ADHD Assessment by Dr Jacobus Hamelijnck (Norfolk and Suffolk NHS Trust)


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This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014.

The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

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ADHD Assessment by Dr Jacobus Hamelijnck (Norfolk and Suffolk NHS Trust)

  1. 1. Assessment Adult ADHD Dr Jaap Hamelijnck Yasir Hameed (MRCPsych) Digitally signed by Yasir Hameed (MRCPsych) DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust ou=Norfolk and Suffolk NHS Trust Reason: I have reviewed this document Location: Date: 2014-05-06 19:48+01:00
  2. 2. Introduction Tasks for assessment Assessment of symptoms Assessment of impairments (executive functioning) Psychiatric assessment Physical health assessment Focus on Strengths Assessment scales.
  3. 3. From Behavioural Syndrome to Executive Dysfunction Person burdened by a syndrome of chronic difficulties in focusing, getting started on tasks, sustaining effort, utilising working memory and modulating emotions that chronically impair their ability to manage necessary tasks of daily life (Brown 2013)
  4. 4. A new working definition of ADHD A complex syndrome of Developmental impairments of executive functions The self-management system of the brain A system of mostly unconscious operations These impairments are situationally variable Chronic, and significantly interfere with functioning in many aspects of the person’s daily life Brown 2013
  5. 5. Assessment Tasks ADHD is syndrome of symptoms with related impairments (executive functions) Clinical assessment with the following goals • Establish the presence of symptoms of ADHD • Assess the severity of the symptoms • Identify the impairments causes and the impact on the person’s life • Genetics • Co-morbidities • MSE (limited value) • Physical health
  6. 6. Assessment of Symptoms Diagnostic Criteria for Adult ADHD • 18 core items • DSM 5; requires 6 or more symptoms • Several symptoms were present before the age of 12 • Several symptoms are present in 2 or more settings • There is clear evidence that the symptoms interfere with or reduce the quality of, social, academic, or occupational functioning • Symptoms are not better explained by an other mental disorder
  7. 7. Core Symptoms DSM-IV Inattention (six or more) 1. Often fails to give close attention to details or makes careless mistakes 2. Often has difficulty sustaining attention in tasks or fun activities 3. Often does not seem to listen when spoken to directly 4. Often does not follow through on instructions and fails to finish work 5. Often has difficulty organizing tasks and activities 6. Often avoids, dislikes, or is reluctant to engage in tasks that required sustained mental effort 7. Often loses things necessary for tasks or activities 8. Is often easily distracted by extraneous stimuli 9. Is often forgetful in daily activities
  8. 8. Core Symptoms DSM-IV Hyperactivity / Impulsivity (six or more) 1. Often fidgets with hands or feet or squirms in seat 2. Often leaves seat in situations in which remaining seated is expected 3. Feelings of restlessness 4. Often has difficulty engaging in leisure activities or doing fun things quietly 5. Is often “on the go” or “driven by a motor” 6. Often talks excessively 7. Often blurts out answers before questions have been completed 8. Often has difficulty awaiting turn 9. Often interrupts or intrudes on others
  9. 9. Same core symptoms, but descriptions not easy to apply to adults. Symptoms list not easy to use as self report questionnaire Hyperactivity symptoms reduce; Attentions symptoms do not Gender differences in symptom persistence Other symptoms associated with adult ADHD Symptoms in Adults Clinical assessment and treatment fo ADHD in Adults. Philip Asherson. 2005;
  10. 10. Age of Onset DSM 5; symptoms present before age of 12 Diagnostic assessment in adulthood requires retrospective assessment of childhood symptoms and assessment of current symptoms. 6 of 9 rule in adults put the cut-off at 99 percentile or 2.5-3 standard deviations from the mean. Proposal to adjust number of symptoms as age increases • 17-29; 4 to 5 of 9 identifies most impaired 7% • 30-49; 3 to 4 of 9 • Over 50; 2 to 3 of 9
