ADHD / ADD: How We Diagnose and Treat It

How Do We Diagnose ADHD/ADD? How Is it Treated?

On the surface, it may seem like Attention Deficit Disorder (ADD) is a fairly easy disorder to diagnose, at least in terms of how it is defined. (I will use the abbreviation ADD to describe both ADD and ADHD, to keep things easier to read.)

Essentially all psychiatric disorders are diagnosed with the DSM-5, the psychiatrist’s “bible”.^[1] The DSM-5 provides descriptive criteria for diagnosis of the major psychiatric and addiction disorders.

ADD is no different.

What is ADHD/ADD?

The definition of ADD/ADHD in the DSM-5, provides diagnostic guides and identifying criteria aligning with related potential symptoms for the various types of ADD which includes:

• “Inattentive” type (the most common presentation in adults)
• “Hyperactive-impulsive” type
• “Combined” when both of these types are present in one individual.

Luckily, the treatment of these various types is the same, if not identical.

For an adult to be formally diagnosed with ADD, per the DSM-5, several of the symptoms must have been present before 12 years of age. Furthermore, these symptoms must negatively impact the person’s functioning (e.g., can’t get their work done due to symptoms of inattention).  So, in theory, you can simply go to a listing of these symptoms in the DSM-5 and see if the person has enough of these to qualify for the diagnosis. (See below.)

For more information about diagnosis and treatment of ADD throughout the lifespan, please visit the websites of the National Resource Center on ADHD and the National Institutes of Mental Health.

Tools used in diagnosis and treatment of ADD/ADHD

• Questionnaires can be used to screen for ADD but a definitive diagnosis requires psychological testing and/or review of medical and other records / psychiatric interview per the DSM-5 [1].
• Part of the workup for ADD includes the Primary Care Physician (PCP) to take a history and physical and get basic lab tests to make sure there is no underlying medical problem. Dr. Weiss is also qualified to help make this determination.
• The PCP or the psychiatrist should consider a urine test for drugs of abuse, as drug addiction can mimic ADD and has a different treatment.
• Treatment with medication alone is often effective, though supplementation with non-medication treatment is always useful.
• Stimulant medications, sometimes used to treat ADD, are controlled substances in the State of Texas requiring close medical monitoring and regulatory requirements such as prescribing on approved electronic prescription media.

Screening for ADD

Before jumping to a definitive diagnosis, it may be prudent to attempt to screen for the ADD diagnosis. Screening is usually done through the use of screening questionnaires to help clarify symptoms for the sake of diagnosis and treatment.

A questionnaire that is helpful and easy to utilize in my experience, is the early version of the ASRS or Adult Self-Report Symptom Checklist.  (In younger people there are tools to aid in diagnosis as well.)

The ASRS was originally designed for the World Health Organization (WHO), the authors (Drs. Adler, Kessler and Spencer) are formidable researchers in the field of ADD and designed the questionnaire for use in any country of the world. It isn’t foolproof but it is helpful.

Note the ASRS is a bit skewed towards children than adults, as well as older (pre-2013) criteria for diagnosing ADHD.

Nevertheless, it is a good tool in terms of ease of use and accuracy when compared to other questionnaires.

How Does the ASRS Work?

In the ASRS, you rate yourself in terms of a symptom, using a four-point scale of 0 for “never” up to 4 for “very often.” The ASRS is broken into Parts A and B. Part A addresses Inattentive criteria (symptoms), and Part B addresses Hyperactivity/Impulsivity criteria (symptoms). There are therefore two diagnostic “types” of ADHD and the ASRS addresses

• 9 symptoms for the “inattentive type”
• 9  symptoms for the “hyperactive type”

They are scored separately on the scale (or to use the lingo of the questionnaire “evaluated”.)

The person taking the ASRS answers questions as being:

“unlikely” (score of 0-16)

“likely” (17-23) or

“highly likely” (24 or greater) to have ADD or ADHD

You are welcome to take the ASRS (linked). Please do not attempt to diagnose yourself with the questionnaire–but it will help you note important features of interest to your psychiatrist.

