Although attention-deficit/hyperactivity disorder (ADHD) is common, occurring in about 5% of children and about 2.5% in adults, it is still a challenging condition to assess and diagnose because so many of its characteristic symptoms are nonspecific and its associated impairments can manifest in virtually any domain of life.
Many with ADHD may not be diagnosed as children because they don’t receive evaluation and treatment until adulthood. To that end, a “thorough evaluation of adult ADHD utilizing various assessment inventories and sources of information helps to improve diagnostic accuracy and reduce the likelihood of misdiagnosis,” wrote J. Russell Ramsay, PhD, in an article in the journal Neuropsychiatric Disease and Treatment. The goal of that article was “to provide a clinically useful review of the various measures that practicing clinicians can use to aid in the diagnostic assessment and monitoring of psychosocial and medical treatment of ADHD in adult patients.”
In this interview, Dr. Ramsay discusses the current understanding of ADHD in adults, the toll it takes on those with this condition, and how clinicians can implement the many screening scales, symptom inventories, and structured interviews in order to monitor and to maximize treatments for adults with ADHD.
MDLinx: How is adult ADHD defined?
Dr. Ramsay: ADHD involves more than just the obvious symptoms of inattention and hyperactivity listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). It’s a neurodevelopmental disorder of impaired self-regulation and, more specifically, organizing behavior across time toward desired goals.
I’m also a psychologist who treats ADHD, so I hear all the rationalizations for procrastination: “Let me do this other thing first and then I’ll be in the mood to go back and do my taxes, or study for the midterm, or whatever.” Well, nobody’s ever “in the mood” to do those things. We want the outcome, we know it’s within our capacity to achieve it, and we know we’ll be better off if we achieve that outcome—but the payoff is not immediate enough to get engaged right now, and that’s the insidious feature of ADHD. It punctuates people’s effort and attention, and it ends up undermining their progress toward the goal. It’s procrastinating an hour at a time, but then never getting to it at all during the day.
For adults with ADHD, many are very often not diagnosed until adulthood. I made this point in the paper: When we look at the lifetime outcomes and different adult roles like education, occupation, and relationships, ADHD is one of the more, if not the most, impairing disorders seen in outpatient psychology and psychiatry practice in terms of fewer years of education achieved, more interrupted and incomplete education, more occupational shifts, relationship discord, and all-around difficulties following through on longer-range tasks.
MDLinx: What’s the most important thing that physicians should know about adult ADHD?
Dr. Ramsay: The field is really moving beyond the “A” and the “H.” The name is not going to change of course, and inattention and hyperactivity are still central features of ADHD, but they’re also sort of red herrings. I think it was Russell A. Barkley, PhD, who said that calling it ADHD is like calling autism an “eye gaze disorder.” Limited eye gaze is a feature of autism but it doesn’t capture the essence of it, and not everybody with autism has problems with eye gaze. Likewise, if somebody is not necessarily hyperactive or inattentive, they may still have ADHD. So now we’re looking more at the executive functions that allow for the capacity of self-regulation, including time management, effort and energy management, organization, impulse control, self-motivation, and emotional regulation.
What I like about this model is that it helps clinicians to look beyond just inattention or hyperactivity. Now we can look for chronic problems, such as organizing behavior over time, keeping to schedules, following through on plans, achieving outcomes, and being on time. These are the better “tells” for ADHD rather than trying to measure how long one pays attention.
MDLinx: What characteristics or symptoms should raise a red flag for clinicians regarding a possible diagnosis of adult ADHD?
Dr. Ramsay: People with ADHD will describe “consistent inconsistency.” That is, repeated descriptions of falling short of reasonable endeavors, tasks, or obligations that the person otherwise has the capacity to complete, but the disorganization, the procrastination, and the self-regulation difficulties get in the way of consistently performing the tasks to achieve otherwise reasonable goals. What people usually describe in the doctor’s office is a track record of repeated interruptions in plans and efforts for otherwise reasonable endeavors. This often happens despite repeated efforts to do things differently: to work harder, to try coping strategies, things like that.
