Assessment of Adult ADHD: A Guide for Primary Care Providers

emotional self control and emotional over reactivity; impulsive decisionmaking; and, general disorganization whether in their personal lives or inthe workplace. Adults with ADHD often appear to be quite discom -bobulated throughout their life.Impact of ExecutiveFunction Deficits onAdult Functioning (2)Adults with ADHD havedifficulty keeping promisesand commit ments toothers, or they may beviewed as being unreliableor inconsistent. They mayhave trouble followingthrough, difficulty multitasking or keeping track ofseveral things at once, and seeing things through to completion.An inability to stop an enjoyable activity and shift to a more important taskis often impaired. People with ADHD have great difficulty doing what theyare supposed to do when they are supposed to do it consistently. Theyoften need somebody to depend on for maintaining order and goaldirection as it is very hard for them to do complex tasks by themselves.Often times they need somebody to help them stay on track and keepthem going in the right direction.Impact of ExecutiveFunction Deficits onAdult Functioning (3)There is a sense of under -achievement where peopledo poorly in school despiteaverage or above averageor even superior intelli -gence. This under achievementoften affectsjobsuccess, impairs work per -formance, and may resultin unsatisfactory relationships in marriages or co-worker relationships orpeer relationships. As I mentioned poor driving outcomes are verycommon in adult ADHD, poor money management, saving for retirementand impulsive spending pose real problems.Trouble doing routine tasks ofdaily life, organizing a household, raising children, parenting, and payingbills show how pervasively this condition affects people in their day to dayfunctioning. So in the assessment you are go to look for clues to helpyou illicit some of these areas of difficulty that are so common to adultswith ADHD.ADHD AssessmentPrinciplesNow for a couple of essen -tial as sess ment prin ci ples,it is very important to be asthorough and comprehen -sive as possible. We don’tassess this condition in asurface level or just givesomebody a rating scale,count symp toms, and con -clude that they must have ADHD. So we are not just doing a surface leveljob here, we need to be more comprehensive. I am going to tell you howto do that in an expedient way in a just a few minutes.Whenever possible you want to include collateral informants whengathering assessment data. Typically, this is either a spouse, or a parent, ora sibling, or somebody who has known the person well for a long time. Itis very important to get multiple sources of information when possible.Obtaining historical records when available is very, very helpful. This helpsto establish the chronicity, the onset and the pervasiveness of impairmentthat is mentioned in the next bullet here.School records, report cards, job performance reviews, medical recordsthings like that can really help us to take a look at the paper trail,it’s a testament to the person’s developmental deviance over time.We also need to rule out other conditions that might better explainADHD symptoms.More about ruling out, what do we tend to rule out? Well we have toconsider if there are better explanations for existing problems before weconclude that someone has ADHD.Ruling Out AlternativeExplanations for ADHDSymptomsWe need to rule out tran -sient situational stressorsas an explanation forADHD-like symptoms.A divorce, a career change,a job change, grief reaction,family or lifestyle changes,people having babies ortwins, or getting married, or things like this can produce stress and ADHDlikesymptoms.Also we have to rule out medical conditions that may also mimic ADHDSymptoms these include things like: chronic fatigue, thyroid difficulties,diabetes, even menopause, and medication side effects. We also need torule out other psychiatric disorders as being responsible for the symptoms,not only ruling out but also looking at whether they coexist with the ADHD.Typically these are things like bipolar disorder, substance abuse, depression,anxiety disorders or personality disorders.Assessment Tools toHelp Diagnose AdultADHDHere are some assess menttools to help diag noseADHD. These are the toolsthat are going to help youanswer those four funda -mental questions that Imentioned in the begin -ning — these are at the heartof an ADHD evaluation.So those are the questions you want to ask and these are the tools thatyou are going to use to answer those questions.There are four major things we use to conduct as assessment: