Focus, starting, and ADHD

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…

Nearly everything on the ADHD list can show up inside a bipolar presentation, and the reverse is not true. So the shared features settle nothing, and the distinctly manic ones carry all the weight.

Put your attention on episodic elevation, grandiosity and a genuinely reduced need for sleep. Those do not belong to ADHD on its own, so they tell…

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…

How an outburst ends tells you more than how it starts. Give an ADHD storm some room and it often burns itself out. The rage that runs for an hour with the lights out behind the eyes is a different animal, and so is the child who genuinely does not mind what you take away.

Ask the parents to walk you through the last three. What set it off, how long it ran, what stopped it, what the child was like an hour afterwards.…

When someone cannot let go of the old rule after the rules have changed, that is the same machinery that loses their keys and drops the thread of a sentence. Stuck, not stubborn.

It shows up in small places. The game changes and they argue for the old version. The usual road is closed and the whole trip falls apart. A plan…

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…

Where a relative has taken ADHD medication, take the details: who they are to your patient, what they were given, what it did, and what was tried and dropped. Then put it in the referral letter.

No blood test tells a prescriber where to start, so a brother's clear response to one drug, or a mother's bad reaction to another, is one of the few…

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…

There is no box you type 'always late' into and get the answer out of. When a sensible strategy is not landing, the work is finding out what is blocking it rather than producing another strategy.

If you notice yourself handing over the fourth tool for the same problem, stop and ask a different kind of question. What happened the last time they…

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…

A man who could not get himself to bed kept his bedtime alarm upstairs, where his wife and baby were sleeping. Switching it off meant climbing the stairs, and leaving it meant waking them. The walk to the alarm was the thing he was trying to do anyway.

That is the part worth copying. Put the cue somewhere that costs something to answer, and make answering it land you where you meant to be. Anything…

Time management is only the fit between tasks and the hours you have: planning them against time, then doing them against time. It is a skill with parts, not a verdict on what kind of person you are.

Most people arrive having already decided they are lazy, and that decision is doing them no good at all. Describing it mechanically gives you both…

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…

It runs the other way as well. Among children referred for dyslexia, a sizeable minority also have ADHD and many have coordination difficulties too. Whatever is written on the referral, treat it as one part of the picture.

Where the reading difficulty is severe, motor involvement is more likely to be there alongside it, which is why the first look should be wider than…

Dyspraxia and developmental coordination disorder are the same thing carrying different passports. Search only the American term and you will miss a large European literature on assessing and helping these children.

Search both, and try the older names while you are there. It matters most when you are looking for what actually helps, since much of the…

When a bright, talkative autistic child arrives looking mainly behavioural, look underneath for a coordination or reading difficulty. Once the first label is in place, whatever comes after tends to get filed under it and never assessed on its own.

Watch for the child who does well in conversation and badly on paper, or who is fine in class and miserable at PE. Those gaps are usually a second…

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.…

Choose the subtests that answer the question you were actually asked, and read whatever reports the family already has before adding anything of your own. Children arrive with thick folders, and they also arrive with nothing at all.

Where occupational therapy, speech and language or neuropsychology have already covered ground, do not cover it again for the sake of a complete…

When you explain executive function to parents and teachers, four words will do: attention, reasoning, speed, memory. Each one can be worked on, and four is a number people can still repeat at the school gate a week later.

The academic models have a dozen headings and nobody outside the field retains them. A short list gives parents something to hang observations on, so…

Two referrals turn up again and again. A young child being asked to leave a school for behaviour, with no developmental or cognitive information anywhere in the file. And a parent saying something is wrong while the school says everything is fine. Both are describing adult frustration rather than a formulation.

In each case the first job is the same: get some data. Not another opinion, not another meeting, but something measured about how this child thinks…

If you cannot remember much about being six, you are in the majority. Early childhood comes back poorly for most adults, while the teenage years are far easier to describe.

So do not sit in an assessment feeling you have failed a test because the early years are a blur. Bring what you can find instead: old school…

A list of symptoms on its own does not make a diagnosis. What counts is that they cost you something real in at least two areas of ordinary life.

That means work or school, money, home, friendships, driving, getting through the week. Almost everyone loses keys and drifts off in meetings, so the…

Much of the symptom wording was written with children in mind. If a question sounds like it is about someone climbing the furniture, translate it into your adult life rather than answering no.

Restlessness at forty is rarely running about. It is being unable to sit through a film, the leg going under the table, two jobs left out of boredom.…

Attention and impulse problems that appear for the first time in middle age or later are not ADHD arriving late. They need a doctor to look, not a prescription.

Several conditions affecting the frontal lobes can show up first as new disinhibition, poor judgement or a change in personality, and some are…

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…