Attention Deficit Hyperactivity Disorder (ADHD): Adults

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1 Attention Deficit Hyperactivity Disorder (ADHD): Adults Diagnosis and Treatment Guideline Background 2 Screening Recommendations/Initial Work-up 2 Diagnosis 3 Treatment Goals 7 Lifestyle Modifications/Non-Pharmacologic Options 7 Pharmacologic Options 10 Follow-up/Monitoring 12 Evidence Summary/References 12 Clinician Lead and Guideline Development 13 Appendix 1. 6-item Adult ADHD Self-Report Scale 14 Appendix item Adult ADHD Self-Report Scale 15 Most recent comprehensive literature review: February 2011 Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. ADHD Diagnosis and Treatment Guideline: Adults 1 Copyright Group Health Cooperative. All rights reserved.

2 Background According the National Institute of Mental Health, ADHD affects approximately 4.4 percent of adults. And more than 80% of adults with ADHD have comorbidities such as anxiety, depression, antisocial personality disorder, neurodevelopmental disorders, substance misuse, or mood and sleep disorders. These comorbidities may complicate diagnosis and affect treatment and outcomes. Follow-up studies of children with ADHD have shown that symptoms of the condition persist into adulthood in 10 66% of cases, with an estimated 15% retaining most of their symptoms and an estimated 50% experiencing persistence of some symptoms. Some symptoms, such as hyperactivity, tend to decrease with age due to adaptation, neurodevelopment, and self-medication; however, attention deficit may persist. The function of individuals who have symptoms of ADHD is significantly dependent upon contextual factors. While two patients may have a similar score using ADHD evaluation tools, their unique living or occupational environments may result in differing levels of impairment. For this reason, the diagnosis and indications for treatment interventions must be determined on an individual basis. Screening Recommendations and Initial Primary Care Work-up Table 1. Recommendations for screening for ADHD Eligible population Test Score Interpretation Adult patients suspected of having ADHD 6-item Adult ADHD Self-Report Scale (ASRS-v1.1, Appendix 1) 0 3 marks in the darkly shaded boxes 4 or more marks in the darkly shaded boxes Unlikely to have ADHD, no need for additional evaluation Symptoms suggest possibility of ADHD and need for additional evaluation [Additional screening recommendations are found on the following page] ADHD Diagnosis and Treatment Guideline: Adults 2

3 Table 2. Additional screening recommendations for ADHD and comorbidities prior to referral to Behavioral Health Services or other ADHD specialist Eligible population Adult patients who have symptoms consistent with ADHD Assessment Ask additional follow-up questions: (Expert opinion) What difficulty are these symptoms causing in your life? How old were you when these symptoms first occurred? What kind of help are you looking for? Screen for depression. Use the first two questions of the PHQ-9. If the patient answers 2 or higher to either, use the full PHQ-9. Screen for alcohol and/or drug misuse or diversion. Use the AUDIT and DAST screening tools. Cardiac history and exam if the patient is likely to receive a stimulant medication, including: History History of cardiovascular symptoms, such as exercise syncope or undue breathlessness Family history of cardiac disease Exam Heart rate Blood pressure Weight Cardiovascular examination Exercise Order an ECG if patient has a past medical or family history of serious cardiac disease, a history of sudden death in young family members, or abnormal findings on cardiac examination. Consider a stress test if the patient participates in strenuous exercise. Rule out alternative medical diagnoses, such as hyperthyroidism. Diagnosis General Approach Diagnosis is typically made by a mental health provider. Primary care providers can make a diagnosis if they have expertise or training in adult ADHD. In addition: o Masters level therapists can assess for adult ADHD. o Psychologists can provide additional consultation if the clinical interview and rating scale data are not sufficient to clarify diagnosis (see Table 3, psychological testing). o Psychiatrists can provide consultation if there are additional questions regarding diagnosis/role of comorbid conditions, particularly if there are questions regarding psychopharmacological management. Diagnosis is based on comprehensive clinical and psychosocial assessment, impact of symptoms on functioning, developmental history, and review of rating scales. Rating scales alone are not sufficient to make a diagnosis of adult ADHD. Contextual factors play a significant role in determining an individual s level of functioning. While two patients may have a similar ADHD severity level, their different living or occupational environments may result in different levels of difficulty or impairment. Diagnosis requires determining that symptoms: o Began in childhood and have persisted through life, and o Are not explained by other diagnoses, and o Have resulted in, or are associated with moderate or severe psychological, social, and/or educational or occupational impairment. ADHD Diagnosis and Treatment Guideline: Adults 3

