Assessment of ADHD in Adults: Methods and Issues

Russell Barkley, PhD - Dedicated to ADHD Science+

16 May 202393:33

EducationalLearning

32 Likes 10 Comments

TLDRDr. Russell Barclay, a clinical professor of Psychiatry at Virginia Commonwealth University, delivers a comprehensive lecture on the assessment of ADHD in adults. He emphasizes the limitations of relying solely on DSM-5 criteria, suggesting that these criteria are biased towards children and may not accurately detect ADHD in adults. Dr. Barclay advocates for a broader perspective that includes executive functioning deficits, particularly in working memory, which he identifies as central to ADHD. He discusses the need to document the presence of symptoms across various life domains and to establish impairment in major life activities. The lecture also addresses the importance of corroborating patient reports with information from others who know the patient well, the challenges associated with the retrospective recall of symptom onset, and the potential for both under- and over-reporting of symptoms. Dr. Barclay further highlights the significance of considering comorbid disorders and the impact of ADHD on various aspects of life, including education, work, social relationships, and health. He concludes by stressing the importance of a multi-faceted assessment approach that goes beyond DSM criteria to ensure a more accurate diagnosis and treatment planning for adult ADHD.

Takeaways

📚 The assessment of ADHD in adults should begin with the DSM-5 criteria, which include symptoms of inattention and hyperactivity-impulsivity.
🔍 At least five out of nine symptoms from each category must be present often or more frequently for an adult diagnosis, with additional criteria for developmental inappropriateness.
⚠️ DSM-5 criteria may be biased towards children and might not be sensitive enough for adult ADHD detection, as hyperactivity often decreases with age.
🧐 The importance of considering executive functioning and working memory in the assessment, as ADHD affects more than just inattention.
🔗 The need to corroborate patient-reported symptoms through others who know the patient well or through archival records due to potential unreliability of self-reporting.
🚫 The DSM-5's requirement of an age of onset of 12 is not developmentally specific to adults and should be reconsidered for a more accurate diagnosis.
🛑 The presence of ADHD symptoms leading to impairment in major life activities is crucial for diagnosis, not just the presence of symptoms.
🧬 ADHD can be a result of acquired brain injuries or illnesses, which should be considered when diagnosing and may present differently than developmental ADHD.
🔄 The transition from DSM-IV to DSM-5 removed the subtypes of ADHD, emphasizing different presentations rather than qualitative differences.
👥 Females may be underdiagnosed due to a male-biased criterion in DSM, and it's important to use gender-normed rating scales for a fair assessment.
⏳ The chronic course of ADHD symptoms is typical, with few periods of remission, which should be distinguished from episodic symptoms of other disorders.

