADHD can lurk beneath the surface, wreaking havoc on a client’s life if we do not learn how to identify our biases and the often-overlooked symptoms of the disorder.



The Dangers of Misdiagnosis

With such robust and effective treatments available for ADHD, it would appear that the problem lies in accurate diagnosis.



Individuals with ADHD are impacted in a variety of areas, including but not limited to:

• Executive functioning
• Decision making
• Memory
• Emotional regulation
• Response inhibition



Untreated ADHD can lead to serious psychological, social, workplace or school, and behavioral problems. It can also lead to increases in depression, anxiety, and even suicide (Abdelnour et al., 2022).



A study of 1001 adults found that individuals with ADHD were more likely to be divorced (28%) than the neurotypical control group (15%). Another study found that individuals with ADHD earn $8,900-$15,400 less than other adults annually. Individuals with ADHD also engage in higher risk-taking behaviors resulting in greater car accidents and deaths (Katzman et al., 2017).



One study estimated 26% of incarcerated youth and 30% of incarcerated adults met criteria for ADHD (Young et al., 2015). Clearly, the number of incarcerated individuals with ADHD is much higher than in the general population.



There is also a relationship between ADHD and substance use disorders (SUD). Seventy percent of adolescents with ADHD also have a SUD. One reason may be that untreated ADHD leads people to self-medicate (Young et al., 2015).



Recognizing Adult ADHD

Many clinicians do not recognize adult ADHD due to an outdated belief that children “outgrow” it.



Nevertheless, evidence suggests that nearly 90% of children with ADHD carry the symptoms into adulthood. Furthermore, 75% of adults with ADHD were not diagnosed in childhood (Abdelbour et al., 2022).



Adult ADHD is a real and persistent problem. However, a 2006 U.S. National Survey found that 89% of adults with ADHD were not receiving treatment (Abdelbour et al., 2022).



It is essential that clinicians recognize adult ADHD as a real and treatable condition. But it’s also important to understand how symptoms of ADHD manifest differently in adults and children.



According to Katzman et al., (2017) common symptoms of ADHD in adulthood are:

• Lack of attention to detail
• Trouble relaxing
• Difficulty organizing tasks and activities
• Excessive fidgeting or talking
• Forgetfulness
• Overworking
• Distractibility



Another example of the differing presentations between adults and children can be found in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), Attention-Deficit/Hyperactivity Disorder Diagnostic Criteria A.2.C: “often runs or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)” (American Psychiatric Association, 2023, p.60).



This example also highlights the importance of considering how adults may develop compensatory behaviors as a result of living with untreated ADHD. These compensatory behaviors can “mask” the disorder and make detection even more difficult in adults (unless we know what to look for).



Why We Often Overlook Individuals with the Inattentive Subtype of ADHD

According to the DSM-V there are three subtypes of ADHD.



The inattentive subtype is characterized by lack of attention to detail or follow-through; difficulty remaining focused, listening, organizing tasks, or sustaining attention; difficulty with sustained mental effort; forgetfulness; and daydreaming (American Psychiatric Association, 2013).



The hyperactive subtype is characterized by fidgeting; difficulty sitting still; inappropriate motor activity; inability to play quietly or restlessness; excessive talking or blurting out; acting as if “driven by a motor”; interrupting; and difficulty waiting their turn (American Psychiatric Association, 2013).



The third subtype is a combined presentation.



Attention has been placed on the inattentive subtype as one that is often missed or misdiagnosed. One reason for this is because the inattentive subtype is more likely to be internalized, and therefore cause problems for the individual; whereas, the hyperactive subtype results in externalized behaviors that can cause difficulties in school and social settings.



Why ADHD is Underdiagnosed in Women and Girls

Studies have repeatedly indicated that women and girls are less likely to receive an ADHD diagnosis compared to boys and men.



One reason may be that according to the DSM-V, females are more likely than males to present with inattentive symptoms (American Psychiatric Association, 2013). Girls often internalize symptoms rather than causing outward disruption (Mullet & Rinn, 2015). Still girls with ADHD face higher intellectual impairment than boys, even though their behavior is less disruptive in the classroom (Ford-Jones, 2015).



Women and girls are also more likely to get diagnosed later in life. ADHD often does not present in girls until adolescence. This is in part because the inattentive subtype often does not cause clinical impairment until greater social and academic pressure is placed on girls (Cheng et al., 2022).



By the time women and girls do receive a formal diagnosis (if at all), they’ve likely developed more masking strategies to compensate for ADHD (Katzman et al, 2017). Women with ADHD often present with restlessness and rumination rather than outward hyperactivity.



Another reason girls and women are less likely to receive an ADHD diagnosis is empirical bias. Most of the research on ADHD was conducted on boys. As a result, early understandings of ADHD placed a strong emphasis on the hyperactive subtype.



