10 CEUs Treating Locking In & Blocking Out: ADHD Adults

Section 16
Diagnostic Procedures for ADHD in Adult Clients

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Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Accurate diagnosis of adult ADHD remains a clinical challenge. It is a “hidden disorder” representing extremes of normal behaviors, with no clear consensus regarding the clinical boundaries (Levy et al), particularly for adults.  Neuropsychological testing most consistently finds deficits in tests of attention, behavioral inhibition, and working memory (Hervey, Epstein, & Curry). These findings have helped to establish the neuropsychiatric validity of ADHD. There is also a growing body of research that may implicate dysfunction of right hemisphere systems in ADHD (see Stefanatos & Wasserstein for a review). However, reported findings are typically observed for ADHD groups and not necessarily seen in all individuals. As yet no characteristic neuropsychological profile exists. There is consequently no definitive “test” for ADHD, although certain deficit patterns are more likely to occur in ADHD. The role of testing in the diagnostic evaluation is still evolving and is likely to become an ever more important source of objective information. Clinical history, specialized symptom rating scales, and selective testing (on an as-needed basis) are the current state of the art. In the diagnostic process, I recommend the following components: • Assess current level of symptoms. • Assess degree of functional impairment. • Establish childhood history. • Perform general psychological evaluation. • Obtain developmental history. • Obtain family psychiatric and neuropsychiatric history. • Institute specialized psychological or neuropsychological testing. • Be mindful of medical mimics.

Current Level of Symptoms                                                                          
Current level of symptoms is most easily assessed by using one or more of the existing ADHD scales, which provide adult and adolescent norms. There is debate about the accuracy of these measures, although empirical studies typically find underreporting of symptoms among adults (Barkley). Thus use of the scales may actually lead to an underestimate of the level of problems, because of the patients’ underreporting or blunted self-awareness. I have found underestimating problems to be especially likely among adolescents who are still struggling with identity formation, rather than among adults, who have experienced more persistent challenges. Sometimes people overreport because they are motivated to get the diagnosis in order to secure academic accommodations, provide an explanation for their dysfunction, or generally be symptom magnifiers (a response set). It is helpful to have additional input from a collateral reporter, such as a spouse or parent (who can be given the same scales), although many adults are reluctant to involve others. For adolescents, collateral informants may be essential because of their tendency to be poor self-observers. The Brown Attention Deficit Disorder Scales (Brown) and the Conners’ ADHD rating scales (Conners, Erhardt, & Sparrow), adult and adolescent versions, are among the most widely used ADHD scales in clinical practice. Each scale has been shown to have reasonable sensitivity and specificity when differentiating between those who have ADHD and control populations. The scales differ in the dimensions of the disorder they emphasize. The Brown scale consists of 40 items that focus on the executive spectrum of problems and, as such, assess difficulties with activation, perseverance, affect regulation, and working memory, as well as with the core symptom of inattention. Sample questions also address tendencies for procrastination, disorganization, and poor self-regulation (e.g., difficulty in waking up in the morning, tendency to feel overwhelmed, slowness of reactions, need for extra time). Hyperkinetic and impulsive spectrum issues are not sufficiently queried. By contrast, the Conners’ scale adheres more closely to the DSM-IV criteria, thereby also providing adult norms for hyperactivity and impulsivity, as well as for core inattention/memory problems. It consists of 66 items, which address a wider spectrum of ADHD symptoms, including poor self-image. For example, boredom, restlessness, and verbal impulsiveness are directly queried on this measure, as is affective lability. However, the many manifestations of executive dysfunction deficits are not as closely assessed. Clinically, I have found the Brown to be more sensitive for inattentive spectrum problems and Conners’ more sensitive for hyperactive/ impulsive spectrum problems. It is useful to administer both measures and draw diagnostic conclusions from the total data set. Scores can also be used as baseline measures to target specific areas for intervention and to monitor change.

Degree of Functional Impairment
Functional impairment is usually evaluated by clinical interviews of the patient and significant others (such as spouse or parent). The general questions here are how much suffering and dysfunction ADHD symptoms are causing in the person’s life. Are the symptoms compromising work and/or social functioning, contributing to the person’s failure to achieve specific life goals, resulting in significant suffering to others (e.g., spouse, children, coworkers), or increasing significant health risks (e.g., substance abuse, risky driving, sexual promiscuity)? Two additional questions need to be considered when evaluating the preceding questions: The first again relates to poor recognition of problems by the client. The second relates to the level of effort required for the person to function, thereby possibly masking the existence of “impairment.”

