This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

1. Assessment Adult ADHD
Dr Jaap Hamelijnck
Yasir
Hameed
(MRCPsych)
Digitally signed by Yasir Hameed
(MRCPsych)
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gn=Yasir Hameed (MRCPsych)
c=United Kingdom l=GB o=Norfolk
and Suffolk NHS Trust ou=Norfolk
and Suffolk NHS Trust
e=yasirmhm@yahoo.com
Reason: I have reviewed this
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Date: 2014-05-06 19:48+01:00

2. Introduction
Tasks for assessment
Assessment of symptoms
Assessment of impairments (executive
functioning)
Psychiatric assessment
Physical health assessment
Focus on Strengths
Assessment scales.

3. From Behavioural Syndrome to
Executive Dysfunction
Person burdened by a syndrome of chronic
difficulties in focusing, getting started on
tasks, sustaining effort, utilising working
memory and modulating emotions that
chronically impair their ability to manage
necessary tasks of daily life (Brown 2013)

4. A new working definition of
ADHD
A complex syndrome of
Developmental impairments of executive functions
The self-management system of the brain
A system of mostly unconscious operations
These impairments are situationally variable
Chronic, and significantly interfere with functioning
in many aspects of the person’s daily life
Brown 2013

5. Assessment Tasks
ADHD is syndrome of symptoms with related impairments
(executive functions)
Clinical assessment with the following goals
• Establish the presence of symptoms of ADHD
• Assess the severity of the symptoms
• Identify the impairments causes and the impact on the person’s life
• Genetics
• Co-morbidities
• MSE (limited value)
• Physical health

6. Assessment of Symptoms
Diagnostic Criteria for Adult ADHD
• 18 core items
• DSM 5; requires 6 or more symptoms
• Several symptoms were present before the age of 12
• Several symptoms are present in 2 or more settings
• There is clear evidence that the symptoms interfere with or reduce the
quality of, social, academic, or occupational functioning
• Symptoms are not better explained by an other mental disorder

7. Core Symptoms
DSM-IV
Inattention (six or more)
1. Often fails to give close attention to details or makes careless
mistakes
2. Often has difficulty sustaining attention in tasks or fun activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish
work
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that
required sustained mental effort
7. Often loses things necessary for tasks or activities
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

8. Core Symptoms DSM-IV
Hyperactivity / Impulsivity (six or more)
1. Often fidgets with hands or feet or squirms in seat
2. Often leaves seat in situations in which remaining seated is
expected
3. Feelings of restlessness
4. Often has difficulty engaging in leisure activities or doing fun
things quietly
5. Is often “on the go” or “driven by a motor”
6. Often talks excessively
7. Often blurts out answers before questions have been completed
8. Often has difficulty awaiting turn
9. Often interrupts or intrudes on others

9. Same core symptoms, but descriptions not easy to apply to
adults.
Symptoms list not easy to use as self report questionnaire
Hyperactivity symptoms reduce; Attentions symptoms do not
Gender differences in symptom persistence
Other symptoms associated with adult ADHD
Symptoms in Adults
Clinical assessment and treatment fo ADHD in Adults. Philip Asherson. 2005;
www.future-drugs.com

10. Age of Onset
DSM 5; symptoms present before age of 12
Diagnostic assessment in adulthood requires retrospective
assessment of childhood symptoms and assessment of current
symptoms.
6 of 9 rule in adults put the cut-off at 99 percentile or 2.5-3
standard deviations from the mean.
Proposal to adjust number of symptoms as age increases
• 17-29; 4 to 5 of 9 identifies most impaired 7%
• 30-49; 3 to 4 of 9
• Over 50; 2 to 3 of 9

11. Associated symptoms
Procrastination
Low tolerance of frustration; minor frustrations couse catastrophic
reactions, loss of temper or anger
Mood lability; frequent changes, several times a day, like a roller coaster
Low self-esteem; expected given the lifelong problems with rejections
and failures
Underachievement
Frequent search for high stimulation
Intolerance of boredom
Hyper-focusing
Trouble going through proper procedures due to boredom and frustration
Worry needlessly
Sense of insecurity
Inaccurate self-observation and assessment of their impact on others

