Focus, starting, and ADHD

When someone says they feel restless inside, ask what the restlessness wants. Restless to move, or restless to do one particular thing until it feels right?

The two feel similar from the inside and point in different directions. With ADHD it is usually undirected: the legs go, the chair is wrong, you need…

A distracted person can be brought back with a nudge. Someone who has gone elsewhere cannot, and the difference shows itself in a couple of seconds.

Say their name, ask something simple, and watch what returns. Attention that has drifted comes back with a small apology and picks the thread up…

Try not to ask why. If the person knew why, they would probably have sorted it out already, and the question tends to land like an accusation.

Ask what happened just before instead. What was going on, what they felt, what came after, what sort of day it had been. Those answers can be worked…

If someone was adopted, or simply does not know their family history, say early and plainly that this is not a problem. It helps to have and it is not needed.

Otherwise the question lands as one more reminder of what is missing, and some people will spend the rest of the appointment feeling they brought the…

When someone says their heart races on their medication, ask whether it ever did before they started. It is the cheapest question you have and it usually sorts the answer out.

Go looking for the old settings: waiting to be called on in class, standing outside a room before a difficult conversation, three in the morning with…

While you are taking the family history, ask about seizure disorders and psychosis too, not only about attention. A family carrying other neurological or psychiatric conditions is worth knowing about whatever you end up concluding.

Keep the list short and ask it plainly: epilepsy, psychosis, learning difficulties, head injuries, anything neurological. Some of it will matter for…

Hypervigilance after trauma and ADHD scanning look much alike from outside. Often the honest answer is that both are present, and the real question is how much of each.

Watching that comes from threat is aimed at something and tends to switch on in particular situations. ADHD distraction is not fussy about where it…

Damage to the front of the brain can produce something that looks a great deal like ADHD: poor impulse control, blunted judgement, a person their family says has changed.

The nineteenth century railway worker who survived an iron rod through the frontal lobes is the standard illustration, and what altered in him was…

Not every bout of eating too much belongs to an eating disorder. Ask whether how the body looks is part of it, because that is where the two paths separate.

When bingeing comes out of ADHD it is often boredom, or the food simply being there with nothing stepping in to stop it, and the person is not…

When you need a date, hand people events rather than months. Was that before or after the holiday? Same year as the move?

Asking whether something happened between October and January invites a guess. Asking whether it was before or after a wedding, a house move or a…

Ask for a number first, then go hunting for exceptions. How is today on a scale of one to ten, and when was it last higher than that?

An assessment can turn into an hour of everything that is wrong, which leaves a person flatter than when they arrived. Exception questions do the…

Find out what they have tried before that did not work. It saves everybody from a plan that failed this person two years ago.

Most people arriving for an assessment have been trying things for years: apps, alarms, lists, an early night, a course somebody recommended.…

Run a short anxiety and depression screener alongside the ADHD measure at every intake, not only when someone mentions their mood.

Mood and anxiety sit beside ADHD often enough that leaving them out means guessing about the concentration difficulty in front of you. Doing it as…

A tick beside 'does your mind race' means less than it looks like. Someone whose mind has raced since they were nine has nothing to compare it against, so ask what changed and when before you let the score speak.

Take the endorsed items one at a time and put a period of time around each one. When did this start? Was there ever a stretch when it was not there?…

Both people will tell you they were up for three nights. The useful question is what they did with those hours: driven and busy points one way, wired and wrecked points another.

In mania the need for sleep falls away and the activity has a purpose behind it, however unrealistic that purpose looks from outside. In ADHD the…

Disruptive mood dysregulation disorder was built partly to keep the bipolar label off children whose future nobody can yet see. Worth remembering when that word lands on a family's paperwork: it describes now, and it does not settle later.

Use it the way it was meant to be used. Review it as the child grows instead of filing it as a fixed fact about their brain, and think about how you…

Ask twice. First, who in the family has an actual diagnosis. Then, who do you look back on now and wonder about. The second question nearly always brings more than the first.

Plenty of families never went near a clinic. Help was not trusted, or the answer at home was to stop complaining and get on with it, so the…

A child who grew up listening for a parent's seizure learns to keep half an ear on the room, and years later that can look a great deal like distractibility. Ask what they were listening out for as a child.

This turns up most often where there was one parent and nobody else to keep watch. The person cannot settle, cannot stay with a task, and has assumed…

Alongside diagnoses, ask how relatives died. Falls from roofs, crashes, deaths with the safety gear left on the ground: these recur in some family lines and they say something a list of diagnoses cannot.

Ask it gently and let people take their time, because you are asking about grief as much as about pattern. What you are listening for is a habit of…

The relative who was shut in a cupboard, tied to a chair or expelled was being managed for the same thing you are assessing now. There was simply no name for it then and no help attached to it.

Told carefully, this changes the story a family tells about itself. Not a line of difficult people, but a trait that has been present for generations…

Before you decide a strategy has failed, check whether the medication underneath it is doing its job. If someone is sitting in front of you still struggling, the honest first answer is usually that it is not, quite.

