Assessment of Adult ADHD in Clinical Practice: Four Letters

Abstract

Objective: Despite guidelines providing detailed recommendations for the assessment of ADHD in adults and increasing clinician awareness of the persistence of ADHD into adulthood, ADHD remains under diagnosed in many countries. Method: A survey of 178 clinicians who regularly perform assessments for adult ADHD was conducted between February 2015 and 2016 to identify possible causes of underdiagnosis related to assessment practices. Results: There was a lack of consensus among clinicians regarding which symptoms are relevant to adult ADHD. Only “difficulties concentrating” was endorsed as a core feature of adult ADHD by a majority of respondents. Few clinicians used (semi-)structured interviews. Psychologists were less likely than physicians to recommend medication. Conclusion: Further clinician training on core symptoms of adult ADHD and diagnostic practices congruent with guideline recommendations may improve symptom recognition among clinicians and diagnostic accuracy. Identification of barriers to the implementation of diagnostic practices recommended by guidelines is needed.

Keywords

adult ADHD assessment differential diagnosis clinical practice guidelines

Background

Rates of diagnosed ADHD have increased significantly in the past years among adults (Bachmann, Philipsen, & Hoffmann, 2017; Zhu, Liu, Li, Wang, & Winterstein, 2018) suggesting that patients and clinicians are becoming more aware of the persistence of ADHD into adulthood. Nonetheless, many adult cases remain undiagnosed and untreated. Prevalence rates of ADHD among adults ranging from 3.1% to 4.7% have been reported by epidemiological studies of nationally representative, community samples in Germany (De Zwaan et al., 2012; Fayyad et al., 2017); however, studies of publicly insured individuals age 18 to 69 years old in Germany report rates of diagnosed ADHD between 0.04% and 0.4% (Bachmann et al., 2017; Schlander, Schwarz, Trott, Viapiano, & Bonauer, 2007). Rates of ADHD diagnosis, which are lower than prevalence rates from epidemiological studies, have been reported in other countries (Aragonès et al., 2010) and world-wide only one fifth of adults meeting ADHD diagnostic criteria in research studies were currently receiving treatment (Fayyad et al., 2017). Many issues contribute to this discrepancy, including stigma (Lebowitz, 2016), culturally influenced (mis)perceptions of ADHD (Asherson et al., 2012), and patients’ ambivalence regarding completing the often complicated process of undergoing an assessment. Lack of recognition of ADHD symptoms by clinicians also contributes to this discrepancy (Aragonès et al., 2010), suggesting that further improvements in diagnostic practices by clinicians are necessary (Fayyad et al., 2017). Improved ADHD diagnosis among adults has obvious implications, including enabling access to treatment leading to reduced functional impairments and improved quality of life for those affected (Brod, Pohlman, Lasser, & Hodgkins, 2012).

Several national guidelines (Association of the Scientific Medical Societies in Germany [AWMF], 2017; Canadian ADHD Resource Alliance [CADDRA], 2018; National Institute for Health and Care Excellence [NICE], 2018) and a European consensus statement (Kooij et al., 2019) have been published to guide assessment of adult ADHD. All recommend that a comprehensive diagnostic interview, which considers factors such as impairments because of the presence and persistence of symptoms in at least two settings, functional or occupational difficulties, developmental history (e.g., onset before age 12), and somatic and psychological comorbidities, along with a medical assessment and collateral reports, when available, serve as the foundation of the diagnostic assessment (AWMF, 2017; CADDRA, 2018; Kooij et al., 2019; NICE, 2018). This information can be supplemented by other sources of data, including rating scales, neuropsychological assessments, and observational findings, as needed. Nonetheless, in previous surveys, clinicians have reported diagnostic practices that are not in line with guideline recommendations (Goodman, Surman, Scherer, Salinas, & Brown, 2012; Knutson & O’Malley, 2010), suggesting that a discrepancy between clinical practice and guideline recommendations exists.

The assessment of adult ADHD in real-world clinical practice is complicated by a number of factors. Although diagnostic criteria for ADHD according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) have been adjusted to account for differences in symptom presentation among adults, verification of the presence of symptoms before age 12 remains necessary, which some adults may not be able to accurately remember (Breda et al., 2019). Moreover, patients with ADHD tend to under report symptoms (Sibley et al., 2012). As such, collateral reports are often critical (Sibley et al., 2012); however, contacting and obtaining information from collateral informants poses many practical difficulties. Moreover, whereas semi-structured interviews, which are suggested by the European Consensus Statement and the German S3 guidelines, have been shown to be psychometrically sound (e.g., Connors’ Adult ADHD Diagnostic Interview for DSM-IV [CAADID]; Ramos-Quiroga et al., 2012 or Diagnostic Interview for ADHD in adults [DIVA]; Pettersson, Söderström, & Nilsson, 2018; Ramos-Quiroga et al., 2019), some are expensive or not available in all languages (Kooij et al., 2019). For some clinicians, it may not be feasible to conduct semi-structured interviews within the timeframe available for the assessment (French, Sayal, & Daley, 2018). Especially in primary care settings, diagnosis of ADHD is often based solely on self-reported symptoms (Goodman et al., 2012), which may lead to misdiagnosis.

Guidelines recommend that patients be assessed for comorbid disorders during the initial assessment and that these disorders should receive treatment priority if they cause more distress or impairment than symptoms attributable to ADHD. However, patients present with heterogeneous and unspecific symptoms and complaints, as well as psychiatric comorbidities (Schneider, Thoering, Cludius, & Moritz, 2015). Rates of comorbid depression and anxiety disorders among adults with ADHD are approximately 43.0% and 36.4%, respectively (Karlsdotter et al., 2016), and particularly patients with substance dependence tend to underreport symptoms (Luderer et al., 2019). Difficulty distinguishing ADHD from other disorders has been identified by psychiatrists as a main barrier to diagnosis (Goodman et al., 2012) and self-report measures of ADHD symptoms are limited by poor specificity as psychiatric populations also endorse symptoms of inattention, hyperactivity, and/or impulsivity at a high rate (Schneider et al., 2015).

