Diagnostic Skill Application II

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A Practical Guide for Diagnosing Adult Attention Deficit Hyperactivity Disorder Lorin Leithead, MS, FNP, and Donna Freeborn, PhD, FNP-BC

ABSTRACT Adult diagnosis of attention deficit hyperactivity disorder (ADHD) is complex and can be

difficult for the primary care provider for a number of factore. including the difficulty of

showing childhood onset and because other disorders manifest similar symptoms. Assessment

instalments validated by independent research can aid diagnosis. Varying in their designs and

pros and cons, 8 independently validated assessment instmments were compared to help

piimary care providers choose the right assessment instrament for their needs and clinic and

thus facilitate the diagnosis of adult A D H D .

Keywords: A D H D , adult attention deficit hyperactivity disorder, assessment

A ttention deficit hyperactivity disorder (ADHD), a condirion causing symptoms of inattention or hyperactivity-impulsivity, has

an adult prevalence of 1.2% to 4.4% in the United States.^'^ ADHD is most commonly diagnosed in childhood, and 60% of those diagnosed will continue to experience persistent symptoms in adulthood.' ' However, some people reach adulthood without a diagnosis, and research has demonstrated that greater than 40% of primaiy care practitioners (PCPs) are uncomfortable diagnosing adult ADHD. Adler and colleagues^ report that an easy, vahdated assessment tool would allow 75% of these PCPs to take a more active role in diagnosing this condition.

p OF aniiiT A D H D is defined m the DiiUJiiostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), as a frequently displayed and severe pattern of inat- tention or hyperactivity-impulsivity observed in individuals.^ There are 2 subtypes of A D H D : hyperactive-impulsive and inattentive, with some people exhibiting behaviors of both. Diagnostic criteria require the presence of 6 symptoms for children identified before age 12 in at least 2 set- tings (eg, work, school, home).** However, only 5 symptoms are required for people older than 17.

Adult diagnosis of ADHD is complex for several reasons. First, no laboratory tests are diagnostic for

A D H D , making the diagnosis mainly dependent on provider insight and assessment tools. Second, ADHD symptoms might be explained by other dis- orders, such as substance abuse or misuse, sleep dis- turbances, and mood or anxiety disorders. In fact, it is crucial that substance abuse or a physical disorder be rviled out during the diagnostic work-up. Third, the diagnosis relies on the establisbment of childhood onset, and childhood records and memories might not be complete or clear. Finally, some ADHD symptoms are demonstrated to decline witb age and become more subtle and difhcult to identify.^

Unlike a child with A D H D who is disruptive in classroom and family settings, an adult with A D H D may have more subde signs, such as a history of failed relationships, inability to keep a job, numerous motor vehicle accidents, or financial difficulties. PCPs are in the unique position of interacting with patients for a myriad of complaints and, by establishing a trusting relationship, can be aware of patients' social difficulties.

Assessment instmments can be usefiil as a result of the factors that confound the diagnosis of adult ADFíD.'" The aim of this review is to identify and analyze adult ADHD instrument scales that have been validated by independent research. Inclusion criteria for instrument evaluation are that the instmment was created to monitor or differentiate subtypes of ADHD in adtilts, is validated by independent research, and is

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available for use in primary care. Variables to be analyzed include reliability, cost, ease of use, administration time, whether the tool uses DSM criteria for diagnosis, and age range. The researcher will also examine if the tool assesses symptom severity of adult ADHD and can be used for follow-up to monitor therapy efficacy.

METHODS

Four online databases were reviewed to identify articles: Medline (1975-2012, 480 results), CINAHL (1987-2012, 380 results), PsycINFO (1926-2012, 1,633 results), and Family and Society Studies Wor- ldwide (1968-2012, 340 results). Articles were ex- cluded if they were phamiacology-based, non-English, or studies of children (subjects younger than 18). Articles were included if they were peer-reviewed randomized controlled trials or any peer-reviewed adult studies (subjects older than 18). Search terms i n c l u d e d attention deficit hyperactivity disorder, ADHD,

attention deficit disorder with hyperactivity, adult, assess-

ment, tools, screening, screening tool, screening scale,

diagnostic tool, diagnostic scale, diagnostic, self-report,

self-disclosure, and rating scale. O n c e each i n s t r u m e n t

was identified, an additional search was performed on it using Medline, CINAHL, PsycINFO, and Family and Society Studies Worldwide in order to find more articles related to it.

