April 26, 2010

Journal Article: Diagnostic Approaches to Adult Attention-Deficit/Hyperactivity Discord

I was reading some articles on Adult ADHD, and came across the online resource called "Primary Psychiatry". A search on Adult ADHD on this site led me to a number of very interesting articles - and I have pasted one below. This is all about the diagnostic approaches to Adult ADHD. Obviously this interests me because of my Adult ADHD assessment - and it goes into some detail about the tests and symptomatology of the disorder. It gets into some detail that some readers may not be interested in, but presents a fairly authoritative description of how they go about diagnosing Adult ADHD.

My next appointment in a couple of days - a couple of sleeps - will be with a clinical psychologist. I'm curious how this meeting will go. Is 'eagerly curious' a phrase?

They say ADHD adults are prone to thinking "That's great, but what's next?"... even when something wonderful has just occurred (like a gift or a significant conversation). BUT damn it I wish it would hurry up already.
If I may go off on a tangent for a minute: I have read that a symptom of ADHD is a certain difficulty with extracting the signal from the noise - noticing what is singularly important. The other side of that coin is the ability to pick up on a larger number of signals from the environment than other folks. ADHDers as adults sometimes learn to cope with this by becoming good at picking up many signals and using it to their advantage. ADHDers are often 'good' at finishing other peoples' sentences ('good' as in effective, but 'good' can be annoying) probably because they are perceptive enough (when interested) in reading all the subtle cues of communication to effectively tune in very clearly on a person's message.

This may be why (if you know me) I'm often finishing your sentences for you, or even cutting you off - to get to the next part. It is as though I am impatient, and thinking 'yes, yes, yes, I know what you're saying... get on with it, I want to know the next part'. Which is ironic, in that I'm often verbosely prattling on while telling a story, or drilling down into the minutia of a description - likely leading non-ADHDers to think 'yes, yes, yes, I know what you're saying... get on with it, I want to get to the next part'.
That's great. Now cut to the chase:

Diagnostic Approaches to Adult Attention-Deficit/Hyperactivity Discord


Attention-deficit/hyperactivity disorder (ADHD) remains under-diagnosed in adults. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ADHD symptom criteria anchor the diagnosis but require interpretation that is sensitive to symptom expression in adults. For example, hyperactive symptoms may become more subjective and hidden in adults. Inattentive symptoms may involve so-called executive functions, such as planning, multitasking, and time management. While collateral reports from significant others are helpful, often the afflicted adults can report meaningfully about their lifelong condition. In addition to symptoms of ADHD, other diagnostic indicators include specific educational, occupational, and psychosocial difficulties. A number of rating scales and diagnostic interviews are available to assist in the diagnostic process.


While childhood attention-deficit/hyperactivity disorder (ADHD) was first recognized in the early 1900s, recognition of the disorder’s persistence into adulthood did not occur until the 1970s. Nevertheless, much is known about the persistence of the disorder into adulthood, the common presenting problems of adults with ADHD, and the manifestations of the disorder that are unique to adults. This article seeks to highlight these presenting symptoms of ADHD in order to aid clinicians in making a diagnosis of ADHD and then goes on to examine diagnostic measurements and interviews that can be used to make a diagnosis of adult ADHD.

Presenting Problems

Adults with ADHD usually describe symptoms of poor attention, lack of concentration, easy distractibility, shifting activities, day-dreaming, and forgetfulness.1 They often begin one task and then find themselves in the middle of several projects. These patients appear to have a poorly developed sense of time and are often harried and late. They lose and misplace important personal items, such as keys, as well as items from work and family projects. They usually avoid tasks that require high levels of concentration and patience, such as balancing their checkbook, filing tax returns, and helping children with homework. Projects are often put off until the last minute, at which time they may become highly motivated and able to focus. Often these patients are drawn to novel stimuli, usually at the expense of the designed object of their attention. Their boredom or intrusiveness often compromises conversations with coworkers, spouses, and children. Others may view adults with ADHD as either flighty or self-centered. Adults with ADHD usually have difficulty regulating their attention, which can lead to repeated problems as they attempt to manage affairs at work, home, and with friends.

