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You’re right that there isn’t a _single_ “scientific” or purely objective test for ADHD. The consensus statements on ADHD make this explicit: diagnosis is clini

by ttul 1y ago

You’re right that there isn’t a _single_ “scientific” or purely objective test for ADHD. The consensus statements on ADHD make this explicit: diagnosis is clinical, not biomarker-based [1][2], even though biomarker tests are being developed and this is a promising area of research. That said, there are structured and semi-objective tools that add quantifiable data to the process, even if they can’t stand alone; and, these tools in combination reveal a very real condition that is also highly treatable once diagnosed: 1. Rating scales (e.g. Vanderbilt, CBCL) use structured questionnaires to quantify symptom frequency. They’re subjective (based on parent/teacher/patient report) but standardized. Many mental health conditions are assessed using standardized rating scales [3]. 2. Continuous Performance Tests (CPTs) and objective activity measures can quantify attention lapses and hyperactivity. They’re more “objective,” but consensus statements say they’re insufficient for diagnosis _in isolation_ [4]. I did a CPT test and it lit up for ADHD, which was helpful in ruling out other conditions. 3. Multi-informant reports (parents, teachers, patients) are required in good clinical practice to triangulate symptoms across contexts [5]. As I wrote in my first comment, ADHD exists only when the symptoms affect functioning in many areas of life. 4. Experimental methods (like neuroimaging or computerized neurocognitive tests) show promise but aren’t yet validated for clinical use [6]. The core of diagnosis remains a comprehensive clinical interview and history guided by DSM/ICD criteria. This is where “inter-rater variability” arises: different psychiatrists may weigh the same evidence differently. Consensus statements acknowledge this diagnostic variability, which is a limitation of current psychiatric nosology in general (not just ADHD). So to answer directly: no, there isn’t a single objective test. But there are quantifiable tools that support diagnosis. The diagnosis itself is still fundamentally consensus- and criteria-driven, not biologically “proven.” But this limitation is minor and is common in psychiatry where many real conditions are diagnosed using a combination of approaches because no single test exists (and may never). [1] Faraone, S. V., Asherson, P., Banaschewski, T., Biederman, J., Buitelaar, J. K., Ramos-Quiroga, J. A., Rohde, L. A., Sonuga-Barke, E. J., Tannock, R., & Franke, B. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789–818. https://doi.org/10.1016/j.neubiorev.2021.01.022 https://doi.org/10.1016/j.neubiorev.2021.01.022 [2] Kooij, J. J. S., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balázs, J., Thome, J., Dom, G., Kasper, S., & Nunes Filipe, C. (2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry, 56, 14–34. https://doi.org/10.1016/j.eurpsy.2018.11.001 https://doi.org/10.1016/j.eurpsy.2018.11.001 [3] Collett, B. R., Ohan, J. L., & Myers, K. M. (2003). Ten-Year Review of Rating Scales. V: Scales Assessing Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 42(9), 1015–1037. https://doi.org/10.1097/01.CHI.0000070245.24125.B6 https://doi.org/10.1097/01.CHI.0000070245.24125.B6 [4] Hall, C. L., Valentine, A. Z., Groom, M. J., Walker, G. M., Sayal, K., Daley, D., & Hollis, C. (2016). The clinical utility of the Continuous Performance Test and Objective Measures of Activity for diagnosing and monitoring ADHD in children: A systematic review. European Child & Adolescent Psychiatry, 25(7), 677–699. https://doi.org/10.1007/s00787-015-0798-x https://doi.org/10.1007/s00787-015-0798-x [5] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. [6] Cao, Q., Zang, Y., Sun, L., Sui, M., Long, X., Zou, Q., & Wang, Y. (2006). Abnormal neural activity in children with attention deficit hyperactivity disorder: A resting-state functional magnetic resonance imaging study. NeuroReport, 17(10), 1033–1036. https://doi.org/10.1097/01.wnr.0000224769.92454.5d https://doi.org/10.1097/01.wnr.0000224769.92454.5d