RESULTS Adult A D H D assessment instruments can focus on current symptoms, look retrospectively at symptoms, or take a combined approach in their assessment of A D H D symptoms. Techniques used in the in- struments include self-report, observer-report, and clinician-administered/interview. The following sections provide an overview of the 7 instruments reviewed, including their respective strengths and weaknesses in a straightforward pro and con format. Table 1 offers a detailed analysis of eacb instrument.

Although most PCPs will become familiar with and use only 1 instrument, differences in client demographics, clinic dynamics, and provider prefer- ences make an analysis of various instruments necessary. Although the DSM-5 is currently the guideline for diagnosis of mental disorders, the DSM-IV was the approptiate guideline at the time the following

instmments were designed. Each instrument has been validated in the adult population.

CURRENT SYMPTOM INSTRUMENTS

Adult ADHD Self Report Scale (ASRS)

Produced by the World Health Organization (WHO),'^ the ASRS symptom checklist is an 18- item instrument that uses symptoms identified by the DSM-4.^^ There is also an ASRS version of 6 items that has been proven effective for screening purposes. Both ASRS versions are appropriate for adult A D H D assessment and use current symptoms in a self-report

Pros. Permission is granted to use the instrument free of charge, making it cost effective as a screening instrument. It is based on the DSM-IV symptoms, allowing the PCP to cross-reference tbe DSM-IV for diagnostic purposes. The screening version of 6 questions is useful in that it can save PCP and patient time by quickly ruling in or out a potential adult A D H D diagnosis. An additional strength is that the ASRS has been translated into multiple languages: Chinese, Danish, Dutch, Finnish, French, German, Hebrew, Japanese, Korean, Norwegian, Portuguese, Russian, Spanish, and Swedish.^"'

Cons. The ASRS measures frequency of symp- toms but does not assess severity of symptoms.

Brown Attention-Deficit Disorder Scales

The 40-item BADDS is a self-report instrument for adults 18 years old or older that uses current symptom assessment.^^ It assesses symptoms used in DSM-IV ctiteria and flirther assesses 5 other criteria: organiza- tion, maintaining attention, sustaining energy, mood and sensitivity, and working memory.^^

Pros. The PCP is able to use questions in an interview style. BADDS is also an effective instrument for monitoring treatment of attention deficit disorder (ADD) patients.^ To belp score the instrument and save time, there is a computer program for purchase; however, it does require the PCP to manually enter the data.

Cons. This instrument only assesses ADD, whereas hyperactivity and impulsivity types are not assessed. Purchase is required for each assessment instrument, thus increasing the long-term cost of using this instrument.

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Conners' Adult ADHO Rating Scales (CAARS)

The third instrument was developed to measure ADHD symptoms in adults 18 or older. ̂ ' It is helpful that assessment of ADHD symptoms addressed in the tool links directly to the DSM-IV criteria." The items in CAARS are designed to assess current ADHD symptoms and not those in the individual's childhood."''^ CAARS uses both a self-report form and observer-report form, providing the PCP additional information about the patient's symptomatology.

Pros. This instmment is based on DSM-IV criteria. There are 3 variations of the instrument: a long, short, and screening version. Each version has a self-report form to be completed by the individual and observer-report form to be completed by parent, spouse, friend, or coworker, which gives the PCP further information on the symptomatology of the patient. There is a built-in inconsistency index that suggests appropriate follow-up questions to clarify disparities." There is also a computer version of the assessment.

Cons. The PCP must become familiar with 3 different instmments so each can be used when ap- propriate. Each instrument, as well as the coinputer version, requires separate purchase, increasing the long-term cost of using this instrument.