Poor recognition is usually not a concern for self-referred patients. By definition they have sought an evaluation because they believe there is some impairment. In this context the clinician needs to clarify the exact problems and parameters. It is tempting to view examples as “only normal,” and one needs to be mindful of base rates of problem behaviors. For example, how frequently do they lose track of required things or conversations at work? How behind are they on their bill payment and e-mail responses? How many areas are out of control? Poor recognition is more likely when someone seeks an evaluation at the request of another. Again, outside reporters are essential when poor self-awareness exists or is suspected. Work evaluations can also be very useful. There is some disagreement among experts regarding what constitutes functional impairment. There is no argument when individuals overtly fail at work or in school because of ADHD-related symptoms, such as chronic lateness, failure to meet deadlines, and interpersonal difficulties (e.g., noncompliance). Disagreement emerges when people do not fail, and may even perform well, but describe expending excessive amounts of time and energy in order to do so. Some argue that, as for an alcoholic, one does not need to be actively drinking (i.e., failing) to have a problem. Simply working excessively hard to compensate, and often at great personal and social cost, becomes the marker for functional impairment. Although this point may seem arbitrary, many individuals who show this profile (and also meet other current and historical diagnostic criteria) often experience dramatic symptom relief with treatment.

Establish Childhood History
Childhood history of ADHD is essential and typically evaluated through a clinical interview. Awareness of the usual developmental course of ADHD is important. In general, the more characteristic developmental findings in a given individual’s life span, the more likely the diagnosis of ADHD. History gathering can also be supplemented by commercial structured history forms. For example, an excellent adult version, created by Brown, is available through Psychological Corporation. Administration of standardized retrospective self-report questionnaires, such as the Wender-Utah Rating Scale (WURS; Wender) is also useful. It is a 25-item measure, gleaned from 61 original items, which separated adults who have ADHD from normal control and depressed adults. However, the recommended cutoff scores are somewhat conservative and were designed to be so for research purposes. In my experience, people who had milder forms of hyperactivity/impulsivity or pure inattentive type ADHD during childhood are likely to be missed on this measure. However, as it was designed to be, a positive score is strongly predictive of accurate diagnosis and good stimulant medication response in adults. When reviewing personal history, I look for the following common developmental markers of ADHD. Poor cooperation with peers and noncompliance are most pronounced in preschoolers but may be seen throughout the life span. Preschoolers also tend to have difficulty with transitions and focused group activities (e.g., circle time). In addition to distractibility and hyperactivity/impulsivity, school-aged children show difficulty in developing routines of daily living (e.g., sleep, grooming, even toilet training) and often have trouble in acquiring basic academic skills. Poor handwriting is extremely common, as are all specific learning disabilities, disorganization, and general underachievement. Adolescents tend to be immature, have more conflicts with parents, have poor social skills, and engage in more high-risk activities, such as alcohol and drug use, unprotected sex, and  reckless driving. Academically, teens who have ADHD show difficulty completing homework and longer projects (Weiss & Murray). Clinically, I have found that preschoolers who have ADHD have a high rate of pervasive developmental delay NOS, and many school age children who have ADHD/inattentive type show nonverbal learning disability profiles. As teens, I have found, boys who have ADHD/combined type are more isolated or antisocial; girls who have ADHD/combined type are more hypersocial, although variations exist. When looking for childhood symptoms, it is important to recall that a highly organized home life can mitigate the expression of many ADHD symptoms. For example, availability of sports or structured teachers, organized schools, or even regimented cultures can mask the expression of many symptoms. As a result, interviews with parents or significant others may be necessary to unveil the existence of earlier excessive impulsivity, disorganization, inattention to detail, forgetfulness, and the like. Overt problems may have only become apparent during middle school, higher education, or even later in the work world. That is, ADHD problems become ever more manifest as environmental demands become more complex and, concurrently, external supports are increasingly removed (Wolf &Wasserstein). When available, report cards and/or teacher letters can be extremely helpful.

General Psychological Evaluation
Inattention and impulsivity are to psychopathology what fever is to medicine. That is, many core ADHD symptoms can be nonspecific symptoms of many other psychological disorders, not only of ADHD. Consequently, it is necessary to rule out other possible psychiatric diagnoses as alternative explanations for the symptoms. Further complicating the diagnostic process is the fact that ADHD frequently occurs in combination with other psychiatric disorders (Wender; Brown). Thus the presence of a comorbid condition does not rule out ADHD. The setting in which assessment occurs is likely to influence the type of comorbidity seen. Prospective studies that follow children into adulthood report high rates of antisocial and substance abuse disorders. By contrast, adults who seek treatment in clinical settings are more likely to report depression and anxiety (Gallager & Blader,). By extension, self-referred people may be more likely to have the mood and anxiety disorders, whereas the people taken in by others (often adolescents) may be more likely to have acting-out problems.