Finally, given that there is no one single definitive diagnostic indictor of ADHD, the complex decision-making required to reach an ADHD diagnosis generally necessitates significant experience and training. Although some guidelines make specific recommendations with regard to which professionals should make an ADHD diagnosis (AWMF, 2017; NICE, 2018), recommendations for the amount of training a clinician should have accumulated before they are able to make a diagnosis remain vague. Indeed, previous work suggests that some subgroups of clinicians feel largely uncertain of their ability to correctly diagnose ADHD in adults (Goodman et al., 2012; Knutson & O’Malley, 2010) and report having had insufficient training (Adler, Shaw, Sitt, & Maya, 2009; Knutson & O’Malley, 2010) or experience (Goodman et al., 2012). Despite increased awareness regarding the importance of improved training, particularly with regard to improving the transition of care from childhood to adulthood (Kooij et al., 2019), it is unclear to what extent most clinicians pursue or are supported in receiving specialized training.

We could find only three surveys conducted examining clinicians’ daily practice with regard to assessment of adult ADHD (Adler et al., 2009; Goodman et al., 2012; Knutson & O’Malley, 2010). These surveys, focused on physicians or nurse practitioners, occurred before the new DSM-5 criteria for adult ADHD were released and were conducted in the United States. Extending upon these, the present study sought to identify which diagnostic methods clinicians in Germany utilize to diagnosis ADHD among adult patients, as well as to collect data regarding clinician training in ADHD assessment and clinicians’ concept of core symptoms of adult ADHD. To our knowledge there has been no similar survey published either among European clinicians or among psychologists in general. Given that clinical practice in the assessment and treatment of ADHD, feelings of confidence with regard to ADHD assessment, and ADHD-specific knowledge has been shown to differ between professional groups (Goodman et al., 2012; Thomas, Rostain, Corso, Babcock, & Madhoo, 2015), in addition to findings within the total sample of respondents, we also examined differences in responses based on professional background (i.e., physicians and psychologists).

Method

Participants

The link to the survey was distributed through newsletters of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN), the ADHS Netzwerk and the journal Neurotransmitter. An email was sent to the largest Yahoo forum for German neuropsychologists. An invitation was also sent to members of the German Society for Behavioral Therapy, the Professional Association of German Neurologists and Psychiatrists, the Professional Association of German Psychiatrists, and the Professional Association of German Neurologists.

Measures

An anonymous online survey was administered through Unipark/Questback® with the aim of collecting data on two separate research questions. The current study reports on the first part of the survey, which examined clinicians’ attitudes and clinical practices with regard to the assessment and treatment of ADHD among adults. The second part of the survey related to treatment of obsessive-compulsive disorder (OCD). Colleagues were invited to participate if they had expertise in ADHD and/or OCD. The survey was conducted between February 2015 and 2016. It was emphasized that clinicians should only complete the survey for the area(s) in which they have expertise (OCD and/or adult ADHD) and that participants should complete the items to reflect how they would typically conduct an assessment instead of under ideal conditions.

Participants who indicated regularly conducting assessments with adults for ADHD were asked a series of questions regarding which symptoms they consider to be of central relevance to adult ADHD, what sources of information they gather during an ADHD assessment, type of interview conducted, information used to verify an ADHD diagnosis, how often they consult with other professionals when making a diagnosis, and their perceptions of the relative importance of certain data for the verification of an ADHD diagnosis. Further questions focused on clinicians’ experiences with ADHD assessments, how certain they feel in their ability to diagnose ADHD, and the amount of ADHD-specific training they had. Finally, participants were asked their opinions regarding the greatest challenges to conducting an ADHD assessment. Participants indicated if they had completed the survey truthfully, and they had an opportunity to leave comments.

A total of 366 respondents entered information regarding their clinical experience (ADHD or OCD). Of these, 206 indicated that they had experience with ADHD assessment (“Do you complete diagnostic assessments with adults [18 years and older] for ADHD?”). Data from two participants had to be deleted because they were incomplete. An additional 26 participants did not answer questions regarding ADHD assessment. The final sample consisted of data from 178 participants.

Strategy of Data Analysis

Chi-square tests and Mann–Whitney U tests were used to compare demographic data and responses to survey items between professional groups. Correlational analyses were conducted using Spearman’s rho. All analyses were carried out using SPSS 25.0. For all analyses, p values <.05 were considered significant.

Results

Description of Participants

The total sample (N = 178) was comprised primarily of psychologists (n = 144; 80.9%) and physicians (n = 32; 18.0%); two participants identified as occupational therapists (1.1%). When applicable, participants provided information regarding further qualifications, including specialties as a psychotherapist (n = 100; 58.1%), neuropsychologist (n = 42, 24.3%), psychiatrist (n = 24, 13.9%), and neurologist or doctor of psychosomatic medicine (n = 6; 3.4%). Physicians were significantly older, reported more years of career experience, and conducted on average more ADHD assessments per month (see Table 1). Physicians conducted the most ADHD assessments per month (M = 6.28, SD = 7.39), followed by neuropsychologists (M = 2.92, SD = 3.85) and psychotherapists (M = 1.33, SD = 1.89).

Table 1.

Descriptive characteristics by professional group.