Current Symptoms Scale (CSS)

The fourth instrument is a part of the Barkley manual. It is an 18-item instrument that uses D S M - IV criteria and an additional 18 items that evaluate symptoms in 10 settings in which ADHD symptoms might occur: home, work, social interactions, com- munity activities, education, relationships, money management, driving, leisure/recreation, daily re- sponsibilities. Eight additional questions rate behavior such as temper, arguing, defying rules, annoying people, blaming others, being annoyed by others, anger, and feeling spiteful/vindictive.'^ The CSS is designed for assessing adults 18 and older, is a self- report, and measures current symptoms.

Pros. Permission is granted for duplicating the instrument after purchase of the manual, making the long-term cost of using this instrument minimal. ^ The DSM-IV symptom criteria were used in creating

the CSS.^^ The CSS is part of the Barkley ADHD workbook that also includes the childhood symptoms scale and a structured interview guide, which provides inexperienced PCPs assistance with diagnosing ADHD.

Cons. The CSS is sold as a group of instruments, requiring the purchase of the complete group.

College ADHD Response Evaluation (CARE)

The last instrument is a self-report and parent-report assessment tool specifically designed for evaluation of college students (2- or 4-year postsecondary school).'^ There is no specific age requirement, yet the normed age of those tested with CARE was 17-23.^^ CARE was developed firom the

Pros. CARE has a built in Comorbidity Screener that alerts the practitioner of possible comorbid con- ditions (eg, anxiety disorders, mood disorders, somatic disorders, disruptive behavior disorders, and substance abuse), aUovwng the PCP to mle them out.̂ **

Cons. Because this instrument is only used for college aged individuals, it requires the PCP to use another instrument if their patient does not fall into that specific age range. (For more details see Table 1.)

RETROSPECTIVE INSTRUMENTS

Wender Utah Rating Scale (WURS)

This retrospective self-report instrument originated firom Wender's monograph of Minimal Brain Dys- fimction in Children. It focuses on the Wender Utah Criteria rather than using DSM-IV symptoms. The instrument was designed to diagnose an adult patient with no childhood diagnosis of ADHD when no childhood observer is available to fill out a rating scale.^^ It does, however, assess A D H D symptoms from childhood.

Pros. W U R S is 1 of the older assessment in- struments, has been found reliable for over 20 years, and is still used today.^^ W U R S has been translated into Spanish, Itahan, French, and Turkish.""'^''

Cons. The instrument does not use DSM-IV criteria for assessing ADHD symptoms. In addition, patients with depression or substance abuse symptoms were shown to have high W U R S scores, showing that the instmment lacks specificity.

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Childhood Symptom Scale

Created by Barkley and Murphy and part of the Barkley manual, '̂' this 18-item instrument uses DSM- IV criteria and an additional 27 items that evaluate chudhood settings in which ADHD symptoms might have occurred.'^ The scale requires the participant to retrospectively answer questions using the participants' stages of life from 5-12 years old and 5-18 years old.'^ There is a self-report and observer-report form.̂ ^

Pros. Permission to copy the instrument after purchasing the manual is granted, making the long-term cost of using this instrument minimal.'^ The DSM-IV symptom criteria were used in creating the childhood symptom scale. The scale is part of the Barkly ADHD workbook that also includes the CSS instrument and a structured interview guide, giving the inexperienced PCP assistance with diagnosing ADHD.

Cons. The Childhood Symptom Scale is sold as a group of instruments, requiring the purchase of the complete set.

CLINICIAN ADMINISTERED ASSESSMENT/INTERVIEW

Spencer and Alder̂ ^ recommend that the PCP use a clinician-administered assessment or interview with each new patient to make the diagnosis of ADHD. The interview format requires more PCP time to complete than simply reviewing independently completed rating scales."'̂ However, this interview supports the clinician in investigating symptoms in a semi-structured format, thus allowing the patient to recognize his or her personal ADHD symptoms.^"'"^ The interview format enables the PCP to collect retrospective and cun^ent data (eg, academic records, test histories, performance reviews, speeding tickets, and grade point average) that can be used to estabhsh ñinctional impairment in adults." '

The interview format also facilitates assessment of 3 of the DSM-IV-TR diagnostic criteria of ADHD: childhood onset, functional impairment in 2 or more settings, and no mental illness diagnosis that explains the impairment.' '" Several interview- based assessment instruments are available, such as Conner's Adult ADHD Diagnostic Interview for DSM-IV (CAADID), Adult Interview by Barkley and Murphy, and Brown ADD Scale Diagnostic form (Brown ADD-DF). Although any instrument

can be used in an interview format, for the new or inexperienced provider, using an instrument designed for interviewing can facilitate the interaction and ease of diagnosis.