structuredinterview tools, symptom rating scales, historical records and neuro -psychological tests. We are not going to concern ourselves so much withneuropsychological tests in this talk because suffice it to say thatneuropsych tests are not diagnostic of ADHD. They do help us to betterunderstand strengths and weaknesses and may help in establishcomorbidity but we’ll focus on the other three areas at this time.Components of anADHD EvaluationIt’s Important for you tounderstand that a typicalevaluation does not requirelengthy, structured inter -views or a comprehensiveneuropsychologicaltestbattery. ADHD assessmentdoes not have to be anonerous difficult process.We can do this fairly reliably in a relatively quick way. Accurate diagnosiscan be obtained by doing a careful, traditional history taking and a recordsreview, combined with the use of symptom rating scales and a clinicalinterview that focuses on the ADHD diagnostic criteria.This is the nub of what I want to talk to you about in this segment.' ' ' '' ' 'a*

Situational Variability ofADHD SymptomsAnother important point tounderstand is the situa -tional variability of ADHDsymp toms. Many peopledon’t understand this incon -sis tency. Adults may functionbetter in one settingversus another. The guide -lines here are, if the task isinherently interesting, if it ishigh stakes, if it is novel, if it is exciting, if it is highly relevant to what theylike, they may look quite normal. But when the task is boring, repetitive,low interest or irrelevant to them they have a great deal of difficulty andsymptoms become exacerbated. That is why you see a great deal ofvariability at school and work.It is important to get spousal reactions. Spouses often feel overburdenedat times. They feel they have to be the glue that keeps things together.They have to be on top of things because their ADHD spouse is unreliable.They feel very frustrated in the relationship.Summary—KeyAssessment PointsIt is very important as aprimary care doc that youhave a conversation withyour patient. Some of thisstuff doesn’t come outuntil you invite a conversa -tion and hear their story alittle bit. It doesn’t have tobe an overly lengthy conver -sation. In the Adult ADHDToolkit you will have some questions in a brief interview that are designedto help you get at this conversation started.Summary—KeyAssessment Points (2)First, ADHD is a legitimateand serious disorder that isassociated with significantimpairment in multiple lifedomains including school,work, social relationships,driving, money manage -ment, and daily adaptivefunctioningSecondly, ADHD is associated with significant comorbidity — mostcommonly oppositional defiant disorder, conduct disorder, substanceabuse, dysthymia, major depression, and anxiety disordersAlso, ADHD has an onset in early childhood or adolescence, persists intoadulthood in most cases, and causes chronic and pervasive impairmentover time and across situationsADHD is not an adult-onset disorder. It does not suddenly arise in adult life.Clinicians should always attempt to rule out other reasons for ADHD-likesymptoms before concluding ADHD is present.Summary—KeyAssessment Points (3)A trial of a stimulant medi -cation is not a test forADHD. And this is notsomething that should bedone as part of an assess -ment, rather medi cationshould be prescribed afterthe assessment when youhave a good idea thatthis person does meetcriteria for ADHD and a medication is appropriate. Don’t do a trial balloonin the beginning to see if there is a positive reaction. In fact, most peopletaking a stimulant, whether they have ADHD or not, would respond in apositive manner.Another thing to remember is that there is no litmus test for ADHD—noneuropychological test battery, no brain scan that can be used to determinewhether ADHD is present or not. The assessment tools described hereshould be used n combination and not used as a stand alone diagnosticmeasures.We need to use the rating scales, interviews with patients and collateralinformants, testing, and historical records in combination to help us makethe best and most informed judgments about diagnosis.The Adult ADHD Toolkit can help you very much make more sense out ofall this and gives you a blueprint of how to do this effectively.Case VignetteNow getting back to the case vignette, I am not going to read it again, butafter listening to this presentation your answer here is all the choices arecorrect EXCEPT prescribing stimulant mediation as part of the assessment.I hope this helps you understand ADHD assess ment better in this segment.Thank You' ' ' '' ' 'D$53"I,%"4'U";$"P$4$5=',B'1-8-'D=*