Assessment Adult ADHD

Dr Jaap Hamelijnck

IntroductionTasks for assessmentAssessment of symptomsAssessment of impairments (executivefunctioning)Psychiatric assessmentPhysical health assessmentFocus on StrengthsAssessment scales.

From Behavioural Syndrome toExecutive Dysfunction

Person burdened by a syndrome of chronicdifficulties in focusing, getting started ontasks, sustaining effort, utilising workingmemory and modulating emotions thatchronically impair their ability to managenecessary tasks of daily life (Brown 2013)

A new working definition ofADHD

A complex syndrome ofDevelopmental impairments of executive functionsThe self-management system of the brainA system of mostly unconscious operationsThese impairments are situationally variableChronic, and significantly interfere with functioningin many aspects of the person’s daily life

Brown 2013

Assessment Tasks

ADHD is syndrome of symptoms with related impairments(executive functions)

Clinical assessment with the following goals• Establish the presence of symptoms of ADHD• Assess the severity of the symptoms• Identify the impairments causes and the impact on the person’s life• Genetics• Co-morbidities• MSE (limited value)• Physical health

Assessment of Symptoms

Diagnostic Criteria for Adult ADHD• 18 core items

• DSM 5; requires 6 or more symptoms

• Several symptoms were present before the age of 12

• Several symptoms are present in 2 or more settings

• There is clear evidence that the symptoms interfere with or reduce thequality of, social, academic, or occupational functioning

• Symptoms are not better explained by an other mental disorder

Core SymptomsDSM-IV

Inattention (six or more)1. Often fails to give close attention to details or makes careless

mistakes2. Often has difficulty sustaining attention in tasks or fun activities3. Often does not seem to listen when spoken to directly4. Often does not follow through on instructions and fails to finish

work5. Often has difficulty organizing tasks and activities6. Often avoids, dislikes, or is reluctant to engage in tasks that

required sustained mental effort7. Often loses things necessary for tasks or activities8. Is often easily distracted by extraneous stimuli9. Is often forgetful in daily activities

Core Symptoms DSM-IV

Hyperactivity / Impulsivity (six or more)1. Often fidgets with hands or feet or squirms in seat2. Often leaves seat in situations in which remaining seated is

expected3. Feelings of restlessness4. Often has difficulty engaging in leisure activities or doing fun

things quietly5. Is often “on the go” or “driven by a motor”6. Often talks excessively7. Often blurts out answers before questions have been completed8. Often has difficulty awaiting turn9. Often interrupts or intrudes on others

Same core symptoms, but descriptions not easy to apply toadults.Symptoms list not easy to use as self report questionnaireHyperactivity symptoms reduce; Attentions symptoms do notGender differences in symptom persistence

Other symptoms associated with adult ADHD

Symptoms in Adults

Clinical assessment and treatment fo ADHD in Adults. Philip Asherson. 2005;www.future-drugs.com

Age of Onset

DSM 5; symptoms present before age of 12Diagnostic assessment in adulthood requires retrospectiveassessment of childhood symptoms and assessment of currentsymptoms.6 of 9 rule in adults put the cut-off at 99 percentile or 2.5-3standard deviations from the mean.

Proposal to adjust number of symptoms as age increases• 17-29; 4 to 5 of 9 identifies most impaired 7%• 30-49; 3 to 4 of 9• Over 50; 2 to 3 of 9

Associated symptoms

ProcrastinationLow tolerance of frustration; minor frustrations couse catastrophicreactions, loss of temper or angerMood lability; frequent changes, several times a day, like a roller coasterLow self-esteem; expected given the lifelong problems with rejectionsand failuresUnderachievementFrequent search for high stimulationIntolerance of boredomHyper-focusingTrouble going through proper procedures due to boredom and frustrationWorry needlesslySense of insecurityInaccurate self-observation and assessment of their impact on others

Semi-structured Interview toestablish the symptoms

A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

Impairments

1. Activation; excessive procrastination, put off getting started on a task,even a task they recognise as very important to them until the lastminute. Keeping track of plans, money or time. Difficulties settingpriorities. Has a hard time waking in the morning.

2. Focus; distracted easily by things going on around them and in theirown minds whilst at other times they are stuck on one focus unable toshift to another task. Reading very difficult to grasp the meaning. Minddrifting all the time and missing important information. Spacing out.Easily side tracked, only remembering some of the details. Doesn’tseem to be listening and getting complaints about it.

3. Effort; sustaining effort very difficult, motivation wanes very quickly,needing high levels of interest to keep going. Unable to continue tasksin allotted time, slacks of unless pressure is on. Requires others to keepthem on task. Chronic difficulty regulating sleep and alertness, stay uplate because can’t shut their head off, big problem getting up in themorning.

A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

Impairments

4. Emotion; not recognised in DSM 5, chronic difficulties managingfrustration, anger, worry, disappointment, desire, and other emotions.Emotions take over, making it impossible to give attention to anythingelse, short fused. Excessively impatient, sensitive to criticism fromothers, gets overly defensive. Can appear apathetic or unmotivated.

5. Memory; often great memory for things that happened long ago but notwhat they have just done, or where they put something. Excessivelyforgetful, intents to do things but forgets, making many mistakes orleaving out words when writing. Always forgetting to bring things orleaving the house with necessary items.

6. Monitoring and regulating self-action; too impulsive in what they sayor do, jumping in to quickly, not being able to interact appropriately. Failto notice others are offended or puzzled and fail to modify theirbehaviour. Pacing of actions, slowing down or speeding up as requiredfor a specific task. Monitor one’s actions and inhibit impulsive actions.

A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

Psychiatric Assessment

Full clinical assessment (psychiatric history)Developmental historyFamily historyPersonal historyPast psychiatric historyDrug and substance misuseComorbidityMSEPhysical health history

Medical Assessment Tool forAdults with ADHD

Have you ever been told by a doctor that you haveheart disease?

Do you ever get chest pain on exertion?

Have you ever passed out or fainted whilst exercising?

Has anyone in your family developed heart diseasebefore the age of 60?Has anyone in your family died of heart disease beforethe age of 60?Do you know if you have high blood pressure or anincreased cholesterolBP/Pulse is it regular?

Weight

Physical Examination (Done by GP)

ECG, ECHO and 24 hr BP if indicated

http://www.ukaan.org/getfile.php?type=site_documents&id=Medical%20Assessment%20Tool%20for%20Adults%20with%20ADHD.doc

Diagnostic IntrumentsDiagnostic Interviews;• DIVA• Brown ADD Scale Diagnostic form• Conners Adult ADHD Diagnostic Interview Schedule• Diagnostic Interview Schedule (DIS)-L

Rating Scales;• Barkeley Adult ADHD rating scale (includes checklist to provide

information on childhood symptoms and informants information)• Conners Adult ADHD rating scale (includes checklist to provide

information on childhood symptoms and informants information)• WHO Adult ADHD Self Report Scale (ASRS)• Brown ADD Scale• Wender Utah Rating Scale (retrospective diagnosis of ADHD in

childhood

Summary

Send out screening forms (Barkley and Murphy, Wender UTAH)Face to face interview consisting of1. Psychiatric assessment2. Semi-structured clinical interview (DIVA)3. Age appropriate rating scale for executive function impairmentsInterview with informantPhysical health screening

Formulate a diagnosis and treatment plan