Accurately Diagnosing ADHD
JUNE 18, 2020
Theresa Cerulli, MD: Let me dig in a little deeper here. Ann, how is ADHD [attention deficit hyperactivity disorder] diagnosed in adults?
Ann C. Childress, MD: It’s really based on history and symptoms. One of the most important things is to look at their past—look at someone’s childhood. Were they diagnosed before? The problem with that is only about 25% of adults with ADHD who come in for treatment were diagnosed as kids. Their recall of childhood symptoms tends to be unreliable. DSM-5 says you should obtain collateral information.
When folks come in, if they’ve got a mom whom I can connect with, that’s great because moms will remember what was on your report card in the second grade, or if she had to pin a note to your shirt. So getting that information, looking at report cards, that can be really helpful. Talking with a spouse. Because this is based on history, it’s just so important to get that collateral information.
And as David Goodman and Andy Cutler said, it’s important when somebody comes in with depression or anxiety to look at other symptoms. Concentration can be a problem in a mood disorder, an anxiety disorder, post-traumatic stress disorder, a cognitive disorder, and also with ADHD. So it’s really important when somebody comes in to not just go down 1 list of symptoms but really to look at things overall.
We have some good diagnostic scales looking at ADHD. The World Health Organization has the 6-item screener that you can even leave in your waiting room. It takes just a minute or 2 for somebody to complete. You can look at that as part of an evaluation. When you want to go deeper and do a really good evaluation, there is the Adult ADHD Self-Report Scale, which features 18 items they can report on. Then you can do the Adult ADHD Clinical Diagnostic Scale, which goes through a whole list of ADHD symptoms as children and then ADHD symptoms as adults. It takes awhile to do. I’m not very fast at it. It takes an hour and a half or 2 hours for me to do, which may not be practical for folks on the front lines in primary care, where they have only 10 or 15 minutes for a visit. But it’s extremely important to look at.
Timothy E. Wilens, MD: You know, I think because of the relatively high prevalence of this condition, it’s very important that we educate and help clinicians think about this and screen for it in addition to all the other things we look at.
Ann C. Childress, MD: Absolutely.
Theresa Cerulli, MD: What I’d like to point out here is that for adults with ADHD, we don’t have any specific diagnostic and treatment guidelines from the American Psychiatric Association, which can make this a bit more challenging. For children and adolescents, we do have some diagnostic guidelines, right? In 2000 or 2001, the American Academy of Pediatrics came out with the first diagnostic and treatment guidelines for ADHD in children and adolescents.
Those guidelines were updated in 2011. Then they were updated again in October 2019. The American Academy of Pediatrics is now taking into consideration how common comorbidities are with ADHD. There is a key action statement added to those guidelines about not only looking at the core symptoms of ADHD, but the common coexisting conditions—the comorbidities.
I like to say that ADHD often does not travel alone. It has companions with it. ADHD is often seen with things like anxiety and depression, as Dr Goodman mentioned earlier.
The other guidelines that are new were put out by the Society for Developmental and Behavioral Pediatrics. These guidelines aren’t for diagnosing only ADHD but also complex ADHD. This really followed suit from the American Academy of Pediatrics. Regarding the complex ADHD, it’s important to look again at the comorbidities.
With that, David, what percentage of adults who have a diagnosis of ADHD were actually diagnosed during childhood, for which these guidelines now apply?
David W. Goodman, MD: We go back and look at the national comorbidity survey replication study. That was a large US epidemiologic study for adult ADHD, and some very interesting facts came out of that. The prevalence for adults was 4.5%, which translates to about 10 million adults, for which only about 25% are currently being treated. But if we look at the survey data—and this goes back to what was published in 2006—of the ADHD individuals, 75% were in mental health treatment. But very few, only 25%, were being treated for ADHD. In the total population, only 10% had been treated for ADHD.
And so the idea that you need to have had a diagnosis of ADHD as a child in order to have ADHD as an adult is not well supported by the research. Often, the children are missed, especially if you’re not disruptive. The girls with inattention and the boys with inattention are often not diagnosed until later in life when the impairments begin to occur, when environmental demands start to exceed what they’re required to do.
This idea that you have to listen to the patient is interesting. But I often say that you can’t hear and you don’t see what you don’t know. And so we increasingly try to put ADHD on the radar screen. I know that everyone on this panel, combined, has trained tens of thousands of prescribers, clinicians, and physicians on this. We have to keep reminding our colleagues that this is a highly prevalent disorder in adults.
Transcript Edited for Clarity