Additionally, these patients report symptoms of impulsivity, impatience, boredom, fidgetiness, and intrusiveness.1 These symptoms are often evident in the context of social situations. Frequently, adults with ADHD have long histories of social impairment, and are often perceived as aloof or self-centered, as they easily become bored or may interrupt or make socially inappropriate comments. Others are quite gregarious and talkative, “the life of the party”—almost an adult equivalent of the “class clown.” Adults with ADHD have a sense of urgency and immediacy to their lives and have little tolerance for frustration, delay, or planning. They are easily irritated waiting in lines and often make decisions without proper consideration of alternatives. Collaboration with others may be a mutually frustrating experience. Also, adults with ADHD experience increased rates of traffic accidents, traffic violations, and license suspensions.2,3

Symptoms of overt hyperactivity may be diminished in patients who have developed compensatory strategies. Recent data support the clinical observation that symptoms of hyperactivity-impulsivity decline over time while symptoms of inattention persist in ADHD patients.4 However, these investigators note that most patients with ADHD continue to struggle with a substantial number of symptoms and a high level of impairment.

For example, adults with ADHD are thought to have deficits of working memory as exemplified by less ability to attend to, encode, and manipulate information.5 Such deficits in working memory may decrease the ability to filter out distractions, which contribute to further symptoms of inattention in adults with ADHD. Although less defined within ADHD, organizational difficulties and procrastination also appear common.

Like children with ADHD, adults with the disorder may be stubborn, demoralized, and develop low self-esteem.6,7 Relationships with family, friends, and employers are often conflictual, which may contribute to high rates of separation and divorce, as well as to the academic and occupational underachievement characteristic of these adults.8,9

Relationships and Family Life

The constant activity of an adult with ADHD can lead to family tension. Problems include difficulties with organization, setting and keeping routines, day-to-day supervision, stress tolerance, mood stability, and compliance with ADHD treatment plans. Parents come home to children who need time and attention, dinner, and help with homework, which adds to the tension. Difficulties juggling family, work, and other responsibilities highlight executive functioning deficits.

Relationships for ADHD patients can be unstable, so reports of counseling or relational difficulties can indicate an ADHD diagnosis if the underlying problems are due to one partner’s symptoms of inattention or hyperactivity. Common issues include not listening, interrupting when the spouse is speaking, or a disorganized or inattentive approach to household responsibilities. The diagnosis of ADHD alone can help considerably, enabling the couple to understand that ADHD is a condition that interferes with planning and sharing tasks. Effective treatment for one partner’s ADHD can possibly lessen or eliminate problems that a couple is experiencing.


Educational or vocational performance below that which is expected (based on a patient’s intelligence and education) may provide an indication of the diagnosis of ADHD. According to evidence gleaned from self-reports and high-school transcripts in the Milwaukee Young Adult Study,10 young adults with ADHD experience significantly more grade retention, suspensions, and/or expulsions than their non-ADHD peers. The dropout rate is also higher and, on average, students with ADHD may have lower class rankings and lower grade point averages. In addition, fewer enter college. For the students with ADHD that do go to college, the graduation rate is much lower than those without ADHD.10


Patients frequently present with occupational problems, such as difficulty finding and keeping a job and job performance below the level of competence. Questions to ask a patient about his or her history of vocational difficulties include: How often have you changed jobs? What was the reason for the job change? and has it been hard to get along with bosses?11 Adults with ADHD often have a low frustration tolerance, which can lead to issues such as high job and relationship turnover and explosive or irritable episodes.

A sense of internal restlessness in adults with ADHD can lead to a compulsive tendency to overwork or choose occupations where frequent movement is an essential component of the job, such as sales and marketing. Childhood hyperactive symptoms, such as difficulty remaining seated, running and climbing excessively, squirming and fidgeting, difficulty playing quietly, and talking excessively, are commonly manifested in adults who work two jobs, work long hours, or choose very active jobs.

Many adults with ADHD do not regulate themselves well and do not self-correct when problems arise, in part due to poor self-monitoring.12 Poor time management and difficulty completing and changing tasks are common manifestations of inattention. If possible, adults often attempt to compensate for limited organizational skills by enlisting the assistance of support staff.12


ADHD can be diagnosed in adults by carefully querying for developmentally appropriate criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),13 and attending to childhood onset of symptoms, persistence through adolescence, current presence of symptoms, and impairment. A variety of issues arise in the assessment and diagnosis of ADHD in adults. The appropriate diagnosis of ADHD in adults initially relies on accurate recall of childhood symptoms and a reliable account of current symptoms and their impact. Some clinicians have questioned the reliability of adults with ADHD to accurately report this information,14 though recently, Murphy and Schachar15 evaluated correlation symptoms between adults with ADHD and other informants and found that ADHD adults can give a true account of their symptoms.

