April 28, 2010

Coming Soon: 2nd Session in my Adult ADHD Assessment - Clinical Psychologist

This afternoon I'm off for my second meeting at the ADHD clinic for my Adult ADHD assessment. I will be meeting with a clinical psychologist.



I am nervous, excited, distracted. Good luck with me getting the high priority work task that just landed on my desk done for tomorrow... But I have chunked it out into little pieces, so I should be good. Oiks.



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Cheers,

Mungo

April 27, 2010

New Feature: AdultADHDBooks.com

One of the essential elements in a diagnosis and subsequent treatment (and coping) plan for Adult ADHD is education. To assist with achieving this goal, I have opened an online bookstore at AdultADHDBooks.com which is now available via the navigation bar on the right side of this blog.

I have partnered with Amazon.com to offer books related to Adult Attention Deficit Hyperactivity Disorder at competitive prices. All transactions are secure and take place through Amazon.com's site.

Please browse and consider buying books at AdultADHDBooks.com.

Sincerely,

Mungo

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

Abstract

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.

Introduction

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.

Education

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

Occupation

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

Diagnosis

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.

Conclusion

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

References

1. Millstein RB, Wilens TE, Biederman J, Spencer TJ. Presenting ADHD symptoms and subtypes in clinically referred adults with ADHD. J Atten Disord. 1997;2(3):159-166.

2. Barkley R, Murphy K, Kwasnik D. Psychological adjustment and adaptive impairments in young adults with ADHD. J Atten Disord. 1996;1(1):41-54.

3. Barkley RA. Accidents and attention-deficit/hyperactivity disorder. TEN. 2001;3(4):64-68.

4. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry. 2000;157(5):816-818.

5. Seidman LJ, Biederman J, Faraone SV, Weber W, Ouellette C. Toward defining a neuropsychology of attention deficit-hyperactivity disorder: performance of children and adolescents from a large clinically referred sample. J Consult Clin Psychol. 1997;65(1):150-160.

6. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(12):1792-1798.

7. Biederman J, Wilens TE, Mick E, Faraone SV, Spencer T. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry. 1998;44(4):269-273.

8. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry. 1993;50(7):565-576.

9. Weiss G, Hechtman LT. Hyperactive Children Grown Up. New York, NY: Guilford Publications; 1986.

10. Fischer M, Barkley RA, Smallish L, Fletcher K. Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. J Abnorm Child Psychol. 2002;30(5):463-475. Erratum in: J Abnorm Child Psychol. 2003;31(5):563.

11. Wender PH, Garfinkel BD. Attention-deficit hyperactivity disorder: adult manifestations. In: Sadock HI, Kaplan BJ, eds. Comprehensive Textbook of Psychiatry. Baltimore, MD: Williams & Wilkins; 1989:1837-1841.

12. Weiss M, Hechtman L, Weiss G. ADHD in Adulthood: A Guide to Current Theory, Diagnosis, and Treatment. Baltimore, MD: Johns Hopkins University Press; 1999.

13. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

14. Shaffer D. Attention deficit hyperactivity disorder in adults. Am J Psychiatry. 1994;151(5):633-638.

15. Murphy P, Schachar R. Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults. Am J Psychiatry. 2000;157(7):1156-1159.

16. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 1st ed. New York, NY: Guilford Publications; 1990.

17. Barkley RA. ADHD and the Nature of Self-Control. New York, NY: Guilford Publications; 1997.

18. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Publications; 1998.

19. Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. Washington, DC: American Psychiatric Association; 2000.

20. DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. New York, NY: Guilford Publications; 1998.

21. Conners CK, Erhardt D, Sparrow E. Conners’ Adult ADHD Rating Scales. North Tonawanda, NY: Multi-Health Systems; 1999.

22. Epstein JN, Johnson D, Conners CK. Conners’ Adult ADHD Diagnostic Interview for DSM-IV. North Tonawanda, NY: Multi-Health Systems; 2001.

23. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22-23.

24. First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders. New York, NY: State Psychiatric Institute, Biometrics Research; 1995.

25. Barkley RA, Murphy K. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. 2nd ed. New York, NY: Guilford Publications; 1998:35-70.

26. Brown TE. Brown Attention-Deficit Disorder Scales for Children. San Antonio, TX: The Psychological Corporation; 2001.

27. Wender PH, Ward MF, Reimherr FW, Marchant BK. ADHD in adults. J Am Acad Child Adolesc Psychiatry. 2000;39(5):543.

28. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(6):885-890. Erratum in: Am J Psychiatry. 1993;150(8):1280.

29. New York University School of Medicine Web site. Department of Psychiatry home page.

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Cheers,

Mungo

April 23, 2010

Next Steps in my Adult ADHD Assessment

Well, I now have 2 more confirmed appointments set up for my Adult ADHD assessment at the ADHD clinic. Next week I will be meeting with a clinical psychologist (this was to have happened a couple of weeks ago, if not for the sad loss of the clinic's director). And after that, I will be meeting with a psychiatrist who was trained under the director. He will be interviewing me, and assessing me with the benefit of notes from my initial session.

