Estimates indicate that ADHD impacts around 3-7% of the adult population in Canada[1], 15% of patients in outpatient clinics,[2] and 21% of substance use disorder patients[3]. It is highly comorbid with other psychiatric conditions. Having conditions such as depression or anxiety doesn't mean that ADHD is non-existent. Diagnosis and treatment of adult ADHD can, therefore, be complex for primary care providers.
Dr. Kam Balchand, psychiatrist at the Residence at Homewood, provides actionable insights on adult ADHD diagnosis. A Fellow of the Royal College of Physicians and Surgeons of Canada and Assistant Clinical Professor (Adjunct) in the Department of Psychiatry and Behavioural Neurosciences at McMaster University, he delivered a presentation at Homewood Health Centre's recent Mental Health Symposium on assessing, understanding and managing Adult ADHD.
Diagnosis using the Adult ADHD Self-Report Scale (ASRS)
The ASRS has become the most popular self-reporting scale for ADHD. However, Dr. Balchand highlights the fact that far too many patients will screen positive for ADHD using this scale[4]. He adds that most self-reporting scales are not specific enough [5]. He says, “They have high false positive rates. We cannot use self-reporting scales to diagnose ADHD."
“The mainstay of ADHD evaluation is still a clinical evaluation"
The DSM5 Diagnostic criteria is recommended as the more comprehensive approach for diagnosing adult ADHD. It contains 18 different criteria for assessing ADHD – nine each for assessing inattention and hyperactivity-impulsivity. Dr. Balchand provided a thorough review of this screening tool with attendees, highlighting that ADHD is likely present when the following criteria have been met:
The presence of 5 or more symptoms of either inattention or hyperactivity based on the DSM5 scale
Symptoms must have persisted for at least 6 months
Symptoms must be present in more than one setting
The presence of several inattentive or hyperactive-impulsive symptoms before age 12 years. For this criterion, self-report questionnaires, self-report symptom checklists, collateral history, and school report cards can assist in identifying ADHD
School report cards help in identifying Adult ADHD
Dr. Balchand says that clinicians should not be hesitant to ask for school report cards, particularly from grades 1-7. “Comments provided by teachers are very helpful. Teachers can really nail those ADHD symptoms in their comments."
Is there adult-onset ADHD?
There is much discussion on this topic and Dr. Balchand says that if ADHD seems to manifest only in adulthood, the primary care provider needs to “look harder." It may be that there were, in fact, features of ADHD in childhood: "A child may have had features of ADHD, but their environments were very structured; their parents and teachers were very supportive, and they had the scaffolding that allowed their ADHD to be controlled." The lack of structure in adulthood can make ADHD more prominent: “At University, things are less structured, and the work is more difficult. When this structure decreases and the cognitive demands increase, the ADHD symptoms increase." Another factor is whether ADHD symptoms showing up in adulthood are caused by other underlying concerns such as a medical condition, a psychiatric condition, or substance use.
Dr. Balchand hopes that primary care providers may use these insights to delve deeper into ADHD diagnosis with their patients.
References:
[1] Canada: 2.9%-7.3% across different studies (Espinet S et al, Brain Sciences, 2022)
[2] (Adamis et al, J Attention Disorders, 2022)
[3] (Rohner et al, Int J Environ Res Public Health, 2023)
[4] Screening for adult ADHD using brief rating tools: What can we conclude from a positive screen? Some caveats - ScienceDirect
[5] The Ability of Self-Report Methods to Accurately Diagnose Attention Deficit Hyperactivity Disorder: A Systematic Review - Allyson G. Harrison, Melanie J. Edwards, 2023 (sagepub.com)