Accurate diagnosis of adult ADHD remains a clinical challenge. It is a "hidden
disorder" representing extremes of normal behaviors, with no clear consensus
regarding the clinical boundaries (Levy et al), particularly for adults. Neuropsychological
testing most consistently finds deficits in tests of attention, behavioral
inhibition, and working memory (Hervey, Epstein, & Curry). These findings
have helped to establish the neuropsychiatric validity of ADHD. There is also
a growing body of research that may implicate dysfunction of right hemisphere
systems in ADHD (see Stefanatos & Wasserstein for a review). However, reported
findings are typically observed for ADHD groups and not necessarily seen in
all individuals. As yet no characteristic neuropsychological profile exists.
There is consequently no definitive "test" for ADHD, although certain
deficit patterns are more likely to occur in ADHD. The role of testing in the
diagnostic evaluation is still evolving and is likely to become an ever more
important source of objective information. Clinical history, specialized symptom
rating scales, and selective testing (on an as-needed basis) are the current
state of the art. In the diagnostic process, I recommend the following components: • Assess
current level of symptoms. • Assess degree of functional impairment. • Establish
childhood history. • Perform general psychological evaluation. • Obtain
developmental history. • Obtain family psychiatric and neuropsychiatric
history. • Institute specialized psychological or neuropsychological testing. • Be
mindful of medical mimics.
Current Level of Symptoms
Current level of symptoms is most easily assessed by using one or more of the
existing ADHD scales, which provide adult and adolescent norms. There is
debate about the accuracy of these measures, although empirical studies typically
find underreporting of symptoms among adults (Barkley). Thus use of the scales
may actually lead to an underestimate of the level of problems, because of
the patients’ underreporting or blunted self-awareness. I have found
underestimating problems to be especially likely among adolescents who are
still struggling with identity formation, rather than among adults, who have
experienced more persistent challenges. Sometimes people overreport because
they are motivated to get the diagnosis in order to secure academic accommodations,
provide an explanation for their dysfunction, or generally be symptom magnifiers
(a response set). It is helpful to have additional input from a collateral
reporter, such as a spouse or parent (who can be given the same scales),
although many adults are reluctant to involve others. For adolescents, collateral
informants may be essential because of their tendency to be poor self-observers.
The Brown Attention Deficit Disorder Scales (Brown) and the Conners’ ADHD
rating scales (Conners, Erhardt, & Sparrow), adult and adolescent versions,
are among the most widely used ADHD scales in clinical practice. Each scale
has been shown to have reasonable sensitivity and specificity when differentiating
between those who have ADHD and control populations. The scales differ in
the dimensions of the disorder they emphasize. The Brown scale consists of
40 items that focus on the executive spectrum of problems and, as such, assess
difficulties with activation, perseverance, affect regulation, and working
memory, as well as with the core symptom of inattention. Sample questions
also address tendencies for procrastination, disorganization, and poor self-regulation
(e.g., difficulty in waking up in the morning, tendency to feel overwhelmed,
slowness of reactions, need for extra time). Hyperkinetic and impulsive spectrum
issues are not sufficiently queried. By contrast, the Conners’ scale
adheres more closely to the DSM-IV criteria, thereby also providing adult
norms for hyperactivity and impulsivity, as well as for core inattention/memory
problems. It consists of 66 items, which address a wider spectrum of ADHD
symptoms, including poor self-image. For example, boredom, restlessness,
and verbal impulsiveness are directly queried on this measure, as is affective
lability. However, the many manifestations of executive dysfunction deficits
are not as closely assessed. Clinically, I have found the Brown to be more
sensitive for inattentive spectrum problems and Conners’ more sensitive
for hyperactive/ impulsive spectrum problems. It is useful to administer
both measures and draw diagnostic conclusions from the total data set. Scores
can also be used as baseline measures to target specific areas for intervention
and to monitor change.