Although the DSM-V now places equal importance on both inattentive and hyperactive subtypes, gender biases prevail. Therefore, women and girls (often presenting with the inattentive subtype) remain largely overlooked (Cheng et al., 2022).



However, as our understanding of ADHD in girls and women changes, so will diagnosis rates.



Since the DSM-IV ADHD symptom criteria shifted focus to include both hyperactivity and inattention, diagnosis in girls increased by a factor of 5.6 (compared to 3.7 in boys) between 1991 and 2008 (Abdelnou et al., 2022).



More research is needed to understand the impact of ADHD on women and girls (including how hormonal shifts related to menstruation and menopause impact ADHD symptoms).



Furthermore, the limited research we have reflects the experience of cis-genered women and girls. Further research is needed to understand how to diagnose and treat ADHD in transgender individuals.



How Racial Bias Contributes to Underdiagnosis in Minority Populations

Racial bias can also play a major role in the recognition of ADHD symptoms. Compared to white counterparts, the likelihood of receiving a diagnosis is 69% less likely for black individuals, 50% less likely for Latinos, and 46% less likely for those belonging to other ethnicities (Mullet & Rinn, 2015).



It is essential that clinicians check their racial biases in order to improve ADHD diagnosis rates in minority populations.



Common Co-Occurring Disorders with ADHD (and What to Look Out For)

The ability to accurately diagnose and treat ADHD is further complicated by comorbidity and overlapping diagnostic symptoms.



As many as 80% of adults with ADHD have at least one co-occurring disorder. According to the National Comorbidity Survey, adults with ADHD are twice as likely to develop a SUD, three times more likely to develop major depressive disorder, six times more likely to develop dysthymia, and four times more likely to have a mood disorder (Katzman et al., 2017).



The DSM-V also lists intermittent explosive disorder, personality disorders, OCD, and tic disorders as common comorbidities with ADHD (American Psychiatric Association, 2013).



Comorbidity is not isolated to adults. Seventy-five percent of children with ADHD have a co-occurring disorder. Those include oppositional defiant disorder, mood disorders, anxiety disorders, and learning disabilities (Mullet & Rinn, 2015).



There is also a 14% comorbidity rate between ADHD and Autism Spectrum Disorder (ASD). However, this coexistence was not recognized until the DSM-V update (Abdelbour et al., 2022). Now, a recognition of co-occurring ADHD and ASD has been coined “AuDHD.”



It is essential that clinicians understand ADHD comorbidities. If we overlook either ADHD or a co-occuring disorder, the clinical picture (and treatment) is incomplete.



The Gifted Child and ADHD: How Twice Exceptional Individuals Fall Between the Cracks

There is a great deal of overlap between ADHD and giftedness, including high activity levels, overexcitability, difficulties concentrating, and impulsivity. Children who are highly gifted may often be misdiagnosed as ADHD due to their propensity to hyper-focus and become easily bored (Mullet & Rinn, 2015).



Both children with ADHD and gifted children may struggle to concentrate in classroom settings; the gifted child due to boredom and lack of challenge; and the ADHD child due to distractibility and lack of stimulation. Therefore, it is essential for clinicians and teachers to understand the distinctions and overlap between the two.



Nevertheless, in two separate studies, both counselors-in-training and teachers were more likely to label students as ADHD rather than gifted (Mullet & Rinn, 2015).



It is also possible for someone to be both ADHD and gifted. Those with both are termed “twice exceptional” or “2E.” One study found that 10% of individuals with ADHD are 2E (Mullet & Rinn, 2015).



Mullet & Rinn (2015) see three outcomes often resulting in 2E children. First, their ADHD overshadows their giftedness, leading to average or below average performance. Second, their giftedness outshines their ADHD, allowing them to compensate for their ADHD. In the third scenario, both giftedness and ADHD may cancel each other out – leading both to remain undiscovered.



It’s important for clinicians to understand the unique struggles faced by these individuals. Just like with the recognition of co-occurring disorders, if either giftedness or ADHD is missed, the clinical picture is incomplete.



Caveats to Keep in Mind

By now, it’s clear that ADHD can present in a variety of ways when we factor in subtype, age, gender, ethnicity, and giftedness. We must also check for hidden signs of ADHD that can be masked by compensatory behaviors, co-occurring disorders, or symptoms that overlap with other disorders leading to misdiagnosis.



It is crucial that we check our biases and consider each individual on a case-by-case basis.



Research will continue to inform our understanding of how ADHD impacts individuals, especially those lesser understood such as women, minorities, transgender, and gifted individuals. Therefore, we must continue to seek education and consultation to ensure we do not overlook the often-misunderstood symptoms of ADHD.



Disclaimer

This blog post is for educational purposes only. It is not intended to be a standalone resource for diagnosing or treating mental health disorders. Always consult with state laws, ethics, treatment guidelines, evolving research, and diagnostic criteria.