For ADHD and Many Other Mental Health or Neurobiological Conditions, the Clinical Judgment of the Diagnosing Physician or Psychologist is of Prime Consideration

By Cynthia Hammer, MSW, Executive Director, Inattentive ADHD Coalition, www.iadhd.org

The DSM-5 outlines specific criteria to help professionals diagnose [ADHD]. Having a standard set of symptoms to reference when assessing clients allows them to diagnose mental health concerns more accurately and, in turn, create a more effective care plan.

The words above, from the Very Well Mind website, with my substitution of "ADHD" for "general anxiety disorder," accurately convey where things stand in diagnosing mental health and neurobiological conditions. Lacking a test, an x-ray, or an MRI that informs the clinician to say yes or no, patients rely on the physician or psychologist's "clinical judgment," their experience, knowledge, and value system.

While one physician may determine you have ADHD, another may not. When an adult expresses frustration to be denied an ADHD diagnosis or to be diagnosed instead with depression or anxiety, we can only commiserate. Our only advice is, "Find another physician. Get a second opinion. If you think you have ADHD, don't give up."

In 1998, Dr. John Ratey, then Assistant Professor of Psychiatry at Harvard Medical School, and Catherine Johnson, Ph.D., a writer specializing in neuropsychiatry and the brain, co-authored the book Shadow Syndromes: The Mild Forms of Major Mental Disorders That Sabotage Us. Almost 25 years ago, based on his clinical practice and clinical research, Dr. Ratey believed that millions of people who attribute their daily life problems to bad parents, low self-esteem, or lack of willpower might be struggling with shadow syndromes.

He believed that chronic sadness, obsessiveness, outbursts of anger, inability to finish tasks, and disabling discomfort in social situations are mild forms of severe mental disorders. He called these milder forms Shadow Syndromes and understood that they could affect people's lives.

In a presentation in 2020 at an international conference on "ADHD and Comorbid Health Conditions across the Lifespan, Stephen Faraone, Ph.D., (President of the World Federation of

ADHD and Distinguished Professor, Department of Psychiatry and of Neuroscience and Physiology, The State University of New York Upstate Medical University) discussed subthreshold cases of ADHD (i.e., where patients had fewer symptoms of ADHD, perhaps 3 -4 instead of the five required for adults by the DSM-5 for an ADHD diagnosis.)

Although the research cited involved fewer than 500 children, the results were consistent.

Subthreshold ADHD looks very similar to full ADHD in many areas of dysfunction, for example, inattention, social problems, depression, and anxiety. In other words, subthreshold ADHD is a shadow syndrome of ADHD and warrants diagnosis and treatment. Dr. Faraone, however, cautions that a clinician needs carefully to evaluate if the adult with subthreshold ADHD demonstrates impairments in multiple settings before proceeding with a diagnosis.

Dr. Faraone explained the several reasons why adults with ADHD might more frequently present with subthreshold ADHD symptoms.

1. They are less likely to recall their ADHD behaviors, and reports from outside observers are unavailable.

2. Symptoms of ADHD typically attenuate over time (or adults learn to mask their ADHD behaviors), so adult ADHD usually displays fewer symptoms than childhood ADHD.

3. They could have grown up in supportive environments with scaffolding for their ADHD challenges so they were unaware of ADHD challenges earlier in their lives.

4. They could have self-medicated with alcohol or other substances and wrongly attributed their life problems to substance abuse.

5. An adult could have subthreshold symptoms in both the inattentive presentation and the hyperactive-impulsive presentation, which aggregate too many more than five ADHD symptoms but still not meet the criteria for an ADHD diagnosis.

6. The DSM-5 lacks criteria for emotional regulation and executive dysfunction, which are starting to be recognized as core elements of ADHD. Adults with ADHD could have challenges in these areas, but the clinician would not include these challenges when evaluating the existence of ADHD.

Conclusion: If you are an adult who believes he has ADHD and has been denied an ADHD diagnosis or were diagnosed instead with depression or anxiety, I urge you. "Find another physician. Get a second opinion. If you think you have ADHD, don't give up." Find a clinician who understands that adults with ADHD often present with subthreshold symptoms.

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