Degree of Functional Impairment
Functional impairment is usually evaluated by clinical interviews of the patient
and significant others (such as spouse or parent). The general questions
here are how much suffering and dysfunction ADHD symptoms are causing in
the person’s life. Are the symptoms compromising work and/or social
functioning, contributing to the person’s failure to achieve specific
life goals, resulting in significant suffering to others (e.g., spouse, children,
coworkers), or increasing significant health risks (e.g., substance abuse,
risky driving, sexual promiscuity)? Two additional questions need to be considered
when evaluating the preceding questions: The first again relates to poor
recognition of problems by the client. The second relates to the level of
effort required for the person to function, thereby possibly masking the
existence of "impairment."
Poor recognition is usually not a concern for self-referred patients. By definition
they have sought an evaluation because they believe there is some impairment.
In this context the clinician needs to clarify the exact problems and parameters.
It is tempting to view examples as "only normal," and one needs
to be mindful of base rates of problem behaviors. For example, how frequently
do they lose track of required things or conversations at work? How behind
are they on their bill payment and e-mail responses? How many areas are out
of control? Poor recognition is more likely when someone seeks an evaluation
at the request of another. Again, outside reporters are essential when poor
self-awareness exists or is suspected. Work evaluations can also be very useful.
There is some disagreement among experts regarding what constitutes functional
impairment. There is no argument when individuals overtly fail at work or in
school because of ADHD-related symptoms, such as chronic lateness, failure
to meet deadlines, and interpersonal difficulties (e.g., noncompliance). Disagreement
emerges when people do not fail, and may even perform well, but describe expending
excessive amounts of time and energy in order to do so. Some argue that, as
for an alcoholic, one does not need to be actively drinking (i.e., failing)
to have a problem. Simply working excessively hard to compensate, and often
at great personal and social cost, becomes the marker for functional impairment.
Although this point may seem arbitrary, many individuals who show this profile
(and also meet other current and historical diagnostic criteria) often experience
dramatic symptom relief with treatment.
Establish Childhood History
Childhood history of ADHD is essential and typically evaluated through a clinical
interview. Awareness of the usual developmental course of ADHD is important.
In general, the more characteristic developmental findings in a given individual’s
life span, the more likely the diagnosis of ADHD. History gathering can also
be supplemented by commercial
structured history forms. For example, an excellent adult version, created
by Brown, is available through Psychological Corporation. Administration of
standardized retrospective self-report questionnaires, such as the Wender-Utah
Rating Scale (WURS; Wender) is also useful. It is a 25-item measure, gleaned
from 61 original items, which separated adults who have ADHD from normal control
and depressed adults. However, the recommended cutoff scores are somewhat conservative
and were designed to be so for research purposes. In my experience, people
who had milder forms of hyperactivity/impulsivity or pure inattentive type
ADHD during childhood are likely to be missed on this measure. However, as
it was designed to be, a positive score is strongly predictive of accurate
diagnosis and good stimulant medication response in adults. When reviewing
personal history, I look for the following common developmental markers of
ADHD. Poor cooperation with peers and noncompliance are most pronounced in
preschoolers but may be seen throughout the life span. Preschoolers also tend
to have difficulty with transitions and focused group activities (e.g., circle
time). In addition to distractibility and hyperactivity/impulsivity, school-aged
children show difficulty in developing
routines of daily living (e.g., sleep, grooming, even toilet training) and
often have trouble in acquiring basic academic skills. Poor handwriting is
extremely common, as are all specific learning disabilities, disorganization,
and general underachievement. Adolescents tend to be immature, have more conflicts
with parents, have poor social skills, and engage in more high-risk activities,
such as alcohol and drug use, unprotected sex, and reckless driving.
