Co-Chairs, Lenard A. Adler, MD, and Oren Mason, MD, prepared useful Practice Aids pertaining to ADHD for this CME activity titled “Overcoming Challenges in the Recognition and Management of Adult ADHD in Primary Care: Optimizing Outcomes to Reduce Disease Burden and Improve Quality of Life.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/3kMSUjb. CME credit will be available until December 22, 2022.

1. Identifying and Diagnosing Adult ADHD1-17
Full abbreviations, accreditation, and disclosure information available
at PeerView.com/CQC40
Screening Principles
Functional Impairment
Diagnostic Work-Up
Maintain a high level of vigilance in screening patients for ADHD
Impairments because of symptoms must be present
The follow-up of a positive screen is a full diagnostic work-up for ADHD
Screening and Rating Scales
Functional Impairment Scales​
Diagnostic Scales
• Point prevalence of ADHD in primary care similar to heart disease and asthma
• Impact of ADHD on family, social, and occupational domains can be higher
• High impact when treated
• Onset of impairments can occur throughout lifespan
– Situational pattern often evident
– Impairments may be transient or time limited
• Note severity and pervasiveness of current impairment
• Impairments will be present in more than one setting
– Relationships: family, social
– Vocation: work, school, hobby, leisure
– Life skills: personal care, time management, self-care, finances
– Risk taking: substance use, driving safety
Adult ADHD Self-Report Screening Scale for DSM-5 (ASRS DSM-5)
Adult ASRS Symptom Checklist v1.1 (ASRS-v1.1)
ADHD Rating Scale IV (ADHD-RS-IV) With Adult Prompts
Adult ADHD Investigator Rating Scale (AISRS)
Brown Attention Deficit Disorder Symptom Assessment Scale (BADDS) for Adults
Wender Utah Rating Scale (WURS)
Weiss Functional Impairment Rating Scale: Self-Report (WFIRS-S)​
Weiss Functional Impairment Rating Scale: Observer (WFIRS-O)​
Adult ADHD Quality of Life Rating Scale (AAQOL)​
Barkley Functional Impairment Scale (BFIS for Adults)
Adult ADHD Clinical Diagnostic Scale (ACDS) v1.2
Barkley Adult ADHD Rating Scale-IV (BAARS-IV)
Conners’ Adult ADHD Rating Scales (CAARS)
Diagnostic Interview for ADHD in Adults (DIVA) 2.0

2. Identifying and Diagnosing Adult ADHD1-17
Full abbreviations, accreditation, and disclosure information available
at PeerView.com/CQC40
ADHD Diagnostic Process
Schedule adequate time
Preparation prior to visit
• Two 30-minute visits (CPT 99214; eg, consecutive days)
• Alternately: 60-minute visit (CPT 99215 or 90801)
• Structured questionnaires completed prior to appointment; at minimum, consider
– Adult ADHD Self-Report Scale: 18 items
– Weiss Functional Impairment Rating Scale: Self-Report
• Screeners: anxiety, depression, mood disorder, SUD
• Establish time course of ADHD symptoms
– Long-standing, not episodic
• Catalogue impairments because of
symptoms
– Often situational or time limited
– Relevant past history (eg, prior SUD,
legal issues)
• Diagnostic screeners for comorbid
disorders
– Interview
– Hamilton Depression Rating Scale
(HDRS)
– Hamilton Anxiety Rating Scale
(HAM-A)
– CAGE Questionnaire (CAGE-AID)
– Mood Disorder Questionnaire (MDQ)
• Establish diagnosis with patient
• Cardiovascular baseline screening
• Disease-state education
• Define patient’s therapy goals
– “What three changes would you most
like to see as a result of therapy?”
• Initiate therapy
– Medication trial of therapy
– Psychosocial support
– Accommodations
• Schedule follow-up in 1 month
• Remember to
– Identify medical comorbidities and
medications that may impair cognitive
function or exclude patient from
ADHD treatment
– Request collateral information about
medical history from someone
close to patient
Visit 1 Visit 2