The Role of Psychological Testing

In order to obtain a definitive diagnosis, it may be necessary for the patient to undergo psychological testing with a trained Psychologist or Neuropsychologist (Ph.D. or Psy.D).  Neuropsychologists are psychologists with additional training in administering psychological testing to assess for conditions like ADD. The psychologist can administer certain tests (e.g., the Brown Attention Deficit Disorder Scales [BADDS]) which along with their clinical skill and training can help make an ADD diagnosis, if it is present. Newer testing approaches also show promise diagnostically including Neurometrics, which is the study of brain waves through EEG or electroencephalogram, brain scan PET (positive emission tomography), or brain scan SPECT (Single Photon Emission Computed Tomography). Lastly, computerized tests may be used including the Continuous Performance Test (CPT) of vigilance and sustained attention as well as other computerized neurocognitive batteries like the MicroCOG, Cog Test  NES2 and CNS Vital Signs.

Nevertheless, a clinical interview and evaluation, including review of all pertinent medical records, by a licensed physician, i.e., a psychiatrist, remains the “gold standard” in diagnosis to which all other testing approaches and types must be compared.

Get a Physical. You Might Have Another Medical Condition

The person being considered for a diagnosis of ADD should also have had a recent annual physical with their Primary Care Physician to rule out “physical” causes of ADD. For instance, you do not use ADD drugs to treat an attentional problem due to hypo- or hyperthyroidism (overactive or underactive thyroid, respectively.) Rather this condition is treated with the appropriate medication, surgical procedure or other treatments. It is only through the person being rendered “euthyroid” (normal thyroid functioning) that their attentional situation is improved. There are other physical conditions that have symptoms similar to ADD — too numerous to count!

This is why ruling out other conditions and disorders is such an important part of diagnosing ADD.  In medicine, we always consider the risk/benefit ratio of a treatment. This is particularly true in the case of medication. Potential side-effects are always a concern (“risk”.) Nevertheless, any medication has potential side-effects.

Getting Labs

General bloodwork should be undertaken. If labs were recently performed, the records should be reviewed for liver, kidney, electrolyte, blood sugar, anemia, hormonal (e.g., thyroid) and other abnormalities diagnostic of physical conditions affecting attentional state.

Beyond performing a history and physical, labs provide the physician with a wealth of information about overall health that might impact ADD or ADD-like symptoms.

Labs and Substance Abuse

It may be prudent to check a urinalysis for the presence of substances that impair attention, including drugs of abuse in order to rule out drug or alcohol intoxication (or withdrawal) as the cause of attentional problems.  It is a well-known clinical fact that a person addicted to stimulants may impersonate ADD to the unsuspecting clinician in order to get their drugs of choice. This is sometimes called “doctor shopping.” A urine test may be crucial to know what is really going on.

Most ADD medications are relatively safe, but many states, like Texas, regulate stimulants, such as those used in some ADD medications, as being at risk for addiction. 

Addiction, therefore, like the example of a thyroid condition above, is “another medical condition” that a patient represents is ADD, but is not. 

ADD / ADHD TREATMENT

Once the diagnosis of ADD is determined, then the treatment phase begins.  ADD is one of those unusual psychiatric disorders whereby medication treatment can be superior to psychotherapy or non-pharmacological medication approaches.  In fact medication therapy may do very well as a stand-alone.  That said, the motivated ADD patient benefits most from the combination of ADD drugs plus creative implementation of behavioral and cognitive approaches.

Treatment with Medication

Medication treatment falls basically into 4 categories:

(1) Stimulants; familiar stimulants include Adderall or Ritalin

(2) The drug Strattera (atomoxetine is the generic) and similar non-stimulant drugs

(3) The α2 agonists, and last but not least

(4) “Other” (for lack of a better term) or miscellaneous (since they are members of various drug classes) remedies. ADD is nuanced. Not all types of drugs are appropriate for all symptoms of ADD.

Why Stimulants?

Stimulant medications all have in common that they work on the nerve cells in the brain in a common manner (by increasing dopamine and norepinephrine availability in between nerve cells) and they are all potentially addictive. Common stimulants used to treat ADD fall into the short-acting and long-acting categories.  Some studies over the years indicate that Adderall (amphetamine salts) may have a slight advantage over methylphenidate (most commonly Ritalin) in adults. Dexedrine (dextroamphetamine) is still on the market as well as drugs that are derivatives of Adderall and Ritalin which are designed to be longer-acting like Vyvanse (lisdexamfetamine) and Focalin XR (dexmethylphenidate).