I am optimistic and excited about these meetings. Hopefully I will get some answers about coping strategies, i.e. what some of the psychometric tests and interviews might have indicated about my strengths and liabilities, and how to implement strategies to manage these. Also, I am hoping that they will prescribe medication that is appropriate and that they will be my single point of contact in the preliminary stages of titration (gradually varying/increasing the dose until a therapeutic effect is reached) and figuring out the right medication (as there are several types - both stimulant and non-stimulant medications).

Something I have rarely touched upon in these posts are my feelings and experiences that have motivated me to pursue an assessment. I will get into that soon, but some of the feelings and memories are too difficult and painful to talk about right now. Suffice it to say (assuming the assessment actually results in a positive diagnosis of ADHD), I have experienced a lot of pain and untold turmoil throughout my life that (as I see it) has been deeply affected by attentional inconsistencies, deficits, working memory impairments and social, interpersonal and psychological troubles related at the core to the attentional and motivational deficits related to ADHD.

But spring has sprung, and you'll see in the picture below of a valley behind our home I took recently that the greening is beginning.



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Cheers,

Mungo

April 22, 2010

Super Big Large Gigantic List of ADHD Related Blogs

I have come across a large and varied set of blogs about Adult Attention Deficit Disorder since starting this blog in late March of 2010. I have listed them below in no particular order, with descriptions and links. I hope you find them entertaining, useful, educational, and fun to read. (If you have a link that you'd like to add to this, please use the comment form or e-mail me via the contact page):
  • I Have ADD? - Adult ADD/ADHD Information and Support
    • Jay "...started this blog in November 2007 with the intention of helping others ADD. After a few posts [he] either lost interest or quite possibly forgot about this blog. And that is classic ADD in action." Lots of organization tips, resources and links

  • So I Married an ADDer - News, Advice and Humour for partners of people with ADD.
    • Erin writes her blog as a tribute to her partner Jenn and the blog us written for "...all of you whose better half is blessed with boundless creativity, compassion, and drive." Some topics include decluttering methods, gear, work life and ADHD related events.

  • 18 Channels - My ADHD Coloured Life
    • Katy is a "...a grad student/event planner/paralegal/artist and generally overcommitted person...with ADHD. And honestly...that's not a bad thing." She writes about managing symptoms of ADHD, organization and reflections on academic life.

  • Primarily Inattentive ADHD
    • Tessermom "work[s] part-time in a busy Emergency Department as a Physician Assistant and [is] am also the full time mom of two sons with ADHD. One of [her] sons is Inattentive and one is Hyperactive. [She is] keenly interested in how these two diseases differ and how they are treated."

  • Another Fine Mess - Looking for the punchline in ADHD
    • Mark is a successful freelance cartoonist. For years [he] thought [that he] was lazy, scatter-brained, irresponsible. [...] But it turns out there’s a reason for it. [He writes his blog in order to]...join the ADHD community, to better understand [himself], and to give [himself] another distraction when [he] should be working on [his] cartoons.

  • Addled - Grappling with Adult ADD
    • Jay writes "I have been diagnosed with Adult ADHD (inattentive-type) and I’ve been on medication for it since then. It’s been quite a ride with highs and lows befitting a roller coaster. I definitely have a few stories and lessons-learned to share so far."
      Lots of great content on this blog.

  • Positively Dysfunctional
    • Nick Harris has only a couple of posts, but his latest one is wonderful where he discusses his symptoms of ADHD: "First off, these aren't problems I've been just having lately, or for a while. I've been like this for as long as I can remember; it came out a little differently as a child but it's essentially the same running themes."

  • Living With AD/HD - Reflections on life as an adult with AD/HD. Hopefully something useful too.
    • Mr. Donne has ADHD (combined type), has editorial and journalistic experience in print media (magazines) - and he adds that he also dropped out of a Communication degree. And in the ADHD community, that last piece is chockful of meaning. It is hard to maintain long term commitments... He has some great, short, terse posts about symptoms, medications, coping strategies.

  • A Splintered Mind - Becoming an Author Despite ADHD, Depression & an Annoying Tic Disorder
    • Douglas Cooty is a prolific (and great) writer and photographer, and he shares his stories and experiences because "Maybe somebody out there needs to know they are not alone when dealing with some of these issues. Maybe somebody just wants to feel better about themselves by reading about the mess that is my world. Maybe they find what I have to say entertaining." He also blogs at ADDaboy!

  • ADD ADHD Blog
    • Dr. Handelman is a Child and Adolescent Psychiatrist, practicing just outside Toronto, Canada. He writes that he deals "...with a lot of child, adolescent and adult ADHD in my practice. I began to realize that many people needed a lot more education about ADHD [...] and my goal is to provide you with information relevant to ADD and ADHD, and to keep you up to date on the newest developments."