Academically, teens who have ADHD show difficulty completing homework and longer
projects (Weiss & Murray). Clinically, I have found that preschoolers who
have ADHD have a high rate of pervasive developmental delay NOS, and many school
age children who have ADHD/inattentive type show nonverbal learning disability
profiles. As teens, I have found, boys who have ADHD/combined type are more
isolated or antisocial; girls who have ADHD/combined type are more hypersocial,
although variations exist. When looking for childhood symptoms, it is important
to recall that a highly organized home life can mitigate the expression of
many ADHD symptoms. For example, availability of sports or structured teachers,
organized schools, or even regimented cultures can mask the expression of many
symptoms. As a result, interviews with parents or significant others may be
necessary to unveil the existence of earlier excessive impulsivity, disorganization,
inattention to detail, forgetfulness, and the like. Overt problems may have
only become apparent during middle school, higher education, or even later
in the work world. That is, ADHD problems become ever more manifest as environmental
demands become more complex and, concurrently, external supports are increasingly
removed (Wolf &Wasserstein). When available, report cards and/or teacher
letters can be extremely helpful.
General Psychological Evaluation
Inattention and impulsivity are to psychopathology what fever is to medicine.
That is, many core ADHD symptoms can be nonspecific symptoms of many other
psychological disorders, not only of ADHD. Consequently, it is necessary
to rule out other possible psychiatric diagnoses as alternative explanations
for the symptoms. Further complicating the diagnostic process is the fact
that ADHD frequently occurs in combination with other psychiatric disorders
(Wender; Brown). Thus the presence of a comorbid condition does not rule
out ADHD. The setting in which assessment occurs is likely to influence the
type of comorbidity seen. Prospective studies that follow children into adulthood
report high rates of antisocial and substance abuse disorders. By contrast,
adults who seek treatment in clinical settings are more likely to report
depression and anxiety (Gallager & Blader,). By extension, self-referred
people may be more likely to have the mood and anxiety disorders, whereas
the people taken in by others (often adolescents) may be more likely to have
acting-out problems.
Standardized checklists are helpful and speed up the evaluation
process. I use the Symptom Checklist-90 Items Revised (SCL-90R) and/or the
Beck Depression and Anxiety Scales. All provide well-normed standards. When
a more complicated analysis of personality functioning is required or requested,
more elaborate questionnaires such as the Minnesota Multiphasic Personality
Inventory (MMPI-2) or the Million Clinical Multiaxial Inventory (MCMI) are
useful. However, the reader is cautioned that current computer-generated reports
for adults were not created with ADHD as a diagnostic possibility. As a result,
many ADHD symptoms can be subsumed under mania and/or antisocial personality.
Projective testing may prove useful, as dictated by the taste, experience,
and preferences of the diagnostician.
Because ADHD can coexist with depression and anxiety, a differential diagnosis
is sometimes very difficult. In such situations the time line of core symptoms
needs to be closely evaluated. I note whether or not symptoms have remained
constant throughout life, improved somewhat in adulthood, or fluctuated along
with mood/anxiety changes. Those who have true ADHD often describe some symptom
remission over time. They also convincingly argue that their comorbid problems
are secondary to their lifelong dysfunction from ADHD. For example, they report
always having been inattentive and disorganized, irrespective of their emotional
state. Absent periods of normal functioning and given a positive family history,
diagnosis of ADHD with depression (or anxiety disorder) may be appropriate.
Those who have primary mood disorder report concentration difficulties that
parallel their degree of depression (during childhood or adulthood). Similarly,
severe anxiety can disturb concentration and cause physical overactivity. If
the symptom course is unclear, treating these more reversible conditions first
and postponing the final diagnostic decision regarding ADHD may be prudent.
Sometimes the person’s concentration, attention, and organization improve
dramatically with relief of depression or anxiety. Often the symptoms remain,
thereby clarifying the diagnosis. Hyperactive/ impulsive symptoms may also
be difficult to differentiate from hypomania or extreme anxiety. Periodicity
of symptoms and overt signs of mania (e.g., excessive spending, hypersexuality,
primitive and loose thinking) can help in forming a diagnosis of bipolar illness.
Treatment of anxiety can clarify the existence of residual ADHD. Again, family
history of probable genetic risk is useful, but not definitive, in this regard.
