BBC Panorama 15 May 2023

1. This Panorama investigation provided examples of poor standards in the assessment and diagnosis of ADHD in the private sector and apparent failure to adhere to NICE guidance, which recommends the assessment be carried out by ‘a mental health specialist trained in the diagnosis and treatment of ADHD’. In particular, the assessment should include ‘a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person’s everyday life and a full developmental and psychiatric history and observer reports and assessment of the person’s mental state.’ 
2. Given that the psychometric instruments commonly used in such assessments were designed and constructed by clinical psychologists and that the taking of a full history and mental state examination are core skills of clinical psychologists, ACP-UK recommends that ADHD assessments should be conducted by clinical psychologists who specialise in this area. If stimulant medication is a likely treatment option, this would require the input of specialists who can prescribe and monitor this. However, ACP-UK also recommends that in accordance with NICE guidelines treatment is not confined to stimulant medication and that psychosocial interventions are always considered and included. Indeed, the NICE guidance makes it clear that environmental modifications should be the first line approach, with medication offered only if ADHD symptoms are causing significant impairment after these have been implemented and reviewed. 
3. In addition, knowledge and understanding of the strengths and limitations of self-report questionnaires and rating scales are essential in the competent interpretation of psychometric data to inform diagnosis. ACP-UK is concerned that there is a need for further consideration of the role of assessment of cognitive function rather than reliance solely on evaluation of self-reported symptom clusters which have overlapping association. It is important to recognise that adults seeking assessment may not have had any prior assessment of their cognitive functioning to consider the impact of possible intellectual disability or specific learning difficulties, and there may be limited historical educational information available. Whilst there is no current requirement for this, this is an evolving area of psychological research, and the addition of tailored cognitive assessment may improve the specificity of diagnosis over clinical interview and self-report and behaviour rating scales alone. It is important therefore that clinicians have the competence to assess, integrate and formulate across explanatory frameworks for the difficulties experienced not just to arrive at a reliable diagnosis, but also to guide tailored and effective support for the difficulties explained by the diagnosis and any co-existing difficulties. This will include the competence to consider existing cognitive assessment information and to decide if further cognitive assessment is indicated. 
4. ACP-UK also would draw attention to the clinical and healthcare context, in which burgeoning numbers are seeking an ADHD assessment and overwhelming limited NHS services. The reasons for this are complex but relate to increasing public awareness of neurodiverse conditions and worsening mental health in the general population following the pandemic. 

References

1. Attention deficit hyperactivity disorder: diagnosis and management. NICE Guideline (2019). https://www.nice.org.uk/guidance/ng87