Thus, diagnostic information is obtained from the patient and, whenever possible, from significant others, such as partners, parents, siblings, and close friends. If ancillary data are not available, information from the patient is acceptable for diagnostic and treatment purposes since, as Murphy and Schachar showed,15 adults with ADHD, like adults with other disorders, are appropriate reporters of their own condition. Careful attention should be paid to the childhood onset of symptoms, longitudinal history of the disorder, and differential diagnoses including medical, neurological, and psychosocial factors contributing to the clinical presentation. Neuropsychological testing should be used in cases in which learning disabilities are suspected, or cases in which learning problems have persisted in treated ADHD adults.16-18

A clinical interview with the patient remains the basis of the adult ADHD diagnosis. Rating scales and neuropsychological testing may help to gauge ADHD symptoms, but a structured or semistructured clinical interview enables practitioners to accurately assess all three core features of the disorder in adults: symptoms dating back to early childhood, significant impairment in at least two settings, and moderate severity ratings for at least six of nine symptoms of inattention and/or hyperactivity.19

Symptoms of inattention in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),19 include failing to give close attention to details or making careless mistakes in schoolwork, work, or other activities; having difficulty sustaining attention in tasks or play activities; not listening when spoken to directly; not following through on instructions; and failing to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). Other inattentive symptoms include frequently having difficulty organizing tasks and activities; avoiding, disliking, or being reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework); frequently losing things necessary for tasks or activities; being easily distracted by extraneous stimuli; and being forgetful in daily activities.19

Symptoms of hyperactivity listed in the DSM-IV-TR19 include fidgeting with hands or feet or squirming in one’s seat; leaving one’s seat in the classroom or in other situations in which remaining seated is expected; and frequently running about or climbing excessively in situations in which it is inappropriate (in adolescents or adults, this last symptom may be limited to subjective feelings of restlessness). Other hyperactive symptoms include having difficulty playing or engaging in leisure activities quietly; being “on the go” or acting as if “driven by a motor”; and frequently talking excessively. Impulsive symptoms include blurting out answers before questions have been completed, having difficulty awaiting one’s turn, and frequently interrupting or intruding on others (eg, butting into conversations or games).19

In the current DSM-IV13 nosology, at least six of nine symptoms of inattention must be present for the inattentive subtype diagnosis, at least six of nine hyperactive-impulsive symptoms must be present for the hyperactive-impulsive subtype diagnosis, and at least six of nine symptoms for both subtypes must be present for a combined subtype diagnosis.13

A range of ratings scales, forms, and structured interviews have been developed to assist with the diagnosis of ADHD in adults. Rating scales, such as the ADHD Rating Scale (ADHD-RS)20 or the Conners’ Adult Attention-Deficit Rating Scale (CAARS),21 can be used to assess current symptoms, while semistructured interviews, such as the diagnostic portion of the Conners’ Adult ADHD Diagnostic Interview for the DSM-IV (CAADID)22 and the Mini-International Neuropsychiatric Interview,23 can be used to assist with diagnosis. In addition, forms such as the CAADID are designed to assist in obtaining the history of symptoms from the patient. Current symptom scales, as well as diagnostic questionnaires, are available in self-report, observer-rated, and clinician-administered forms. For childhood history, collateral information obtained from a parent or older sibling, if possible, is extremely helpful. Formal records, such as report cards and conduct reports, are also illuminating. To assess comorbidity, one can either conduct a semi-structured interview or use an assessment tool, such as the Structured Clinical Interview for DSM-IV Axis I Disorders.24 These scales are discussed in greater detail below.