  11. 11. Associated symptoms Procrastination Low tolerance of frustration; minor frustrations couse catastrophic reactions, loss of temper or anger Mood lability; frequent changes, several times a day, like a roller coaster Low self-esteem; expected given the lifelong problems with rejections and failures Underachievement Frequent search for high stimulation Intolerance of boredom Hyper-focusing Trouble going through proper procedures due to boredom and frustration Worry needlessly Sense of insecurity Inaccurate self-observation and assessment of their impact on others
  12. 12. Semi-structured Interview to establish the symptoms
  13. 13. A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.
  14. 14. Impairments 1. Activation; excessive procrastination, put off getting started on a task, even a task they recognise as very important to them until the last minute. Keeping track of plans, money or time. Difficulties setting priorities. Has a hard time waking in the morning. 2. Focus; distracted easily by things going on around them and in their own minds whilst at other times they are stuck on one focus unable to shift to another task. Reading very difficult to grasp the meaning. Mind drifting all the time and missing important information. Spacing out. Easily side tracked, only remembering some of the details. Doesn’t seem to be listening and getting complaints about it. 3. Effort; sustaining effort very difficult, motivation wanes very quickly, needing high levels of interest to keep going. Unable to continue tasks in allotted time, slacks of unless pressure is on. Requires others to keep them on task. Chronic difficulty regulating sleep and alertness, stay up late because can’t shut their head off, big problem getting up in the morning. A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.
  15. 15. Impairments 4. Emotion; not recognised in DSM 5, chronic difficulties managing frustration, anger, worry, disappointment, desire, and other emotions. Emotions take over, making it impossible to give attention to anything else, short fused. Excessively impatient, sensitive to criticism from others, gets overly defensive. Can appear apathetic or unmotivated. 5. Memory; often great memory for things that happened long ago but not what they have just done, or where they put something. Excessively forgetful, intents to do things but forgets, making many mistakes or leaving out words when writing. Always forgetting to bring things or leaving the house with necessary items. 6. Monitoring and regulating self-action; too impulsive in what they say or do, jumping in to quickly, not being able to interact appropriately. Fail to notice others are offended or puzzled and fail to modify their behaviour. Pacing of actions, slowing down or speeding up as required for a specific task. Monitor one’s actions and inhibit impulsive actions. A new understanding of ADHD in children and adults; executive function impairments. Brown 2013.
  16. 16. Psychiatric Assessment Full clinical assessment (psychiatric history) Developmental history Family history Personal history Past psychiatric history Drug and substance misuse Comorbidity MSE Physical health history
  17. 17. Medical Assessment Tool for Adults with ADHD Have you ever been told by a doctor that you have heart disease? Do you ever get chest pain on exertion? Have you ever passed out or fainted whilst exercising? Has anyone in your family developed heart disease before the age of 60? Has anyone in your family died of heart disease before the age of 60? Do you know if you have high blood pressure or an increased cholesterol BP/Pulse is it regular? Weight Physical Examination (Done by GP) ECG, ECHO and 24 hr BP if indicated h%20ADHD.doc
  18. 18. Diagnostic Intruments Diagnostic Interviews; • DIVA • Brown ADD Scale Diagnostic form • Conners Adult ADHD Diagnostic Interview Schedule • Diagnostic Interview Schedule (DIS)-L Rating Scales; • Barkeley Adult ADHD rating scale (includes checklist to provide information on childhood symptoms and informants information) • Conners Adult ADHD rating scale (includes checklist to provide information on childhood symptoms and informants information) • WHO Adult ADHD Self Report Scale (ASRS) • Brown ADD Scale • Wender Utah Rating Scale (retrospective diagnosis of ADHD in childhood
  19. 19. Summary Send out screening forms (Barkley and Murphy, Wender UTAH) Face to face interview consisting of 1. Psychiatric assessment 2. Semi-structured clinical interview (DIVA) 3. Age appropriate rating scale for executive function impairments Interview with informant Physical health screening Formulate a diagnosis and treatment plan