Adult ADHD: Screening, assessment and diagnosis
Consider an ADHD diagnosis if the patient has experienced any of the following situations:
- Their child or any first-degree family member was diagnosed with ADHD.
- The patient was diagnosed with ADHD as a child or adolescent.
- The patient felt a calming, focused sensation on a psychostimulant, cannabis or cocaine.
- The patient had psychometric testing as a child or adolescent that suggested a learning disability, particularly a problem with working memory.
- The patient or a loved one suspects ADHD.
Give patients who fit any of these situations the Adult ADHD Self-Report Scale (Kessler et al., 2005).
The scale does not make the diagnosis and does not have a threshold marker, but it will help to determine whether adult ADHD should be considered.
Note :An expanded version of CADDRA's Assessment Toolkit is available in eBook and Print versions.
Making a diagnosis
Although the core symptoms of childhood ADHD are inattention, impulse control problems and motor hyperactivity, impulse control problems and motor hyperactivity generally lessen by adolescence, but inattention remains.
Various issues associated with ADHD are problematic for adults, though not diagnostic. These issues include:
- procrastination and poor time-management skills
- poor organizational skills
- feeling rushed or missing the subtleties of information
- problems in interpersonal relationships, including parenting skills
- appearing to not take responsibility for himself or herself
- difficulty delivering (e.g., missed deadlines)
- difficulty paying bills, completing reports or assignments ("paper is kryptonite" to the person with ADHD)
Clinical observations and diagnosis
The following clinical observations are not sufficient to rule out a diagnosis of ADHD:*
- The clinician does not observe hyperactivity in the office setting.
- The patient reports a lot of problems with organization, time management and executive function but is reliable in keeping appointments, filling out forms and paying for treatment.
- The patient says he or she has read about ADHD and thinks he or she has this problem.
- There is no family history of ADHD.
- The spouse or parent suggests symptoms of ADHD, which the patient dismisses.
- The patient is well educated or employed in a high-level position.
- The patient is very bright, and early school report cards do not describe problems with attention or behaviour. For some patients, increased autonomy and challenge led to evidence of impairment in later years. Other patients may describe unusual coping strategies such as excess time on homework or increased need for assistance.
- The patient was clearly hyperactive, impulsive and inattentive when younger but currently only has difficulty with a few residual symptoms. In some patients, impairment is still clinically significant.
- The patient does not remember or denies symptoms in childhood, and school report cards are not available. Usually a careful developmental history will reveal evidence of the impact of the disorder, even if the patient did not have insight, either at the time or now, into the symptoms that provoked these consequences.
Confirming the diagnosis
If you suspect the patient may have ADHD, follow these steps to confirm the diagnosis and begin treatment:
- Apply DSM criteria to determine whether the patient has symptoms
- Use the CADDRA Assessment Form to help take the patient's history and guide management. This is the recognized Canadian standard and the form can be photocopied or downloaded and put into the medical record.
- Use the Weiss Functional Impairment Rating Scale – Self-Report (WFIRS-S) (Available in the CADDRA ADHD Assessment Toolkit to document the patient's baseline level of impairment, and use the scale sequentially to determine whether treatment is moving the patient toward normal functioning.
- If you suspect a learning disability, consider referring the patient to a community psychologist. This is expensive but necessary when the patient has problems with organization (executive functioning deficits), reading comprehension (e.g., making mistakes in reading, particularly in work situations) and graphomotor skills (e.g., their handwriting can't keep up with how fast they are processing information).
- Begin the psychoeducation process.