Diagnosis and Testing for ADHD

Rakesh Jain, MD, MPH: There are certain signs and symptoms that should prompt us to think about ADHD [attention-deficit/hyperactivity disorder], and to think about proactively including it or excluding it. Some of the things I will share with you are not age sensitive. It doesn’t matter how old the person is. If we hear about those symptoms, we must screen for ADHD. We must do so because ADHD, in many ways, is a low-hanging fruit. It’s a very treatable condition, so to not diagnose it becomes a significant error.

For example, if I hear from an individual or their parents or their social system around them report that they’re having a lot of trouble paying attention, particularly to things they don’t want to do but need to do, this would prompt me to conduct an evaluation. If I start hearing a lot about distractibility, or if I hear a lot about forgetfulness—repeat, repeat, repeat, repeat—when that happens, it prompts me to do an evaluation.

Also, hyperactivity. You might say that’s a childhood problem. No. Adolescence can express it by jumping from task to task. Adults can express it by being unable to sit still in meetings, at church activities, or even during conversations with their spouses. All those symptoms should prompt us to look for ADHD. It’s not to say that any of them is diagnostic by itself. That, of course, requires a full evaluation. But they should serve as red flags so we don’t miss this important diagnosis. 

As far as using tools to diagnose ADHD, it’s always better to start with the screening process. If I conducted a full evaluation for ADHD in every person I see, even though that may sound like an ideal way to go, it will not amount to very much. It’s simply not doable. I suggest the following: a 2-tiered approach. No. 1 is to screen the patient. I’ll tell you more about that in a second. No. 2 in this tiered system is, if the screen is positive, then we can confirm it with the gold standard way to do so.

Let’s first talk about the screening approach. One of my favorite instruments is the ADHD rating scale, although you’re welcome to use the ASRS [Adult ADHD Self-Report Scale] in your adult patients. You can use the Conners Comprehensive Behavior Rating Scale for children, adolescents, or adults, and there’s a host of screening instruments available. Which option you choose isn’t that important, as long as you choose 1 and use it. It’s called screening for a reason. It’s supposed to be given to a lot of people.

If it indicates a potential positivity, then the gold standard tool to use would be the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th edition] criteria, which by the way, all of us can and should use—psychiatry, child psychiatry, pediatrics, family practice, MDs, NPs [nurse practitioners], PAs [physician assistants], whomever. Nonprescribers? Absolutely. You have an equal responsibility to identify the condition.

The DSM-5 criteria are very elegant. They include a list of 9 symptoms from inattention and 9 from hyperactivity/impulsivity. Once we have at least a certain number from either, then we move on to the next criterion, which is to start having symptoms before age 12. Not a diagnosis, but start having symptoms before age 12. We can then move on to making sure it causes impairment in at least 2 settings. Then we make sure no other condition is fully explaining the patient’s symptoms. When those criteria are met, you can take it to the bank. You can take it to the bank that you have a rock-solid, scientifically valid diagnosis of ADHD, irrespective of the person’s age. That often is the beginning of a wonderful journey for the patient and their family.

Andrew J. Cutler, MD: In my experience, a large percentage of adults who I diagnose with ADHD were not diagnosed during childhood. There are not good statistics on this, however. It’s a little difficult to study. There are many reasons for this. Maybe there were attitudes against the diagnosis of ADHD by parents or others around the child, around the adult. Or maybe the person was able to compensate and cope and made it through somehow. Maybe there was some underachievement. Then in adulthood, various stressors and strains and demands can bring out the symptoms or make them more problematic.

As I mentioned earlier, we know that at least 9% of children have been diagnosed with ADHD, so we think that the incidence is in that range—the 8% to 10% range. We think the incidence of actually meeting the criteria for the diagnosis is about 4.4%, or about half in adults. A lot of adults don’t meet the criteria for the diagnosis anymore, but this is a genetic neurobiological disorder. Think of it like a wiring problem in the brain. There’s no other example in clinical medicine of you outgrowing such a disorder, but as I mentioned, you may outgrow the diagnosis.

It’s also very important to realize that the DSM-5 criteria require that symptoms started before age 12. If somebody presents and says to you that their symptoms started recently or only during adulthood, that should prompt you to look for other possible conditions that could cause symptoms that resemble ADHD.

However, what is probably most commonly going on is that the symptoms were not recognized. Or maybe it’s hard for the person to remember when they were in elementary school. Or maybe there were various compensation strategies that were able to be employed during the school years when there was more structure that have not been present as the person moved into adulthood.

Transcript Edited for Clarity