Standardized checklists are helpful and speed up the evaluation process. I use the Symptom Checklist-90 Items Revised (SCL-90R) and/or the Beck Depression and Anxiety Scales. All provide well-normed standards. When a more complicated analysis of personality functioning is required or requested, more elaborate questionnaires such as the Minnesota Multiphasic Personality Inventory (MMPI-2) or the Million Clinical Multiaxial Inventory (MCMI) are useful. However, the reader is cautioned that current computer-generated reports for adults were not created with ADHD as a diagnostic possibility. As a result, many ADHD symptoms can be subsumed under mania and/or antisocial personality. Projective testing may prove useful, as dictated by the taste, experience, and preferences of the diagnostician.

Because ADHD can coexist with depression and anxiety, a differential diagnosis is sometimes very difficult. In such situations the time line of core symptoms needs to be closely evaluated. I note whether or not symptoms have remained constant throughout life, improved somewhat in adulthood, or fluctuated along with mood/anxiety changes. Those who have true ADHD often describe some symptom remission over time. They also convincingly argue that their comorbid problems are secondary to their lifelong dysfunction from ADHD. For example, they report always having been inattentive and disorganized, irrespective of their emotional state. Absent periods of normal functioning and given a positive family history, diagnosis of ADHD with depression (or anxiety disorder) may be appropriate. Those who have primary mood disorder report concentration difficulties that parallel their degree of depression (during childhood or adulthood). Similarly, severe anxiety can disturb concentration and cause physical overactivity. If the symptom course is unclear, treating these more reversible conditions first and postponing the final diagnostic decision regarding ADHD may be prudent. Sometimes the person’s concentration, attention, and organization improve dramatically with relief of depression or anxiety. Often the symptoms remain, thereby clarifying the diagnosis. Hyperactive/ impulsive symptoms may also be difficult to differentiate from hypomania or extreme anxiety. Periodicity of symptoms and overt signs of mania (e.g., excessive spending, hypersexuality, primitive and loose thinking) can help in forming a diagnosis of bipolar illness. Treatment of anxiety can clarify the existence of residual ADHD. Again, family history of probable genetic risk is useful, but not definitive, in this regard.

Specialized Testing
Psychological and neuropsychological testing is useful for evaluating attention and executive functions, as well as for gaining a better understanding of commonly comorbid LDS. Other neuropsychological domains, such as memory, language, and visuomotor abilities, may also be compromised to varying degrees (Gallagher & Blader). Despite some guidelines derived from the child literature (e.g., executive dysfunction), as yet there is no consensus regarding the expected neuropsychological profile of adults (Hervey et al.).

Computerized tests (CPTs) of sustained attention are among the most frequently employed neuropsychological measures. This high utilization rate probably reflects the fact that CPTs measure the two primary neurocognitive domains associated with ADHD, attention and response inhibition. Specifically, CPTs require the examinee to respond rapidly when presented a target stimulus and not to respond when shown a distracter stimulus. Multiple response dimensions can be computed, usually including omission errors, commission errors, reaction time and different types of variability. Traditional CPTs (e.g., Test of Visual and Auditory Attention; TOVA) have few target stimuli embedded among many nonsignal stimuli, thereby stressing attention. Other CPTs (for example, the Conners’) have a higher target stimulus probability, thereby stressing the ability to inhibit (see Riccio & Reynolds for a review). Most are visual, although some also use the auditory mode (e.g., Integrated Visual and Auditory [IVA] CPT and TOVA). Hervey and colleagues supported the importance of this assessment approach in their recent meta-analysis of adult ADHD research (2004). On a group level, CPTs were highly successful in discriminating between normal control individuals and identified patients. Moreover, CPT versions and response dimensions that emphasized attention (i.e., traditional CPTs and omission errors) were more sensitive than CPT versions and tasks emphasizing inhibition (i.e., commission errors and less traditional CPTs). Other response dimensions were less frequently studied, although reaction time variance was also highly discriminating. On an individual level, however, as for all standards for ADHD, there can be false negative and false positive results. I have found the first occurs when people can compensate for their deficits during the relatively brief period required for the test (about 15–20 minutes). The second occurs when there are alternative disruptive mechanisms operative, such as an anxiety or mood disorder or psychosis.

