Saturday, November 22, 2008

ADULT ADHD: HOW DO WE DIAGNOSE IT?

There are several clues that a new patient has adult ADHD before I ever see them for an ADHD evaluation. Staff may comment to me about a new patient who is having difficulty following directions to get to our office. New patients who arrive too late for their first appointment and have to be rescheduled often have ADHD. 


My initial observations and interactions with the patient often give me clues and can help with the ADHD evaluation. Anxiety about meeting a psychiatrist may make it hard to pay attention to direct them into the correct door to enter my office. I help with directions including telling them and pointing to the doorway where we are going and suggesting where they may want to sit in the consulting room. They also may need some more time to scan the room and if they get distracted by my diplomas or pictures, I will try to give him some structure to focus on the interview at hand by asking them how I may help. Quite occasionally people with ADHD say they don't know how I may help. Often if I ask them what symptoms are bothering them that caused them to come see me, then they can get specific about their concerns. 


Chief complaint:


The patient's chief complaint usually include a previous diagnosis of ADHD or their belief that they may have ADHD. Those who believe themselves to have ADHD have often been to my website and review the criteria for ADHD and have completed ADHD evaluation questionnaires. Usually they have fulfilled or much surpassed the threshold for the diagnosis. Frequently patients come to me under pressure from a partner or an employer for forgetfulness, not completing tasks, not listening or paying attention to detail, tardiness. Other patients come for anxiety, depression, bipolar, substance abuse issues, relationship problems and I discover they have ADHD when I do my usual comprehensive exam on all new patients that includes ADHD symptoms questions. 


History of present illness:


Most patients give a history of having had problems for many years that usually goes back into childhood before there was an evaluation for ADHD. Distractibility and inattention usually usually first caused problems during the school years. However, it may have been in high school or college that the patient first realized it took them longer than their classmates to read a chapter because of having to reread so much and that they were not making grades as good as peers that they knew were not as smart as they . Others became aware of their inefficient use of time when they started working in a job that required a lot of paperwork. Others only became aware of the nature of their problem when they became involved in a serious relationship or marriage and their partner confronted them about their not paying attention when they were talking to them or kept interrupting them. Others started their own business and found they were procrastinating at doing what they had to do to make their business go. Examples are not doing paperwork for taxes, not returning calls punctually to business clients, not writing proposals, or not invoicing regularly. 


Specific symptoms:


I have developed my own practical questions over the years to elicit the various ADHD symptoms that make up the criteria for the formal diagnosis of ADHD in adults. Most patients who have the condition can resonate and confirm if they have symptoms or not. Also, I do some preparation with the patient before I ask the questions. I ask them to simply answer yes or no to each question, choosing a yes or no based on which is closest to the truth. I asked them not to start elaborating by changing the criteria I have set, and not to start expounding with examples to confirm a yes. If I don't set the structure, they may talk for several minutes and neither of us know if the answer is a yes or a no. I alert them that if they start expounding that I will try to gently interrupt them and I hope I don't insult them with this structure. 


Here are the questions I use to help with an evaluation of ADHD:


(This first set of questions are criteria for the inattentive type of ADHD. Yes to six of these questions are necessary for the diagnosis.) 





  1. In classes over the years have you had trouble keeping your mind on the teacher and found yourself daydreaming a lot?


  2. Do you have pattern of making a fair amount of careless mistakes on tests, even when you knew the correct answers? 


  3. Have you had a good many complaints over the years about your not listening? 


  4. Have you been plagued by procrastination fairly regularly throughout your life? 


  5. Can you write up a project plan, i.e. can you write an outline for an essay or project that includes points or steps in a logical sequence? 


  6. Do you have a pattern of avoiding most things that require sustained mental effort? 


  7. Do you have pattern of frequently misplacing or losing things? 


  8. Have you tended to be easily distracted throughout your life? 


  9. Do you have pattern throughout your life up being somewhat absent-minded or forgetful? 





(Four of these hyperactivity-impulsivity symptoms are necessary to meet the criteria for the subtype of hyperactivity.) 



    Hyperactivity: 



  1. Are you chronically a rather fidgety person, i.e., regularly squirm in your seat, drum with your fingers, shuffle papers, or do things that annoy people around you? 


  2. Do you have pattern throughout life of having difficulty staying in your seat for one hour for classes or meetings? 


  3. If you go into a room where a group of people you know are sitting around having a sedate conversation, do you try to liven it up by making it fun or exciting? 


  4. Are you the type of person who is usually on the go and/or driven by a motor and/or would rather be doing something physical more than something mental? 


  5. Do you talk excessively or quite occasionally get feedback that you talk too much? 




    Impulsivity: 



  1. Do you tend to blurt out the answer before the person has finished their question? 


  2. Does it seem harder for you to wait on your turn than for the average person? 


  3. Do you tend to interrupt others conversations? 



Through this ADHD evaluation, if the patient meets the criteria for one or both subtypes of adult ADHD, I'll proceed with a conversation with them about the medication choices, benefits, and potential adverse reactions, and begin treatment if the patient is ready to start it at this time.


Dr. Darvin Hege has 25 years of experience dealing with patients who may fit the criteria for ADHD and need an ADHD evaluation. He offers evening and weekend office hours at his Atlanta, GA practice. Call today at 770 458-0007 for an ADHD evaluation and for help deciding the most effective and safest treatment. 

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