On the surface of it, this may seem like a fairly easy disorder to diagnose, at least in terms of how it is defined, which is a purely “descriptive” definition, as is true with essentially all psychiatric disorders, per the DSM or Diagnostic and Statistical Manual of Psychiatric Disorders published by the American Psychiatric Association now in its fifth edition.
Therefore, referring to the definition of this disorder in the psychiatrist’s “bible” or DSM-5 (Diagnostic and Statistical Manual of Mental Disorder, 5th edition), there is basically a menu of potential symptoms for the various types of ADD, which includes the “inattentive” (the most common presentation in adults), as well as the “hyperactive-impulsive” type and finally the “combined” when both of these types are present in one individual. For an adult to be diagnosed with ADD (for the sake of simplicity we use “ADD” to designate any type of ADD including hyperactive), several of the symptoms must have been present before 12 years of age. Furthermore, these symptoms must negatively impact the person’s functioning (e.g., can’t get their work done due to symptoms of inattention). So, in theory, you can simply go to a listing of these symptoms and see if the person has enough of these to qualify for the diagnosis (see attached).
But before jumping to a definitive diagnosis, it may be prudent for the sake of saving time, to attempt to screen for the ADD diagnosis. Here, there have been developed various “questionnaires,” the best of which and easiest to utilize in my experience is the original ASRS or Adult Self-Report Symptom Checklist (see link below). Originally designed for the World Health Organization (WHO), the authors (Dr’s Adler, Kessler and Spencer) are formidable researchers in the field of ADD and designed the questionnaire for use in any country of the world.
Admittedly, this version of the ASRS is more tailored to the older 4th edition of the DSM diagnosis of ADD and also is a bit more skewed towards diagnosing children rather than adult ADD. Nevertheless, in terms of ease of use and accuracy it easily trumps other questionnaires: Here, you simply rate yourself in terms of that symptom using a four point scale of 0 for “never” up to 4 for “very often.” There are 9 symptoms for the inattentive part of the questionnaire and 9 for hyperactive, and they are scored (or to use the lingo of the questionnaire “evaluated”) separately as either being
“unlikely” (score of 0-16), “likely” (17-23) or “highly likely” (24 or greater) to have ADHD.
Ultimately, the tricky part for the clinician in terms of the diagnosis of ADD comes in terms of “ruling out” other disorders which may be more primary in the individual but mimic ADD. Therefore, the diagnosis entails that the symptoms which appear to be consistent with ADD are not better accounted for by another psychiatric disorder (e.g., schizophrenia [psychosis], mood disorder, anxiety disorder, personality disorder, substance intoxication or withdrawal, or dissociative disorder). Therefore, a paranoid schizophrenic may oftentimes have inattentive symptoms, but this is due to the underlying psychotic disorder (and resultant confused thinking) and not genuine ADD. Similarly, depressed individuals often have trouble concentrating, but again this is not true ADD. Alcoholics and drug addicts may not think clearly due to the effects of the drug or their withdrawal, but again this would not be due to ADD.
How do we ultimately know the true cause of inattentiveness in an individual is due not to ADD but really another psychiatric disorder? The proof is in the pudding as they say, so that for instance if once the addicts’ “high” or withdrawal wears off for a long enough period, and their attention returns, then they do not have ADD. Similarly, if a psychotic disorder is successfully treated with anti-psychotics or a depressed/bipolar disordered individual is no longer manic or depressed at which point they are able to become properly attentive then they do not have ADD.
Diagnostically, then, in order to obtain a definitive diagnosis, it is often necessary to undergo psychological testing with a trained psychologist (Ph.D. or Psy.D). The psychologist can administer certain tests (e.g., the Brown Attention Deficit Disorder Scales [BADDS]) which along with their clinical acumen can make the diagnosis. Newer testing modalities also show promise diagnostically including Neurometrics (or the study of brain waves through EEG or electroencephalogram), brain scan PET (positive emission tomography), or brain scan SPECT (Single photon emission computed tomography). Lastly, computerized tests may be utilized including the Continuous Performance Test (CPT) of vigilance and sustained attention as well as other computerized neurocognitive batteries like the MicroCOG, Cog Test NES2 and CNS Vital Signs. Nevertheless, assessment by a trained psychologist remains the “gold standard” in diagnosis to which all other testing modalities must be compared.
