Pay Attention: Neurology and ADHD, Part 2

How should an ADHD diagnosis be made? What, if any, is the neurologist's role?

John L. Barton, PhD, ABPP: I think the diagnosis should be made according to the DSM-5 criteria and I think the evidence-based assessment would call for multiple sources of information. Not only should you be getting information from the patient, but, if possible, you should be getting information from parents regarding this person's childhood experience with these symptoms. And then somebody who knows the person well now so you can get a current perspective on those symptoms. This might be a spouse, a roommate, a boss, or if they're still in frequent touch with their parents, parents could serve as both of those collateral reporters.

Further, there has to be demonstration of substantial impairment. I think that while every human being now and forever has been somewhat inattentive, somewhat active, and somewhat impulsive, usually those symptoms don't create extensive impairment in the person's ability to function. In order to be diagnosed you have to establish there is substantial impairment and/or distress. One way to do that is to use some well-established and well-standardized behavioral rating scales, both to determine the person meets criteria and that there is substantial impairment. Again, collateral informants are an important source of information. Usually if the question is only, “Does this person have ADHD or not?” then extensive neuropsychological testing really is not warranted.

I think that the neurologist's role in the diagnosis of ADHD is rather limited. If seen by a physician, it is much more likely that the primary care physician would evaluate and then refer to neurologist to rule out other unresolved neurological explanations for the symptoms of inattention, hyperactivity, impulsivity, poor rule-governed behavior and inconsistent effort and performance.

What are your thoughts on the changes made on ADHD in DSM-V?

I think they're an improvement on previous editions of DSM. One of the things they did was to reconsider ADHD as a disorder that extends over the lifespan and so, they had to make the diagnostic criteria more adolescent and adult friendly. It was said that children don't outgrow ADHD, they simply outgrow the DSM criteria. DSM-5 took that into consideration and tried to make them more applicable to a lifespan perspective. However, adapting symptoms for children to work for adults is somewhat awkward. They also lowered the threshold for meeting those criteria, although there's certainly research that would say it didn't adequately modify the criteria to reflect changes across the lifespan and certainly not for older adults. There is also little attention paid to how the criteria might be most appropriately applied for pre-schoolers.

They also changed the age of onset of showing symptoms by age 7 to showing these symptoms in childhood, which I think was appropriate. They then changed the section in which it is grouped in the manual so as to be clustered with the neurodevelopmental disorders, rather than disorders of infancy and childhood. I think all of these things were good.

How do ADHD symptoms and impairments change with age?

You often hear about children with ADHD “bouncing off the walls.” With age, I think you see a decrease in motor restlessness and hyperactivity over time, but there's some sense that instead of motor restlessness, there's mental restlessness, becoming easily and quickly bored, wanting to get on to the next thing, seeking out more highly stimulating activities, starting but not finishing many projects. I think the impulsivity changes; instead of so much physical intrusion and physical action, it becomes more like rash decisions, impulse buying, bad driving, and difficulty stopping when they should. While the symptoms of inattention decrease across the lifespan, they tend to decrease less, and show up as problems with organization, trouble doing things in the proper order, and forgetfulness.

At the same time, the demands of family, school, jobs, and society escalate. The expectations for self-governed behavior increase and the supports that often help these kids through middle school and high school decrease, or are eliminated. So when kids move out of home and parents can't be there to support and act as their executive functions or frontal lobes, then what enabled them to “get by” turns in to getting into some real difficulty. We saw lots of freshman or sophomores at ASU who did pretty well in high school because they got lots of help from their parents but when they get into the dorm or into the fraternity house and don't have those supports, they end up doing pretty poorly. They don't maintain healthy behaviors, making them more likely to overeat, smoke or drink or use drugs, and use them in impulsive ways. They have more job changes as they get into older adulthood; they have more interpersonal problems including marital dissatisfaction and much higher rate of traffic violations.

What's your opinion on the Sluggish Cognitive Tempo debate? Is it a subtype of ADHD or are they two distinct disorders? 

I think they're probably two distinct disorders. Some of the symptoms in the DSM-5 criteria for inattention can be seen as manifestations of hyperactivity or impulsivity in that people with ADHD can pay attention to what they're focused on, but can't sustain it because they're off to something else. Whereas the inattention in SCT is where they can't focus on the right thing; they're focusing on what they're going to do for dinner or that video game they were playing, or they don't really know what they're focused on. I think that's a qualitatively different type of inattention.

Those kids or adults with SCT are likely to be described as daydreamers, physically lethargic and may have a hard time getting started, whereas the inattention that's associated with the current DSM criteria, those are likely to be described as careless, they're sort of allergic to sustained mental effort, and they're poorly organized. That seems to be a qualitatively different presentation.

Those with SCT tend to be less impaired in terms of their executive functioning and are less likely to have general impairment in life than those with DSM-5 inattention. Those with SCTmay have more impairment at school or at work. They're more likely to have internalizing symptoms such as anxiety, depression compared to those with the Inattentive type of ADHD.

What unique issues need to be taken into account when treating women versus men with ADHD?

They are at greater risk some kind of eating pathology, especially binge eating, and they're more at risk for anxiety and depression. These comorbid issues have to be addressed and treated. Because of the importance of social relationships in the lives of women and the greater risk for problems in peer relationships and interpersonal relationships, those also have to be addressed. Like anyone with ADHD, they need a good understanding of the disorder, a way to think constructively about their past, and have hope for the future. n

John L. Barton, PhD, ABPP is Director of Clinical Psychology Center at Arizona State University, and Director of Pediatric Psychology Services in the Barrow Neurological Institute at Phoenix Children's Hospital.