ADHD Diagnosis and Screening in Adults

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1 ADHD Diagnosis and Screening in Adults Clinical assessment using DSM-5 TM * criteria and the ASRS checklist Date of preparation: May 2015 Job code: INTSP/C-ANPROM/NBU/14/0095 *DSM-5 is a registered trade-mark. Copyright 2013 American Psychiatric Association. All rights reserved.

2 ADULT ADHD Mean worldwide prevalence of ADHD is estimated at 3.4% ( %) in adults. 1 ADHD in childhood and adolescence is acknowledged to persist into adulthood in ~50 66% of individuals. 2-5 The European Network Adult ADHD Consensus Statement 6 lists potential reasons for under-diagnosis of adult ADHD: - Lack of recognition/misunderstanding of ADHD 6 - Age-dependent change in the presentation of ADHD symptoms may lead to missed diagnoses 6 - Symptoms of comorbidity complicate diagnosis. 6 Comorbidities are common in adult ADHD: - An observational study of newly diagnosed adults with ADHD (n=367) found that on average 2.4 psychiatric comorbidities were present at the time of first diagnosis and that 66.2% of the sample had a least one psychiatric comorbidity 7 - A population-based survey of adult twins born in Sweden (n=17,899) found that symptoms of ADHD were associated with an increased risk for symptoms of generalised anxiety disorder (odds ratio [OR]: 5.6), major depression (OR: 2.8), bipolar disorder (OR: 8.0), obsessive-compulsive disorder (OR: 3.9) and alcohol dependence (OR: 2.6), with no significant difference between genders. 8 The impact of ADHD can be felt at home, 9,10 and in the workplace, and may put a strain on relationships 9,10 with family, friends, and colleagues. ADHD can also be associated with substantial financial burden for individuals and societal healthcare services. 12,13 DIAGNOSING ADHD IN ADULTS There is currently no single tool used for the diagnosis of ADHD. Formal diagnosis is made using evidence accumulated from the initial clinical assessment and medical classification systems. 14,15 Formal assessment and diagnosis should only be made by appropriately qualified healthcare professionals, such as specialist psychiatrists, specialist nurses, or other qualified healthcare professionals, who have training and expertise in the diagnosis of ADHD. 15 There are two main classification systems for diagnosing ADHD: American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5 ) 16 and the the International Classification of Mental and Behavioural Disorders 10th revision (ICD-10). 17 These medical classification systems may be used alone or in conjunction with a range of rating scales. The DSM-5 states that ADHD is characterised by a persistent pattern of inattention and/ or hyperactivity-impulsivity that interferes with development, has symptoms presenting in two or more settings (eg at home, school or work), and negatively impacts directly on social, academic or occupational functioning. The symptoms must be present before age The ICD-10 refers to hyperkinetic disorder (HKD) as a persistent and severe impairment of psychological development, characterised by a combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement; and pervasiveness over situations and persistence over time of these behavioural characteristics. These guidelines are more stringent than those in the DSM-5, as they recommend that both hyperactive and inattentive symptoms be present to confirm diagnosis; thus, HKD can be considered a form of ADHD. 17 Page 2

3 THE DSM-5 AND ADULT ADHD The Diagnostic and Statistical Manual of Mental Disorder (DSM) is the handbook used by healthcare professionals around the world as the authoritative guide to the diagnosis of mental disorders. It contains descriptions, symptoms and other criteria for diagnosing mental disorders, and provides a common language for clinicians to communicate about their patients while establishing consistent and reliable diagnoses. The definition of ADHD has been updated in DSM-5 to more accurately characterise the experience of affected adults. By adapting criteria for adults, DSM-5 aims to ensure that children with ADHD can continue to get care throughout their lifespan if needed. The criteria for ADHD diagnosis in DSM-5 are as follows: 16 A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterised by Inattention (see page 4 of this guide for a listing of these symptoms) and/or Hyperactivity and Impulsivity (see page 5 of this guide for a listing of these symptoms). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (eg at home or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (eg mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). The DSM-5 states that it must be specified whether the individual with ADHD is in partial remission (when partial ADHD criteria have been met for the past 6 months with full criteria met previously, and the symptoms still result in impairment in social, academic or occupational functioning); and the current severity of the disease. 16 Furthermore, the DSM-5 TM states that the current severity of ADHD should be specified as follows: 16 Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. Moderate: Symptoms or functional impairment between mild and severe are present. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present; or the symptoms result in marked impairment in social or occupational functioning. Page 3

4 DSM-5 ADHD: SYMPTOMS OF INATTENTION* Predominantly INATTENTIVE presentation: For older adolescents or adults (aged 17 and over) five (or more) of the following nine symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. PATIENT OFTEN: A Fails to give close attention to details or makes careless mistakes at work, or during other activities (eg overlooks or misses details, work is inaccurate). B Has difficulty sustaining attention in tasks or activities (eg has difficulty remaining focussed during lectures, conversations or lengthy readings). C Does not seem to listen when spoken to directly (eg mind seems elsewhere, even in the absence of any obvious distraction). D Does not follow through on instructions and fails to finish chores or duties in the workplace (eg starts tasks but quickly loses focus, easily side-tracked). E Has difficulty organising tasks and activities (eg difficulty managing sequential tasks, difficulty keeping materials and belongings in order, messy, disorganised, poor time management, fails to meet deadlines). F Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg preparing reports, completing forms, reviewing lengthy papers). G Loses things necessary for tasks or activities (eg work materials such as pencils, books, tools, keys, paperwork, wallet, eyeglasses, mobile telephones). H Easily distracted by extraneous stimuli (may include unrelated thoughts). I Forgetful in daily activities (eg running errands, returning calls, paying bills, keeping appointments). Page 4 *These are based on symptoms specifically for adults - please refer to the DSM-5 for a full list of symptoms.

