Attention Deficit Hyperactivity Disorder (ADHD) remains the most common neurological disorder among children in the U.S. Identifying ADHD at any stage of life is important. For treatment professionals working with adults, ADHD often co-occurs with addiction and depression and the relationship is bi-directional, meaning that one doesn’t necessarily cause the other. The new ASRS screening tool reported recently by Ustun et al in JAMA Psychiatry is less complicated and more accurate.
Truthfully, most people with ADHD are relieved to learn that their lack of focus, poor school or job performance, etc., is not because they are unintelligent, lazy or just don’t care—and that there is good treatment readily available.
Revised Screening Criteria for Adult ADHD
Major changes in the ASRS include:
- Lowering the number of symptoms required for diagnosis from 6 to 5.
- Raising the age at onset of childhood symptoms from 7 years to 12 years.
- Reducing the emphasis on “clinically significant impairment” to a broadened requirement that symptoms “interfere” or “lower quality” of day-to-day functioning.
The accuracy of the new scale is validated via an independent clinical sampling of patients seeking evaluation at New York University Langone Medical Center’s (NYU Langone) Adult ADHD Program by Ustun et al, using study controls (n = 300) from matched cohorts from the primary care clinics at NYU Langone.
The increased prevalence of ADHD among adults is confounding to say the least, as ADHD is a “spectrum” disorder that is usually diagnosed in children as young as six by their pediatrician or by a school psychologist that includes specific subtypes, symptoms and varying degrees of severity.
The revised criteria and the new screening instrument has increased sensitivity for adults and will thus identify adult ADHD more readily. The authors report that the new scale has excellent cross-validated concordance with blinded clinical diagnoses of ADHD by DSM 5 criteria.
The Predictive Value of the New ASRS
Of the six questions on the new ASRS, two items were found to have the highest predictive value. They are: chronic procrastination and a dependence on others to keep their life in order. Interestingly, these are not typical ADHD symptoms, per se. Rather, among adults, these items reflect deficits in executive functioning.
Moreover, these findings suggest whether the DSM 4 criteria, primarily designed for screening children, adequately captured ADHD among adults. Only time and follow-up research will tell.
Clearly ADHD is woefully underdiagnosed among adults. As a result, undiagnosed and untreated adults with ADHD spend countless hours struggling to understand their own erratic behavior and lack of success. In fact, many don’t realize they have ADHD until they have experienced a crisis or sought help for a co-occurring illness such as depression or SUD, which further complicates diagnosis and treatment.
Why Does This Matter?
According to the Substance Abuse Mental Health Service Administration (SAMHSA), 2005, approximately one third of adults with ADHD have histories of alcohol abuse or dependence, and approximately one in five report having abused or been addicted to drugs other than alcohol. Optimal patient-centered treatment demands that treatment professionals address and assess all co-morbid illness and begin treatment or provide a referral to an expert for further assessment or treatment.
Until recently, ADHD among adults was rare. Over the past 30 years the prevalence of adults diagnosed with ADHD has steadily risen from 2 to 5 percent. The World Health Organization’s Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening (ASRS) recently modified their scale to incorporate changes in the definitions and scope of Adult ADHD in the DSM-5 (compared with DSM-IV) in 2013. These changes will most certainly increase the prevalence among adults. This data also confirms what I, and many other, treatment professionals have suspected for years. Adult ADHD is strongly correlated with addictive disease and depression. A 2014 study by Kristiansen, et al, showed that over 40% of adults diagnosed with ADHD had a co-occurring psychiatric diagnosis. This is not surprising for most addiction treatment professionals, because the best treatment centers screen all their patients for common co-morbidities such as depression, anxiety disorders and ADHD. As a result, many adults receiving addiction treatment are diagnosed with ADHD for the first time in their life.
ADHD in adults usually manifests as lack of focus, aloofness, short-term memory problems and, as mentioned, poor executive functioning. Proper diagnosis is the first step. This paper helps us to understand the clinical diagnosis, broadens the scope and simplifies the process in making an initial diagnosis in much the same way that Aaron Beck and others did with the diagnosis of depression. The final ASRS scale included just six questions, which are:
- How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? (DSM-5 A1c)
- How often do you leave your seat in meetings or other situations in which you are expected to remain seated? (DSM-5 A2b)
- How often do you have difficulty unwinding and relaxing when you have time to yourself? (DSM-5 A2d)
- When you’re in a conversation, how often do you find yourself finishing the sentences of people you are talking to before they finish them themselves? (DSM-5 A2g)
- How often do you put things off until the last minute? (Non-DSM)
- How often do you depend on others to keep your life in order and attend to details? (Non-DSM)
Adults were asked to respond to each question as follows: How often have the symptoms in the question occurred over the last six months: never (0), rarely (1), sometimes (2), often (3) and very often (4).
The test achieved a total accuracy rating (when including false positives and false negatives) of 67.3% in the general population and 82.8% in the clinical population. The authors conclude:
“The new scale is short, easily scored, can detect nearly all of adult ADHD cases in the general population with high sensitivity and specificity, and discriminates well among patients presenting for evaluation and specialty treatment.”
Identifying ADHD at any stage of life is important. For addiction treatment professionals working with adults, the new ASRS screening tool will make it easier to diagnose ADHD that often co-occurs with addiction and depression. The more we understand that although addictive disease is primary, it has predictable co-morbidities, the better they can be addressed, improving treatment outcomes and saving lives.