Adderall or Ritalin themselves may come in long-acting formulations such as Ritalin SR (slow release), Ritalin LA (long-acting), and Adderall XR (extended release). Daytrana is a Ritalin (methylphenidate)-like formulation that is delivered in the form of a skin patch.

The newest “kid on the bock” or some say the “sexy” new medication is Jornay. Jornay is a methylphenidate or Ritalin-like formulation designed to be taken into the system further down than is usual.  So it is designed to be absorbed in the colon or large intestine/bowel rather than “the usual” for most medications, in the stomach/small intestine site. The result is a 12-hour delay so you take it at night if you want to wake up with it in your system the next morning!

In fact, it is not uncommon to utilize both short and long-acting stimulants in combination in order to ensure that there is enough medication in the system to improve attention but not so much that side effects supervene. The most common side effects of stimulants are lack of appetite and insomnia, aside from potential drug abuse or addiction.

ADD Medications that Are Controlled Substances Regulated by the DEA, Federal, and State Oversight

Although stimulant drugs are versatile in that they come in various formulations (above) and can be safely administered with dosage adjustment on a day-to-day basis, a consideration is regulation by law of such medications.  Texas laws regulate such medications, as do other states.  Also, the Federal government stipulates the manner in the 50 states in which controlled substances are regulated. A given state may choose to make the regulation more (but not less) strict.

In this vein, Texas has chosen to have the Department of Public Safety (DPS) issue prescriptions each with a unique bar-code as well as number on it for schedule II medications (schedule I is most restricted drug class, V the least).

This serves to decrease the illegal diversion of these medications. On the other hand, due to the prescriber’s and pharmacist’s enhanced responsibilities, this policy also tends to make it more difficult for a legitimate patient to receive these medications.  Therefore, if the prescriber does not dot all the i’s, or cross all the t’s, then the patient may in good faith arrive at the pharmacy with their prescription but find it may not be honored.  As an example, pharmacies require that the # of pills (e.g., 30 for a 30 day supply) be literally spelled out (i.e., the word “thirty”) on the prescription so that if this is not properly done the medication is denied. Similarly, each pharmacy may decide to create its own internal rules so that controlled substances may not be given for more than a 30 day period.

Strattera Is Not a Controlled Substance

The second category of ADD drugs is Strattera, which acts on the cells similar to the antidepressants (it is a norepinephrine reuptake inhibitor) and therefore is not potentially addictive.  Studies have shown Strattera to be as effective as stimulants in treating ADD.  However, drawbacks include slower onset of action–they do not kick in as quickly–presumably related to its mechanism, which resembles antidepressants.  Strattera is also less flexible in its dosing schedule than stimulants in that it is prescribed at a consistent dose on a daily basis as opposed to stimulants where “drug holidays” may be employed over the weekend or during the summer when school is out.

The major side-effects of Strattera are dry mouth, nausea, and sleepiness. Patients usually get used to dry mouth and do not find it necessary to stop the drug for this reason.

a2 Type Drugs

The third class of ADD drugs work via activating specific receptors in the brain called the α2 type and which include Catapres (clonidine) and Intuniv (guanfacine). Although these are only approved by the FDA (Food and Drug Administration) for children and adolescents, they may be effective when they are utilized “off label” in adults.

Other Drugs Used to Treat ADD

The rest of the drugs used to treat ADD are not as useful overall statistically in a given population, but in any individual patient, they still may help either alone or combined with other medications. The first group in this miscellaneous category includes the wakefulness-promoting agents Provigil (modafinil) and the chemically related Nuvigil (armodafinil).  Although they are clinically related to stimulants, promoting wakefulness and arousal, their “mechanism of action” (how they operate on the brain), which is similar to antidepressants (norepinephrine reuptake inhibiter) makes them on the upside unlikely to be drugs of abuse but on the downside less effective for ADD overall than stimulants.

Drugs or Medications Similar to Antidepressants

Next, drugs traditionally in the anti-depressant category may be effective for ADD but statistically less so than the stimulants, Strattera or the α2 agonists. These include Wellbutrin (bupropion), Effexor (venlafaxine) and the older tricyclic antidepressants (examples include Elavil [amitriptyline] and Norpramine [desipramine]). For the sake of completeness included here are dietary supplementation maneuvers such as with the trace elements zinc, iron, magnesium and iodine as well as omega 3 fatty acid supplementation, although it is recommended these be utilized along with traditional prescription drug treatment as they don’t do the trick alone.