Q & A

What is the primary focus of Dr. Russell Barclay's lecture?
-The primary focus of Dr. Russell Barclay's lecture is the assessment of ADHD in adults, including the specific nature components, and issues involved in the assessment process.
What are the two dimensions of neuropsychological traits involved in ADHD according to DSM-5 criteria?
-The two dimensions of neuropsychological traits involved in ADHD according to DSM-5 criteria are inattention, with nine symptoms, and hyperactive and impulsive behavior, also with nine symptoms.
How many symptoms from the inattention list must be documented for an adult to meet DSM-5 criteria for ADHD?
-For adults, at least five out of the nine symptoms of inattention must be documented to meet DSM-5 criteria for ADHD.
What is the issue with using the DSM-5 clarifications in parentheses for adjusting symptoms to be more developmentally appropriate for teens and adults with ADHD?
-The issue is that these clarifications were never tested for their accuracy in determining the presence of the disorder, and their use may lead to a very low relationship with the actual root symptoms they are supposed to modify.
What is the recommended approach to establishing the presence of ADHD symptoms that lead to impairment during the developmental period?
-The recommended approach is to establish that the symptoms are developmentally inappropriate for the individual, occur often or more frequently, and lead to impairment in major life activities at some time during the developmental period, which could be up to about age 24.
Why is it suggested to be cautious about using the DSM-5 criteria for diagnosing ADHD in adults?
-It is suggested to be cautious because the DSM-5 criteria may lose sensitivity to detecting adult ADHD as they are heavily biased towards childhood symptoms and may not accurately represent the manifestation of ADHD in adults.
What are some of the problems associated with the DSM-5 criteria when applied to adults?
-The DSM-5 criteria have problems such as being heavily childhood-biased, potentially losing sensitivity in detecting adult ADHD, having too many symptoms of hyperactivity which overweighs the criteria towards children, and not having enough symptoms of impulsivity on the symptom list.
What is the suggested age of onset for ADHD symptoms for diagnosis, according to Dr. Barclay?
-Dr. Barclay suggests that there should be no specific number assigned to the age of onset, but rather it should simply be recognized as occurring during development.
Why is it important to consider symptoms beyond the DSM-5 criteria when evaluating adults for ADHD?
-It is important to consider symptoms beyond the DSM-5 criteria because the DSM-5 is not developmentally specific to adults and may not accurately detect the presence of ADHD in adults. Using additional symptoms that are more sensitive and accurate for adults can improve the detection of the disorder.
What are some of the additional symptoms that Dr. Barclay suggests could be used in addition to the DSM-5 criteria for documenting the presence of adult ADHD?
-Dr. Barclay suggests using symptoms of executive functioning deficits, such as problems with goal attainment, task completion, meeting deadlines, preparing for the future, and using working memory to re-engage goals after distractions.
What is the significance of considering impairment relative to the general population when defining a disorder?
-Considering impairment relative to the general population is significant because it helps to establish a benchmark for what constitutes ineffective functioning in major life activities. This benchmark is essential for diagnosing a disorder and distinguishing it from typical variations in behavior or personality.

Outlines

00:00

😀 Understanding ADHD Assessment in Adults

Dr. Russell Barclay, a clinical professor of Psychiatry, discusses the intricacies of assessing ADHD in adults. He emphasizes the importance of adhering to DSM-5 criteria, which includes documenting symptoms of inattention and hyperactivity/impulsivity. The lecture highlights the need to establish the presence of ADHD through the documentation of at least five out of nine symptoms for adults, considering developmental inappropriateness, and ensuring symptoms are not just occasional but occur often. Dr. Barclay also cautions against over-reliance on DSM's clarifications for symptoms, as they haven't been tested for accuracy in diagnosing ADHD in adults.

05:02

🧐 The DSM's Limitations in Diagnosing Adult ADHD

The paragraph delves into the limitations of the DSM-5 when diagnosing ADHD in adults. It points out that ADHD can develop due to brain injuries or illnesses and that the DSM criteria might not fully capture the adult manifestation of ADHD. The speaker suggests that the DSM's requirement for symptoms to be present in multiple domains and cause significant impairment in major life activities is crucial. However, the DSM's criteria are criticized for being biased towards children, potentially losing sensitivity in detecting adult ADHD, and having an insufficient number of impulsivity symptoms for a comprehensive diagnosis.

10:05

👨‍⚕️ Addressing Gender Bias and the Onset of ADHD

This section addresses the gender bias in the DSM criteria, which historically had a higher male to female ratio in its studies, leading to a potential underdiagnosis in females. The paragraph also discusses the inadequacy of the age of onset criterion of 12 years old for ADHD, suggesting it should be higher or removed to account for a broader developmental period. The unreliability of self-reported age of onset is highlighted, and the need for corroboration of symptoms through others or archival records is emphasized.

15:09

🧠 Executive Functioning and ADHD in Adults

The focus of this paragraph is on the importance of considering executive functioning when diagnosing ADHD in adults. It discusses how ADHD's inattention symptoms are more about an inability to focus on future tasks rather than the present moment. The paragraph outlines nine symptoms that have been found to be more indicative of adult ADHD than the hyperactivity-focused DSM criteria. These symptoms are related to various executive functions, emphasizing the need to look beyond the DSM-5 when assessing adults.