Clinically, the person being considered for a diagnosis of ADD should also have had a recent (within the last year) history and physical from their PCP (Primary Care Physician) in order to rule out “physical” causes of ADD. For instance, you do not treat an attentional problem due to hypo- or hyperthyroidism with ADD drugs but rather through the appropriate medication, surgical procedure, or radioactive iodine treatment. In this case, it is only through the person being rendered “euthyroid” (normal thyroid functioning) that their attentional situation is improved.
Beyond performing a history and physical, it is prudent to check a urinalysis for drugs of abuse in order to rule out drug or alcohol intoxication (or withdrawal) as the causative agent of attentional problems. It is a well-known clinical fact that the addict hooked on stimulants is famous for “impersonating” ADD to the unsuspecting clinician in order to get their drugs of choice, in which case a urine test may be crucial to know what is really going on.
Once the diagnosis of ADD is determined, then the treatment phase begins. ADD is one of those unusual psychiatric disorders whereby medication treatment is in and of itself vastly superior to psychotherapy or non-pharmacological approaches and in fact medication therapy may do very well as a stand-alone. Having said that, the motivated ADD patient benefits most from the combination of ADD drugs plus creative implementation of behavioral and cognitive approaches. Thus, non-drug therapies which are of proven benefit include psychoeducation (list-making, prioritizing, etc.), bibliotherapy (reading books/materials about ADD), individual and group psychotherapy, journaling, exercise, and meditation.
Medication treatment falls basically into 4 categories: (1) stimulants; (2) the drug Strattera (atomoxetine is the generic); (3) the α2 agonists, and last but not least (4) “other” (for lack of a better term) or miscellaneous (since they are members of various drug classes) remedies.
Stimulant medications all have in common that they work on the nerve cells in the brain in a common manner (by increasing dopamine and norepinephrine availability in between nerve cells) and they are all potentially addictive. Common stimulants used to treat ADD fall into the short-acting and long-acting categories. Some studies over the years indicate that Adderall (amphetamine salts) may have a slight advantage over methylphenidate (most commonly Ritalin) in adults. Dexedrine (dextroamphetamine) is still on the market as well as drugs that are derivatives of Adderall and Ritalin which are designed to be longer-acting like Vyvanse (lisdexamfetamine) and Focalin XR (Dexmethylphenidate). Adderall or Ritalin themselves may come in long-acting formulations such as Ritalin SR (slow release), Ritalin LA (long-acting) and Adderall XR (extended release). Daytrana is a Ritalin (methylphenidate)-like formulation which is delivered in the form of a skin patch. In fact, it is not uncommon to utilize both short and long acting stimulants in combination in order that there is enough medication in the system to improve attention but not so much that side-effects supervene. The most common side effects to the stimulants are lack of appetite and insomnia, aside from potential drug abuse or addiction.
Although stimulant drugs are versatile in that they come in various formulations (above) and can be safely administered with dosage adjustment on a day-to-day basis, an appreciable downside comes due to their regulation by the Texas medical practice act. Therefore, it is a legal fact that although the Federal government stipulates the manner in the 50 states in which controlled substances are regulated, it is also true that any given state may choose to make the regulation thereof more (but not less) strict. In this vein, Texas has chosen to have the Department of Public Safety (DPS) issue prescriptions each with a unique bar-code as well as number on it for schedule II medications (schedule I is most restricted drug class, V the least). This serves to decrease the illegal diversion of these medications. On the other hand, due to the prescriber’s and pharmacist’s enhanced responsibilities, this policy also tends to make it more difficult for a legitimate patient to receive these medications. Therefore, if the prescriber does not dot all of his i’s or cross t’s, then the patient may in good faith arrive at the pharmacy with their prescription but find it may not be honored. As an example, pharmacies require that the # of pills (e.g., 30 for a 30 day supply) be literally spelled out (i.e., the word “thirty”) on the prescription so that if this is not properly done the medication is denied. Similarly, each pharmacy may decide to create their own internal rules so that controlled substances may not be given for more than a 30 day period.