DISCUSSION

The diagnosis of ADHD in adults is multifaceted. The primary data for diagnosis and treatment are obtained by self-report, but self-report is not entirely accurate." Both self- and informant reports provide important information on ADHD symptoms, and using both resources clarifies patient symptomatology. Van Voorhees and colleagues^ examined concordance between self- and informant-reported symptoins. In the event of discordance, self-report generally shows greater symptoms than observer report.^ Upon en- countering self- and informant-reported discordance in symptoms, the informant report should be used for additional information. It should not be used to reject the diagnosis of ADHD but rather to prompt the PCP to pursue further questioning to differentiate ADHD from mental illness. '" '

Childhood symptoms are required to diagnose adult ADHD. The accuracy of the adult to correctly recall childhood ADHD symptoms is questionable.'^' To obtain an accurate retrospective history, the PCP needs to collect contemporaneous data through self- report and observer report. " In circumstances where no observer report can be obtained, the PCP must rely on the patient's recall of childhood ADHD symptoms.̂ ^

Diagnosis is made after assessing retrospective history of symptoms, current history of symptoms, and functional impairment in all areas of an ind- ividual's ufe, including family, medical, develop- mental, education, occupation, psychiatric, and social. ' If the PCP is unsure of diagnosis, referral to a specialist is indicated.

Choosing the right assessrhent instrument and becoming familiar with it will aid the PCP in diagnosing adult ADHD. The right assessment in- strument can vary based on the needs of the PCP patient population. For instance, the C A P ^ in- strument is structured for a PCP who mainly assesses college-age patients seeking diagnosis or treatment of adult ADHD. A PCP who feels uncomfortable or seldom diagnoses adult ADHD might benefit

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from a clinician-administered interview instrument that provides structure during the assessment. An advantage of the Current Symptoms Scale and the Childhood Symptoms Scale is that they are both found in Barkley's ADHD workbook, therefore the purchase of 1 workbook provides a new PCP with 2 instruments and permission to copy forms in the workbook.

As shown, there are pros and cons to each adult ADHD instrument. Knowing the types of patients generally seen in the clinic will assist the PCP in choosing the most appropriate instrument. Becoming familiar with the tool is essential to saving time and energy for both the patient and PCP.

CONCLUSION Many validated assessment instruments are available for the PCP to help diagnose ADHD. The DSM-IV requires the PCP to explore the adult patient's past, which can be done through both self- and observer reports or through semi-structured interviews. The PCP needs to be aware that adult ADHD assessment is multifaceted and that the assessment instruments are only a part of the diagnosis; all areas of an in- dividual's life should be examined in making an adult ADHD diagnosis.

A clinician-administered/interview can give tbe PCP information on severity of symptoms and where symptoms occur (eg, home, work, school). Obtain- ing retrospective and current data to estabhsh func- tional impairment is necessary. After assessment of retrospective history, current history, and functional impaimient, if a diagnosis is still unclear, a referral to a specialist is appropriate.

Further research should focus on other adult ADHD assessment tools that have not had indepen- dent research in order to increase the accuracy and efficiency of adult ADHD diagnosis by PCPs. fSti

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Lorin Eeithead, MS, FNP, can be reached at lleithead@gmail.

com. Donna Freeborn, PhD, FNP-BC, CNM, is director

of the family nurse practitioner program at Brigham Young

University in Provo, UT. In compliance with national ethical

guidelines, the authors report no relationships with business or

industry that would pose a conßict of interest.

694 The Journal for Nurse Practitioners - JNP Volume 9, Issue 10, November/December 2013

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