  • ADHD Roller Coaster: "Is It You, Me, or Adult A.D.D.?"
    • Gina Perry, author of "Is It You, Me, or Adult A.D.D., writes "What’s the connection between Attention-Deficit/Hyperactivity Disorder and a roller coaster? When the partners of adults with ADHD join a support group, they frequently use this analogy–because life with their undiagnosed or “in-denial” ADHD partners is sometimes thrilling but too many times it’s whiplash-inducing, from sudden, unexpected drops on the roller coaster of moods and impulses, distractions and forgotten promises." She also blogs at You and Me... And Adult AD/HD

  • Coach Nancy
    • Nancy A. Ratey is internationally recognized as one of the foremost authorities on personal and professional coaching for adults with Attention-Deficit/Hyperactivity Disorder(AD/HD). As one of the founders of the AD/HD coaching profession, Nancy has been active for the last two decades in developing programs and lecturing on issues related to AD/HD. Nancy has served on the CHADD professional advisory board.
      I have her book The Disorganized Mind, and I highly recommend it.

  • Thoughts on ADHD and Marriage - by Dr. Ned Hallowell and Melissa Orlov
    • Dr. Ned Hallowell and Melissa Orlov blog about marriage when one or both spouses has ADHD. What is it like? What are common themes in marriages with ADHD? What strategies can be used to improve these relationships? How can struggling couples get their marriages back on track so both partners can thrive?
      I have Dr. Hallowell's book 'Driven to Distraction' and also highly recommend this book.

  • My Inattentive Life - A look into the life of a teacher, author, therapist, musician, and father who also suffers from the inattentive subtype of ADHD
    • Josh is a mental health professional and knows very well what it means when I say the words "I suffer from the inattentive subtype of ADHD." He writes to communicate his feelings about it and introduces his blog by saying "I avoid talking about this a lot. It's embarrassing. Because ADHD is the disorder du jour of my generation, there is a lot of baggage and assumption when one admits "hey, btw, I have ADHD." Many people think it's not real." Yip - I can see this coming as my diagnosis comes through in a few weeks.

  • thinkythink - becca colao's hyperthink delight.
    • Becca Colao is an ADHD coach. She writes that "[f]or me, ADHD means thinking too much and too fast. Not many people talk about this experience, so that’s what I do here. [...] I've found there's not information out there about this "hyperthinking" experience of ADHD, and I wanted to humbly begin to change that with my blog. I also coach people around focus, distraction, time, planning, and finding the most effective strategies, systems, and structures to suit the way they are built. Many of my clients have ADHD."

  • ADD'ing it all up - Looking at the world through curiosity colored glasses
    • Mike posts on his blog "with a unique perspective on life, by someone with ADD. I try to keep it down to earth. This blog may also be useful to people without ADD. [...] In addition to being cathartic( helpful to myself by writing this ), I hope this blog is helpful to the readers." This is a very interesting blog - short, concise and pithy commentaries on the struggles, successes and challenges of an ADHD life, written wonderfully.

  • ADD or BS - The ramblings of an ... an ... sorry, what was I talking about? Oh yes, the ramblings of an ADHD skeptic, who's just been "diagnosed" with ADHD.
    • A writer as wonderfully skeptical as I am - he writes "I don't know if I believe the diagnosis. I don't know if I even believe in ADD. I'm pretty sure I have serious doubts about the use of that second "D". And I've not a clue about the wisdom, efficacy, or otherwise of swallowing daily a concoction of amphetamine-based stimulants. But I'm playing along. This blog is just me thinking aloud about the whole deal." A great thinker - you'll be smarter after reading his posts.

  • ADD-Libbing - To ad lib is to be spontaneously witty. To ADD lib is to blog about my clever observations as a lady in her early forties as I navigate life's adventures since my "official" ADD diagnosis 3 years ago..
    • She writes "When I came home from my trip, I borrowed "Driven to Distraction" from the library. Midway through reading the first chapter, I burst into tears. I felt that the book had been written about me." Me too. What a book. And What a disorder.

  • Kick My ADD - Attempting to get my Adult Attention Deficit Disorder under control without prescription medication
    • Self-diagnosed (a contradiction in terms, I'd argue), Renee writes "Here’s the big issue: I don’t want to go to a doctor to get treatment because I don’t want to be on medication. This is my personal belief at the moment, and I’m going to see how well I can manage the symptoms myself before seeing a doctor again, if that becomes necessary." Some great tips on organization, techniques, systems and more to better cope with ADHD symptoms.

  • Jeff's A.D.D. Mind - If A.D.D. Is A Gift... Can I Return It For Something Else?
    • A reader of his wrote "This is not an “A.D.D. Is a Gift” blog by any means. Jeff thinks having A.D.D. sucks, and writes highly analytic and thoughtful posts about how the condition complicates, colors, and otherwise confounds normal life in ways that usually go unnoticed. It’s not a reassuring read, but it’s a brave one, and I concur on a lot of the things he says about the A.D.D. life we both share."

