You greet a new patient who complains of difficulty concentrating at work and is unable to “keep up” since making partner at a law firm or becoming an attending physician at a hospital. Is this an authentic case of a high-functioning person with undiagnosed adult ADHD, a subtle request for performance enhancement, or something altogether different?
We all know about specialized ADHD clinics that offer imaging and comprehensive assessment; but in your office, how can you use readily available screening tools and a comprehensive clinical interview to diagnose adult ADHD? Either approach might result in an ADHD diagnosis and/or a prescription of stimulant medication, but is any one approach more effective? How can we use existing screening tools wisely?
One starting point might be my decade of experience as the student health psychiatrist at a competitive US medical school. Our highly-driven students have taught me a lot about adult ADHD. Technically, ADHD is a developmental disorder with childhood onset that results in chronic and pervasive impairment in academic, social, vocational, or daily functioning. It must be documented beyond self-report to impair two life settings. The problem is that the DSM criteria and research studies have primarily looked at children, and the symptoms and impairments of adult patients do not quite match those of children.
Differential Diagnosis of Adult ADHD The clinician’s task is to create a responsible strategy to screen carefully, diagnose accurately, and implement an effective treatment plan in a limited time frame. Are you confident that the anxiety of making partner or becoming an attending over the last six months does not better account for sudden-onset symptoms? Does the patient have any medical conditions or require lab work to rule out the same? Has your patient been drinking a lot more or smoking more pot? Is ADHD a part of your practice that you want to grow and work with, or would this case be better handled with a referral to someone recognized in the community as an expert?
Rating scales provide the most efficient method of screening for ADHD symptoms, but are only the first step in a conversation that will ultimately yield a clinical diagnosis. For example, in his book Taking Charge of Adult ADHD (New York, NY: The Guilford Press; 2010), Dr. Russell Barkley has identified nine main symptoms that you need to explore with adult patients. Remember the key domains of ADHD are distractibility, impulsivity, and hyperactivity. Does your patient:
Get distracted easily by extraneous stimuli or irrelevant thoughts?
Make decisions impulsively?
Have difficulty stopping activities?
Start a project without reading or listening to directions?
Fail to follow through on commitments to others?
Have trouble doing things in their proper order?
Have a complicated driving record?
Have difficulty sustaining attention in tasks or fun stuff?
Have difficulty organizing tasks and activities?
Endorsing four of the first seven criteria, or six out of the total nine, can lead you comfortably to a working hypothesis of ADHD. Next steps may include a more detailed clinical history, psychological testing as needed, or a medication trial. A related scale, Barkley’s CSS (Current Symptom Scale) is protected by copyright and reviews 18 symptoms in a user-friendly workbook (Barkley RA & Murphy KR. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. New York, NY: The Guilford Press; 2006).
In my practice I often use the Adult ADHD Self-Report Scale (ASRS-v1.1), as well. Pioneered for use by the World Health Organization, it is available for free on the Internet (and in seven languages) and consists of two main sections. The first six questions, answered with a user-friendly Likert scale, look at symptoms over the last six months. If four of these six are answered in the shaded area of the instrument, there is a 94% chance that the patient has adult ADHD. (The first four target inattentiveness and the last two hyperactivity.) The remaining 12 questions help to elicit details of the two subtypes. The sensitivity of the ASRS has been questioned, however, in that it might miss one-third of patients who meet diagnostic criteria for adult ADHD in detailed diagnostic interviews (Kessler RC et al, Psychol Med 2005;35(2):245–256). You can download the ASRS-v1.1 online at http://bit.ly/XiMEPM.
Confirming Your Suspicions Multiple rating scales, books, websites, and organizations (many referenced in Barkley’s book) can assist you and your patient over time. Remember that the patient is your partner in this exploration. Personally, I try to avoid being the “expert” and telling patients what they “have.” Instead, the more I can collaborate with patients to learn about their situation, the more I can confirm my conviction that ADHD is or is not the operative diagnosis. It helps to determine the immediate impact of impairment, create a plan to get better, and carefully rule out comorbid anxiety or depression. If a patient does not have a primary anxiety disorder, for instance, then living with untreated ADHD will, by definition, create multiple invitations to feel anxious when external events (eg, deadlines and life commitments) meet the internal baseline of distractibility. Delay can also create anxiety, feeding procrastination and even greater anxiety as the cycle intensifies.