	Total Sample(n = 178)		Psychologists(n = 144)		Physicians(n = 32)
Variable	M	SD	M	SD	M	SD	Significance
Age, years	45.54	10.53	44.15	10.54	52.09	7.58	U = 1252.50; p <.001
Sex Female Male	n 115 63	% 64.6 35.4	n 100 44	% 69.4 30.6	n 13 19	% 40.659.4	χ²(1) = 9.46, p = .002
Professional experience, years			14.45	8.76	23.63	8.65	U = 1019.00; p <.001
ADHD evaluations per month <1 1-4 5-10 11+	2.74	4.20%20.860.115.23.9	1.97	2.76%25.063.29.72.1	6.16	7.12%3.146.937.512.4	U = 992.50, p < .001χ²(1) = 27.94, p < .001
Overall level of clinical experience with ADHD little some much a lot		%27.2 ^a43.122.86.6		%33.7 ^b40.422.13.8		%6.7^c50.026.716.7	χ²(3) = 27.94, p = .006
ADHD-specific training none little a few hours several hours extensive training		%23.9 ^d27.628.414.26.0		%27.2^e30.124.313.64.9		%13.8^f20.741.413.810.3	χ²(4) = 5.88, p = .21
Have read guidelines for ADHD diagnosis (e.g., German S3 Guidelines)		74.6^d		73.8^e		75.9^f	χ²(1) = 0.05, p = .82

Note. ^a) n = 134; ^b) n = 104; ^c) n = 30; ^d) n = 134; ^e) n = 103; ^f) n = 29.

Clinicians’ Opinions of Clinical Characteristics Central to ADHD in Adults

Clinicians were first asked to provide their opinions about which clinical characteristics are central to ADHD among adults (see Table 2; “In your opinion, which clinical characteristics are central to ADHD among adults?”). Clinicians were not provided with any further cues or instructions regarding specific patients they should have in mind when responding. There was a relative consensus among clinicians regarding symptoms such as impairments in concentration, problem solving and planning, as well as difficulty with organization. Although 21.3% of respondents indicated that psychomotor activity had little relevance to ADHD in adulthood, another 26.2% endorsed it as a core feature. Impairments in social behavior/aggression were endorsed as having “little relevance” by approximately half of clinicians, whereas 35.8% indicated that this symptom was relevant. There was a significant discrepancy between physicians and psychologists regarding the relevance of impairments in social behavior or aggression, distractibility from external stimuli, and impaired divided attention.

Table 2.

Symptom Characteristics of ADHD Among Adults.

“In your opinion, which clinical characteristics are central to ADHD among adults?” (n = 172)	n	Irrelevant%	Little relevance%	Relevant%	Core feature%	Significance
Hyperactivity and impulsivity
Psychomotor hyperactivity or restlessness						χ²(2) = 5.43, p = .07
All	164	0.0	21.3	52.4	26.2
Psychologists	134	0.0	23.9	47.8	28.4
Physicians	28	0.0	10.7	71.4	17.9
Impulsivity						χ²(2) = 1.61, p = .45
All	165	0.0	7.3	63.6	29.1
Psychologists	135	0.0	7.4	65.2	27.4
Physicians	28	0.0	7.1	53.6	39.3
Impaired social behavior/aggression						χ²(2) = 6.52, p = .04
All	134	11.2	53.0	35.8	0.0
Psychologists	107	13.1	57.0	29.9	0.0
Physicians	25	4.0	40.0	56.0	0.0
Inattention
Impaired motivation						χ²(3) = 7.16, p = .07
All	151	3.3	24.5	63.6	8.6
Psychologists	122	4.1	27.9	59.8	8.2
Physicians	28	0.0	7.1	82.1	10.7
Difficulties concentrating						χ²(1) = .75, p = .39
All	170	0.0	0.0	37.1	62.9
Psychologists	138	0.0	0.0	38.4	61.6
Physicians	30	0.0	0.0	30.0	70.0
Impaired divided attention						χ²(3) = 11.38, p = .01
All	167	1.2	10.2	52.7	35.9
Psychologists	135	1.5	12.6	55.6	30.4
Physicians	30	0.0	0.0	40.0	60.0
Impaired working memory						χ²(3) = 3.10, p = .38
All	146	3.4	17.8	62.3	16.4
Psychologists	119	3.4	20.2	58.8	17.6
Physicians	25	4.0	8.0	76.0	12.0
Distractibility from internal stimuli						χ²(3) = 4.40, p = .22
All	150	1.3	4.0	60.0	34.7
Psychologists	123	1.6	4.1	63.4	30.9
Physicians	25	0.0	4.0	44.0	52.0
Distractibility from external stimuli						χ²(2) = 7.25, p = .03
All	174	0.0	1.7	50.6	47.7
Psychologists	140	0.0	2.1	55.0	42.9
Physicians	32	0.0	0.0	31.3	68.8
Reduced frustrated tolerance						χ²(3) = 2.61, p = .46
All	137	2.2	12.4	70.1	15.3
Psychologists	113	2.7	14.2	68.1	15.0
Physicians	24	0.0	4.2	79.2	16.7
Memory problems						χ²(3) = 7.92, p = .05
All	129	11.6	44.2	38.0	6.2
Psychologists	104	14.4	47.1	32.7	5.8
Physicians	24	0.0	33.3	58.3	8.3
Difficulty with organization						χ²(3) = 3.74, p = .29
All	154	0.6	7.8	58.4	33.1
Psychologists	124	0.8	9.7	58.1	31.5
Physicians	29	0.0	0.0	58.6	41.4
Impairments in problem-solving and planning						χ²(3) = 3.07, p = .38
All	155	2.6	6.5	61.3	29.7
Psychologists	126	3.2	7.1	61.1	28.6
Physicians	27	0.0	0.0	66.7	33.3

Note. Percent “not relevant” and “little relevance” versus “relevant” and “central characteristic.” Chi-square test indicates significant differences between physicians and psychologists. Bold items indicate rate of endorsement ≥60%.

