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Evaluating Attentional Complaints in Adults

November 20, 2020

Diagnosing attention-deficit/hyperactivity disorder (ADHD) in adults requires looking beyond the list of symptoms in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), Danell Bjornson, PMHNP-BC, said at a recent Psych Congress Regionals session.

The criteria in the DSM-5 were developed for children, so adults with the disorder often present differently, said Bjornson, a psychiatric mental health nurse practitioner and co-owner of the Northwest ADHD Treatment Center in Portland, Oregon.

“More commonly, the first things patients report are the secondary issues that result from a lifetime of underachievement, failure, criticism, and negative self-talk,” Bjornson said, adding adults often also present with anxiety, depression, or feeling “overwhelmed and stressed-out.”

Bjornson said she started the clinic 6 ½ years ago because she became passionate about treating adult ADHD after seeing how “transformative” it is when patients receive the correct diagnosis and begin appropriate treatment. Most mental health clinicians are trained in diagnosing and treating ADHD in children and adolescents, but often not in evaluating adults for the condition, she said.

“No matter where you practice, be it general psychiatry, psychology, or primary care, you will encounter adults with undiagnosed ADHD, especially during periods of transition, for instance when they’re starting college, entering the workforce, having children,” Bjornson said. Females with ADHD are often first misdiagnosed with anxiety or mood disorders, delaying diagnosis until a later age, when symptoms worsen at these transitional points, she added.

The attention-related symptoms that are common in adults with ADHD include forgetfulness, getting distracted easily, procrastination, and poor listening, according to the presentation.
At Bjornson’s clinic, new clinicians are told to evaluate adults longitudinally, not just cross-sectionally.

“When evaluating new patients, you’re looking for evidence of symptoms from early in life, not something that’s just been occurring lately,” she said.

Their evaluation for ADHD includes at least these 3 components:

• Screening, using tools such as the Adult ADHD Self-Report (ASRS) V1.1, ADHD-Rating Scale-IV with Adult Prompts, and the Wender Utah Rating Scale.

• A diagnostic biopsychosocial interview to uncover ADHD symptoms and rule out other mental health conditions. This should include psychiatric, substance use, developmental, social, work, and medical histories, and a history of ADHD symptoms in family members.

• A collateral report to assess the impact of symptoms. Parents are often most useful for this, but medical records, therapy notes, employee evaluations, report cards, and driving records can also be used.

When interviewing patients, Bjornson stressed that clinicians should avoid leading questions, and instead start with open-ended, broad questions, then drill down based on the patient’s responses.

She also urged attendees to be mindful that ADHD runs in families. According to the presentation, ADHD is a highly heritable disorder with estimated heritability rates of 70% to 80%, which is comparable with bipolar disorder. If a child has ADHD, there is a 25% chance one of their parents has the disorder, and if a parent has ADHD, there is a 57% chance their child will, Bjornson said.

—Terri Airov


“Essential tools for recognizing and treating ADHD patients from young adulthood and beyond.” Presented at the Psych Congress Regionals 2020 Virtual Experience: November 14, 2020.

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