  • Dr. June Kaufman's ADHD Blog Diary
    • Dr. Kaufman is "a practicing clinical psychologist who works with AD(H)D children, adolescents and adults, helping them develop strategies for optimum functioning with their brain style. I have lived my whole life with AD(H)D, and despite all the challenges, I am still married to the same person and have raised two sons, one of whom is ADHD. Completing my doctorate was arduous, to say the least." Inspiring blog, a ton of resources, and very knowledgeable writings.

  • It's ALL Opinion… - Confessions of a Serial Thinker
    • Scott writes about a lot of things, and has a post written "...for all those who have dealt with their own ADHD, or have children dealing with it, to help offer another perspective. Used wisely and harnessed, this can be a truly incredible gift." He's a great writer, drop by and read some more.

  • My ADD / ADHD Blog - Thoughts, Tips, and Information from Tara McGillicuddy, an ADHD Coach and Woman with ADHD
    • Tara is an Senior Certified ADHD Coach. She has been educating and supporting people with ADD through her website Living with ADD for several years. She is also the director of ADDClasses.com.

  • ADHD & the City - Love. Work. Sanity. Or not.
    • Jane writes about relationships, treatment in a blog about "surviving and thriving with ADD. [...] She is active in the adult ADD community, and hopes that one day ADDers will be recognized for their true worth, their creativity, their contributions, and their spark."
Thanks for reading! If you enjoyed this, perhaps you'd like to subscribe to the RSS feed.

Cheers,

Mungo

April 20, 2010

Jasper/Goldberg Adult ADD/ADHD Screening Quiz by Larry Jasper & Ivan Goldberg

Use this questionnaire to help determine if you need to see a mental health professional for diagnosis and treatment of ADD or ADHD in an adult.
Instructions: The 24 items below refer to how you have behaved and felt DURING MOST OF YOUR ADULT LIFE. If you have usually been one way and recently have changed, your responses should reflect HOW YOU HAVE USUALLY BEEN.

For each item, indicate the extent to which it is true by checking the appropriate box next to the item.

I scored in the mid-eighties. Betcha can't beat that! :-(

1. At home, work, or school, I find my mind wandering from tasks that are uninteresting or difficult.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

2. I find it difficult to read written material unless it is very interesting or very easy.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

3. Especially in groups, I find it hard to stay focused on what is being said in conversations.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

4. I have a quick temper... a short fuse.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

5. I am irritable, and get upset by minor annoyances.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

6. I say things without thinking, and later regret having said them.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

7. I make quick decisions without thinking enough about their possible bad results.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

8. My relationships with people are made difficult by my tendency to talk first and think later.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

9. My moods have highs and lows.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

10. I have trouble planning in what order to do a series of tasks or activities.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

11. I easily become upset.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

12. I seem to be thin skinned and many things upset me.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

13. I almost always am on the go.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

14. I am more comfortable when moving than when sitting still.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

15. In conversations, I start to answer questions before the questions have been fully asked.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

16. I usually work on more than one project at a time, and fail to finish many of them.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

17. There is a lot of "static" or "chatter" in my head.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

18. Even when sitting quietly, I am usually moving my hands or feet.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

19. In group activities it is hard for me to wait my turn.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

20. My mind gets so cluttered that it is hard for it to function.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

21. My thoughts bounce around as if my mind is a pinball machine.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

22. My brain feels as if it is a television set with all the channels going at once.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

23. I am unable to stop daydreaming.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much

24. I am distressed by the disorganized way my brain works.
Not at all
Just a little
Somewhat
Moderately
Quite a lot
Very much



Copyright 1990, 1991, 1992, 1993 Larry Jasper & Ivan Goldberg. All rights reserved. Adopted from the printed edition of the Jasper/Goldberg Adult ADD Screening Examination for electronic distribution.

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Cheers,

Mungo

April 18, 2010

How Do I Know If I Have Adult ADHD? Webinar Presented by Dr. Umesh Jain

Have a gander at this TotallyADD.com on demand webinar (i.e. already played, not live), featuring Dr. Umesh Jain answering a series of audience-supplied questions. This is the fellow I saw at a seminar recently at the Ontario Science Center. He's a great speaker, and really down to earth in his presentation, yet very authoritative.

(Press the Play Icon - the triangle - and wait a few seconds for the volume to kick in...):


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Cheers,

Mungo

April 17, 2010

The Value of Screening for Adults With ADHD & The Adult ADHD Self-Report Scale Symptom Checklist

Research suggests that the symptoms of ADHD can persist into adulthood, having a significant impact on the relationships, careers, and even the personal safety of patients who may suffer from it. Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults.