Consistency in rates of endorsement improved somewhat when subgroups (clinicians having at least several hours of ADHD-specific training and clinicians who reported feeling “certain” to “very certain” of their ability to make an ADHD diagnosis) were examined (see Supplementary Table 1). Difficulties concentrating and distraction from external stimuli were endorsed by more than 60% of respondents as being core features of adult ADHD.

Nearly all participants endorsed the presence of symptoms prior to age 12 (90.1%), as well as reports of work-related problems (87.8%) as being “important” or “essential” when making an ADHD diagnosis among adults (“Please indicate how important you find the following factors to be for the diagnostic verification of ADHD.”). Moreover, 69.2% endorsed that meeting the cutoff on a self-report measure of current ADHD symptoms was essential or important to the verification of ADHD, whereas slightly fewer (64.2%) endorsed meeting the cutoff on a self-report scale of ADHD symptoms present during childhood as being essential or important. Clinicians were slightly less likely to view current (56.0%) and childhood symptoms (56.7%) from collateral report scales as being important or essential sources of information. Questions regarding social problems (e.g., having few friends, stressful interpersonal relationships; 68.8%) and undergoing a successful trial of stimulant medications (54.9%) were endorsed by over half of the participants. The presence of psychiatric comorbidities (47.1%) and neuroimaging findings (15.3%) were less frequently endorsed as being important or essential sources of information.

Clinical Practices in the Assessment of ADHD With Adults

When asked about their own diagnostic practices, although most respondents endorsed using self-report scales of current and past symptoms (see Table 3), almost half indicated that they “never” or “rarely” use collateral report scales of past or current symptoms. Responses regarding the use (or nonuse) of symptom checklists and standardized cognitive/neuropsychological tests were not endorsed by a clear majority of respondents. Few clinicians in the overall sample reported conducting interviews with collateral informants. Clinical interview was the most commonly used method. Respondents were most likely to conduct an unstructured interview (82.2%); a minority (31.1%) used a structured or semi-structured interview. Respondents indicated that their interviews (unstructured, structured, or semi-structured) lasted between 15 and 200 min with a mode of 60 min and a mean length of 73 min.

Table 3.

Diagnostic Practices Among Professional Groups.

“How often do you use the following instruments when conducting an assessment for adult ADHD?”	All (n = 170)		Psychologists (n = 136)		Physicians (n = 32)		Significance
	% always/often	% never/rarely	% always/often	% never/rarely	% always/often	% never/rarely	Significance
Self-report scale
Current symptoms	76.5	16.5	77.2	14.7	71.9	25.0	χ²(2) = 2.64, p = .27
Past symptoms	69.4	19.4	66.9	21.3	84.4	9.4	χ²(2) = 3.80, p = .15
Informant report scale
Current symptoms	37.3^a	47.3	38.2	44.9	35.5^b	58.1	χ²(2) = 2.83, p = .24
Past symptoms	30.8^a	50.3	33.1	48.5	22.6^b	58.1	χ²(2) = 1.36, p = .50
Symptom checklist	39.4	41.2	39.7	41.2	37.5	43.8	χ²(2) = 0.75, p = .96
Standardized cognitive/neuropsychological tests	46.5	39.4	51.5	35.3	25.0	59.4	χ²(2) = 7.78, p = .02
Clinical interview	80.0	10.6	77.2	11.0	93.8	6.3	χ²(2) = 5.23, p = .07
Informant report (interview)	19.1^c	60.5	17.4^d	62.1	24.1^e	55.2	χ²(2) = 0.76, p = .68
Consultation (e.g., with psychiatrist, psychologist, or other occupational group)	54.1^f	25.2	60.6^g	17.3	31.0^e	51.7	χ²(2) = 14.74, p = .001

Note. Response options “always,” “often,” “sometimes,” “rarely,” and “never.”

n = 169.

n = 31.

n = 162.

n = 132.

n = 29.

n = 135.

n = 104.

Treatment Recommendations

Most clinicians (91.9%) endorsed that they would recommend cognitive-behavioral therapy (CBT) to adult clients with ADHD (see Figure 1). Although 75.9% of all respondents would recommend pharmacotherapy with a stimulant, psychologists were significantly less likely to recommend medication (physicians: 96.7%; psychologists: 67.0%; χ²[1] = 10.55, p = .001). In addition, 81.5% of respondents indicated they would recommend occupational therapy.

Figure 1.

Clinicians’ treatment recommendations for adults diagnosed with ADHD.

Greatest Challenges to Diagnosing ADHD Among Adults

Only comorbidity was endorsed by over half of participants (59.5%) as being a major challenge to the diagnosis of adults ADHD (see Figure 2). Approximately one third of respondents indicated that the lack of consensus regarding “gold standard” measure(s) (33.1%) and clinicians’ lack of clinical knowledge and experience (31.8%) represented major challenges when conducting assessments for ADHD with adults.

Figure 2.

Clinician opinions regarding major challenges to ADHD diagnosis among adults.

Diagnostic Certainty

Although 40.4% of respondents overall felt “certain” or “very certain” of their ability to make an ADHD diagnosis among adults (“How certain do you feel regarding your ability to diagnose ADHD in adults?”), 20.6% indicated that they felt “uncertain” and 39.0% felt “moderately” certain. Clinicians with more ADHD experience (Spearman’s ρ = 0.69, p <.001) and training (Spearman’s ρ = 0.45, p <.001), as well as those who were physicians (Spearman’s ρ = 0.25, p = .004), older (Spearman’s ρ = 0.24, p = .004), or had a greater number of years of professional experience (Spearman’s rho = 0.25, p = .004), reported greater certainty in their ability to diagnose ADHD among adults.