Also, it’s not all or nothing. It’s not like they never accomplish a goal, but there’s that consistent inconsistency, as I mentioned. Like Dr. Barkley would say: “A kid with ADHD has two good days in a row and it’s held against him the rest of his life.”
MDLinx: Your article reviews many types of measures, scales, and inventories designed to assess and monitor ADHD. Why is this article necessary at this time?
Dr. Ramsay: It’s always helpful to have a review article like this that provides “one-stop shopping” for the lay of the land right now. Also, it’s useful for different audiences. One is mental health clinicians who don’t specialize in adult ADHD, but who encounter it enough that they want to be informed about what options they can use in their own evaluation or when they’re referring patients to colleagues. Another audience includes practicing physicians who don’t do these evaluations but want to be able to decipher a report from a psychologist on a particular patient. And for myself, it forced me to track down some things that I had known about or that colleagues had developed, and I had to really roll up my sleeves and look at them more closely.
MDLinx: Why is it important to use a validated assessment tool for diagnosing adult ADHD?
Dr. Ramsay: Most people say, “I have those same problems all the time. Doesn’t everybody have ADHD at least a little bit?” Well, yes, everybody procrastinates at times, but the issue with ADHD is that it’s a quantitative difference not a qualitative difference. It’s the number of problems, the frequency, the magnitude of the difficulties, and the fact that it’s a chronic developmental lag over time. Developmentally, a person with ADHD is not exhibiting the self-regulation levels and capacities that would be expected by someone their age.
So, having some sort of validated assessment tool is an important component of an overarching evaluation. Assessment measures are performed to accurately identify when it is ADHD and to determine the other potential sources of a presenting problem when it’s not ADHD, so that people can get the treatment that’s going to be most helpful to them. But an overarching evaluation also means that you can’t rely on any one measure, or even a handful of measures, without a good diagnostic interview and developmental history to put it in clinical context as well as developmental context.
MDLinx: How does a clinician decide which assessment tool to use?
Dr. Ramsay: It depends on clinical practice. For a physician or health care professional who is considering a referral, they may want to use one of the screening scales to find out if it makes sense to refer this patient on for a more comprehensive evaluation. For example, a new version of the World Health Organization Adult ADHD Self-Report Scale, which was designed to be consistent with the DSM-5, has good psychometrics as a screening scale but it’s only meant to screen, not diagnose, just to see if the patient should be referred on.
On the other hand, a lot of the scales and the structured interviews are used for a gold standard comprehensive neuropsychological evaluation in a specialty program like our Adult ADHD Program at Penn, which handles complex diagnostic cases. We really want to get a wealth of information from a bunch of different sources and also assess for depression, anxiety, trauma, or any other things that could cause or co-exist with attention problems.
Then there are clinicians in private practice who want to have a few tools in the toolbox to perform a competent, if not comprehensive, outpatient evaluation when somebody comes in presenting with potential ADHD. There are also researchers who want assessment tools to monitor follow-up treatment or to track other outcome measures.
MDLinx: Why is it important to monitor treatment in adult ADHD?
Dr. Ramsay: Monitoring provides another source of information and a systematic way to gather a wider range of data in order to ultimately optimize treatment. So even if medications are resulting in improvements, we want to track the symptoms that are improving and by how much, and maybe are there some residual symptoms that could still be targeted. And we can target those not only by medications but also by psychosocial treatment to further reduce symptoms and improve functioning.
There are many effective treatments—medication treatments, psychosocial treatments—that have been found to be very helpful. There are some specific treatments that have been designed or modified for adults with ADHD that should be able to provide a lot of relief and improvement and hope. There’s a lot that can be done.
About Dr. Ramsay: J. Russell Ramsay, PhD, is co-Director of the University of Pennsylvania Adult ADHD Treatment and Research Program and Associate Professor of Clinical Psychology in Psychiatry at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, PA.