Welcome to Assessmentof Adult ADHD: A Guidefor Primary Care ProvidersMy name is Dr. KevinMurphy and I am the Direc tor of the Adult ADHD Clinic of CentralMassa chusetts, formerChief of the Adult ADHDClinic at UMass MedicalCenter, and now AssociateResearch Professor atSUNY Upstate MedicalCenter.

Faculty DisclosureHere are my faculty disclo -sures.

Learning ObjectivesAfter completing this mod -ule participants will be ableto identify and properlyassess adult patients withADHD and identify as sess -ment tools that will assistthem in con ducting a cred -ible ADHD evalua tion inadults.

Case VignetteHere is a case vignette Iwant you to think about.Karen is a 20-year-oldcollege sophomore whoreports current problemswith concentration, dis -tracti bility, impulsivity, for -get fulness, restlessness,fidgeting, and disorgan iza -tion. She is having troublestudying, paying attention

in lectures, sustaining her effort in motivation and getting her work done. Her symptoms are causing her great frustration, poor grades and afeeling that she is not working up to her potential. She is concerned thatshe may have ADHD and is seeking your help to determine if she has itand how she can treat it.

Case Vignette (cont)Now thinking of assess -ment your assess mentof Karen might include allof the following except: a)ask her to complete anADHD rating scale forcurrent and childhoodfunctioning b) prescribe astimulant medication to seeif it helps her symptoms

c) consult with a parent about her past and present symptoms andfunctioning d) inspect any available records, report cards, teachercomments, progress reports etc. for evidence of ADHD like symptoms orimpairment e)conduct an interview with Karen to obtain additionalinformation and history and to explore alternative explanations for hersymptoms or, lastly f) refer her to a psychologist for additional testing.I want you to think about Karens presenting problems. I will come backto this at the end of my talk and the answer should become clear to youby the end of this presentation.

An Adult ADHDAssessment: FourFundamental QuestionsNow an ADHD adult as -sessment should bedesigned to answer fourfundamental questions. First, is there credible evi -dence that the patientexperiences adult ADHDsymptoms in early child -

hood and that at least by the middle school years that these symptomsled to substantial and chronic impairment across settings?Second, is there credible evidence that ADHD symptoms currently causesignificant impairment across settings in childhood and adulthood?

Four FundamentalQuestions (Cont)Third, are there explan -ations other than ADHDthat better account for theclinical picture?Fourth, for patients who domeet criteria for ADHD isthere evidence for theexistence for comorbidconditions?

Primary Care ProvidersShould Suspect ADHDWhen Patients Now primary care provi -ders should suspect thepossibility of ADHD whenpatients present with someof the following types ofissues. Under stand thatnone of these are by them -selves diag nostic of ADHD,but it is something you

should be on the lookout for as a possibility of ADHD. If you see thingslike organizational skill difficulties, erratic or inconsistent school and workhistory, anger control problems, overly talkative and interrupting frequentlyor inappropriately, marital problems, parenting problems, trouble withmoney management, substance use or abuse problems and/or drivingdifficulties including frequent accidents or speeding tickets or generaldriving infractions.

Assessment of Adult ADHD:A Guide for Primary Care Providers

by Kevin Murphy, PhDTranscript from webcast from Adults with ADHD: Making Exam Room Decisions

' ' ' '' ' '

!""#""$#%&'()'!*+,&'!-.-/'!'0+1*#')(2'321$425'642#'32(71*#2"'

9.:$%'!3;;.0/;$P.'"'0I*34"%5'*.2$/"I,%'5,'0..'$B'$5'7.4(]

^? 5;.7#01,,2724$/7

' ' ' '' ' '

' ' '' ' ' ' ' ' ' ''

'! ' ' ' ' ' ' ' ' ' '

! ' ' ' ' ' ' ''

! ' ' '' ' ''

! ' ' ' ' ' '' ' ' ' ' ' ' '' '

! ' ' ' ' ' ' '' ' ' ' ' ' '' ' ' '

! ' ' ' ' ' '

*%.";9B,5'%

"%.5.4

' ' ' '' ' '

' ' ' '' ' ''

! ' ' ' '! ' ' ' ' ' ' '! ' ' ' ' ' '! ' ' ' '

'! ' ' ' ' ' '! ' ' ' '! ' ' ' ' ' '! ' ' ' ' '

:,;>.";A=i8--1

' ' ' '' ' '

' ' ' '' ' ''

! ' ' ' '! ' ' ' ' ' ' '! ' ' ' ' ' '! ' ' ' '

'! ' ' ' ' ' '! ' ' ' '! ' ' ' ' ' '! ' ' ' ' '

,7D0;.2$:%.I">%.7

' ' ' '' ' '

' ' ' '' ' ''

! ' ' ' '! ' ' ' ' ' ' '! ' ' ' ' ' '! ' ' ' '

'! ' ' ' ' ' '! ' ' ' '! ' ' ' ' ' '! ' ' ' ' '

.