andoando 1y ago
1. Standardized is absolutely meaningless here. We can develop any set of symptoms, develop a standardized questionnaire, and have millions of people who meet it. 2. CPT measures attention/focus in an entirely made up lab scenario. Attention and focus are not singular numbers, and are deeply tied to the actual emotions, risks, rewards present in a situation, and cannot be so easily measured. I can see the value of a test that measures noticeable difference between two groups, but that says nothing about the cause of those differences, but simply that we can identify different groups of people. You may also very well be selecting here who are depressed, stressed, low energy, or simply people who see no point in spending energy on a completely meaningless task, etc. In any case, I do not believe the evidence of CPT in differentiation is well established. https://pubmed.ncbi.nlm.nih.gov/38317541/ https://pubmed.ncbi.nlm.nih.gov/38317541/ https://pubmed.ncbi.nlm.nih.gov/37800347/ https://pubmed.ncbi.nlm.nih.gov/37800347/ 3. Personal reports of another person's mental state is as subjective as you can get. All were selecting here is people who do not fit the defined, artificially built, educational or work systems. One may even be excellent, motivated student of music but all accounts fail in a classroom setting. >The core of diagnosis remains a comprehensive clinical interview and history guided by DSM/ICD criteria. Clinical interviews are guided, and their interpretation is subjective. DSM is as subjective as you can get. Every single on of the symptoms has the wording "Often", as decided by a person evaluating another person's account of their life. Do you have an objective measure of what "often" means?". More importantly, a collection of symptoms does not constitute a singular cause. By the admission of the DSM itself, two people with the diagnosis can share only 4 out of the 9 symptoms (me 1-6, you 3,9), meaning every single one of the symptoms has independent causes. How do you know one does not simply have 6 symptoms by caused by entirely different factors? In a population of hundreds of millions, its a guarantee. You could again, define random symptoms, give it a name and have millions of people going "Wow, no way, I meet all of this, I didnt know I have xyz!" Lastly, I find it really interesting is that the diagnosis of ADHD came far before we had any of this technology and research you point to. Why was it so popularly pushed and accepted then? Is it possible, were simply trying very hard to fit a completely socially agreed upon disorder?
- ttul 1y ago
  You've raised some common and valid criticisms of how ADHD is diagnosed. 1. On standardized scales being "meaningless": The term "standardized" here doesn't just mean a consistent set of questions. It means the scoring is normed against a large, representative population. So when a parent says their child "often" loses things, the scale helps a clinician determine if that "often" is statistically significant compared to other children of the same age and gender. It's a tool to quantify subjective reports. You're right that any set of symptoms can be standardized, but these scales are specifically designed to measure the frequency and severity of behaviors outlined in the DSM/ICD criteria. They aren't a standalone test, but one data point in a larger clinical picture. Most psychiatric conditions rely on this kind of structured self-reporting. The people working in this field work very hard to apply statistics properly when designing and running these tests; it's so far from random it's not even funny. 2. On CPTs: I agree that a CPT is an artificial lab scenario. That's a well-known limitation called a lack of "ecological validity." No one claims it perfectly replicates real-world focus. Consensus statements are clear that CPTs are insufficient for diagnosis on their own. Their value isn't in definitively saying "you have ADHD," but in providing an objective measure of things like attention lapses and impulse control that can supplement the subjective reports. If someone's self-report suggests severe inattention but they score perfectly on a CPT, that's a data point a clinician needs to investigate further. It can help in the process of differential diagnosis. The studies you linked highlight its limitations, which is consistent with the consensus view that it's a supplementary, not a primary, tool. 3. On multi-informant reports: You say these are "as subjective as you can get," which is true, they are subjective. The entire point is to gather subjective reports from multiple contexts to see if a pattern emerges. A core criterion for ADHD is that the symptoms cause impairment in two or more settings (e.g., home and school/work). If a child is only described as hyperactive and inattentive in a boring classroom but is a focused and motivated musician at home, a good clinician would question an ADHD diagnosis and look for other factors. The goal is to see if the problem is with the person's underlying regulation skills across environments, not just their "fit" in a single, artificial system. 4. On the DSM and clinical interviews: The word "often" is intentionally not given a hard number because it's relative to a person's developmental stage. "Often" losing homework is different for a 7-year-old than for a 30-year-old. This is where clinical judgment, guided by the DSM criteria, comes in. As for the symptom overlap, you're describing a feature of many polythetic diagnostic systems, not a flaw unique to ADHD. It recognizes that the disorder can manifest differently in different people. The clinician's job isn't just to count symptoms, but to assess the entire pattern, determine the level of impairment, and critically, rule out other potential causes for those symptoms (anxiety, depression, trauma, etc.). The diagnosis is a synthesis of all this information. Again, standardized test scoring DOES have the effect of giving a "definition" to the term "Often", because when thousands of forms are filled in, individuals' different definitions of the term converge in a statistically significant way onto a concept that is meaningfully comparative. 5. Finally, your historical point is interesting. Descriptions of ADHD-like symptoms date back centuries, long before the DSM. Sir Alexander Crichton wrote about "the incapacity of attending" in 1798. The diagnosis wasn't just invented out of thin air in the 20th century. It's a modern label for a pattern of behavior that has been observed for a very long time. The research and technology we have today are being used to better understand its neurobiological underpinnings, not to retroactively justify a "socially agreed upon disorder". I'm really curious what the next century of study will do to illuminate this condition. I suspect we will have significantly greater understanding of the role of genetics and perhaps, one day, a blood test will diagnose ADHD.