12. Semi-structured Interview to
establish the symptoms

19. A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

20. Impairments
1. Activation; excessive procrastination, put off getting started on a task,
even a task they recognise as very important to them until the last
minute. Keeping track of plans, money or time. Difficulties setting
priorities. Has a hard time waking in the morning.
2. Focus; distracted easily by things going on around them and in their
own minds whilst at other times they are stuck on one focus unable to
shift to another task. Reading very difficult to grasp the meaning. Mind
drifting all the time and missing important information. Spacing out.
Easily side tracked, only remembering some of the details. Doesn’t
seem to be listening and getting complaints about it.
3. Effort; sustaining effort very difficult, motivation wanes very quickly,
needing high levels of interest to keep going. Unable to continue tasks
in allotted time, slacks of unless pressure is on. Requires others to keep
them on task. Chronic difficulty regulating sleep and alertness, stay up
late because can’t shut their head off, big problem getting up in the
morning.
A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

21. Impairments
4. Emotion; not recognised in DSM 5, chronic difficulties managing
frustration, anger, worry, disappointment, desire, and other emotions.
Emotions take over, making it impossible to give attention to anything
else, short fused. Excessively impatient, sensitive to criticism from
others, gets overly defensive. Can appear apathetic or unmotivated.
5. Memory; often great memory for things that happened long ago but not
what they have just done, or where they put something. Excessively
forgetful, intents to do things but forgets, making many mistakes or
leaving out words when writing. Always forgetting to bring things or
leaving the house with necessary items.
6. Monitoring and regulating self-action; too impulsive in what they say
or do, jumping in to quickly, not being able to interact appropriately. Fail
to notice others are offended or puzzled and fail to modify their
behaviour. Pacing of actions, slowing down or speeding up as required
for a specific task. Monitor one’s actions and inhibit impulsive actions.
A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.

22. Psychiatric Assessment
Full clinical assessment (psychiatric history)
Developmental history
Family history
Personal history
Past psychiatric history
Drug and substance misuse
Comorbidity
MSE
Physical health history

23. Medical Assessment Tool for
Adults with ADHD
Have you ever been told by a doctor that you have
heart disease?
Do you ever get chest pain on exertion?
Have you ever passed out or fainted whilst exercising?
Has anyone in your family developed heart disease
before the age of 60?
Has anyone in your family died of heart disease before
the age of 60?
Do you know if you have high blood pressure or an
increased cholesterol
BP/Pulse is it regular?
Weight
Physical Examination (Done by GP)
ECG, ECHO and 24 hr BP if indicated
http://www.ukaan.org/getfile.php?type=site_documents&id=Medical%20Assessment%20Tool%20for%20Adults%20wit
h%20ADHD.doc

24. Diagnostic Intruments
Diagnostic Interviews;
• DIVA
• Brown ADD Scale Diagnostic form
• Conners Adult ADHD Diagnostic Interview Schedule
• Diagnostic Interview Schedule (DIS)-L
Rating Scales;
• Barkeley Adult ADHD rating scale (includes checklist to provide
information on childhood symptoms and informants information)
• Conners Adult ADHD rating scale (includes checklist to provide
information on childhood symptoms and informants information)
• WHO Adult ADHD Self Report Scale (ASRS)
• Brown ADD Scale
• Wender Utah Rating Scale (retrospective diagnosis of ADHD in
childhood

25. Summary
Send out screening forms (Barkley and Murphy, Wender UTAH)
Face to face interview consisting of
1. Psychiatric assessment
2. Semi-structured clinical interview (DIVA)
3. Age appropriate rating scale for executive function impairments
Interview with informant
Physical health screening
Formulate a diagnosis and treatment plan