Discussion

The present survey sought to examine the clinical practices, training, and diagnostic knowledge of clinicians conducting assessments for adult ADHD. Consistent with previous surveys of physicians (Adler et al., 2009), a majority (79.9%) of respondents indicated having only had “a few hours” of ADHD-specific training. One quarter reported not having read diagnostic guidelines for ADHD. Given that our survey was aimed specifically at clinicians who regularly work with adults with ADHD, these findings suggest that at least some clinicians conducting ADHD assessments have little formal ADHD training and may not be up-to-date on current diagnostic recommendations.

Although many of the symptoms listed by the diagnostic criteria for ADHD were identified by a majority of respondents as being central to adult ADHD (e.g., difficulties concentrating, distractibility), our results also revealed disagreement among clinicians regarding core features of adult ADHD. For example, whereas psychomotor hyperactivity is listed as a feature of ADHD by the DSM-5 and International Classification of Diseases, Tenth Revision (ICD-10), approximately one fifth of respondents indicated that hyperactivity has little relevance to adult ADHD. Only “difficulties concentrating” was identified by more than half of respondents as being a “core feature” of ADHD. Symptoms such as impairments in social behavior or aggression and memory impairment were also not clearly identified as being “relevant” or “irrelevant” to adult ADHD. Such findings highlight the challenges patients and clinicians face when undergoing or conducting an ADHD assessment due to the considerable heterogeneity of the disorder (Faraone et al., 2015), as well as changes in ADHD presentation across the lifespan (Karam et al., 2017; Kooij et al., 2019). Symptoms such as hyperactivity may present very differently between adults (e.g., feelings of inner restlessness) and children (e.g., running around) (Kooij et al., 2019), which may have contributed to the lack of consensus by clinicians in our survey. Moreover, clinicians’ perceptions of which symptoms are central to ADHD may vary depending upon which patients they are primarily seeing (e.g., college students vs. middle-aged or older adults). Nonetheless, these findings appear to indicate some uncertainty or at least a lack of consensus among clinicians about what symptoms are relevant to ADHD in adulthood and it is likely that this uncertainty contributes to diagnostic inaccuracy. This underscores the necessity of using diagnostic tools such as checklists or (semi-)structured interviews when conducting ADHD assessments.

Most respondents reported using self-report scales of current or past symptoms and conducting an (unstructured) interview. Whereas slightly more than half of clinicians endorsed collateral reports as being an important source of information for the diagnosis, only 20% to 40% reported regularly obtaining them. Failing to obtain collateral report, when available, is problematic due to the limited accuracy of self-reported childhood symptoms (Breda et al., 2019) and underreporting by adult patients with ADHD (Sibley et al., 2012). Use of semi-structured interviews has been shown to better predict outcomes than self-report alone (Adler et al., 2008). Administering collateral report scales in addition to a self-report scale has been shown to optimize diagnostic sensitivity (Sibley et al., 2017). Time pressure to reach a diagnosis (Saleh, Fuchs, Taylor, & Niarhos, 2018), instrument cost or lack of availability in the desired language (Ramos-Quiroga et al., 2019), increased resources needed to contact collateral informants, and the challenges of interpreting discrepant data between self and collateral reports (Sibley et al., 2017) have been previously cited as reasons why clinicians may fail to obtain collateral reports or conduct (semi)-structured interviews. Diagnostic tools such as the DIVA (www.divacenter.eu), which is available online for free or at a low cost in many languages, may help to overcome such barriers (Kooij, 2013). The time needed to administer the DIVA (i.e., 1-1.5 hr; Kooij & Francken, 2010) is similar to the average time to conduct a diagnostic interview as reported by clinicians in our survey. Given the aforementioned advantages of using (semi-)structured interviews, assessment time would be better spent using (semi-)structured versus unstructured interviews, when possible.

In addition, 51.5% of psychologists versus 25.0% of physicians reported conducting cognitive or neuropsychological testing. Although 24.3% of respondents identified as neuropsychologists who likely see patients with ADHD in the context of a referral for neuropsychological testing, these findings suggest that other clinicians also conduct cognitive/neuropsychological testing. This is contrary to German guidelines, which indicate that cognitive/neuropsychological tests should be used to clarify issues such as low (occupational) performance and cannot be employed to rule-out or confirm an ADHD diagnosis. The European Consensus Statement and CADDRA also state that cognitive/neuropsychological testing should be used as a secondary or supplementary assessment tool. In an initial ADHD assessment with the aim of establishing a diagnosis, time would be better spent assessing for comorbid conditions and establishing their severity. Cognitive and neuropsychological testing could then be conducted in a second step, if necessary. This is especially important as 87.0% of clinicians in our survey viewed comorbidity as a “large” or “moderate” challenge to ADHD assessment and approximately half of patients with ADHD have at least one comorbid DSM-IV diagnosis (Fayyad et al., 2017). Improved assessment of comorbidity would help to close the large treatment gap that exists for individuals with ADHD, most of whom do not receive either ADHD-specific treatment or treatment for comorbid psychiatric disorders (Fayyad et al., 2017).