3. Identifying and Diagnosing Adult ADHD1-17
Full abbreviations, accreditation, and disclosure information available
at PeerView.com/CQC40
Comorbid Psychiatric Disorders
Are Very Common
The following psychiatric disorders have elevated rates in
adults with ADHD
Psychiatric screeners for adults
The following should NOT be used to dismiss a diagnosis​of ADHD​
• Bipolar disorder
• Major depressive disorder
• Substance use disorder
• Hamilton Depression Rating Scale (HDRS)
• Hamilton Anxiety Rating Scale (HAM-A)
• CAGE Questionnaire (CAGE-AID)
• Mood Disorder Questionnaire (MDQ)
• The clinician does not observe hyperactivity in the office​
• There is no family history of ADHD​
• The patient
– Has past or current anxiety​or depression​
– Is sedentary with sluggish mannerisms
– Is quiet or shy or has a reticent personality
– Is well educated or employed in a high-level position
– Is financially success​
ful
– Is well mannered, has a stylish appearance, or has polished social skills
– Showed clear signs of hyperactivity, impulsivity, and​inattention in childhood but has
difficulty only with residual​symptoms now
– Does not remember or denies symptoms in childhood,​and school records
are unavailable
• Anxiety disorders
• Personality disorders
1. Kessler RC et al. Arch Gen Psychiatry. 2010;67:1168-1178. 2. Goodman DW. Prim Psychiatry. 2009;16:21-30. 3. Barkley RA. Barkley Adult ADHD Rating Scale—IV (BAARS-IV). New York, NY: Guilford Press; 2011.
4. Conners KC et al. (CAARS) Conners' Adult ADHD Rating Scales. Torrance, CA: WPS Publishing; 1998. 5. https://www.advancedassessments.co.uk/resources/ADHD-Screening-Test-Adult.pdf.
6. https://nyulangone.org/files/psych_adhd_checklist_0.pdf. 7. https://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/ASRS-5_English.pdf. 8. Adler LA et al. In: Adler LA et al, eds. Attention-Deficit
Hyperactivity Disorder in Adults and Children. Cambridge, UK: Cambridge University Press; 2015:224-232. 9. DuPaul GJ et al. ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. New York, NY:
Guilford Press; 1998. 10. Spencer TJ et al. J Atten Disord. 2010;14:57-68. 11. Brown T. Brown Attention-Deficit Disorder Scales. Boston, MA: Springer; 2011. 12. http://neurosciencecme.com/library/rating_scales/
adhd_wender.pdf. 13. http://www.shared-care.ca/files/Weiss_Functional_Impairment_Self-Report.pdf. 14. Canu WH et al. J Atten Disord. 2020;24:1648-1660. 15. Brod M et al. Atten Defic Hyperact Disord.
2015;7:141-150. 16. Barkley RA. Barkley Functional Impairment Scale (BFIS for Adults). New York, NY: Guilford Press; 2011. 17. Katzman MA et al. BMC Psychiatry. 2017;17:302.

4. Shared Decision-Making in ADHD1-9
Full abbreviations, accreditation, and disclosure information available
at PeerView.com/CQC40
The Role of the Clinician and Patient in Shared Decision-Making
Clinician Patient
Provides evidence-based information/education
Informs about risks involved with each option
Has professional expertise
Trusts patient’s worldview and values patient
experiences, thereby building therapeutic alliance
Presents multiple treatment options with risks and
benefits of each, so that patient is active participant
rather than passive in selecting treatment
Has lived-experience expertise
Clarifies and aligns decisions with goals
Shares values and preferences to promote
mutual understanding
Barriers for Clinicians and Patients in
Shared Decision-Making
Takes personal accountability for medical
decisions, including those about medications
and types of therapies
Includes families/caregivers to facilitate SDM
and help to enact the treatment plan
Lack of time Stigma about mental
illness inhibiting open
communication and
willingness to consider
medication
Believing patients have low
capacity to make decisions
Provider’s own treatment
preference
Patients not advocating for
their own involvement
Less experience
(less provider experience
is associated with lower
patient involvement)
Not having been provided
the option to participate in
shared decision-making
Lack of structural support Not wanting to make
the final decision
Clinician
Patient

5. Shared Decision-Making in ADHD1-9
Full abbreviations, accreditation, and disclosure information available
at PeerView.com/CQC40
The Key Components of Engaging Patients
in the Decision-Making Process
1. Introduce choice
2. Describe options
3. Help make decisions
Identify/summarize problem
Offer choices
Emphasize importance of personal preferences
Discuss any uncertainties in treatment
Check reaction
Defer final decision until you are able to discuss options in more detail if patient asks,
“What would you do?”
Determine what the patient already knows
List and describe options including risks and benefits of stimulant and nonstimulant medications
for the treatment of ADHD
Provide decision support such as decision aids, which can help patients understand their options
List options again and apply teach-back method by asking patient how they would describe the
options to a loved one
Focus on preferences
Check to see if patient is ready to make a decision or if they need more time or have
additional questions
Agree on treatment plan
Ensure patient understands that the plan can be modified and decisions can be reviewed
at any time
1. Slade M. World Psychiatry. 2017;16:146-153. 2. Zisman-Ilani Y et al. JAMA Psychiatry. 2021;78:1183-1184. 3. Da Costa H et al. J Nerv Ment Dis. 2020;208:329-339. 4. Guidry-Grimes L. AMA J Ethics.
2020;22:E446-E451. 5. Maples NJ et al. Community Ment Health J. 2021 June 27 [Epub ahead of print]. 6. Farrelly S et al. Health Expect. 2015;19:448-458. 7. Rodenburg-Vandenbussche S et al. J Eval Clin Pract.
2020;26:645-658. 8. Matthews EB et al. Front Psychiatry. 2021;12:681165. 9. Gravel K et al. Implement Sci. 2006;1:16.