Ask about the shape of the day rather than the dose alone. When does it come on, when does it wear off, which hours are the hard ones, is there any…

Before handing anyone a new system, make sure they can say back why it should work better than what they are doing now. A strategy with no reason attached gets dropped the first time it is inconvenient.

Ask them to explain it to you in their own words and listen for whose reason it is. If the logic is only yours, it will hold for about a week. It is…

Strategies for ADHD are visible. A timer on the table, a list on the wall, an alarm going off in a meeting. If someone has not yet made peace with having ADHD, each of those is an announcement, and it will quietly get dropped.

So ask, before handing over another tool: how do you feel about the diagnosis itself? Sometimes the honest answer is that they still half hope it was…

Ask what they think this will cost them in effort, then say what you think. People rarely give up because a strategy failed. They give up because it turned out to be harder than anyone had told them.

Be specific about the first fortnight, since that is when it is worst and the payoff has not arrived yet. Someone who expected a small effort and met…

When something did not get done, find out which half broke. Did they not know what to do or when? Or was the plan fine, and the moment for doing it came and went?

Ask for the last time it happened, hour by hour, up to the point where it did not happen. A planning failure needs somewhere reliable to catch tasks…

Awareness is knowing what needs doing and when. Motivation is doing it once you know. Nearly every app on the market solves the first one, which is why buying another one so rarely helps.

Test it with one question: at the moment it did not happen, did you know? If the answer is yes, the reminder was never the missing piece, and a…

Carry the rough proportions into every ADHD assessment. Executive function difficulty in the great majority, coordination difficulty in around half, dyslexia in something like a quarter to two fifths. A workup that never asks about handwriting, sport or reading is not finished.

The behaviour problem you were called about is often the visible end of an unidentified reading or coordination difficulty. Ask what PE is like, what…

Expect more anxiety, low mood, drinking and drug use in the young people coming through now. And expect the boys to say less about it, so go looking for irritability, trouble and substances instead of waiting to be told.

Ask parents what they are seeing rather than only what they have been told, and ask the young person directly and privately. Screening that rests on…

Parents with one affected child often ask what they might do differently before the next one. Answer honestly: there are lists of suggestions in circulation, the evidence behind most of them is thin, and the question underneath is usually about blame.

Take the question seriously and take the guilt seriously alongside it. Give what is genuinely known, say plainly where recommendations run ahead of…

Keep the tasks short, a couple of minutes each, with results back the same day. A long test given to a child who cannot sustain attention measures how long they can last, not the thing you were trying to measure.

Brevity is not a convenience you are allowing yourself. It is what keeps the data honest, and it keeps the child willing for whatever you ask next.…

Ask about food two generations back. What the parents were like about it, what the grandparents were like, what the rules were at the table.

Much of how a person eats was learned long before anybody mentioned a diagnosis, and a fair amount of the shame around it was learned in the same…

The scales worth using are the ones that ask about situations rather than symptoms alone. Home, school, work, and what actually happens in each.

A questionnaire counting how often somebody loses their keys will label half the population. What a diagnosis needs is evidence that the difficulty…

Executive function scales ask how the week actually went. That is often more use than an afternoon of testing in a quiet room.

Office testing happens in the best conditions a person will ever meet: no interruptions, someone sitting with them, a clear finish line in sight.…

Ask about the family properly: parents, brothers and sisters, children, then aunts, uncles and grandparents. Include drinking and drug use, in them as well as in the person sitting with you.

This tends to be the highest yield few minutes of an assessment, because the condition runs strongly in families. Relatives who were never assessed…

Ask for the most frightening moment of their life, then the next one down, then the next, until there is a scale running from one to a hundred. You get the ladder you needed, and they get something they did not expect: fear comes in sizes.

Do it slowly and write it in their words rather than yours. Most people arrive believing anxiety is one solid block that either has hold of them or…

The family history is not the warm up before the real assessment. Give it proper time and it will often tell you more than any single rating scale in the folder.

Walk through the family rather than asking one summary question about it. Who struggled at school, who could never sit through a meal, who changed…

If someone is about to send off a saliva kit to fill in the family history they never had, have a conversation first. These tests hand back more than health information, and they hand it back with nobody in the room.

A father who is not the father, a sibling nobody mentioned, a donor conception no one planned to explain: these arrive by email on an ordinary…

'I am disorganised' cannot be treated. 'The post piles up on the hall table until something ends up with a debt collector' can. Spend the time getting the problem down to something that specific.

Push for the particulars: which task, which moment, what was happening just before, what they did instead. Where you can, ask someone who was there…

Run the assessment yourself and watch while they work. Under real effort you will see the small movements, the tics and the overflow that never appear in ordinary conversation, and none of it reaches you if a technician or an app does the testing.

Sit where you can see hands and face. Note what happens as the task gets harder: the tongue that comes out, the leg that starts going, the free hand…

Processing speed is the stubborn one. It shifts a little with repeated, rhythmically paced practice and hardly at all with explanation, so say that to a family at the start rather than when they are disappointed.

Teaching a strategy will not make a slow processor quick, and telling a child to hurry up only makes the work more unpleasant. Graded practice with…