The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included the following team of psychiatrists and researchers:
Lenard Adler, MD
Associate Professor of Psychiatry and Neurology
New York University Medical School

Ronald C. Kessler, PhD
Professor, Department of Health Care Policy
Harvard Medical School

Thomas Spencer, MD
Associate Professor of Psychiatry
Harvard Medical School
Healthcare professionals can use the ASRS v1.1 as a tool to help screen for ADHD in adult patients. Insights gained through this screening may suggest the need for a more in-depth clinician interview. The questions in the ASRS v1.1 are consistent with DSM-IV criteria and address the manifestations of ADHD symptoms in adults. Content of the questionnaire also reflects the importance that DSM-IV places on symptoms, impairments, and history for a correct diagnosis.

You can download a PDF version of the ADHD-ASRS Symptom Checklist v1.1 here, so that you can give it a try.

I filled in this checklist at the beginning of my first Adult ADHD assessment meeting. The checklist takes about 5 minutes to complete and can provide information that is critical to supplement the diagnostic process. Use this screener to see if you have enough symptoms (keep in mind that for a diagnosis, clinicians take severity and duration of symptoms into account), in order for you to then seek a proper diagnosis through a healthcare provider.

Pete Quily, Adult ADD Coach has provided lists of various ADHD support groups for different regions:
For anyone interested in the psychometrics of this scale, please see below (remember, I took statistics SEVERAL times because I kept failing, but this sort of stuff remains interesting to me...

Psychometric data for the ADHD ASRS:
Distributional Characteristics of the ASRS scale in the General Population Information:
  • Range 0-72
  • Mean 17.19
  • Standard Error 1.43
  • Median 17
  • Skewness 0.72
  • Kurtosis 2.74
  • Percentiles:
  • 25th 13
  • 75th 17
  • 80th 18
  • 90th 29
  • 95th 33
  • Values >95th Percentile:
  • 34-54, 57, 60
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Cheers,

Mungo

Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder from DSM-IV-TR

What follows is the listing for the diagnostic criteria for Attention-Deficit/Hyperactivity Disorder from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)

A. Either (1) or (2):
(1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

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Mungo

Diagnosis of AD/HD in Adults - Set of Guidelines Around Clinicians Conducting an Evaluation

This article is ©2003 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and describes:
  • the common symptoms of AD/HD in adults
  • how professionals evaluate adults for possible AD/HD
  • what to expect when consulting a professional for an AD/HD evaluation
What is AD/HD?

Attention-deficit/hyperactivity disorder (AD/HD) is a common neurobiological condition affecting 5-8 percent of school age children,1,2,3,4,5,6,7 with symptoms persisting into adulthood in as many as 60 percent of cases (i.e. approximately 4% of adults). 8,9

In most cases, AD/HD is thought to be inherited, and tends to run in some families more than others. AD/HD is a lifespan condition that affects children, adolescents, and adults of all ages. It affects both males and females, and people of all races and cultural backgrounds.

  • Some common symptoms and problems of living with AD/HD include:
  • Poor attention; excessive distractibility
  • Physical restlessness or hyperactivity
  • Excessive impulsivity; saying or doing things without thinking
  • Excessive and chronic procrastination
  • Difficulty getting started on tasks
  • Difficulty completing tasks
  • Frequently losing things
  • Poor organization, planning, and time management skills
  • Excessive forgetfulness
Not every person with AD/HD displays all of the symptoms, nor does every person with AD/HD experience the symptoms of AD/HD to the same level of severity or impairment. Some people have mild AD/HD, while others have severe AD/HD, resulting in significant impairments. AD/HD can cause problems in school, in jobs and careers, at home, in family and other relationships, and with tasks of daily living.

AD/HD is thought to be a biological condition, most often inherited, that affects certain types of brain functioning. There is no cure for AD/HD. When properly diagnosed and treated, AD/HD can be well managed, leading to increased satisfaction in life and significant improvements in daily functioning. Many individuals with AD/HD lead highly successful and happy lives. An accurate diagnosis is the first step in learning to effectively manage AD/HD.

How is AD/HD diagnosed?

There is no single medical, physical, or genetic test for AD/HD. However, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources. These include AD/HD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information obtained from family members or significant others who know the person well. AD/HD cannot be diagnosed accurately just from brief office observations, or just by talking to the person. The person may not always exhibit the symptoms of AD/HD in the office, and the diagnostician needs to take a thorough history of the individual's life. A diagnosis of AD/HD must include consideration of the possible presence of co-occurring conditions.