20:12

📉 The Prevalence and Impact of ADHD in Adults

This section discusses the chronic nature of ADHD symptoms and the various domains of life that can be impaired by ADHD, such as education, work, social relationships, and more. It also touches on the genetic and neurological basis of ADHD, highlighting its heritability and the increased health risks associated with it. The paragraph emphasizes the extensive training and comprehensive evaluation required to accurately diagnose ADHD in adults, including the use of rating scales and the consideration of comorbid disorders.

25:14

🚫 Critique of Neuropsychological Testing for ADHD Assessment

Dr. Barclay criticizes the use of neuropsychological testing for diagnosing ADHD, stating that these tests are not predictive of real-world executive functioning and are not correlated with the impairments seen in daily life. He argues against their use in high-stakes decisions, such as determining eligibility for accommodations or social benefits, due to their poor false negative rate and non-specificity. The paragraph calls for clinicians to rely on more ecologically valid methods, such as rating scales and patient interviews, for assessing ADHD.

30:17

🤔 Diagnostic Challenges and Strategies

The paragraph addresses the challenges in diagnosing ADHD, including under- or over-reporting of symptoms, poor retrospective recall, and the need for corroboration from multiple sources. It advises clinicians to use a combination of interviews, rating scales, and archival records to cross-validate patient reports. The speaker also warns about the possibility of malingering, especially in situations where there might be a personal gain, and emphasizes the importance of a thorough differential diagnosis to rule out other disorders.

35:17

📚 Comprehensive Assessment of Adult ADHD

This section outlines the steps involved in a comprehensive assessment of adult ADHD, which includes open-ended interviews, semi-structured interviews focusing on current complaints and symptoms, structured interviews based on DSM criteria, and the use of rating scales. It also involves documenting comorbid disorders, conducting a differential diagnosis, and considering the patient's intellectual or cognitive deficits and specific learning disabilities. The paragraph concludes with a reminder of the importance of looking beyond DSM criteria and considering the broader impact of ADHD on various aspects of life.

Mindmap

Keywords

💡ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. In the video, it is discussed extensively as the primary focus, with an emphasis on its assessment in adults. The script highlights the complexity of diagnosing ADHD in adults, differentiating it from other conditions, and the importance of considering executive functioning deficits.

💡DSM-5 Criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the standard criteria for psychiatric diagnoses, including ADHD. The script mentions the DSM-5 criteria as the starting point for assessing ADHD, noting the need for documentation of specific symptoms related to inattention and hyperactivity-impulsivity. It also discusses the limitations of these criteria, especially when applied to adults.

💡Executive Functioning

Executive functions are cognitive processes that enable goal-directed behavior, including planning, working memory, inhibition, and emotional regulation. The video emphasizes that ADHD impacts executive functioning more broadly than just attention, affecting major life activities and future-oriented goal pursuit. The script suggests that symptoms of ADHD should be assessed in the context of executive functioning deficits.

💡Inattention

Inattention refers to the difficulty focusing or paying attention, a core symptom of ADHD. The script differentiates the type of inattention associated with ADHD as being future-oriented and related to goal pursuit, distinguishing it from the inattention seen in other disorders. It is highlighted that ADHD's inattention involves a significant problem with working memory and resistance to distractions.

💡Hyperactivity-Impulsivity

Hyperactivity and impulsivity are behavioral symptoms of ADHD, involving excessive motor activity and a lack of self-control, respectively. The video discusses how these symptoms manifest in adults differently than in children, with a focus on disinhibition and poor self-regulation. The script also notes that hyperactivity decreases with age and may not be as diagnostically relevant in adults.

💡Developmental Inappropriateness

Developmental inappropriateness is a criterion for diagnosing ADHD, which requires that symptoms are inconsistent with an individual's developmental level. The video discusses the need to establish that ADHD symptoms are developmentally inappropriate, particularly in adults, by comparing them to the general population and using rating scales sensitive to developmental stages.

💡Comorbidity

Comorbidity refers to the presence of one or more additional conditions co-occurring with a primary condition. In the context of the video, it is noted that adults with ADHD frequently have other disorders, which must be assessed and considered in the diagnostic process. The script emphasizes the importance of identifying and addressing these comorbid conditions in treatment planning.

