https://ww1.cpa-apc.org/Publications/Archives/Bulletin/1998/Feb/clinic.htm

Rapid Screening for Attention DeficitHyperactivity Disorder in Adults

Manuel Matas, MD, FRCPC1, Douglas Staley, MA2

There has been an explosion of interest in attention deficit hyperactivity disorder (ADHD) in recent years. This condition was formerly known as minimal brain dysfunction (MBD). The Bureau of Drug Surveillance at Health Canada has reported a 3- to 4-fold increase in the number of methylphenidate (Ritalin) prescriptions in Canada between 1990 and 1995. Ritalin is the preferred drug treatment for ADHD.In adults, ADHD is usually called attention deficit disorder (ADD). As the ADHD child matures into adulthood, the hyperactivity often wanes and dissipates, but the afflicted individual may be left with extreme restlessness and the other hallmark symptomsa short attention span, impulsivity, and distractibility. There are often many secondary symptoms as well, such as anxiety, depression, substance use disorders, poor school or work performance, extreme disorganization, procrastination, difficulties with interpersonal relationships, and low self-esteem.At one time, it was thought that children would outgrow this condition. It was routine practice for physicians to stop prescribing Ritalin for ADHD children once they reached puberty. We now know, as the result of several recently published long-term follow-up studies (14), that a significant percentage of children with ADHD will continue to have residual symptoms throughout adolescence and adulthood (estimates range from 30% to 70%).The DSM-IV has subdivided ADHD into the predominantly hyperactive type and the predominantly inattentive type. Girls and women are more likely to be the predominantly inattentive type; boys and men are more likely to be the predominantly hyperactiveimpulsive type.There are a number of adults with this disorder who were never diagnosed as children. This is especially true of women with the predominantly inattentive type of ADHD. Since they were quiet and daydreamed in class but were not disruptive, they did not receive early identification of their disorder as often as boys did.There are now many adults, especially adult women, who are requesting an assessment for ADHD after one or more of their children has been diagnosed with ADHD because they notice many similar symptoms in themselves. This is to be expected because ADHD is known to have a familial and genetic basis (57).Family studies, twin studies, and adoption studies all point to a genetic predisposition to ADHD, most likely mediated by an aberration of catecholamine metabolism (8,9). First-degree relatives of ADHD children have 4 to 5 times the rate of ADHD compared with first-degree relatives of controls. Furthermore, the fathers of ADHD children have a higher rate of substance use disorders and antisocial personality disorders, while the mothers of ADHD children have a higher than expected rate of somatization disorder (Briquets syndrome). The relationship between ADHD and Briquets syndrome is not fully understood, but there is some evidence for assortative mating of people with somatization disorder and antisocial or alcoholic spouses, which would increase both genetic and environmental risk factors for ADHD in the offspring, especially if the alcoholic or antisocial fathers also have ADHD (1012).Psychiatrists are therefore faced with the dilemma of making a retrospective diagnosis of a condition for which the sine qua non is that hyperactiveimpulsive or inattentive symptoms were present before the age of 7. While a review of report cards can be helpful, they are not always available. Collateral history from spouses or parents is often very useful.In order to supplement the DSM-IV diagnostic criteria for ADHD, we have been using 2 brief screening questionnairesthe Attention Deficit Hyperactivity Disorder-Checklist (ADHD-CL), developed by Barkley and colleagues (13), and the Wender Utah Rating Scale (WURS), whose authors claim to be able to make a retrospective childhood diagnosis of ADHD using this scale (14).The WURS is a 61-item scale that can be given to adults to describe their own childhood behaviour. The authors identified 25 items on the scale that showed the greatest difference between patients with ADHD and 2 comparison groupsnormal adults and psychiatric adult outpatients with unipolar depression. The patients with ADHD had significantly higher mean scores on all 25 items than the 2 comparison groups. A cutoff score of 46 or higher correctly identified 86% of the patients with ADHD, 99% of the normal subjects, and 81% of the depressed subjects. A cutoff score of 36 or higher correctly identified 96% of the adults with ADHD and 96% of the normal subjects. The higher cutoff of 46 is thus more specific, but there may be some loss of sensitivity.The WURS can be filled out by the patient in the doctors waiting room. Some patients may want to take it home with them, however, and discuss some of the items regarding their childhood behaviour with their parents.The ADHD-CL is an 18-item questionnaire that can be filled out by the patient in a few minutes. We found that patients who score more than 30 on the ADHD-CL are likely to meet the Utah Criteria for ADHD (15).The Utah Criteria for ADHD are the following traits: 1) A childhood history of ADHDfidgety, restless, always on the go, talking excessively, attention deficit, behaviour problem in school, impulsivity, overexcitability, and temper outbursts. 2) The adult features of ADHD are: persistent motor hyperactivity, attention deficits, affective lability, inability to complete tasks, hot temper, explosive short-lived outbursts, impulsivity, and stress tolerance.We administered the 2 rating scales to 2 groups of patients. The first group consisted of patients diagnosed with ADHD based on DSM-IV criteria. Where the diagnosis was in doubt, psychological testing was administered (Conners Continuous Performance Test, WAIS-R, California Verbal Learning Test, and the Wisconsin Card Sorting Test). While psychological testing can be helpful to identify the neuropsychological abnormalities typically associated with ADHD, these tests are not definitive. The control group consisted of a random sample of adult psychiatric outpatients who were referred for a variety of other non-ADHD conditions, including major depression, bipolar disorder, dissociative disorder, posttraumatic stress disorder, schizophrenia, and social phobia.The results are presented in Table 1. There were no significant differences between the 2 groups in terms of gender or age, but the ADHD group scored significantly higher on both the ADHD-CL and WURS scales compared with the control group.Table 1. Comparison of ADHD and Control Groups: gender:N (percentage)other variables: mean scoreSD (range)

VariableADHD (n = 23)Control (n = 23)Significance

GenderM = 14 (60.9%)F = 9 (39.1%)M = 18 (78.3%)F = 5 (21.7%)c2= 1.64NS

Age34.26764)38.70 10.56 (2162)t (44) = 1.31; NS

ADHD-Checklist40.1151)18.6 8.9 (137)t (44) = 8.99P< 0.0001

Wender Utah Rating Scale65.6093)36.1 14.5(462)t(44) = 5.82P< 0.0001

Both results are highly significant statistically. We conclude, therefore, that both the ADHD-CL and the WURS are useful screening questionnaires to distinguish ADHD adults from a non-ADHD population of psychiatric outpatients. It is important to remember, however, that these are only screening instruments, and it is still essential to take a thorough clinical history, including a family history, for every patient.

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