4 Table 3. Diagnosis of ADHD Diagnostic approach Assess clinical and psychosocial status Establish developmental history of ADHD Assess impact of symptoms on functioning Use rating scale Collect observer reports (e.g., partner, parent, friend) Rule out psychiatric comorbidities Psychological testing Action Assess current mental status and review behavioral and symptomatic concerns in the different settings of the person s life. Establish history of ADHD symptoms in childhood (preferably before the age of 7), either retrospectively or prospectively. Preferred: Use behavioral symptoms noted in school records or information from parents or sibling. Acceptable: Use patient self-report when collateral information is not available. Confirm symptoms have clinically significant impact on social, educational, or occupational functioning. and Confirm impairment exists in at least two different, important settings (e.g., home and work). Use the 18-item Adult Self-Report Scale (ASRS-v1.1, Appendix 2); consider likelihood of ADHD if score on part A is 4 or more. The frequency scores in part B provide additional cues and can serve as further probes into the patient s symptoms. Use interview or rating scale to corroborate presence of ADHD symptoms. Consider using the full version of the ASRS and modifying the language for observer usage. Many psychiatric conditions have symptoms of impairment in attention, concentration, difficulty with task completion, or inappropriate behavior. Assess presence of comorbid symptoms: Depression (PHQ-9) Alcohol (AUDIT) Drug misuse (DAST-10) Anxiety (GAD-7) As appropriate, also assess for symptoms of bipolar disorder. Testing is typically not necessary to diagnose ADHD. Patients with adult ADHD frequently have difficulties with what is referred to as executive function (e.g., impulse control, organization and planning, working memory, sustained attention). But not all adults with ADHD have these difficulties, and there are adults who have executive functioning deficits who do not have ADHD (i.e., difficulties may be associated with a learning disability or history of brain trauma). Rule out learning disability Executive function difficulties can typically be identified through clinical interview/observation; however, testing may be helpful to: Determine the extent and severity of difficulties with executive functioning for treatment planning. Determine the extent of comorbid disorders and their impact on symptoms and treatment of ADHD (if this hasn t been clarified in the clinical interview). Consider referral to Speech, Language, and Learning for assessment. [Table 3. footnotes found on the following page] ADHD Diagnosis and Treatment Guideline: Adults 4

5 [Table 3. footnotes from the previous page] 1 Additional scales that might be helpful in certain circumstances: Barkley Adult ADHD Rating Scale IV (BAARS IV), which has normative information by specific age group, ADHD subtype (e.g., inattentive, hyperactive/impulsive, and combined), and retrospective report (i.e., presence of symptoms in childhood). Achenbach adult rating scales, if there is need for a rating scale to assess severity of a wide range of mental health symptoms. Not recommended (diagnostic testing): Brain imaging (e.g., SPECT, PET scan, MRI, or CT) is not recommended for diagnosing adult ADHD. [DSM-IV diagnostic criteria found on the following page] ADHD Diagnosis and Treatment Guideline: Adults 5

6 DSM-IV Diagnostic Criteria Table 4. Formal criteria for ADHD diagnosis (pediatric and adult) Diagnostic approach Criteria DSM-IV 1 Presence of either of the following (1 or 2): 1. Six (or more) 2 of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has difficulty sustaining attention in tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). Often has difficulty organizing tasks and activities. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools). Is often easily distracted by extraneous stimuli. Is often forgetful in daily activities. or Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity Often fidgets with hands or feet or squirms in seat. Often leaves seat in classroom or in other situations in which remaining seated is expected. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness). Often has difficulty playing or engaging in leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor." Often talks excessively. Impulsivity Often blurts out answers before questions have been completed. Often has difficulty waiting turn. Often interrupts or intrudes on others (e.g., butts into conversations or games). Additional criteria Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home). There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. When DSM-V is published in 2013, the following changes are expected: The three subtypes of childhood ADHD will no longer be identified as separate conditions. The age of onset will be extended up to age 12. Reduction of symptom threshold for diagnosis from six to four symptoms. European Consensus Statement established that a threshold of four out of nine symptoms in the DSM-IV criteria of either domain of inattention or hyperactivity-impulsivity is sufficient to indentify impairment in adults with a history of childhood onset and significant impairment. ADHD Diagnosis and Treatment Guideline: Adults 6

