Approaching the Diagnosis of ADHD

Theresa R. Cerulli, MD: Birgit, what signs and symptoms prompt testing for ADHD [attention-deficit/hyperactivity disorder] in adults?

Birgit H. Amann, MD: When an adult comes into the office, the first thing we do is take a good history. We’re all very aware of that. Sometimes these adults will come out with classic or core ADHD symptoms: “I’m here because I’m distracted, forgetful, and fidgety.” It’s not uncommon for them to talk, not so much about those core symptoms but rather, “I’m overwhelmed, irritable, and edgy. My significant other says they don’t want me to go to functions anymore because I don’t act properly socially”—things like that. We need to understand, prior to coming to see us, what’s worked for them? What hasn’t worked for them? What have they been on? Maybe they’ve been on ADHD treatments. Maybe they’ve only been on other things, like antidepressants. I screen everyone, no matter why they come in. They’re going to get an ADHD screener, along with other screeners for mood disorders.

Theresa R. Cerulli, MD: I hear you talking a lot about, functionally, what the symptoms look like in our patients’ lives. Are there specific criteria that you’re using for the diagnosis of ADHD?

Birgit H. Amann, MD: Certainly. Let’s reflect for a moment on the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, fifth edition] criteria because it’s changed a lot as it relates to our adults. In particular, we still have our core ADHD symptoms of inattention, hyperactivity, and impulsivity. In our patients 17 years of age and older, we look for 5 or more symptoms within the inattentive section and or the hyperactive-impulsive section. We look for symptoms before age 12. Some adults have a hard time remembering that far back, so I’ll commonly say that if we had all your report cards in front of us from that time frame or from elementary school, what would be the most common comment? That helps me to sometimes get that story of symptoms before age 12. We look for difficulties, as Rakesh said, in 2 or more settings. For the adult, maybe it’s home and work or adults that are attending school and home. We need all those things together to officially make the diagnosis of ADHD.

Theresa R. Cerulli, MD: It’s more challenging than it sounds to make an accurate diagnosis. Because of what we’ve discussed with regard to the heterogeneity of how this condition presents, it’s also the confounding variable of comorbidities. Isn’t it in the challenge in diagnosing? Any comments on ADHD and how to think about ADHD, simple vs ADHD with comorbidities?

Birgit H. Amann, MD: The first comment is to think about it and consider it very strongly. The most recent CDC [Centers for Disease Control and Prevention] guidelines for adolescents suggest that 36% of our children have ADHD alone, but 64% have ADHD and 1 or more comorbidities. We need to think the same way in our adults. We need to be looking for these comorbidities. We may need to treat both the ADHD and the coexisting condition.

David W. Goodman, MD: We talk about comorbidities, but for clinicians in the office interview, it becomes very challenging to separate out anxiety that’s primary vs anxiety that’s secondary to ADHD. I wonder whether you folks have some specific suggestions about how to decide which symptoms get diagnosed, assessed, and then dropped in the accurate diagnostic bucket. Because that becomes the basis upon which you get a diagnostic prioritization and then a pharmacologic or treatment algorithm. If you don’t get it right at the inception, everything after that will not be optimal for the patient. And then over time, you introduce clinical bias in regard to your perspective on what’s going on. Once you have clinical bias, it’s hard to step back and do a clean objective reassessment.

Greg Mattingly, MD: I agree. The rookie mistake—I guarantee we’ve all made it—is you treat the chief complaint. But the chief complaint is just a chief complaint, not a diagnosis. We talked about ADHD plus anxiety, ADHD plus depression, ADHD plus my marriage or my job is falling apart, so I need something because I’m stressed. What’s driving the bus? What has its roots in childhood? Where did things start? What’s bringing you in is a crisis of depression, anxiety, not being able to sleep, my marriage is falling apart, spending too much money, not managing my diabetes. One of those things is always underneath it driving the bus. If I was going to debate a little or disagree with my colleagues, once you learn to screen for ADHD, it has a higher accuracy than screening for depression. For our friends in primary care, many of you have learned how to screen for and treat depression. You’ve learned how to use the PHQ-2 [Patient Health Questionnaire–2] and the PHQ-9 [Patient Health Questionnaire–9], the diagnostic accuracy. Once ADHD shows up on your radar screen, you learn how to use a rating scale that your patient fills out. You look at the symptoms. It has a higher accuracy than the diagnosis of depression.

Transcript Edited for Clarity