Most respondents indicated that they would recommend CBT followed by occupational therapy, and we also found that psychologists tend to be more hesitant to recommend stimulants. This discrepancy may be due to differences in training backgrounds as psychologists typically receive little training regarding psychiatric medications and in Germany psychologists do not have prescription privileges. In a previous survey of clinicians employed in college health care settings in the United States, counselors and nurses were also less likely than physicians to recommend medication (Thomas et al., 2015). Given the demonstrated efficacy of stimulants (Faraone, Spencer, Aleardi, Pagano, & Biederman, 2004), and guidelines recommending that even adults with mild ADHD symptoms should consider stimulants as a first-line approach (AWMF, 2017), interventions particularly focused on educating psychologists about stimulants may be helpful to align psychologists’ practices with evidence-based approaches. Furthermore, our finding that 81.5% of respondents would recommend occupational therapy requires some explanation. Although we did not specifically ask respondents why they would recommend occupational therapy, in Germany occupational therapists typically provide services such as psychoeducation and administer psychosocial interventions (including CBT-based interventions). Thus, the high referral rate to occupational therapy likely reflects German guideline recommendations for psychosocial interventions, CBT, and other interventions, such as those aimed at improving occupational skills (i.e., identifying occupational strengths, social skills training).

Recommendations for Training

As a majority of respondents (72.7%) endorsed “lack of clinician knowledge and experience” as a large or moderate barrier to ADHD diagnosis and a majority of clinicians reported feeling either “uncertain” or only “somewhat certain” about their ability to make an ADHD diagnosis, it is likely that clinicians who work with patients with ADHD would welcome further ADHD training. Consistency in symptom endorsement improved somewhat among clinicians who had obtained at least several hours of ADHD-specific training, as well as those who reported feeling certain in their ability to diagnose ADHD. Although not a perfect proxy for diagnostic accuracy, our survey suggests that increased ADHD-specific training and experience serves to increase diagnostic certainty.

Particularly, training focused on improving understanding of core ADHD symptoms, differential diagnosis, identification of comorbidities, and the utility of gaining (reliable) collateral reports when available is necessary for both psychologists and physicians involved in ADHD assessments. As a first step, use of well-validated diagnostic tools, such as those listed by CADDRA and the German S3 Guidelines, is essential to establishing an accurate ADHD diagnosis. In line with basic professional ethical standards, clinicians should at a minimum have read the ADHD diagnostic guidelines relevant for their occupation and geographical region, be aware of the availability of such diagnostic tools, and implement them in their daily practice. Beyond this, accurate diagnosis also requires adequate supervised clinical experience and training in using such tools. Thus, development and implementation of regulated profession-specific requirements for ADHD-specialty training, including course work and supervised clinical practicums for medical or graduate students, as well as continuing education requirements or specialty certification for clinicians, are necessary to move toward improving diagnostic accuracy. Requirements for specialty certification for physicians and psychologists conducting ADHD assessments with children have recently been established in Germany (Kassenärztliche Bundesvereinigung, 2014). Moreover, at a structural level, there is an urgent need for more mental health services for adults with ADHD. The increasing establishment of ADHD-specialty clinics in Germany and internationally will serve to establish multidisciplinary teams of ADHD specialists. Finally, primary care professionals (PCPs) also play a critical role in the ADHD diagnostic process. The need for ADHD-specific training among PCPs was recently discussed by French et al. (2018).

Limitations

Although psychiatrists, neurologists, or PCPs make most ADHD diagnoses, our survey was comprised largely of psychologists. Therefore, our findings may not be generalizable to physicians. Nonetheless, many psychologists conduct ADHD assessments and in the study by Adler et al. (2009), 55% of PCPs indicated they would refer patients to psychologists for ADHD assessments. Moreover, over half of our sample reported having “little to no” ADHD-specific training and approximately 25% reported not having read the guidelines for the assessment and treatment of ADHD. Based on a strict interpretation of guidelines, these individuals should either pursue more training prior to conducting ADHD assessments or refer patients to other clinicians with ADHD-specialty training. Whereas all clinicians in our survey indicated experience in conducting diagnostic assessments with ADHD, we did not ask about the specific setting in which participants worked. It is likely that our findings are not reflective of clinician practices in ADHD specialty clinics. Future surveys could improve upon our work by including professionals working in such specialty clinics. In addition, our survey did not examine reasons why some guideline recommendations were not implemented by clinicians in daily practice. For example, it is unclear if clinicians did not obtain collateral reports because such collateral informants were not available or because clinicians did not request or pursue collection of such data. Future surveys should better clarify to what extent clinicians obtain collateral reports when reliable informants are available. Taken together, such discrepancies between guideline recommendations and actual clinical practice likely reflect in part the long-standing “scientist-practitioner gap” (Kazdin, 2017). Further work is needed to better understand barriers clinicians face to obtaining essential data and clinicians’ beliefs regarding the utility of such data.

Conclusion

Despite increasing prevalence rates of ADHD among adults over the past years, ADHD diagnosis remains disproportionately low. Our survey suggests that guidelines are not sufficient to ensure the accurate assessment of ADHD. Further training is needed to improve clinicians’ understanding of ADHD in adulthood and to align diagnostic practices with guideline recommendations. Whereas discrepancies between respondents regarding the relative importance of peripheral symptoms (e.g., memory problems) were most common, a lack of consensus was found even for core symptoms listed by diagnostic criteria. Particularly among psychologists, improved awareness regarding the benefits of stimulant medications is needed to bring their treatment recommendations in line with evidence-based guidelines. Clinicians continue to view differential diagnosis and suboptimal diagnostic criteria as major challenges to ADHD diagnosis, suggesting further work specifically in these areas is needed.