5 DSM-5 ADHD: SYMPTOMS OF HYPERACTIVITY/IMPULSIVITY* Predominantly HYPERACTIVITY/IMPULSIVITY presentation: For older adolescents or adults (aged 17 and over) five (or more) of the following nine symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. PATIENT OFTEN: A Fidgets with or taps hands or feet or squirms in seat. B Leaves seat in situations when remaining seated is expected (eg leaves his or her place in the office or other workplace). C Feelings of restlessness. D Unable to engage in leisure activities quietly. E Is on the go, acting as if driven by a motor (eg uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless). F Talks excessively. G Blurts out an answer before a question has been completed (eg cannot wait for turn in conversation). H Has difficulty waiting his or her turn (eg while waiting in line). I Interrupts or intrudes on others (eg butts into conversations or activities; may intrude into or take over what others are doing). Note: COMBINED presentation is considered in individuals with at least 5 inattentive and 5 hyperactive/impulsive symptoms (in addition to meeting all other DSM-5 criteria) in the last 6 months. *These are based on symptoms specifically for adults - please refer to the DSM-5 for a full list of symptoms. Page 5

6 ADULT ADHD SELF-REPORT SCALE (ASRS) SYMPTOM CHECKLIST D E I F A E A B C G H B C D F G H I The ASRS symptom checklist 18,19 was developed by the World Health Organization to correspond with the 18 symptoms included in the DSM-IV 20 before it was replaced by the DSM-5 TM criteria in The grey and pink letters on the left side correspond with the DSM-5 TM criteria. Healthcare professionals can use the ASRS as a tool to help screen for ADHD in adult patients. The questionnaire takes about five minutes for patients to complete. The patient answers the questions below, rating each of the criteria shown using the scale on the right side of the page. As they answer each question, they should place an X in the box that best describes how they have felt and conducted themselves over the past 6 months. PART A 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 organisation? 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 B 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? Never Rarely Sometimes Often Very often PART A: If 4 or more marks appear in the darkly shaded boxes within PART A then the patient has symptoms highly consistent with ADHD in adults and further 20, 21 investigation is warranted. Part A has been validated as follows: Threshold for likely to have ADHD: 4 significant items Positive predictive value (PPV) using 3% element of prevalence: 80% Sensitivity: 69% Specificity: 99% PART B: The frequency scores on Part B provide additional cues and can serve as further probes into the patient s symptoms. Page 6

7 REFERENCES 1. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007; 190: Lara C, Fayyad J, de Graaf R, et al. Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative. Biol Psychiatry 2009; 65: Barkley RA, Fischer M, Smallish L, et al. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnorm Psychol 2002; 111: Ebejer JL, Medland SE, van der Werf J, et al. Attention deficit hyperactivity disorder in Australian adults: prevalence, persistence, conduct problems and disadvantage. PLoS One 2012; 7: e Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006; 36: Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010; 10: Piñeiro-Dieguez B, Balanzá-Martínez V, García-García P, et al. Psychiatric comorbidity at the time of diagnosis in adults with ADHD: The CAT study. J Atten Disord 2014; Friedrichs B, Igl W, Larsson H, et al. Coexisting psychiatric problems and stressful life events in adults with symptoms of ADHD--a large Swedish population-based study of twins. J Atten Disord 2012; 16: Pitts M, Mangle L, Asherson P. Impairments, diagnosis and treatments associated with attention-deficit/hyperactivity disorder (ADHD) in UK adults: results from the lifetime impairment survey. Arch Psychiatr Nurs 2015; 29: Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes ; 10: Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. J Clin Psychiatry 2006; 67: de Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult attention-deficit/ hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med 2008; 65: Hodgkins P, Montejano L, Sasane R, et al. Cost of illness and comorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis. Prim Care Companion CNS Disord 2011; Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder first upgrade. Eur Child Adolesc Psychiatry 2004; 13 Suppl 1: i7-i National Institute for Health and Care Excellence. NICE Clinical Guideline 72 March 2013 update. Available at: Last accessed May American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Available at: Last updated 1993; 1: Last accessed May Kessler RC, Adler L, Ames M, et al. The WHO ASRS: a short screening scale for use in the general population. Psychol Med 2005; 35: Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist. Available at: harvard.edu/ncs/ftpdir/adhd/18%20question%20adhd-asrs-v1-1.pdf. Last accessed May American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, Surman CBH (editor). ADHD in adults: a practical guide to evaluation and management. Chapter 2: Clinical Assessment of ADHD in Adults. Springer Science Business Media, New York, Page 7

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