Clinical guidelines for diagnosis of AD/HD are provided in the American Psychiatric Association diagnostic manual commonly referred to as the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). These established guidelines are widely used in research and clinical practice. During an evaluation, the clinician will try to determine the extent to which these symptoms apply to the individual now and since childhood. The DSM-IV-TR symptoms for AD/HD are listed below:

Symptoms of Inattention
  1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  2. Often has difficulty sustaining attention in tasks or play activities
  3. Often does not seem to listen when spoken to directly
  4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  5. Often has difficulty organizing tasks and activities
  6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
  7. Often loses things necessary for tasks or activities
  8. Is often easily distracted by extraneous stimuli
  9. Is often forgetful in daily activities
Symptoms of Hyperactivity
  1. Often fidgets with hands or feet or squirms in seat
  2. Often leaves seat in classroom or in other situations in which remaining seated is expected
  3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  4. Often has difficulty playing or engaging in leisure activities quietly
  5. Is often "on the go" or often acts as if "driven by a motor"
  6. Often talks excessively
Symptoms of Impulsivity
  1. Often blurts out answers before questions have been completed
  2. Often has difficulty awaiting turn
  3. Often interrupts or intrudes on others (e.g., butts into conversations or games)
A diagnosis of AD/HD is determined by the clinician based on the number and severity of symptoms, the duration of symptoms, and the degree to which these symptoms cause impairment in various life domains (e.g. school, work, home). It is possible to meet diagnostic criteria for AD/HD without any symptoms of hyperactivity and impulsivity. The clinician must further determine if these symptoms are caused by other conditions, or are influenced by co-existing conditions.

It is important to note that the presence of significant impairment in at least two major settings of the person's life is central to the diagnosis of AD/HD. Impairment refers to how AD/HD interferes with an individual's life. Examples of impairment include losing a job because of AD/HD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending or failure to pay bills in a timely manner, or getting on academic probation in college due to failing grades. If the individual manifests a number of AD/HD symptoms but does not manifest significant impairment, s/he may not meet the criteria for AD/HD as a clinical disorder.

The DSM-IV TR specifies three major subtypes of AD/HD:
  1. Primarily Inattentive Subtype. The individual mainly has difficulties with attention, organization, and follow-through.
  2. Primarily Hyperactive/Impulsive. The individual mainly has difficulties with impulse control, restlessness, and self-control.
  3. Combined Subtype. The individual has symptoms of inattention, impulsivity, and restlessness.
Internet Self-Rating Scales

There are many Internet sites about AD/HD that offer various types of questionnaires and lists of symptoms. These questionnaires are not standardized or scientifically validated and should never be used to self-diagnose or to diagnose others with AD/HD. A valid diagnosis can only be provided by a qualified, licensed professional.

Who is qualified to diagnose AD/HD?

For adults, an AD/HD diagnostic evaluation should be provided by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor, or other type of physician), or clinical social workers.

Whichever type of professional the individual may choose, it is important to ask about their training and experience in working with adults with AD/HD. Many times the professional's level of knowledge and expertise about adult AD/HD is more important for obtaining an accurate diagnosis and effective treatment plan than the type of professional degree. Qualified professionals are usually willing to provide information about their training and experience with adults with AD/HD. Reluctance to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek out a different professional.

How do I find a professional qualified to diagnose AD/HD?

Ask your personal physician for a referral to a health care professional in your community who is qualified to perform AD/HD evaluations for adults. It may also be helpful to call a university-based hospital, a medical school, or a graduate school in psychology in your area. If there is an AD/HD support group in your area, it may be very helpful to go there and talk with the people attending the group. Chances are that many of them have worked with one or more professionals in your community and can provide information about them.

How do I know if I need an evaluation for AD/HD?

Most adults who seek an evaluation for AD/HD experience significant problems in one or more areas of living. Some of the most common problems include:
  • Inconsistent performance in jobs or careers; losing or quitting jobs frequently
  • A history of academic and/or career underachievement
  • Poor ability to manage day-to-day responsibilities (e.g., completing household chores or maintenance tasks, paying bills, organizing things)
  • Relationship problems due to not completing tasks, forgetting important things, or getting upset easily over minor things
  • Chronic stress and worry due to failure to accomplish goals and meet responsibilities
  • Chronic and intense feelings of frustration, guilt, or blame
A qualified professional can determine if these problems are due to AD/HD, some other cause, or a combination of causes. Although some AD/HD symptoms are evident since early childhood, some individuals may not experience significant problems until later in life. Some very bright and talented individuals, for example, are able to compensate for their AD/HD symptoms and do not experience significant problems until high school, college, or in pursuit of their career. In other cases, parents may have provided a highly protective, structured and supportive environment, minimizing the impact of AD/HD symptoms until the individual has begun to live independently as a young adult.

How should I prepare for the evaluation?

Most people are a little nervous and apprehensive about being evaluated for any type of condition such as AD/HD. This is normal and should not stop anyone from seeking an evaluation if s/he is having significant problems in life and AD/HD is suspected. Unfortunately, some of the common misperceptions about AD/HD (e.g., it only occurs in children, or the person is just looking for an excuse) make many people reluctant to seek help.

Many professionals find it helpful to review old report cards and other school records, dating back to kindergarten or even the preschool years. If such records are available, they should be brought to the first appointment. Copies of reports from any previous psychological testing should also be brought to the appointment. For adults who experience problems in the workplace, job evaluations should be brought for review if available.