Current DSM-IV-TRDiagnostic Criteria forADHD Now I am going to brieflyreview the current DSM-IVcriteria for ADHD. TheDSM-IV lists the symptomsin two dimensions: theinattentive dimension andhyperact ive- impuls ivedimension. To meet criteria

you must exhibit six or more inattentive symptoms or six or more hyper -active-impulsive symptoms to a degree that is maladaptive andinconsistent with development level.

DSM-IV Criteria: 6 of 9 Inattention Symptoms (See slide above)

DSM-IV Criteria: 6 of 9 Hyperactive-Impulsive (See slide above)

Current DiagnosticCriteria (cont)The DSM-IV criteria alsoindicate that there must beonset before age 7.This turns out to be one of the more controversialareas and is most likelygoing to be changed in thenext edition of the DSM. There needs to be impair -

ment in two or more settings to have this diagnosis. There must be clearevidence of clinically significant impairment and social academic oroccupational functioning. There are three subtypes delineated in the DSM-IV, including:

ADHD, predominately inattentive type, where people meet thecriteria for the 6 to 9 inattention symptoms and do not meet thecriteria for the 6 hyperactive-impulsive symptoms ADHD, predominately hyperactive-impulsive type where peoplemeet the criteria for the hyperactive-impulsive symptoms, butnot the attention symptoms ADHD, combined type where people meet criteria for both sets ofsymptoms on the inattention and the hyperactive-impulsive lists

Before I go to the next slide lets discuss in more detail the age of onsetcriteria. This is the more controversial part of the DSM-IV and recentresearch shows that using age seven onset criteria excluded nearly 50%of adults who met all other criteria. This study found that there were nodifferences in severity of the disorder, in comorbidity, or in life impairmentsbetween those who met the age seven criteria and those who did not.The age seven criteria also pose a recall problem in this respect. A recentstudy showed that when both adults with ADHD and their parents wereasked to describe when the onset symptoms occurred they differed asmany as four years. This suggests that recall is a fairly unreliable way ofmeasuring onset and is certainly not reliable enough to include it as partof the formal diagnostic criteria. So what we think is a more appropriateage of onset is age sixteen. Recent research has shown that age sixteencaptures these cases every bit as well as age seven or before. And its stillconsidered a childhood onset problem, but extending the age of onset tosixteen is more appropriate. I dont want you to be looking at this as rigid.If somebody meets all the criteria and the age of onset is eight or nineyou may still say they meet the criteria. We need to be a little flexible.

What differentiatesADHD from normalsymptoms of everyday life?Now one of the questionsI get frequently from peopleis, how to differentiate trueADHD from just normalsymptoms of everyday life.It is true that the symptomsof ADHD are common tonormal human function.

Well here are some guidelines to help you to differentiate ADHD fromnormal functioning.Individuals with ADHD report having a greater number of the 18 itemsthat I just mentioned. Symptoms occur more frequently and with greaterseverity in individuals with true ADHD. There is also development deviancemeaning that people are not performing as well as their same age peersalong these dimensions. Most importantly the impact of the symptoms isfar greater in true ADHD and results in chronic and pervasive impairmentin major life activities. This is a very important point because you cannothave a disorder without impairment. So people can have symptoms ofADHD but if they do not produce impairment there is no disorder. We arealways looking to determine the impact in terms of what is happening andhow these difficulties are affecting people in their major life activities.In fact new research has shown that deficits in executive functioning foundin many adults with ADHD, also helps to differentiate ADHD from normalfunctioning. We will discuss this issue in more detail.

Impact of ExecutiveFunction Deficits onAdult FunctioningIn terms of the impact of executive functioningdeficits we find that thereis a poor persistence ontasks and people havedifficulty sustaining theireffort and motivationtoward future goals. Thereis also difficulty planning

ahead proactive planning and anticipating future consequences. Adultswith ADHD tend to live in the here and now.Other executive deficts include: poor time management where peoplemight be very late, and have difficulty judging or estimating time; poor

' ' ' '' ' '

-D!baU'A;$5.;$"T^'d',B'l'a%"C.%I,%'D=*0=/7$"5;$/'100,/$"I,%'JVWW^L?''+,-.%/01!*-%2*3&-101!-'*4-%"-'*5/#*4$%&-'*+,0/#2$#0*67&8*$2)9)**'

10

' ' ' '' ' '

' '' ' ' ' ''

! ' ' ' ' ' ' '! ' ' '! ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' '! ' ' ' '

'' ' ' ' '' * * * * * * '

lB,d

' ' ' '' ' '

' '' ' ' ' ''

! ' ' ' ' ' ' '! ' ' '! ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' '! ' ' ' '

'' ' ' ' '' * * * * * * '

aU!bD-%.C"a%

' ' ' '' ' '

' '' ' ' ' ''

! ' ' ' ' ' ' '! ' ' '! ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' '! ' ' ' '

'' ' ' ' '' * * * * * * '

;.5$;AaU=D%,I%

' ' ' '' ' '

' '' ' ' ' ''

! ' ' ' ' ' ' '! ' ' '! ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' ' ' ' '! ' '! ' ' ' '

'' ' ' ' '' * * * * * * '

"T$; ^

*,5,,;'I*.'*"%"&.*.%5'! >,,;'.*,I,%"4'0.4Bb/,%5;,4'! a*

emotional self control and emotional over reactivity; impulsive decisionmaking; and, general disorganization whether in their personal lives or inthe workplace. Adults with ADHD often appear to be quite discom -bobulated throughout their life.