Supplemental Material

supplementary_material – Supplemental material for Assessment of Adult ADHD in Clinical Practice: Four Letters—40 Opinions

Supplemental material, supplementary_material for Assessment of Adult ADHD in Clinical Practice: Four Letters—40 Opinions by Brooke C. Schneider, Daniel Schöttle, Birgit Hottenrott, Jürgen Gallinat and Steffen Moritz in Journal of Attention Disorders

Footnotes

Acknowledgements

We would like to thank Juri Schnepel for his assistance with data preparation.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: S.M. received royalties from Springer and Beltz (publishers) and occasionally acts as a speaker for Janssen-Cilag. B.C.S. has received payments for workshops on Metacognitive Training for Depression. D.S. received honoraria for lectures from or has been an advisor to Janssen GmbH, Lundbeck GmbH, Otsuka Pharma GmbH, and Takeda. All other authors report no relationships with commercial interests.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Brooke C. Schneider

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Brooke C. Schneider, PhD, is a research associate in the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany. She is also a licensed psychotherapist in cognitive-behavioral therapy.

Daniel Schöttle, PD, Dr. med., is head of the acute station for psychiatric disorders, as well as the specialty clinic for ADHD and autism spectrum disorders of the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany.

Birgit Hottenrott, Dipl.-Psych., is a research associate in the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany. She is also a licensed psychotherapist in cognitive-behavioral therapy.

Jürgen Gallinat, Univ.-Prof., Dr. med., is director of the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany.

Steffen Moritz, Prof., PhD, is head of the Clinical Neuropsychology Research Group in the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany.

References

Adler

L. A.

Faraone

S. V.

Spencer

T. J.

Michelson

Reimherr

F. W.

Glatt

S. J.

. . . Biederman

(2008). The reliability and validity of self- and investigator ratings of ADHD in adults. Journal of Attention Disorders, 11, 711-719. doi:10.1177/1087054707308503

Adler

L. A.

Shaw

Sitt

Maya

(2009). Issues in the diagnosis and treatment of adult ADHD by primary care physicians. Primary Psychiatry, 16, 57-64.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Aragonès

Lluís Piñol

Ramos-Quiroga

J. A.

López-Cortacans

Caballero

Bosch

(2010). Prevalence in adults of attention deficit hyperactivity disorder using the medical records of primary care. Revista Espanola de Salud Publica, 84, 417-422.

Asherson

Akehurst

Kooij

J. J. S.

Huss

Beusterien

Sasané

. . . Hodgkins

(2012). Under diagnosis of adult ADHD: Cultural influences and societal burden. Journal of Attention Disorders, 16, 20S-38S. doi:10.1177/1087054711435360

Association of the Scientific Medical Societies in Germany. (2017). S3 guideline for attention-deficit/hyperactivity disorder in children, adolescents and adults—Long version. Retrieved from https://www.awmf.org/uploads/tx_szleitlinien/028-045l_S3_ADHS_2018-06.pdf

Bachmann

C. J.

Philipsen

Hoffmann

(2017). ADHD in Germany: Trends in diagnosis and pharmacotherapy: A country-wide analysis of health insurance data on attention-deficit/hyperactivity disorder (ADHD) in children, adolescents and adults from 2009-2014. Deutsches Ärtzeblatt International, 114, 141-148. doi:10.3238/arz-tebl.2017.0141

Breda

Rohde

L. A.

Menezes

A. M. B.

Anselmi

Caye

Rovaris

D. L.

. . . Grevet

E. H.

(2019). Revisiting ADHD age-of-onset in adults: To what extent should we rely on the recall of childhood symptoms? Psychological Medicine. doi:10.1017/S003329171900076X

10.

Brod

Pohlman

Lasser

Hodgkins

(2012). Comparison of the burden of illness for adults with ADHD across seven countries: A qualitative study. Health and Quality of Life Outcomes, 10, Article 47. doi:10.1186/1477-7525-10-47

11.

Canadian ADHD Resource Alliance. (2018). Canadian ADHD practice guidelines (4th ed.). Toronto, Ontario: Author. Retrieved from https://www.caddra.ca/wp-content/uploads/CADDRA-Guidelines-4th-Edition_-Feb2018.pdf

12.

De Zwaan

Gruß

Müller

Graap

Martin

Glaesmer

. . . Philipsen

(2012). The estimated prevalence and correlates of adult ADHD in a German community sample. European Archives of Psychiatry and Clinical Neuroscience, 262, 79-86. doi:10.1007/s00406-011-0211-9

13.

Faraone

S. V.

Asherson

Banaschewski

Biederman

Buitelaar

J. K.

Ramos-Quiroga

J. A.

. . . Franke

(2015). Attention-deficit/hyperactivity disorder. Nature Reviews: Disease Primers, 1, 15020. doi:10.1038/nrdp.2015.20

14.

Faraone

S. V.

Spencer

Aleardi

Pagano

Biederman

(2004). Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder. Journal of Clinical Psychopharmacology, 24, 24-29. doi:10.1097/01.jcp.0000108984.11879.95

15.

Fayyad

Sampson

N. A.

Hwang

Adamowski

Aguilar-Gaxiola

Al-Hamzawi

. . . Kessler

R. C.

(2017). The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Attention Deficit and Hyperactivity Disorders, 9, 47-65. doi:10.1007/s12402-016-0208-3

16.

French

Sayal

Daley

(2018). Barriers and facilitators to understanding of ADHD in primary care: A mixed-method systematic review. European Child and Adolescent Psychiatry, 28, 1037-1064. doi:10.1007/s00787-018-1256-3

17.

Goodman

D. W.

Surman

C. B.

Scherer

P. B.

Salinas

G. D.

Brown

J. J.

(2012). Assessment of physician practices in adult attention-deficit/hyperactivity disorder. The Primary Care Companion for CNS Disorders, 14(4), PCC.11m01312. doi:10.4088/pcc.11m01312

18.

Karam

R. G.

Rovaris

D. L.

Breda

Picon

F. A.

Victor

M. M.

Salgado

C. A. I.

. . . Bau

C. H. D.

(2017). Trajectories of attention-deficit/hyperactivity disorder dimensions in adults. Acta Psychiatrica Scandinavica, 136, 210-219. doi:10.1111/acps.12757

19.