7 Treatment Goal The primary goal of treatment is to minimize the impact of ADHD symptoms on patient functioning while maximizing the patient s ability to compensate or cope with any remaining difficulties. General Approach If the patient has comorbid conditions, treat the more severe disorder(s) first. For example, if the patient is both depressed and has ADHD and if the ADHD is having the biggest impact on the patient s functioning treat ADHD first. Once the most severe disorder is treated, it is important to continue treatment of other comorbid disorders (e.g., depression and ADHD both need to be treated in order to maximize treatment effectiveness). Education about ADHD is essential to assist the patient in making informed decisions about pharmacotherapy and the importance of behavioral and lifestyle changes. Pharmacotherapy should be considered one component of a comprehensive treatment program that addresses psychological, behavioral, educational, or occupational needs. Lifestyle Modifications/Non-Pharmacologic Options Educating Patients about ADHD Table 5. Discussion points for educating patients about ADHD Topic Discussion points ADHD properties ADHD waxes and wanes in its intensity throughout life and in certain circumstances. Follow-up studies of children with ADHD have shown that symptoms of the condition persist into adulthood in 10 66% of cases, with an estimated 15% retaining most of their symptoms and an estimated 50% experiencing some symptoms. More than 80% of adults with ADHD have comorbidities such as anxiety, depression, antisocial personality disorder, neurodevelopmental disorders, substance misuse, or mood and sleep disorders. The comorbidities may complicate diagnosis and affect treatment and outcomes. Diagnosis ADHD is diagnosed using a comprehensive psychological assessment, developmental history, and rating scales. (Describe assessment procedure to patient, including possible tests.) ADHD is a valid disorder recognized by many established organizations. Individuals with ADHD may have difficulty functioning in their lives; this does not mean they are lazy or unintelligent. Individuals with ADHD may have been told something is wrong with them and that they cannot change; this is not true. Treatment options A cure for ADHD does not currently exist. Treatment includes psychosocial interventions and pharmacotherapy. Psychosocial interventions are designed to help patients learn to manage and cope with their symptoms and function better in life. Pharmacological treatments have risks as well benefits, and may sometimes be limited due to safety concerns (e.g., patient has additional health problems such as heart disease or substance abuse). [Table 5. continues on the following page] ADHD Diagnosis and Treatment Guideline: Adults 7

8 [Table 5. continued from the previous page] Topic Strategies for successful management Resources for additional information Discussion points Establishing structure helps ADHD patients initiate, engage, and complete tasks. Tools to assist them with organization (e.g., planners, calendars, checklists, sticky notes, smart phones, PDAs) are important ways of assisting adults with ADHD to cope with their lack of organizational skills Adults with ADHD do best when they pick vocations and hobbies that are interesting and stimulating to them. Establishing a social support network helps adult patients with ADHD manage their daily lives. By participating in community-based ADHD support groups, patients can both get support (e.g., I am not the only one who has these difficulties ) and learn how to manage and cope with their symptoms. Having a healthy lifestyle (exercise, good diet, plenty of sleep) also helps adults with ADHD feel better about themselves and cope with their symptoms. Substance use can often worsen ADHD symptoms and limit treatment benefits. To improve symptoms and overall health, engagement with support systems to manage substance use (e.g., health care providers, family, or community groups) can be helpful. See Patient Education on InContext for information on the many ADHD books, Web sites, and community resources that are available. Cognitive Behavioral Therapy (CBT) Optimally, CBT should be combined with pharmacological treatments that improve the core ADHD symptoms of inattention, impulsivity, hyperactivity, and/or distractibility. Consider CBT when: It can be used in combination with medications, or especially when medications alone have proved to be only partially effective or ineffective. The patient has made an informed choice not to use medications or is intolerant of them. The patient has difficulty accepting the diagnosis of ADHD and adhering to a medication regimen. The patient has a comorbid condition such as depression or anxiety that could benefit from CBT. Symptoms are remitting and psychological treatment is considered sufficient for targeting residual (mild-to-moderate) functional impairment. CBT framework The basic framework/rationale for CBT is as follows: Adults with ADHD have had core impairments since childhood such as distractibility, disorganization, difficulty with following through on tasks, and impulsivity that prevent them from learning or using effective coping skills to deal with basic life tasks (e.g., work, school, and relationships). The lack of effective coping skills over time leads to repeated failure experiences and chronic underachievement. This results in an inability to manage symptoms and continued functional impairment. As a result of this chronic failure, adults have received much negative feedback from their parents, partners, teachers, and peers, leading to negative thoughts and feelings (e.g., I am no good, I am a failure ). These negative feelings can result in an avoidance of coping efforts out of fear of failure and lead to comorbid disorders such as depression or anxiety. ADHD Diagnosis and Treatment Guideline: Adults 8