Specialized Testing
Psychological and neuropsychological testing is useful for evaluating attention
and executive functions, as well as for gaining a better understanding of
commonly comorbid LDS. Other neuropsychological domains, such as memory,
language, and visuomotor abilities, may also be compromised to varying degrees
(Gallagher & Blader). Despite
some guidelines derived from the child literature (e.g., executive dysfunction),
as yet there is no consensus regarding the expected neuropsychological profile
of adults (Hervey et al.).
Computerized tests (CPTs) of sustained attention are among the most frequently
employed neuropsychological measures. This high utilization rate probably reflects
the fact that CPTs measure the two primary neurocognitive domains associated
with ADHD, attention and response inhibition. Specifically, CPTs require the
examinee to respond rapidly when presented a target stimulus and not to respond
when shown a distracter stimulus. Multiple response dimensions can be computed,
usually including omission errors, commission errors, reaction time and different
types of variability. Traditional CPTs (e.g., Test of Visual and Auditory Attention;
TOVA) have few target stimuli embedded among many nonsignal stimuli, thereby
stressing attention. Other CPTs (for example, the Conners’) have a higher
target stimulus probability, thereby stressing the ability to inhibit (see
Riccio & Reynolds for a review). Most are visual, although some also use
the auditory mode (e.g., Integrated Visual and Auditory [IVA] CPT and TOVA).
Hervey and colleagues supported the importance of this assessment approach
in their recent meta-analysis of adult ADHD research (2004). On a group level,
CPTs were highly successful in discriminating between normal control individuals
and identified patients. Moreover, CPT versions and response dimensions that
emphasized attention (i.e., traditional CPTs and omission errors) were more
sensitive than CPT versions and tasks emphasizing inhibition (i.e., commission
errors and less traditional CPTs). Other response dimensions were less frequently
studied, although reaction time variance was also highly discriminating. On
an individual level, however, as for all standards for ADHD, there can be false
negative and false positive results. I have found the first occurs when people
can compensate for their deficits during the relatively brief period required
for the test (about 15–20 minutes). The second occurs when there are
alternative disruptive mechanisms operative, such as an anxiety or mood disorder
or psychosis.
Measures of executive functioning (e.g., Trails B or Rey Complex Figure Drawing)
are also promising, but not universally sensitive. That is, not all people
who have ADHD have deficits on all, or even some, measures of executive functions
(Gallagher & Blader). These results may reflect limits in current assessment
methodology. Nevertheless, selected neuropsychological tests of executive functions
are often compromised in those who have ADHD, thereby permitting some objective
support for the diagnosis. Complete evaluation is especially indicated for
adolescents and young adults who are still in the process of completing their
education. They may be unaware of coexisting learning problems and of their
specific underlying neuropsychological basis, both of which the testing can
clarify. Many people who have ADHD may, in fact, have some degree of nonverbal
learning disorder (Stefanatos & Wasserstein), which is only unmasked through
testing. Identifying and clarifying unrecognized learning disabilities, or
validating their past existence, can be one of the most valuable contributions
of formal evaluations. Overall then, in both adolescents and adults, comprehensive
evaluation is useful for the following: 1. Understanding better
the individual’s strengths and weaknesses when planning
treatment. 2. Generating a baseline against which to monitor
change through interventions, both from pharmacotherapy and psychotherapy. 3. Providing
evidence for legally mandated accommodations at school or on the job. 4. Informing
diagnosis. In short, specialized testing is not considered necessary for diagnosis,
but can be essential for allowing a more objectively informed diagnosis and
providing legal services. It is also helpful for understanding of the individual
and for permitting the individual to better understand himself or herself.
Finally, treatment can be shaped, monitored, and facilitated with testing input.