Karlsdotter

Bushe

Hakkaart

Sobanski

Kan

C. C.

Lebrec

. . . Deberdt

(2016). Burden of illness and health care resource utilization in adult psychiatric outpatients with attention-deficit/hyperactivity disorder in Europe. Current Medical Research and Opinion, 32, 1547-1556. doi:10.1080/03007995.2016.1189892

20.

Kassenärztliche Bundesvereinigung [The National Association of Statutory Health Insurance Physicians]. (2014). Eckpunkte zum AD(H)S-Vertragskonzept. Retrieved from https://www.kbv.de/html/7404.php

21.

Kazdin

A. E.

(2017). Addressing the treatment gap: A key challenge for extending evidence-based psychosocial interventions. Behaviour Research and Therapy, 88, 7-18. doi:10.1016/j.brat.2016.06.004

22.

Knutson

K. C.

O’Malley

(2010). Adult attention-deficit/hyperactivity disorder: A survey of diagnosis and treatment practices. Journal of the American Academy of Nurse Practitioners, 22, 593-601. doi:10.1111/j.1745-7599.2010.00546.x

23.

Kooij

J. J. S.

(2013). Adult ADHD: Diagnostic assessment and treatment (3rd ed.). London, England: Springer-Verlag.

24.

Kooij

J. J. S.

Bijlenga

Salerno

Jaeschke

Bitter

Balázs

. . . Asherson

(2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry, 56, 14-34.

25.

Kooij

J. J. S.

Francken

M. H.

(2010). Diagnostisches Interview für ADHS bei Erwachsenen [Diagnostic interview ADHD in adults]. DIVA Foundation, Den Haag, Netherlands.

26.

Lebowitz

M. S.

(2016). Stigmatization of ADHD: A developmental review. Journal of Attention Disorders, 20, 199-205. doi:10.1177/1087054712475211

27.

Luderer

Kaplan-Wickel

Richter

Reinhard

Kiefer

Weber

(2019). Screening for adult attention-deficit/hyperactivity disorder in alcohol dependent patients: Underreporting of ADHD symptoms in self-report scales. Drug and Alcohol Dependence, 195, 52-58. doi:10.1016/J.DRUGALCDEP.2018.11.020

28.

National Institute for Health and Care Excellence. (2018). Attention deficit hyperactivity disorder: Diagnosis and management [NICE Guideline NG87]. Retrieved from https://www.nice.org.uk/guidance/ng87

29.

Pettersson

Söderström

Nilsson

K. W.

(2018). Diagnosing ADHD in adults: An examination of the discriminative validity of neuropsychological tests and diagnostic assessment instruments. Journal of Attention Disorders, 22, 1019-1031. doi:10.1177/1087054715618788

30.

Ramos-Quiroga

J. A.

Bosch

Richarte

Valero

Gómez-Barros

Nogueira

. . . Casas

(2012). Criterion and concurrent validity of Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) Spanish version. Revista de Psiquiatría y Salud Mental, 5, 229-235. doi:10.1016/J.RPSMEN.2012.05.002

31.

Ramos-Quiroga

J. A.

Nasillo

Richarte

Corrales

Palma

Ibáñez

. . . Kooij

J. J. S.

(2019). Criteria and concurrent validity of DIVA 2.0: A semi-structured diagnostic interview for adult ADHD. Journal of Attention Disorders, 23, 1126-1135. doi:10.1177/1087054716646451

32.

Saleh

Fuchs

Taylor

W. D.

Niarhos

(2018). Evaluating the consistency of scales used in adult attention deficit hyperactivity disorder assessment of college-aged adults. Journal of American College Health, 66, 98-105. doi:10.1080/07448481.2017.1377206

33.

Schlander

Schwarz

Trott

G. E.

Viapiano

Bonauer

(2007). Who cares for patients with attention-deficit/hyperactivity disorder (ADHD)? Insights from Nordbaden (Germany) on administrative prevalence and physician involvement in health care provision. European Child and Adolescent Psychiatry, 16, 430-438. doi:10.1007/s00787-007-0616-1

34.

Schneider

B. C.

Thoering

Cludius

Moritz

(2015). Self-reported symptoms of attention-deficit/hyperactivity disorder: Rate of endorsement and association with neuropsychological performance in an adult psychiatric sample. Archives of Clinical Neuropsychology, 30, 186-191. doi:10.1093/arclin/acv015

35.

Sibley

M. H.

Pelham

W. E.

Molina

B. S. G.

Gnagy

E. M.

Waxmonsky

J. G.

Waschbusch

D. A.

. . . Kuriyan

A. B.

(2012). When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment. Journal of Consulting and Clinical Psychology, 80, 1052-1061. doi:10.1037/a0029098

36.

Sibley

M. H.

Swanson

J. M.

Arnold

L. E.

Hechtman

L. T.

Owens

E. B.

Stehli

. . . Stern

(2017). Defining ADHD symptom persistence in adulthood: Optimizing sensitivity and specificity. Journal of Child Psychology and Psychiatry, 58, 655-662. doi:10.1111/jcpp.12620

37.

Thomas

Rostain

Corso

Babcock

Madhoo

(2015). ADHD in the college setting: Current perceptions and future vision. Journal of Attention Disorders, 19, 643-654. doi:10.1177/1087054714527789

38.

Zhu

Liu

Wang

Winterstein

A. G.

(2018). Prevalence of ADHD in publicly insured adults. Journal of Attention Disorders, 22, 182-190. doi:10.1177/1087054717698815

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.60 MB