Many professionals will ask the individual to complete and return questionnaires before the evaluation, and to identify a significant other who will also participate in parts of the evaluation. Timely completion and return of the questionnaires will expedite the evaluation.

What is a comprehensive evaluation?

Although different clinicians will vary somewhat in their procedures and testing materials, certain protocols are considered essential for a comprehensive evaluation. These include a thorough diagnostic interview, information from independent sources such as the spouse or other family members, DSM-IV symptom checklists, standardized behavior rating scales for AD/HD, and other types of psychometric testing as deemed necessary by the clinician. These are discussed in more detail below.

The Diagnostic Interview: AD/HD Symptoms

The single most important part of a comprehensive AD/HD evaluation is a structured or semi-structured interview, which provides a detailed history of the individual. In a "structured" or "semi-structured" interview, the interviewer asks a pre-determined, standardized set of questions, in order to increase reliability and decrease the chances that a different interviewer would come up with different conclusions. This allows the clinician to cover a broad range of topics, discuss relevant issues in more detail, and ask follow up questions while ensuring coverage of the domains of interest. The examiner will review the diagnostic criteria for AD/HD and determine how many of them apply to the individual, both at the present time and since childhood. The interviewer will further determine the extent to which these AD/HD symptoms are interfering with the individual's life.

The Diagnostic Interview: Screening for Other Psychiatric Disorders

The examiner will also conduct a detailed review of other psychiatric disorders that may resemble AD/HD or commonly co-exist with AD/HD. AD/HD rarely occurs alone. In fact, research has shown that many people with AD/HD have one or more co-existing conditions. The most common include depression, anxiety disorders, learning disabilities, and substance use disorders. Many of these conditions mimic some AD/HD symptoms, and may, in fact, be mistaken for AD/HD. A comprehensive evaluation includes some interviewing to screen for co-existing conditions. When one or more co-existing conditions are present along with AD/HD, it is essential that all are diagnosed and treated. Failure to treat co-existing conditions often leads to failure in treating the AD/HD. And, crucially, when the AD/HD symptoms are a secondary consequence of depression, anxiety, or some other psychiatric disorder, failure to detect this will result in incorrectly treating the individual for AD/HD. Other times, treating the AD/HD will eliminate the other disorder and the need to treat it independently of AD/HD.

The examiner is also likely to ask questions about the person's health history, developmental history going back to early childhood, academic history, work history, family and marital history, and social history.

Participation of a Significant Other

It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, parent, partner) who knows the person well. This procedure is not to question the person's honesty, but rather to gather additional information. Many adults with AD/HD have a spotty or poor memory of their past, particularly from childhood. They may recall specific details, but forget diagnoses they were given or problems they encountered. Thus, the clinician may request that the individual being evaluated have his or her parents fill out a retrospective AD/HD profile describing childhood behavior.

Many adults with AD/HD may also have a limited awareness of how AD/HD-related behaviors cause problems for them and have impact on others. In the case of married or cohabitating couples, it is to the couple's advantage for the clinician to interview them together when reviewing the AD/HD symptoms. This procedure helps the non-AD/HD spouse or partner develop an accurate understanding and an empathetic attitude concerning the impact of AD/HD symptoms on the relationship, setting the stage for improving the relationship after the diagnostic process has been completed.

Finally, it should be noted that many adults with AD/HD feel deeply frustrated and embarrassed by the ongoing problems caused by their AD/HD. It is very important that the person being evaluated discuss these problems openly and honestly, and not hold back information due to feelings of shame or fear of criticism. The quality of the evaluation, and the accuracy of the diagnosis and treatment recommendations, will be largely determined by the accuracy of the information provided to the examiner.

Standardized Behavior Rating Scales

A comprehensive evaluation includes the administration of one or more standardized behavior rating scales. One of the rating scales may be a checklist of the DSM-IV-TR AD/HD symptoms reviewed earlier in this information and resource sheet. These are questionnaires based on research comparing behaviors of people with AD/HD to those of people without AD/HD. Scores on the rating scales are not considered diagnostic by themselves, but serve as an important source of objective information in the evaluation process. Most clinicians ask the individual undergoing the evaluation and the individual's significant other to complete these rating scales.

Psychometric Testing

Depending on the individual and the problems being addressed, additional psychological, neuropsychological, or learning disabilities testing may be used as needed. These do not diagnose AD/HD directly but can provide important information about ways in which AD/HD affects the individual. The testing can also help determine the presence and effects of co-existing conditions. For example, in order to determine whether the individual has a learning disability, the clinician will usually give a test of intellectual ability as well as a test of academic achievement.

Medical Examination

If the individual being evaluated has not had a recent physical exam (within 6-12 months), a medical examination is recommended to rule out medical causes for symptoms. Some medical conditions (e.g., thyroid problems, seizure disorders) can cause symptoms that resemble AD/HD symptoms. A medical examination does not "rule in" AD/HD but is extremely important in helping to "rule out" other conditions or problems.