by ttul 1y ago

andoando 1y ago

1. Standardized is absolutely meaningless here. We can develop any set of symptoms, develop a standardized questionnaire, and have millions of people who meet it. 2. CPT measures attention/focus in an entirely made up lab scenario. Attention and focus are not singular numbers, and are deeply tied to the actual emotions, risks, rewards present in a situation, and cannot be so easily measured. I can see the value of a test that measures noticeable difference between two groups, but that says nothing about the cause of those differences, but simply that we can identify different groups of people. You may also very well be selecting here who are depressed, stressed, low energy, or simply people who see no point in spending energy on a completely meaningless task, etc. In any case, I do not believe the evidence of CPT in differentiation is well established. https://pubmed.ncbi.nlm.nih.gov/38317541/ https://pubmed.ncbi.nlm.nih.gov/38317541/ https://pubmed.ncbi.nlm.nih.gov/37800347/ https://pubmed.ncbi.nlm.nih.gov/37800347/ 3. Personal reports of another person's mental state is as subjective as you can get. All were selecting here is people who do not fit the defined, artificially built, educational or work systems. One may even be excellent, motivated student of music but all accounts fail in a classroom setting. >The core of diagnosis remains a comprehensive clinical interview and history guided by DSM/ICD criteria. Clinical interviews are guided, and their interpretation is subjective. DSM is as subjective as you can get. Every single on of the symptoms has the wording "Often", as decided by a person evaluating another person's account of their life. Do you have an objective measure of what "often" means?". More importantly, a collection of symptoms does not constitute a singular cause. By the admission of the DSM itself, two people with the diagnosis can share only 4 out of the 9 symptoms (me 1-6, you 3,9), meaning every single one of the symptoms has independent causes. How do you know one does not simply have 6 symptoms by caused by entirely different factors? In a population of hundreds of millions, its a guarantee. You could again, define random symptoms, give it a name and have millions of people going "Wow, no way, I meet all of this, I didnt know I have xyz!" Lastly, I find it really interesting is that the diagnosis of ADHD came far before we had any of this technology and research you point to. Why was it so popularly pushed and accepted then? Is it possible, were simply trying very hard to fit a completely socially agreed upon disorder?

ttul 1y ago
You've raised some common and valid criticisms of how ADHD is diagnosed. 1. On standardized scales being "meaningless": The term "standardized" here doesn't just mean a consistent set of questions. It means the scoring is normed against a large, representative population. So when a parent says their child "often" loses things, the scale helps a clinician determine if that "often" is statistically significant compared to other children of the same age and gender. It's a tool to quantify subjective reports. You're right that any set of symptoms can be standardized, but these scales are specifically designed to measure the frequency and severity of behaviors outlined in the DSM/ICD criteria. They aren't a standalone test, but one data point in a larger clinical picture. Most psychiatric conditions rely on this kind of structured self-reporting. The people working in this field work very hard to apply statistics properly when designing and running these tests; it's so far from random it's not even funny. 2. On CPTs: I agree that a CPT is an artificial lab scenario. That's a well-known limitation called a lack of "ecological validity." No one claims it perfectly replicates real-world focus. Consensus statements are clear that CPTs are insufficient for diagnosis on their own. Their value isn't in definitively saying "you have ADHD," but in providing an objective measure of things like attention lapses and impulse control that can supplement the subjective reports. If someone's self-report suggests severe inattention but they score perfectly on a CPT, that's a data point a clinician needs to investigate further. It can help in the process of differential diagnosis. The studies you linked highlight its limitations, which is consistent with the consensus view that it's a supplementary, not a primary, tool. 3. On multi-informant reports: You say these are "as subjective as you can get," which is true, they are subjective. The entire point is to gather subjective reports from multiple contexts to see if a pattern emerges. A core criterion for ADHD is that the symptoms cause impairment in two or more settings (e.g., home and school/work). If a child is only described as hyperactive and inattentive in a boring classroom but is a focused and motivated musician at home, a good clinician would question an ADHD diagnosis and look for other factors. The goal is to see if the problem is with the person's underlying regulation skills across environments, not just their "fit" in a single, artificial system. 4. On the DSM and clinical interviews: The word "often" is intentionally not given a hard number because it's relative to a person's developmental stage. "Often" losing homework is different for a 7-year-old than for a 30-year-old. This is where clinical judgment, guided by the DSM criteria, comes in. As for the symptom overlap, you're describing a feature of many polythetic diagnostic systems, not a flaw unique to ADHD. It recognizes that the disorder can manifest differently in different people. The clinician's job isn't just to count symptoms, but to assess the entire pattern, determine the level of impairment, and critically, rule out other potential causes for those symptoms (anxiety, depression, trauma, etc.). The diagnosis is a synthesis of all this information. Again, standardized test scoring DOES have the effect of giving a "definition" to the term "Often", because when thousands of forms are filled in, individuals' different definitions of the term converge in a statistically significant way onto a concept that is meaningfully comparative. 5. Finally, your historical point is interesting. Descriptions of ADHD-like symptoms date back centuries, long before the DSM. Sir Alexander Crichton wrote about "the incapacity of attending" in 1798. The diagnosis wasn't just invented out of thin air in the 20th century. It's a modern label for a pattern of behavior that has been observed for a very long time. The research and technology we have today are being used to better understand its neurobiological underpinnings, not to retroactively justify a "socially agreed upon disorder". I'm really curious what the next century of study will do to illuminate this condition. I suspect we will have significantly greater understanding of the role of genetics and perhaps, one day, a blood test will diagnose ADHD.