By definition, many or most of the symptoms of ADHD have been present since childhood or adolescence. Patients may have tests showing a reading or language problem in grade school. Perhaps the most frequent misunderstanding among clinicians is the belief that ADHD is a diagnosis of distractibility rather than a more complex difficulty regulating the extremes of hyper- and hypofocus. When taking an academic history, you might find examples of procrastination, time management problems, or reading discomfort (hypofocus). Conversely, you may find creative adaptations to learning styles, including auditory modes of compensation, working in groups to retain material, or recognized areas of excellence (hyperfocus).
Listen for study styles, including extensive use of caffeine, nicotine, or studying in particularly quiet or noisy places. Moving beyond academic or professional life, you may uncover difficulties in romantic relationships (infidelity), child rearing (uncontrolled anger or difficulty multi-tasking), housekeeping (multiple tasks begun simultaneously), or finances (debt). Important clinical information includes asking about particular methods of cleaning the house, the presence of stacks of papers, avoidance of complicated paperwork, overspending or overeating, and the inability to slow down during leisure time.
Many patients may compensate by working hard to cover their tracks, often leaving some incredulous that ADHD or a compensated learning disability might exist. “How could you have ADHD? You graduated cum laude from an Ivy League school, have glowing references, and a strong work ethic—no way!” One hallmark of compensatory behavior is internalized shame: patients know how to engage in compensatory behavior, have done so for years, and believe that they are either weak or stupid in response to the extra efforts to keep up with peers. Compensatory behaviors might include excessive use of caffeine, tobacco, marijuana, credit cards, compulsive stacks of notes, erratic housekeeping, and all-night cram sessions—hearing about these in the consulting room merits further inquiry about adult ADHD.
Treatment Options A final “after the fact” soft diagnostic tool is a medication trial. If you are this far along with your patient, a test dose might be in order. Whether you start with methylphenidate (Ritalin) or amphetamine salts (Adderall), the patient’s response to a stimulant can be an invaluable guide to treatment. Patients who respond by saying that they feel calmer, are able to sit still, and perhaps even say they feel “normal” for the first time are in my experience likely to have adult ADHD. Those who say they do not feel so different but notice that their to-do lists are done by dinner or who no longer fight with their partner at bedtime over chores left undone are also likely candidates. Those who feel exacerbations in mood or anxiety symptoms are worthy of clinical evaluation for bipolar and/or anxiety spectrum disorders. Although the idea that medication response can be used to diagnose ADHD does not have much empirical support, and people without ADHD may also become more productive on stimulants, when a patient responds to medication by saying that things become more salient, clear, or “smooth,” this can be confirmatory of a diagnosis.
Once you get to this point, many possible steps unfold. Multiple medication strategies exist; questions of ADHD coaching or psychotherapy referrals come to mind; education about the syndrome and its management are high-yield; and referrals for neuropsychiatric testing to screen for any masked learning disabilities (such as compensated dyslexia or visual processing disorder) can prove invaluable.
Helping a previously undiagnosed patient to get the right treatment can affect all spheres of functioning. It is my experience that if one works carefully with the patient over time to find relative relief of painful symptoms of academic failure or frustrating experiences with learning and organization, then treatment for adult ADHD is analogous to all good treatment. Thinking of this work as “cosmetic” is stigmatizing, since it is a myth that we all have ADHD symptoms like those who actually meet criteria for the disorder.
TCPR’s VERDICT: Rating scales are useful in beginning a conversation, but they reflect a certain point in time and have the limitations of human recall. They are excellent conversation starters and can even be used to track progress or response to medication. However, none of them will replace the value of being in the room over time with your patient and teasing out what is—and is not—adult ADHD and for whom. The above approach represents the time-honored tradition of spending time with patients in a clinical struggle and seeing them through it.