Medical Mimics
There are a number of medical conditions (e.g., hypertension, glaucoma) that
either cause symptoms that resemble ADHD, coexist with ADHD, or may affect
an individual’s ability to tolerate stimulant medication. All would
require further medical evaluation, and some might change the diagnostic
formulation. Head injury and lead toxicity are the two most common causes
of acquired inattentive/hyperactive dysexecutive syndromes. Seizure disorders
of all types can be mistaken for inattentive ADHD, and the presence of discrete
staring spells or episodic inattentive symptoms indicates need for neurological
referral. Sleep disorders are common among children and adults who have ADHD
and may worsen the clinical presentation. These disorders may also exist
independently of ADHD and cause disturbed attention because of lack of sleep.
In particular, narcolepsy or obstructive sleep apnea may be suspected when
there are reports of excessive daytime somnolence. Referral to a sleep expert
should be considered when these symptoms are severe, diurnal rhythms are
extremely irregular, or there is clear sleep stage disorganization (e.g.,
dreaming as soon as the person falls asleep). Endrocrinopathies, particularly
thyroid disorders, can lead to extremes of arousal and/or irritability but
are usually accompanied by other significant physical problems (e.g., temperature
intolerance, bowel and skin changes) (Pearl et al.). In middle aged women
autoimmune hypothyroidism, and possibly menopause, can cause poor concentration.
This may worsen borderline ADHD cases and can lead to the unusual presentation
of symptoms that increase in adulthood. Again, medical consultation is necessary
if any of these illnesses is suspected. Conversely, I have seen previously
unrecognized ADHD in an adult who had a known LD be confused with insipient
dementia. During a period of protracted stress he began to show severe memory
and functional problems. For example, his fiancée described his losing
her engagement ring, forgetting routine daily tasks, and placing notebooks
in the refrigerator. Once the ADHD was recognized and treated, and his life
stress decreased, he returned to his baseline high level of functioning (chief
executive officer of his own company). Thus accurate diagnosis was key, but
not easy.
- Wasserstein, Jeanette; Diagnostic Issues For Adolescents And Adults With
ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p 535.
Misdiagnosis of attention deficit hyperactivity disorder:
‘Normal behaviour’ and relative maturity
- Ford-Jones P. C. (2015). Misdiagnosis of attention deficit hyperactivity disorder: 'Normal behaviour' and relative maturity. Paediatrics & child health, 20(4), 200–202.
Personal
Reflection Exercise #2
The preceding section contained information
about diagnostic procedures for ADHD in adult clients. Write
three case study examples regarding how you might use the content of this section
in your practice.
Reviewed 2023
Update
Diagnosis of children with attention-deficit/hyperactivity disorder
(ADHD) comorbid autistic traits (ATs) by applying quantitative
magnetic resonance imaging techniques
- Tang, S., Liu, X., Nie, L., Chen, Z., Ran, Q., & He, L. (2022). Diagnosis of children with attention-deficit/hyperactivity disorder (ADHD) comorbid autistic traits (ATs) by applying quantitative magnetic resonance imaging techniques. Frontiers in psychiatry, 13, 1038471. https://doi.org/10.3389/fpsyt.2022.1038471
Peer-Reviewed Journal Article Reference: Kofler, M. J., Harmon, S. L., Aduen, P. A., Day, T. N., Austin, K. E., Spiegel, J. A., Irwin, L., & Sarver, D. E. (2018). Neurocognitive and behavioral predictors of social problems in ADHD: A Bayesian framework. Neuropsychology, 32(3), 344–355.
Kofler, M. J., Sarver, D. E., Austin, K. E., Schaefer, H. S., Holland, E., Aduen, P. A., Wells, E. L., Soto, E. F., Irwin, L. N., Schatschneider, C., & Lonigan, C. J. (2018). Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training. Journal of Consulting and Clinical Psychology, 86(12), 964–979.
Kofler, M. J., Singh, L. J., Soto, E. F., Chan, E. S. M., Miller, C. E., Harmon, S. L., & Spiegel, J. A. (2020). Working memory and short-term memory deficits in ADHD: A bifactor modeling approach. Neuropsychology, 34(6), 686–698.
QUESTION
16 According to Wasserstein, what are key components of the diagnostic process
for adult ADHD? To select and enter your answer go to Test.