Rating Scales

Rating scales are a useful tool for assessing whether a patient meets the DSM-IV13 diagnostic criteria necessary for an adult ADHD diagnosis. Because they provide structure and, in some cases, extensive prompts that can be used to probe patients further, they are especially helpful for clinicians with less adult ADHD experience. Rating scales can also be useful in assessing current symptoms. In terms of diagnosis and severity, the use of the 18 core DSM-IV13 symptoms has been well established as valid and reliable. There are a number of diagnostic systems and rating scales that assess domains outside of the traditional DSM-IV13 core symptoms. While they may provide useful clinical information, the relationship of these additional domains to ADHD itself remains unclear. For instance, while functional impairments, such as social and occupational deficits, are important features of ADHD, they are not specific and are frequently present in individuals without ADHD who have other disorders.

Diagnostic Scales

The CAADID is a clinician-administered interview that assesses the presence of the 18 DSM-IV13 symptoms for childhood and adulthood.22 Specific prompts and examples of symptoms are provided for each query, and impairment in school or work, home, and social settings is assessed for childhood and adulthood. A diagnosis of ADHD, including subtype, can then be established. The interview queries patients about childhood history, including gestational, delivery, temperament, developmental, environmental, and medical history risk factors. Childhood academic history and adult educational, occupational, and social/interpersonal histories are also queried, as are health history and psychiatric history.

Barkley’s Current Symptoms Scale–Self-Report Form25 is a self-report scale of 18 symptom items that correspond to those listed in the DSM-IV13 diagnostic criteria. Odd-numbered items assess frequency of inattentive symptoms and even-numbered items assess hyperactive-impulsive symptoms on a 0–3 Likert-type frequency scale (0=never or rarely, 1=sometimes, 2=often, 3=very often). The scale also asks patients to note how often their symptoms interfere with school, relationships, work, and home life, and to report the age of onset for their symptoms. Finally, it addresses oppositional defiant disorder (ODD) comorbidity with eight questions about symptoms of ODD. Barkley also has a Childhood Symptoms Scale–Self-Report Form, a Developmental Employment, Health, and Social History Form, and Work Performance Rating Scale–Self-Report Forms, all of which can be sent to the patient to complete before their first clinic visit. In addition, the Current Symptoms Scale–Other Report Form provides observer ratings. Together, these scales form a picture of the patient’s past and present symptoms and functioning.25

The Brown Attention-Deficit Disorder (ADD) Scales Diagnostic Form26 is clinician-administered and begins with queries about clinical history, including impact of symptoms on work, school, leisure, peer interactions, and self-image. Patients are also asked whether early schooling was impacted by their symptoms. The clinician asks the patient about the clinical history of his or her family and about the patient’s physical health, substance use, and sleep habits. The clinician also obtains collateral data from an observer or significant other and screens for the full array of comorbid disorders.26

Current Symptom Surveys

Current symptom surveys can be divided into clinician-administered and self-report forms. Some scales are normed and can provide population comparisons. Because some symptoms, such as internalized restlessness, feeling disorganized, and being easily distracted, are not always apparent to observers, self-report scales are an effective way to capture the symptoms of adults with the disorder. However, for new patients who are less self-aware of their symptoms, it is very helpful for the clinician to be able to ask about symptoms in a semi-structured format that allows them to utilize an extensive list of examples given as prompts.

The ADHD-RS20 is an 18-item rating scale that rates symptoms using a 4-point Likert-type severity scale (0=none, 1=mild, 2=moderate, and 3=severe). It is based on the DSM-IV criteria for ADHD, with nine items assessing inattentive symptoms and nine items assessing hyperactive and impulsive symptoms. The ADHD-RS has been developed and standardized as a clinician-administered rating scale for children but can be used as an adult scale after the clinician has been trained to do so.

The Brown ADD Scale26 is a frequency scale with 40 items. In response to descriptions such as “misunderstand directions for assignments, completion of forms, etc.” and “starts tasks (eg, paperwork, chores) but does not complete them” patients give a rating from 1–3 of how often the symptom occurs (0=never, 1=once a week or less, 2=twice a week, and 3=almost daily). This assessment has normed, standardized, validated clinician-rated and self-report forms.