Measures of executive functioning (e.g., Trails B or Rey Complex Figure Drawing) are also promising, but not universally sensitive. That is, not all people who have ADHD have deficits on all, or even some, measures of executive functions (Gallagher & Blader). These results may reflect limits in current assessment methodology. Nevertheless, selected neuropsychological tests of executive functions are often compromised in those who have ADHD, thereby permitting some objective support for the diagnosis. Complete evaluation is especially indicated for adolescents and young adults who are still in the process of completing their education. They may be unaware of coexisting learning problems and of their specific underlying neuropsychological basis, both of which the testing can clarify. Many people who have ADHD may, in fact, have some degree of nonverbal learning disorder (Stefanatos & Wasserstein), which is only unmasked through testing. Identifying and clarifying unrecognized learning disabilities, or validating their past existence, can be one of the most valuable contributions of formal evaluations. Overall then, in both adolescents and adults, comprehensive evaluation is useful for the following: 1. Understanding better the individual’s strengths and weaknesses when planning treatment. 2. Generating a baseline against which to monitor change through interventions, both from pharmacotherapy and psychotherapy. 3. Providing evidence for legally mandated accommodations at school or on the job. 4. Informing diagnosis. In short, specialized testing is not considered necessary for diagnosis, but can be essential for allowing a more objectively informed diagnosis and providing legal services. It is also helpful for understanding of the individual and for permitting the individual to better understand himself or herself. Finally, treatment can be shaped, monitored, and facilitated with testing input.

Medical Mimics
There are a number of medical conditions (e.g., hypertension, glaucoma) that either cause symptoms that resemble ADHD, coexist with ADHD, or may affect an individual’s ability to tolerate stimulant medication. All would require further medical evaluation, and some might change the diagnostic formulation. Head injury and lead toxicity are the two most common causes of acquired inattentive/hyperactive dysexecutive syndromes. Seizure disorders of all types can be mistaken for inattentive ADHD, and the presence of discrete staring spells or episodic inattentive symptoms indicates need for neurological referral. Sleep disorders are common among children and adults who have ADHD and may worsen the clinical presentation. These disorders may also exist independently of ADHD and cause disturbed attention because of lack of sleep. In particular, narcolepsy or obstructive sleep apnea may be suspected when there are reports of excessive daytime somnolence. Referral to a sleep expert should be considered when these symptoms are severe, diurnal rhythms are extremely irregular, or there is clear sleep stage disorganization (e.g., dreaming as soon as the person falls asleep). Endrocrinopathies, particularly thyroid disorders, can lead to extremes of arousal and/or irritability but are usually accompanied by other significant physical problems (e.g., temperature intolerance, bowel and skin changes) (Pearl et al.). In middle aged women autoimmune hypothyroidism, and possibly menopause, can cause poor concentration. This may worsen borderline ADHD cases and can lead to the unusual presentation of symptoms that increase in adulthood. Again, medical consultation is necessary if any of these illnesses is suspected. Conversely, I have seen previously unrecognized ADHD in an adult who had a known LD be confused with insipient dementia. During a period of protracted stress he began to show severe memory and functional problems. For example, his fiancée described his losing her engagement ring, forgetting routine daily tasks, and placing notebooks in the refrigerator. Once the ADHD was recognized and treated, and his life stress decreased, he returned to his baseline high level of functioning (chief executive officer of his own company). Thus accurate diagnosis was key, but not easy.
- Wasserstein, Jeanette; Diagnostic Issues For Adolescents And Adults With ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p 535

Misdiagnosis of attention deficit hyperactivity disorder:
‘Normal behaviour’ and relative maturity

- Ford-Jones P. C. (2015). Misdiagnosis of attention deficit hyperactivity disorder: 'Normal behaviour' and relative maturity. Paediatrics & child health, 20(4), 200–202.

Personal Reflection Exercise #2
The preceding section contained information about diagnostic procedures for ADHD in adult clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article Reference:
Kofler, M. J., Harmon, S. L., Aduen, P. A., Day, T. N., Austin, K. E., Spiegel, J. A., Irwin, L., & Sarver, D. E. (2018). Neurocognitive and behavioral predictors of social problems in ADHD: A Bayesian framework. Neuropsychology, 32(3), 344–355.

Kofler, M. J., Sarver, D. E., Austin, K. E., Schaefer, H. S., Holland, E., Aduen, P. A., Wells, E. L., Soto, E. F., Irwin, L. N., Schatschneider, C., & Lonigan, C. J. (2018). Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training. Journal of Consulting and Clinical Psychology, 86(12), 964–979.

Kofler, M. J., Singh, L. J., Soto, E. F., Chan, E. S. M., Miller, C. E., Harmon, S. L., & Spiegel, J. A. (2020). Working memory and short-term memory deficits in ADHD: A bifactor modeling approach. Neuropsychology, 34(6), 686–698.

According to Wasserstein, what are key components of the diagnostic process for adult ADHD? Record the letter of the correct answer the Test.


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