When I went through my ADHD assessment, I remember asking so many questions about how the decision would be made.
How would they calculate whether or not I had ADHD?
It felt like such a big moment in my life. I knew that, either way, the result would shape how I saw myself and what my future might look like. Looking back now, it makes sense that clarity felt so important. It’s one of the key things we, as ADHDers, crave to feel secure.
I had spent years trying to figure out why certain things always felt harder than they should. Like many people, I had built systems and workarounds that just about kept life running, but at a huge cost to my energy. In my last article, I looked at what it’s like to sit on the patient side of the desk. But I kept wondering about the other side. What does the clinician actually look for? How do they make sense of all that messy human data and decide if it adds up to ADHD?
To find out, I went back to clinical psychologist Dr Fleur-Michelle Coiffait, who has spent almost two decades assessing and supporting neurodivergent people. Talking to her gave me a very different perspective on the process I had gone through myself. It’s easy to imagine diagnosis as a tick-box exercise, a binary yes or no, but it turns out it’s far more nuanced.
“There are the cold, hard facts,” she told me, “and then there is the nuance, the grey area that tells you how someone is really living their life.”
That grey area is where most of us actually live.
In the UK, ADHD diagnosis follows strict frameworks: the NICE guidelines (NG87, 2018) and the DSM-5 criteria. On paper, you need at least five symptoms of inattention or hyperactivity-impulsivity that have been present since childhood and cause significant impairment across different parts of your life. It sounds straightforward, but people rarely are.
For clinicians like Dr Fleur-Michelle, the challenge isn’t simply ticking boxes but understanding how those traits show up day to day. “Part of my job is to uncover whether someone is using lots of scaffolding,” she said. “If all those supports were taken away, would things fall apart?”
That question hit home for me. I had worried that because I could keep things together, it meant I didn’t qualify. But what clinicians are actually looking at is the effort it takes. Many of us get by through sheer determination, habit, or fear of failure. We build coping mechanisms that hide the symptoms, but at the cost of constant exhaustion.
Masking is part of that. It’s the learned behaviour of suppressing what comes naturally to fit the expectations of work, school, or relationships. Dr Fleur-Michelle gave the example of a DSM-5 symptom: “difficulty remaining seated.” Most adults learn to override that impulse because we know it’s not socially acceptable to fidget in a meeting. “What I’ll ask,” she explained, “is: if you were at home, free from those expectations, would you still feel that drive to move?”
That kind of question exposes the invisible work that goes into appearing fine. I recognised myself immediately in her example, sitting through meetings, trying to appear calm while my body was screaming to get up and move. From the outside, it looks like self-control. From the inside, it’s a small act of endurance.
When an assessment takes place, clinicians have to gather evidence that symptoms have been present since before the age of twelve. That used to be age seven, but changed in 2013 with the introduction of the DSM-5. A small but welcome change, because ADHD symptoms often become clearer when demands increase, for example at secondary school or when someone leaves home. It also takes into account those with inattentive type ADHD, or those with higher cognitive abilities – who have unwittingly started to create their own workarounds, structures for getting things done, or ways of masking their frustrations. Even then, it’s rarely obvious. Sometimes parents, partners, or old school reports are brought in to help piece together the story.
But there are times when the evidence doesn’t line up neatly.
“If we’re unsure,” Dr Fleur-Michelle said, “we go back and get more information.” That might mean digging deeper into specific examples of forgetfulness, organisation, or impulsivity, or asking someone close to the person for their perspective. It might also mean ruling out something else entirely.
Trauma, for example, can look a lot like ADHD. The hypervigilance, restlessness, and difficulty concentrating that come with trauma can easily mimic ADHD symptoms. “If there’s a clear history of trauma and the symptoms only appeared after that,” she said, “we have to consider that first. The two can look very similar.”
That distinction matters. It’s not about gatekeeping diagnosis but about giving people the right kind of help. ADHD often coexists with other conditions such as anxiety and depression, so clinicians have to ask whether the symptoms predate those or result from them. It’s a complex puzzle, and that’s exactly how it’s meant to be approached.
Something that still baffles both of us is that emotional dysregulation — the rollercoaster of intense feelings, the frustration, the sensitivity, the shame — isn’t part of the DSM-5 diagnostic criteria. For me, that’s one of the most defining features of ADHD. It’s not just about attention or focus; it’s about emotion that feels bigger and faster than everyone else’s.
“It makes no sense to me,” Dr Fleur-Michelle said. “Emotional intensity and rejection sensitivity are some of the most impactful aspects of ADHD. They’re what bring people to tears in my office.”
Leaving emotion out of the criteria means a huge part of the lived experience goes unmeasured. But for many of us, it’s the emotional fallout — the burnout, the shame, the constant feeling of ‘why can’t I just get this right?’ — that pushes us to seek help in the first place.
That feeling of shame is one I know well. Before my diagnosis, I’d been treated for depression and anxiety for years. The medication helped a little, the therapy helped a little, but the core struggle never went away. I always felt like I was trying to play life on hard mode.
When I mentioned that to Dr Fleur-Michelle, she nodded. “Most people I assess have already been on antidepressants,” she said. “They’ve done CBT, they’ve done everything, and they’re still saying, ‘Something’s not right.’”
According to the National Institute for Health and Care Research (NIHR, 2022), adults with ADHD are more than five times as likely to attempt suicide as those without the condition. That statistic is frightening, but it makes sense when you understand how chronic misunderstanding of ADHD can slowly wear someone down.
What saved me wasn’t just getting the diagnosis, it was the self-understanding that came with it. Knowing that my overwhelm, frustration, and sensitivity weren’t character flaws or poor mental health, but signs of a brain that works differently, changed everything. Having language for that difference gave me permission to stop fighting it.
Clinicians like Dr Fleur-Michelle see this moment every day. “The list is the smallest part,” she told me. “It’s about interpreting the whole picture.” The checklist might be what the DSM-5 requires, but the real assessment happens in the stories, patterns, and emotional context that surround it.
And it’s not just about confirming ADHD. Sometimes, through the process, clinicians discover that something else explains a person’s experience more accurately — autism, trauma, or another form of neurodivergence.
“Our goal is always understanding,” she said. “A diagnosis is only one route to clarity.”
That line has stayed with me. Because that’s ultimately what this whole process is about: clarity. Understanding why life has felt the way it has, and what you can do about it.
When I think back to that assessment now, I see it differently. It wasn’t just a test I had to pass; it was a collaboration. Together, we pieced together something coherent from the chaos.
It’s easy to forget that clinicians aren’t just following a script. They’re listening, interpreting, and connecting dots across years of someone’s life. The best ones, like Dr Fleur-Michelle, make you feel seen in a way that’s both scientific and deeply human.
And that’s what separates a diagnosis from an understanding. The frameworks matter, but the empathy matters more.
References
- National Institute for Health and Care Excellence (NICE) NG87: Attention Deficit Hyperactivity Disorder: Diagnosis and Management (2018)
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013)
- National Institute for Health and Care Research (NIHR). ADHD and Suicide Risk in Adults (2022)