Conclusion

Towards the end of the evaluation the clinician will integrate the information that has been collected through diverse sources, complete a written summary or report and provide the individual and family with diagnostic opinions concerning AD/HD as well as any other psychiatric disorders or learning disabilities that may have been identified during the course of the assessment.The clinician will then review treatment options and assist the individual in planning a course of appropriate medical and psychosocial intervention. Afterwards, the clinician will communicate with the individual's primary care providers, as deemed necessary.

Suggested Reading
  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
  • Brown, T.E. (Ed.) (2000). Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press.
  • Goldstein, S., & Teeter Ellison, A. (Eds.) (2002). Clinician's guide to adult AD/HD: Assessment and intervention. New York: Academic Press.
  • Murphy, K.R., & Gordon, M. (1998). Assessment of adults with AD/HD. In Barkley, R. (Ed.) Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. (pp. 345-369). New York: Guilford Press.
References
  1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM IV (4th ed., text, revision), Washington, D.C.: American Psychiatric Association.
  2. Mayo Clinic. (2002). How Common is Attention-Deficit/Hyperactivity Disorder? Archives of Pediatrics and Adolescent Medicine 156(3): 209-210.
  3. Mayo Clinic (2001). Utilization and Costs of Medical Care for Children and Adolescents with and without Attention-Deficit/Hyperactivity Disorder. Journal of the American Medical Association 285(1): 60-66.
  4. Surgeon General of the United States (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services.
  5. American Academy of Pediatrics (2000). Clinical practice guidelines: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158-1170.
  6. Centers for Disease Control and Prevention (2003). Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder. Morbidity and Mortality Weekly Report 54: 842-847.
  7. Froehlich, T.E., Lanphear, B.P., Epstein, J.N., et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Archives of Pediatric and Adolescent Medicine (2007), 161:857-864.
  8. Faraone, S.V., Biederman, J., & Mick, E. (2006) The age-dependent decline of attention-deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychol Med (2006), 36: 159-65.
  9. Kessler, R.C., Adler, L., Barkley, R., Biederman, J., et al. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am Journal of Psychiatry (2006), 163:724-732.
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Cheers,

Mungo

April 15, 2010

Historical Autobiographical Documents - Report Cards from School

For years I wouldn't look at my report cards from early school and high school. They sat stacked, and gathering dust in an old box in the basement. When I fished some of them out prior to my first Adult ADHD Assessment session a couple of weeks ago to provide some third-party verification of academic performance, I was saddened yet forgiving of this fellow's report cards (that poor fellow being me).

They clearly indicate attentional and behavioural inconsistency problems throughout my early years. Here are snippets of teachers' comments from my report cards:

Elementary School
(ages 6 through 10)
  • "Though his project was late, it was most imaginative and thorough, in preparation."
  • "We find him lacking in organizational skills, evidenced by some difficulty in sorting out relevant material in the more advanced logical thinking exercises."
  • "He is a delightful effervescent boy who is above all else, polite."
  • "He enthusiastically joins in group discussions and contributes to class charts. His enthusiasm overrules his composure at times causing him to speak out before being asked."
  • "He has a broad range of knowledge and offers intelligent opinions, but he has a disturbing habit of interrupting other children to state these opinions."
  • "He asks questions when curious or in doubt"
  • "He is easily distracted."
High School
(ages 14 through 18) - some of these teachers' comments were cruel and generalized - not particularly constructive in my opinion:
  • "He was disappointing this year."
  • "I was disappointed by him."
  • "Get your attitude sorted out and refrain from silly behaviour."
  • "What a shame... never gave himself the chance to achieve."
  • "Failed to accept sufficient responsibility."
  • "Your poor mark was the result of inconsistent sometimes unmotivated work."
And the classic, somewhat defeated sounding comment:
  • "You did not care about this course, nor did you put in any kind of effort."
But several read as follows:
  • "88% - Excellent Work!"
  • "It was a pleasure teaching him this semester! Great mark!"
Note: These were from classes that I really enjoyed and found fascinating, like Biology and History.

Have a look at these comments also:

Figure 1: Exam mark of 80%, overall mark of 46% - a result of inconsistent attention.



Figure 2: Inconsistency, erratic (read 'impulsive'), and intense intelligence - so it wasn't that I could get great marks based on intelligence alone.


Figure 3: Apparent social difficulties due to impulsive behaviours (non sequitors, interrupting behaviour) trumps my keen interest, and submission of work that surpasses that of my peers.

Well, it was hard to read these, but they all fit disturbingly well into a diagnosis of ADHD. And now that I have a 'narrative' in the form of the criteria and symptoms of ADHD, I can attribute some consistent meaning to these inconsistent and poor report cards. And because of this I feel much better about these reports cards - maybe I won't have to hide them away anymore. Maybe I can post them on a blog for the world to view!

Thanks for reading! If you enjoyed this, perhaps you'd like to subscribe to the RSS feed.

Cheers,

Mungo

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