9 Key components of CBT The CBT approach is typically short-term and structured and includes: agenda setting, monitoring progress toward goals, skill building using worksheets and lessons, and assignment and review of homework. The therapy focuses on: o Behavioral skills training, specifically the teaching of compensatory skills to cope with the core ADHD impairments (see Table 6 for more information). o Addressing dysfunctional patterns of thought associated with avoidance, procrastination, attentional shifts, and mood difficulties. CBT for adults with ADHD has been found to be effective when delivered in a group format. Table 6. Recommended skills training for CBT treatment of ADHD Skill training Organization and planning Problem-solving Distraction management Procrastination management Details of teaching Promote consistent use of organizational aids such as calendars, checklists, electronic devices, whiteboards, sticky notes, etc. Develop triage system for mail and other papers. Structure the day and the environment. Develop problem-solving skills. Learn to look at a situation rationally. Learn to adaptively think about problems and stressors through positive self-talk. Learn to identify and disrupt negative thoughts. Build and maximize one s attention span. This includes breaking tasks into smaller steps that correspond with an individual s attention span. Learn to effectively use a timer and other distractibility reminders. Develop motivational skills to deal with problems with procrastination. Not Recommended (Non-Pharmacologic Options) Studies and reports on complementary/alternative treatments for ADHD have only featured child subjects. According to the organization Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), the following have not been shown to be effective: Elimination of sugar, salicylates, or artificial coloring from diet Nutritional supplements such as glyconutritional supplements, fatty acid supplementation, megadose vitamins, amino acid supplementation, or herbals Sensory integration training Antimotion sickness medication Anti-fungal medication for Candida Chiropractic treatments Optometric vision training Metronome training Neurofeedback More information on these treatments is available in this CHADD document: [PDF] ADHD Diagnosis and Treatment Guideline: Adults 9

10 Pharmacologic Options Drug treatment should be the first-line approach for adults with ADHD with either moderate or severe levels of impairment, unless the patient would prefer a psychological approach (NICE 2008). Before initiation of stimulant treatment for adults with ADHD: Establish that a cardiac history and assessment has been performed. Inform patients that no clinical trials exist on long-term stimulant therapy for adults with ADHD; the safety of long-term use is not known. Inform patients of the risk of time-limited dysphoria if stimulant therapy is discontinued after longterm use. Inform patients of the other risks of stimulant therapy, including elevation of blood pressure, cardiac arrhythmia and death, sleep disturbance, anorexia, mood or behavior disturbance, psychological dependence, and abuse potential. Initiate ADHD medications at the lowest possible dose and titrate slowly. Before switching medications, titrate to the maximum dose (if there are no side effects). For information on side effects, contraindications, formulary status (e.g., prior authorization), and other pharmacy-related issues, see the Group Health Formulary, the Healthwise Knowledgebase, or other resources. Table 7. Recommended pharmacologic options for adults with ADHD Medication dosage forms Initial dose 1 Titration schedule Maximum recommended daily dose 1 st line 2 Recommended unless patient has a history of substance misuse or diversion with risk for relapse, or a cardiac or other medical condition for which stimulants would be contraindicated. Amphetamine mixed salts (Adderall XR) 10 mg daily in the morning Increase by 10 mg every 7 days as needed. 60 mg 2 nd line 2 Alternative recommendation unless patient has a history of substance misuse or diversion with risk for relapse, or a cardiac or other medical condition for which stimulants would be contraindicated. Methylphenidate HCL ER or Methylphenidate HCL ER (generic Concerta) or Dextroamphetamine SR 10 mg daily in the morning 18 mg daily in the morning 10 mg daily in the morning Increase by 10 mg every 7 days as needed. Increase by 18 mg every 7 days as needed. Increase by 10 mg every 7 days (typically dosed twice daily) as needed. 60 mg 72 mg 3 40 mg 3 rd line First-line for patients if stimulants are contraindicated (e.g., cardiac condition or history of substance misuse or diversion). Atomoxetine (Strattera) [PA] 4 40 mg daily in the morning Increase to 80 mg after 3 days. May increase to 100 mg after 2 4 additional weeks as needed. 100 mg [Table 7. continues on the following page] ADHD Diagnosis and Treatment Guideline: Adults 10