💡Impairment

Impairment in the context of ADHD refers to the negative impact on major life activities due to the symptoms of the disorder. The video stresses that evidence of impairment is necessary for a DSM diagnosis and that it should be assessed across multiple domains of functioning. Impairment is distinguished from mere presence of symptoms, with an emphasis on its role in documenting the severity of ADHD's impact.

💡Archive Records

Archive records, such as educational transcripts, medical records, and employment history, can provide objective evidence of an individual's functioning over time. The script discusses the utility of these records in corroborating a patient's self-reported history of ADHD symptoms and impairment, especially when there is a lack of reliable recall or potential discrepancies in reporting.

💡Rating Scales

Rating scales are assessment tools used to quantify symptoms and impairments associated with ADHD. The video advocates for the use of well-normed rating scales to gather objective data on the degree of deviance from age and sex norms. These scales assess various aspects of ADHD symptoms and executive functioning, providing a more comprehensive picture than what is captured by DSM criteria alone.

💡Neuropsychological Testing

Neuropsychological testing assesses cognitive functions such as memory, attention, and executive functions. However, the video criticizes the use of such testing for diagnosing ADHD in adults, as these tests often fail to correlate with the actual impairments observed in daily life. The script argues against relying on neuropsychological tests for diagnostic or treatment planning purposes in ADHD assessment.

Highlights

Assessment of ADHD in adults should begin with the DSM-5 criteria, which are the standard for establishing the presence of the disorder.

DSM involves two dimensions of neuropsychological traits: inattention with nine symptoms and hyperactivity/impulsivity with nine symptoms.

For adults, at least five symptoms from each set must occur often or more frequently for the diagnosis of ADHD.

Symptoms must be developmentally inappropriate, with a drop in the threshold from six to five symptoms for adults.

The DSM-5 has added clarifications to make symptoms more developmentally appropriate for teens and adults.

There is a caution against using DSM clarifications due to their unproven accuracy in determining the disorder's presence.

The requirement for corroboration of symptoms through others who know the patient well is new to DSM-5.

ADHD can develop secondary to acquired brain injuries, which may warrant a qualified diagnosis of 'Acquired ADHD'.

Cross-setting occurrence of symptoms and evidence of impairment in major life activities are required for DSM diagnosis.

Exclusion of other disorders is necessary before establishing a DSM diagnosis of ADHD.

DSM-5 no longer has subtypes of ADHD, only different presentations based on the patient's current symptoms.

Problems exist with using the DSM criteria for adults, as the criteria are heavily childhood-biased.

The DSM symptom list for inattention needs to be broadened to reflect executive functioning and working memory.

Hyperactivity symptoms in the DSM are overly weighted toward children and may not be diagnostic of adult ADHD.

Impulsivity symptoms in the DSM may not be sufficient, and additional symptoms should be considered in evaluations.

The age of onset criterion of 12 in the DSM is not appropriate for adults and should be adjusted or removed.

Research has identified nine symptoms of executive functioning that are better for classifying adults with ADHD.

In adult practice, looking for at least four symptoms, not five, may be sufficient for diagnosis.

The DSM is weighted toward boys more than girls, which is unfair and may lead to underdiagnosis in females.

Self-awareness in ADHD is often diminished, leading to unreliable self-reporting of symptoms.

Impairment must be defined relative to the general population, not high-functioning peer groups.

Transcripts

Browse More Related Video

Adult ADHD What You Need to Know

Why I Was Afraid to Disclose My ADHD (ft. Dr. Patrick LaCount)

Modern Concepts of ADHD

ADHD and Autism: The overlap of traits in smart kids & adults

Adult ADHD | Inattentive

Defining Features of ADHD That Everyone Overlooks: RSD, Hyperarousal, More (w/ Dr. William Dodson)

Related Tags

ADHD Assessment DSM-5 Criteria Executive Functioning Adult Psychiatry Clinical Lecture Neuropsychological Traits Developmental Disorders Impulsivity Behavior Inattention Symptoms Hyperactivity ADHD Diagnosis