Adult Attention Deficit Hyperactivity Disorder (ADHD):
A Path to Diagnosis & Treatment
March 10, 2017
Samuel Justin Sinclair, Ph.D.
Assistant Professor, William James & College &
Owner, Samuel Justin Sinclair, Ph.D. PLLC
345 Boston Post Road, Suite 3U
Sudbury, MA 01776
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that has received increasing attention in recent decades, impacting somewhere between 5% and 10% of children living in the United States (US Center for Disease Control, 2017). People struggling with the disorder commonly experience varying levels of inattention and distractibility, disorganization / executive dysfunction, and hyperactivity and impulsivity. Whereas girls are less frequently diagnosed overall and more likely to meet criteria for the inattentive sub-type, hyperactivity-impulsivity has been more commonly observed in boys – which remains a major source of debate. As individuals grow into adulthood, they are more likely to report symptoms of inattention regardless of gender, with less prevalence of hyperactivity-impulsivity symptoms noted.
Notably, between 2003 and 2011 ADHD diagnoses for children between the ages of 4 and 17 increased by roughly 42%, which may reflect any number of factors including greater attention now being paid to the disorder, improved methods for making accurate diagnosis (e.g., neuropsychological testing), and potentially over and/or misdiagnosis. Historically, ADHD has been seen as a childhood disorder. Indeed, in the current (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), criteria include that there must be some evidence of inattentive or hyperactive-impulsive symptoms prior to the age of 12 for a diagnosis to be made. However, there has also been an increasing focus on diagnosing ADHD in adult populations, which presents a number of unique challenges to patients and their medical providers.
Challenges in Evaluating for Adult ADHD
Chief among these dilemmas is ensuring accurate diagnosis. In many contexts, patients are asked to self-report symptoms of inattention and/or hyperactivity-impulsivity, either in a brief clinical interview or on a questionnaire. Based on these self-reported assessments, diagnoses are then made as a function of symptom endorsement. However, there are an array of other psychiatric / medical conditions with secondary cognitive symptoms (e.g., inattention, distractibility, poor memory), which can mimic ADHD. For example, neurovegetative symptoms including cognitive disruption / impairment are frequently manifest in the context of major mood (e.g., major depressive & bipolar) and anxiety disorders. Given numerous epidemiological studies that have demonstrated high comorbidity rates between ADHD and other common psychiatric disorders (e.g., depression, anxiety, alcohol and drug abuse), it is important to rule these latter conditions out in order to arrive at an accurate diagnosis and effective treatment plan. This is especially true given the potential for certain ADHD treatments (e.g., stimulant medications) to inflame symptoms of anxiety and stress.
Another dilemma when evaluating for ADHD in adulthood includes acquiring an accurate clinical history in order to understand the developmental course of the disorder. As noted above, current diagnostic criteria include confirming evidence of inattention and/or hyperactivity-impulsivity before the age of 12, which most frequently impacts academic and/or social performance in some way. In the case of the adults, obtaining and corroborating such histories can prove difficult, which in turn complicates accurate diagnosis. Finally, practitioners have also frequently raised concerns about the potential for misusing stimulant medications in cases where adults do endorse these types of symptoms, which also has the potential to confound diagnosis and treatment. As a result, some medical providers are loath to make such a diagnosis in the first place, which in turn may impact care for those truly struggling with the disorder.
Accurately Diagnosing Adult ADHD
As a means of systematically addressing the majority of these concerns, psychological / neurocognitive testing is perhaps the gold-standard for evaluating and diagnosing conditions such as ADHD in adulthood. These types of evaluations are typically multi-faceted, and include a comprehensive clinical interview as a means of exploring not only a person’s history of cognitive symptoms, but also other types of psychiatric and/or medical conditions. Likewise, these types of evaluations usually combine self-reported assessments of ADHD symptoms with objective performance on different kinds of cognitive tasks – measuring abilities including attention, cognitive flexibility, working memory, and other aspects of executive functioning. In some cases, individuals who self-report problems in certain cognitive domains may not necessarily demonstrate these weaknesses on objective cognitive tasks, which in turn becomes important when making differential diagnosis. Finally, these types of evaluations also typically screen for other types of psychiatric / medical conditions (mood and anxiety disorders, or substance use for example), as a means of ruling out other possibilities.
These types of assessments can be valuable not only in arriving at an accurate diagnosis, but also in terms of informing one’s medical care prospectively. For example, an effective treatment plan for someone struggling with ADHD alone may be very different than someone with ADHD and comorbid anxiety and substance use disorders. This latter complexity will help patients and their medical providers make decisions about the type and intensity of treatment that may be indicated. Primary Care Providers may also find value in these types of evaluations, especially in cases where they are trying to decide whether to administer treatment themselves or refer to a specialist, or when there are ancillary clinical concerns raises (for example, worries that a patient may struggle with substance misuse).
When considering whether to have such an evaluation done, it is important to locate a mental health provider (e.g., psychologist) with training and specialization in this area. Whereas all practitioners providing these types of services are usually doctoral-level psychologists, not all psychologists are uniquely trained and specialized to conduct psychological and neuropsychological assessment. Primary Care Physicians are often a good resource to locate practitioners in the area who conduct these types of comprehensive evaluations. I also maintain a private practice in Sudbury, MA where I specialize in both psychological and neuropsychological assessment, and psychological treatment. As such, I am happy to consult with you on any questions you may have with respect to the process, and/or to explore having this type of evaluation done.
Samuel Justin Sinclair, Ph.D. PLLC
345 Boston Post Road, Suite 3U
Sudbury, MA 01776