The Wender-Reimherr Adult ADD Scale (WRAADS) is intended to measure the severity of the target symptoms of adults with ADHD using criteria from the Wender Utah Rating Scale.27,28 It measures symptoms in seven categories: attention difficulties, hyperactivity/restlessness, temper, affective lability, emotional over-reactivity, disorganization, and impulsivity. The scale rates individual items from 0–2 (0=not present, 1=mild, 2=clearly present) and summarizes each of the seven categories on a 0–4 scale (0=none, 1= mild, 2=moderate, 3=quite a bit, 4=very much). The WRAADS may be particularly useful if the clinician wishes to assess possible mood lability symptoms of ADHD.

The screening version of the CAARS21 is a 30-item frequency scale with items such as “has difficulty organizing tasks and activities” and “is on the go or acts as if driven by a motor.” Symptoms are assessed with a combination of frequency and severity. Patients respond on a 4-point Likert-type scale (0=not at all or never, 1=just a little, once in a while, 2=pretty much/often, and 3=very much/very frequently). All 18 items from the DSM-IV13 can be extrapolated from the CAARS. There are also observer and self-report versions of the CAARS. Both the clinician-administered and self-rated versions of this scale have been validated and normed.

The full Adult Self-Report Scale (ASRS) Symptom Checklist (version 1.1) is an 18-item scale that can be used as an initial symptom assessment to identify adults who might have ADHD.29 The scale queries patients about the 18 symptom domains identified by the DSM-IV, with modifications to assess the adult presentation of ADHD symptoms. Furthermore, a context basis of symptoms is provided. The scale is intended to be used in patients at risk for having ADHD, whether secondary to presenting symptoms, family history, or comorbidity. A six-item screening version (extracted from the full 18-item symptom assessment scale) is available for assessing patients in the community, regardless of whether they are at increased risk for ADHD. Neither the six-item screening version nor the full 18-item symptom assessment version is meant to be a stand-alone diagnostic tool. The diagnosis of ADHD is still predicated upon assessment of current symptoms, impairment, and childhood onset of symptoms. The ASRS and other symptom assessment tools are designed to be diagnostic aids in fulfilling the first criteria. As this section reviews symptom assessment tools, the discussion will focus on the 18-item ASRS Symptom Checklist.

The ASRS was developed by Adler, Kessler, and Spencer, and a steering committee of experts on adult ADHD. The ASRS Symptom Checklist is now available through the World Health Organization (WHO) and on the New York University Web site.29

In the ASRS, symptoms are rated on a frequency basis: 0=never, 1=rarely, 2=sometimes, 3=often, and 4=very often. Nine items assess inattention and nine assess hyperactivity-impulsivity. Once the patient has completed the scale, it can be readily scored and used as a starting point to talk more in depth about a patient’s clinical history. There are scoring guidelines based upon the total score in either the inattentive and hyperactive/impulsive subsets (using the higher of the two) that yield a diagnostic likelihood of the patient having ADHD. The scale has been validated using the National Comorbidity Survey cohort and in well-characterized adult ADHD populations.

Differential Diagnosis

As always, it is important to remember that when diagnosing for ADHD, a variety of medical and psychiatric conditions should be considered as part of the evaluation of ADHD in adults. Such conditions include sleep disorders, headaches, visual and auditory disorders, seizure disorders, endocrine disorders, hepatic function, use of illicit substances and herbal remedies, and impact of concurrent medications on cognition (eg, anticholinergic or antihypertensive medications). Laboratory tests, such as thyroid studies, electroencephalograms, baseline electrocardiograms, or baseline hepatic function tests are generally not necessary unless indicated by the patient’s symptoms or family history. Additionally, clinicians should obtain a history of anxiety disorders (including trauma), mood disturbances (including bipolar disorder), current and past substance use, aggression and impulse control problems, legal involvement, and psychosis. Furthermore, current stresses, as well as issues involving the patient’s adherence, are important to the overall treatment plan.


DSM-IV13 criteria provide the standard for diagnosis through all age ranges. The cardinal criteria for diagnosing ADHD are the presence of sufficient current symptoms and impairment in two realms (realms include home, school or work, and social interactions). A clinical interview, aided by the use of rating scales and (when appropriate) collateral information about childhood from parents or siblings, provides data for a comprehensive assessment. The poor psychosocial outcomes of patients with ADHD, often a consequence of unrecognized, untreated symptoms, can also serve as diagnostic indicators. Diagnostic and symptom assessment scales can be helpful in diagnosing and establishing the symptoms of ADHD in adults. PP


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