Diagnosis of ADHD in Adults
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Background: Attention Deficit Hyperactivity Disorder that spans into adulthood is increasingly becoming a recognized and valid entity; however, the diagnostic criteria long-used for childhood ADHD is being questioned as to whether it is relevant for an adult population.
Clinical question: What are the controversies surrounding the diagnosis of adult ADHD?
Methods: Design: This is an unsystematic article comparing what the authors see as the advantages and disadvantages of the Wender Utah Criteria, the DSM-IV criteria, and various laboratory assessment strategies in the diagnosis of adult ADHD. All relevant and available current evidence was not summarized; the information included was at the discretion of the authors. This review had a methods section in the abstract, but not in the body of the article. No explicit methodology was mentioned.
Validity: A focused clinical question was not addressed. Highlighting the diagnostic controversies in adult ADHD is quite a broad topic. The authors make no mention of any diagnostic techniques that were excluded from the review, nor do they critically appraise primary research studies to backup their points of view.
Results:
Wender Utah Criteria: The patient & an informant (eg parent) are interviewed to retrospectively assess a childhood diagnosis of ADHD via the Wender Utah Rating Scale. The patient is interviewed for ongoing symptoms of hyperactivity and inattention. Wender describes seven symptom clusters: inattentiveness, hyperactivity, mood lability, irritability and hot temper, impaired stress intolerance, disorganization, and impulsivity. The diagnosis is made if 1)a retrospective diagnosis of childhood ADHD can be made, 2)ongoing difficulties with inattentiveness and hyperactivity and demonstrated, 3)and two of the other symptoms listed above are present. The authors state that Wender was important in establishing the need for third-party informants, restrospective childhood diagnosis as well as careful description of current symptoms. They do point out, though, that these criteria have diverged from the DSM over the years, specifically mentioning that substantial research has not closely linked irritability & hot temper with ADHD and that this conflicts with diagnoses of oppositional defiant d/o and conduct d/o. Also, the inclusion of "mood lability" in the diagnostic criteria might cause difficulties in distinguishing between other mood disorders. Lastly, the Utah criteria exclude the diagnosis of ADHD when there is coexisting major depression, psychosis or severe personality disorder. The authors state that significant numbers of patients with these coexisting diagnoses who also suffer from marked inattention and hyperactivity could be missed and not therefore not receive treatment that could be helpful.
DSM-IV Criteria:
- Criterion A: The limitations mentioned include the fact that no adults were included in the DSM field trial, the work group that wrote the criteria were concerned with childhood disorders, and that several of the criteria ("runs & plays excessively" and "has difficulty playing…quietly") do not pertain to adults. Secondly, the authors state that 6 of the 9 criteria might be too strict and fail to identify adults with impairment.
- Criterion B: The authors question whether the criteria for age of onset should be before 7 years of age. They state that many adults cannot accurately recollect that many years ago, and that a "significant percentage" of children thought to have ADHD did not display symptoms prior to age 7. They propose that the criteria should be abandoned or the age should be increased to 12.
- Criterion C & D: The authors suggest that adults can manifest difficulties of functioning in many different areas that children cannot, including marital relationships, child rearing, financial management, etc and that these possibilities are not reflected in the criteria.
- Criterion E: The authors question whether several of the DSM ADHD symptoms (concentration difficulties, restlessness, increased speech & acting "on the go"), can be clearly differentiated from other diagnoses of anxiety, depression & mania.
- Subtypes: They state that these subtype classifications have never been validated in adults with ADHD & that there is insufficient empirical evidence to use these subtypes after childhood. The DSM does not state if the adult subtype should be based on the child or adult symptom presentation.
Laboratory-Based Diagnostic Methods: Many neuropsychiatric tests (eg EEG, SPECT, continuous performance tests, and neuropsychological batteries) have been proposed as a basis for the diagnosis of adult ADHD. The authors argue that most of these studies are limited to single research groups & small #’s of subjects. The authors state that there is insufficient data to support the use of these mechanisms in the diagnosis.
Conclusions: The authors have several points of conclusion. They state that they believe the disorder should remain a clinical diagnosis. They argue for a set universally accepted diagnostic criteria that can prevent over and underdiagnoses and can increase the comparability and generalizability of research data. They argue that the age of onset should be increased to 12. They argue that clinicians should make every effort to obtain third-part corroboration. They caution clinicians to be watchful for abuse of the stimulants they might prescribe. Lastly, they argue that clinicians should be particularly watchful of coexisting psychiatric conditions and treat accordingly.
Comments: Strengths: This article reminds us of the current diagnostic limitations for adult ADHD and the need for further work in this area, as well as highlighting some of the specific deficiencies of the diagnostic criteria. Weaknesses: This was in no way a systematic review. They do reference many primary research articles, but they do not critically appraise any of them. They simply discuss the conclusions of the research. In addition, the information in the article was at the author’s discretion, and the bulk of the article was the authors’ opinions.
Bottom line: In this unsystematic review article, the authors compare the diagnostic advantages and disadvantages of the Wender Utah Criteria, the DSM-IV criteria, and various laboratory assessment strategies in the diagnosis of adult ADHD. While raising the issue of diagnostic challenge in this disorder, the evidence included in the article is at the discretion of the authors and is not comprehensive; therefore, this article would not qualify as a systematic review. The authors’ conclusions are that adult ADHD should remain a clinical diagnosis and that much broader areas of functioning need to be assessed when evaluating adults for this disorder.
Presented by Sarah Richey, MD, May 9, 2005
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