Impact of ExecutiveFunction Deficits onAdult Functioning (2)Adults with ADHD havedifficulty keeping promisesand commit ments toothers, or they may beviewed as being unreliableor inconsistent. They mayhave trouble followingthrough, difficulty multitasking or keeping track of

several things at once, and seeing things through to completion. An inability to stop an enjoyable activity and shift to a more important taskis often impaired. People with ADHD have great difficulty doing what theyare supposed to do when they are supposed to do it consistently. Theyoften need somebody to depend on for maintaining order and goaldirection as it is very hard for them to do complex tasks by themselves.Often times they need somebody to help them stay on track and keepthem going in the right direction.

Impact of ExecutiveFunction Deficits onAdult Functioning (3)There is a sense of under -achievement where peopledo poorly in school despiteaverage or above averageor even superior intelli -gence. This under achieve-ment often affects jobsuccess, impairs work per -formance, and may result

in unsatisfactory relationships in marriages or co-worker relationships orpeer relationships. As I mentioned poor driving outcomes are verycommon in adult ADHD, poor money management, saving for retirementand impulsive spending pose real problems.Trouble doing routine tasks ofdaily life, organizing a household, raising children, parenting, and payingbills show how pervasively this condition affects people in their day to dayfunctioning. So in the assessment you are go to look for clues to help you illicit some of these areas of difficulty that are so common to adultswith ADHD.

ADHD AssessmentPrinciplesNow for a couple of essen -tial as sess ment prin ci ples,it is very important to be asthorough and comprehen -sive as possible. We dontassess this condition in asurface level or just givesomebody a rating scale,count symp toms, and con -

clude that they must have ADHD. So we are not just doing a surface leveljob here, we need to be more comprehensive. I am going to tell you howto do that in an expedient way in a just a few minutes.Whenever possible you want to include collateral informants whengathering assessment data. Typically, this is either a spouse, or a parent, ora sibling, or somebody who has known the person well for a long time. Itis very important to get multiple sources of information when possible.Obtaining historical records when available is very, very helpful. This helpsto establish the chronicity, the onset and the pervasiveness of impairmentthat is mentioned in the next bullet here. School records, report cards, job performance reviews, medical recordsthings like that can really help us to take a look at the paper trail, its a testament to the persons developmental deviance over time. We also need to rule out other conditions that might better explain ADHD symptoms.

More about ruling out, what do we tend to rule out? Well we have toconsider if there are better explanations for existing problems before weconclude that someone has ADHD.

Ruling Out AlternativeExplanations for ADHDSymptomsWe need to rule out tran -sient situational stressorsas an explanation forADHD-like symptoms.A divorce, a career change,a job change, grief reaction,family or lifestyle changes,people having babies or

twins, or getting married, or things like this can produce stress and ADHD-like symptoms. Also we have to rule out medical conditions that may also mimic ADHDSymptoms these include things like: chronic fatigue, thyroid difficulties,diabetes, even menopause, and medication side effects. We also need torule out other psychiatric disorders as being responsible for the symptoms,not only ruling out but also looking at whether they coexist with the ADHD.Typically these are things like bipolar disorder, substance abuse, depression,anxiety disorders or personality disorders.

Assessment Tools toHelp Diagnose AdultADHDHere are some assess menttools to help diag noseADHD. These are the toolsthat are going to help youanswer those four funda -mental questions that Imentioned in the begin -ning these are at the heartof an ADHD evaluation.

So those are the questions you want to ask and these are the tools thatyou are going to use to answer those questions.There are four major things we use to conduct as assessment: structuredinterview tools, symptom rating scales, historical records and neuro -psychological tests. We are not going to concern ourselves so much withneuropsychological tests in this talk because suffice it to say thatneuropsych tests are not diagnostic of ADHD. They do help us to betterunderstand strengths and weaknesses and may help in establishcomorbidity but well focus on the other three areas at this time.

Components of anADHD EvaluationIts Important for you tounderstand that a typicalevaluation does not requirelengthy, structured inter -views or a comprehensiveneuropsychological testbattery. ADHD assessmentdoes not have to be anonerous difficult process.

We can do this fairly reliably in a relatively quick way. Accurate diagnosiscan be obtained by doing a careful, traditional history taking and a recordsreview, combined with the use of symptom rating scales and a clinicalinterview that focuses on the ADHD diagnostic criteria. This is the nub of what I want to talk to you about in this segment.

' ' ' '' ' '

a*4"%0'Ja(>r0LS'Q,P'DS02";"%4>"4%,I";,$;a(J&,4,7/=0