Neuropsychological Testing Is the Gold Standard for Diagnosis

For the reasons given above, you can see that proper diagnosis of ADD is crucial to finding the right treatment. I have found it medically and psychiatrically prudent to require the patient’s diagnosis be confirmed by a trained psychologist in psychological testing–even if I may use a questionnaire to screen for the disorder. Alternatively, if time permits, with a cooperative patient with appropriate documentation, a psychiatric interview approach strictly using the DSM-5 criteria for ADD may be used.

Another approach is, if there is a positive screening for ADD, to try treatment with Strattera, as it is not so heavily regulated while continuing to monitor historically for the presence of ADD symptomatology. If Strattera fails to treat the ADD, then a stimulant medication may be a next step.

Medication Works, But Non-Medication Techniques Have a Place

Although the use of medications has been emphasized, I believe that non-pharmacological treatment approaches should not be ignored. Medication is extremely effective, but non-medication treatments working with medication can be very effective in treating ADD.  Non-drug therapies that are of proven benefit include psychoeducation (list-making, prioritizing, etc.), coaching techniques, bibliotherapy (reading books/materials about ADD), individual and group psychotherapy, journaling, exercise, and meditation. These approaches tend to accompany medication rather than used as a stand-alone treatment.

I have had physician and non-physician friends alike who have successfully bolstered their pharmacological regimen with a variety of treatment measures.  An excellent resource is the CHADD website (which stands for Children and Adults with ADD). Information there can help the ADD patient develop a non-prescription drug adjunct. Another consideration is a herbal/dietary regimen, to supplement ADD prescription drugs.

ADD Group Support

I have known patients to join therapist-led ADD groups as well as CHADD style (or “meetup” type) support groups.  All of this and more can be found on the CHADD site.  There you will also find reading materials to supplement a pharmacotherapy regimen.  CHADD’s Attention magazine may be purchased and is an excellent resource as well. Finally, national ADD conferences, as well as advocacy groups are available for the motivated patient. The online magazine ADDitude has up-to-date and useful information.

Combining Approaches

As you can see, there are a number of approaches to treat ADD/ADHD. For many patients, medication is effective. Combining medication and non-medication approaches along with developing a support system may be the most successful treatment for the person with ADHD or ADD. 

Some things to think about

1: Most drugs prescribed in the United States are not used for their precise FDA indications but are rather used “off label.”
2: The nerve cells transmit chemicals called neurotransmitters such as norepinephrine and serotonin into the space between them, thus stimulating a receptor on the neighboring nerve cell, which in turn causes protein synthesis and that on a large scale ultimately changes thinking and behavior.

DSM-5 Criteria for ADHD

This is not a complete quote from the DSM-5, which addresses forms of ADHD for more than 10 pages.  Here are some highlights:

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older, and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
   
   
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
  
• Often has trouble holding attention on tasks or play activities.
  
• Often does not seem to listen when spoken to directly.
  
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
  
• Often has trouble organizing tasks and activities.
  
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
  
• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
  
• Is often easily distracted
  
• Is often forgetful in daily activities.
  
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
   
   
• Often fidgets with or taps hands or feet, or squirms in seat.
  
• Often leaves seat in situations when remaining seated is expected.
  
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
  
• Often unable to play or take part in leisure activities quietly.
  
• Is often “on the go” acting as if “driven by a motor”.
  
• Often talks excessively.
  
• Often blurts out an answer before a question has been completed.
  
• Often has trouble waiting his/her turn.
  
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  
• Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
  
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
  
• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.’

Changes in the DSM-5
The fifth edition of the DSM was released in May 2013 and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD: symptoms can now occur by age 12 rather than by age 6; several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting; new descriptions were added to show what symptoms might look like at older ages; and for adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children. As you can see, distinctions are a bit blurry when making the diagnostic transition from children to adolescents to adults. There are assumptions that adult ADHD/ADD follow childhood or adolescent ADHD/ADD. If you are an adult and have been diagnosed with ADHD or ADD in the past, or feel you might have ADHD or ADD and have never had that diagnosis, I suggest you call me and we can set up an appointment to discuss your symptoms and medical history, (per the DSM-5).

Reference
[1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.