In the second category of ADD drugs is Strattera, which acts on the cells similar to the antidepressants (it is a norepinephrine reuptake inhibitor) and therefore is not potentially addictive. Studies have shown Strattera to be as effective as stimulants in treating ADD, however, drawbacks include slower onset of action (presumably related to its mechanism which resembles antidepressants). Strattera is also less flexible in its dosing schedule than stimulants in that it is prescribed at a consistent dose on a daily basis as opposed to the stimulants where “drug holidays” may be employed over the weekend or during the summer when school is out. The major side-effects of Strattera are dry mouth (although patients usually do not find it necessary to stop the drug for this and get used to it), nausea, and sleepiness.
The third class of ADD drugs have in common that they work via activating specific receptors in the brain called the α2 type and which include Catapres (Clonidine) and Intuniv (guanfacine). Although these are only approved by the FDA (Food and Drug Administration) for children and adolescents, they may be effective when they are utilized “off label” in adults.
The rest of the drugs used to treat ADD are not as useful overall statistically in a given population, but in any individual patient still may help either alone (“monotherapy”) or as adjuncts (combined with other medications). The first group in this miscellaneous category includes the wakefulness promoting agents Provigil (Modafanil) and the chemically related Nuvigil (armodafinil). Although they are clinically related to stimulants (promoting wakefulness and arousal) their mechanism of action which is similar to antidepressants (norepinephrine reuptake inhibiter) makes them on the upside unlikely to be drugs of abuse but on the downside less effective for ADD overall than stimulants.
Next, drugs traditionally in the anti-depressant category may be effective for ADD but statistically less so than the stimulants, Strattera or the α2 agonists. These include Wellbutrin (bupropion), Effexor (venlafaxine) and the older tricyclic antidepressants (examples include Elavil [amitriptyline] and Norpramine [desipramine]). For the sake of completeness included here are dietary supplementation maneuvers such as with the trace elements zinc, iron, magnesium and iodine as well as omega 3 fatty acid supplementation, although it is recommended these be utilized along with traditional prescription drug treatment.
Therefore, for this reason I have found it medical-psychiatrically prudent to stipulate the patient’s diagnosis be confirmed by a trained psychologist in psychological testing (although I may use a questionnaire to screen for the disorder). Another gambit is to follow-through given a positive screening for ADD with Strattera treatment as it is not so heavily regulated. That way, once the psychological testing is complete and the diagnosis has been made, either the patient has already responded to Strattera or if the course of Strattera has failed then the stimulant medication may then be utilized.
I would like to end by saying that although the use of medications has been accentuated here, in line with my statement that they are extremely efficacious for treating ADD, this is not to imply that non-pharmacological treatment modalities should be ignored. I have had physician and non-physician friends alike who have successfully bolstered their pharmacological regimen with a variety of treatment measures. An excellent resource is the CHADD website which stands for Children and Adults with ADD. Information gleaned here can help the ADD patient devise a non-prescription drug adjunctive herbal/dietary regimen (in order to to supplement ADD prescription drugs). Furthermore, I have known patients to join therapist-led ADD groups as well as CHADD style (or “meetup” type) support groups. All of this and more can be found on this website. Also contained are various reading materials which the ADD sufferer can access to supplement their pharmacotherapy regimen. Attention magazine may be purchased and is an excellent resource as well. Finally, National ADD conferences as well as advocacy groups are available for the motivated patient.
1: Most drugs prescribed in the United States are not used for their precise FDA indications but are rather used “off label.
2: The nerve cells transmit chemicals called neurotransmitters such as norepinephrine and serotonin into the space between them, thus stimulating a receptor on the neighboring nerve cell, which in turn causes protein synthesis and that on a large scale ultimately changes thinking and behavior.
DSM-5 Criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:
Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.
ADHD in Adults
ADHD often lasts into adulthood. For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the National Resource Center on ADHD and the National Institutes of Mental Health.
Changes in the DSM-5
The fifth edition of the DSM was released in May 2013 and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD: symptoms can now occur by age 12 rather than by age 6; several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting; new descriptions were added to show what symptoms might look like at older ages; and for adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.