11 [Table 7. continued from the following page] Medication dosage forms Initial dose 1 Titration schedule Maximum recommended daily dose Other alternatives First-line agent for patients with a history of substance misuse or diversion with risk for relapse (unless the patient is abusing alcohol). Bupropion IR or Bupropion SR or 100 mg twice daily x 7 days, then increase to 100 mg three times daily 150 mg daily in the morning x 7 days, then increase to 150 mg twice daily (Consider starting at lower doses [e.g., 100 mg].) After 4 weeks at 100 mg three times daily, increase to 150 mg three times daily. After 4 weeks at 150 mg twice daily, increase to 200 mg twice daily. Bupropion XR 150 mg daily in the morning After 4 weeks at 150 mg daily, increase to 300 mg daily. 450 mg (IR) 400 mg (SR) 450 mg (XR) Consider starting at lower doses for those with small body habitus or history of medication sensitivity or intolerability. Long-acting stimulants are acceptable first-line treatments for adult ADHD; they are convenient and have decreased potential for diversion or abuse. Short-acting formulations are also available and may be appropriate in certain populations. Examples include: Patients who have a well-established therapeutic relationship with their primary care provider. Patients who require supplemental dosing in the late afternoon/evening. Patients who can manage ADHD symptoms by using stimulants on an as-needed basis. The Canadian ADHD Resource Alliance (CADDRA) guideline recommends doses up to 108 mg daily; the maximum dose approved by the FDA is 72 mg daily. Atomoxetine prior authorization criteria: For use in patients who have ADHD and: Have failed at least two formulary stimulant agents of different classes. Have a tic disorder or Tourette syndrome (1 st line). Have a contraindication for stimulants (1 st line). ADHD Diagnosis and Treatment Guideline: Adults 11

12 Follow up/monitoring At all follow-up visits: Assess whether the patient s behavioral or functional goals are being met. Consider using the 6-item ASRS to determine degree of treatment effectiveness. Medication Monitoring Table 8. Recommended medication monitoring Medication Items to monitor Frequency All medications Stimulants Atomoxetine Bupropion Medication adherence Treatment effectiveness Adverse impact on sleep or behavior Adverse impact on appetite or weight Blood pressure Heart rate Evidence of abuse or diversion potential Blood pressure Neuropsychiatric effects (e.g., anxiety, irritability, hypomania, suicidal ideation) Blood pressure Neuropsychiatric effects (e.g., anxiety, irritability, hypomania, suicidal ideation) 1. Initially and while titrating dosage, monitor every 3 4 weeks; 2. Then every 3 months until stable; 3. Once stable, every 6 months. Evidence Summary/References This guideline was adapted from the following evidence-based guidelines: Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines, Third Edition Available online at: [PDF] Kooij S, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network. BMC Psychiatry. 2010;10:67. Available online at: [PDF] Additional information was pulled from these sources: National Institute for Health and Clinical Excellence (NICE). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE Clinical Guideline Available online at: Nutt DJ, Fone K, Asherson P, et al. Evidence-based guidelines for management of attentiondeficit/hyperactivity disorder in adolescents in transition to adult services and in adults. J Psychopharmacol. 2007;21(1): Available online at: [PDF] ADHD Diagnosis and Treatment Guideline: Adults 12

13 Clinician Lead and Guideline Development Clinician Lead David K. McCulloch, MD, Clinical Improvement Phone: Last Update Most recent comprehensive literature review: February 2011 Interim update: October 2011 Process of Development This guideline was adapted from the following evidence-based guidelines: Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA), CADDRA ADHD guidelines (2011) European consensus statement on diagnosis and treatment of adult ADHD (2010) National Institute for Health and Clinical Excellence (NICE), attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults (2008) British Association of Psychotherapists, evidence-based guidelines for management of attentiondeficit/hyperactivity disorder in adolescents in transition to adult services and in adults (2007) The following specialties were represented on the Group Health development teams: behavioral health, family medicine, pediatrics, and pharmacy. ADHD Diagnosis and Treatment Guideline: Adults 13

14 DA Rev. Date

15 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Patient Name Today s Date Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page.as you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today s appointment. Never Rarely Sometimes Often Very Often 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Part A 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When you re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Part B DA-1833 Rev. Date

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