Jan20, 2022 Anthony S. Nhlapo, Clinical Psychologist

Clinical Guidelines for Assessing & Diagnosing ADHD in Transitioning Young Adults and Adults

It is important to note that although ADHD is mostly recognized and diagnosed in childhood, there is a strong evidence that the condition persists into adulthood and that the related impairments are evident in both transitioning young adults and adults who may not have been diagnosed with ADHD in childhood. There is consensus in literature that more than 60% of children diagnosed with ADHD will continue to have the symptoms presenting in various forms way into their adulthood. This figure is more likely to increase if we were to consider those who were not diagnosed in childhood.

There are at least 4 groups of adults that clinicians need to be aware of during an assessment of ADHD. The first group are those who were diagnosed with ADHD in childhood, but in denial the care-givers refused treatment and as a result they remain untreated. The second group are those who were diagnosed with ADHD in childhood, received treatment, but for one reason or the other, the care-givers stopped the treatment. The third group may have had their ADHD related symptoms missed or misdiagnosed as anxiety, OCD, ODD, CD, Bipolar Mood Disorder, etc. and were only treated for such. The last group include those who were diagnosed with the condition, got the treatment, but for some reason were told that they have outgrown the condition once they finished high school.

Although spontaneous recovery from illnesses is not unusual in medicine, partial remission beyond the age of 18 does not necessarily mean the condition is cured. It may mean that the ADHD symptoms are no longer causing moderate to severe impairment in the sufferer. However, a majority of people who were born with this neurodevelopmental disorder are less likely to be freed from the impairing symptoms unless they are identified, assessed and managed accordingly.

A failure to detect or manage ADHD in adults does not only have serious implication for the individual concerned, but lead to preventable family life problems, underperforming in tertiary for the young adult who is furthering his/her education, poor performance as an employee as well as behavioural problems that can be easily perceived as antisocial conduct. Thus, the main aim of this document is to provide the clinicians with practical and evidence-based clinical guidelines in recognizing and assessing/evaluating ADHD in adults who have transitioned from adolescence as well as adults in educational settings, working environment and those in relationships. The correct assessment/evaluation will result in a better evidence-based management of the condition and therefore an improved level of care and functioning for the adult with ADHD.

Longitudinal Approach to Assessing Adult ADHD

A longitudinal and corroborative evidence-based approach to assessing ADHD is not only a best practice, but it helps to rule our other conditions that can easily mask as any type of ADHD if not properly evaluated. There should therefore no need to hurry in reaching a diagnosis. The following steps are recommended when assessing and diagnosing ADHD in adults:

Step 1 – Structured Clinical Interview

• Structured Clinical interview with the patient. A structured interview minimizes the likelihood of missing some important questions, the everyday examples of the reported symptoms, their severity and level of impairment on the patient.
• The use of Diagnostic Interview for ADHD in Adults (DIVA 2.0) is thus recommended as it contains all the questions and examples of ADHD related symptoms and how the individuals experience these symptoms on daily basis.
• The clinical interview should also make attempt to rule out depression, anxiety, substance abuse or other medical conditions that may have overlapping symptoms consistent with ADHD.
Step 2 – Information Gathering
• Collateral information from family, including interview with parents or other family members who know the patient from childhood.
• It is important that such contact with the family of the patient should cover childhood history including developmental milestones, cognitive abilities, emotional and behavioural issues especially between ages 5 to 12.
• The use of an observer questionnaire is also important to assess for current symptoms and how they impair the patient’s functioning in multiple domains or settings, e.g. home and work, home and school (tertiary).
• An interview with a partner/spouse of the patient presenting with ADHD symptoms is necessary in order to establish the partner/spouse’s experience of the patient.
Step 3 – Other Sources
• School report cards or other academic related information is crucial as this reflects the severity of the symptoms and how the impair the patient’s functioning.
• Collateral information from employer or colleagues, including supervisor of the patient is valuable to establish their performance in a work setting.
Step 4 – Testing
• It is important to emphasize at this point that testing provides additional information and should not be seen as purely diagnostic. The comprehensive clinical interview and information gathering from other sources such as family, school report cards, clinician’s observations and other sources remain central to the assessment and diagnosis of ADHD.
• Clinicians should be reminded that any testing carries with it limitations that if not properly considered wrong conclusions can be easily made about the results of such testing.
• The results of any testing should be viewed in the contexts of all the available information gathered clinically so as to avoid making inaccurate diagnoses.
• Administer intellectual assessment tools such as IQ testing, especially in cases where there is a strong suspicion that the patient may be struggling with learning difficulties or some intellectual related problems.
• Neuropsychological tests and/or other standardized tools tests such as Test of Variables of Attention (TOVA).
• Quantitative EEG Mapping may serve as an additional tool during the assessment.
Step 5 – Report Writing & Feedback
Compile the report with practical recommendations such as referral to the psychiatrist if symptoms are moderate to severe and recommend cognitive rehabilitation to help the patient externalize the deficits.