Assessment of ADHD in Adults: Methods and Issues

In this presentation, Dr. Barkley presents his view on the best means for clinically evaluating ADHD in adults. The focus of the evaluation on establishing the DSM5 criteria for adult ADHD are initially discussed along with the adjustments one should make in those criteria for adults. This is followed by information to be obtained the issues to be addressed by the evaluation and the guidelines for doing so are then presented. The types of rating scales and psychological tests that are useful in the evaluation of ADHD will also be reviewed. Special attention is given to the problems with using neuropsychological testing to make a diagnosis of ADHD in adults. The presentation concludes with the issues that arise in making an ADHD diagnosis in adults including the problem of malingering in certain populations. This presentation is 1.5 hours in length.

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[tarakann]

As a 47 year old woman going through peri-menopause I can attest to my adhd traits and symptoms being exacerbated at the moment and needing my medication to be adjusted. Thank you for all your work you have done my 10 year old son has a brighter future because of your lifetime dedication to adhd

[jonathanberry]

🎯 Key Takeaways for quick navigation:

00:06 🎙️ *Introduction to ADHD assessment in adults*
- Dr. Russell Barkley introduces the focus of his lecture on the assessment of ADHD in adults.
- Explanation of Dr. Barkley's credentials and intention to discuss ADHD assessment in adults.
- Mention of DSM-5 criteria as the foundation for ADHD diagnosis in adults.
- Highlighting the two dimensions of neuropsychological traits for ADHD diagnosis.
01:03 📋 *DSM-5 Criteria for ADHD in Adults*
- Dr. Barkley delves into the specifics of the DSM-5 criteria for ADHD in adults.
- In-depth discussion on inattention and hyperactive/impulsive behavior symptoms for adults.
- Emphasis on the threshold adjustments made for developmental inappropriateness between children and adults.
- Cautionary note about using DSM-5 clarifications and their potential inaccuracies.
04:38 🧠 *Cognitive and Developmental Considerations*
- The discussion shifts to broader cognitive issues and developmental considerations in ADHD assessment.
- Addressing the limitations of the DSM-5 criteria, particularly its childhood bias.
- Emphasizing the need to consider executive functioning and working memory in ADHD assessments for adults.
- Highlighting the challenges in using age 12 as the onset criterion and its unreliable recall.
07:49 🚺 *Gender and Age Considerations in ADHD Diagnosis*
- Dr. Barkley discusses gender biases and age considerations in ADHD diagnosis, especially concerning females and age specificity.
- Highlighting the biases towards males in earlier studies and the implications for female ADHD diagnosis.
- Emphasizing the need to consider age of onset beyond 12 and its unreliability.
- Addressing the potential impact of ADHD on self-awareness and symptom reporting reliability.
09:36 📊 *Beyond DSM-5: Incorporating Executive Functioning*
- The focus is on the importance of executive functioning and introducing additional symptoms for a comprehensive ADHD assessment in adults.
- Discussing the limitations of the DSM-5 in capturing adult ADHD, especially related to executive functioning deficits.
- Introducing alternative symptoms and rating scales to enhance ADHD diagnosis accuracy.
- Emphasizing the need to look beyond the DSM-5 criteria and incorporate executive functioning evaluations.
30:52 🧠 *Understanding the Core of ADHD in Adults*
- Emphasizes the broad spectrum of ADHD symptoms beyond hyperactivity and inattention.
- The symptom dimension of ADHD is not just specific to motor activity but also includes cognitive and emotional disinhibition.
- Evaluating adults requires considering not only DSM-5 criteria but also additional symptoms related to poor inhibition and executive functioning.
32:58 🗨️ *Cognitive Impulsivity and ADHD*
- Cognitive impulsivity is characterized by disorganized thinking and impulsive decision-making without considering future consequences.
- Individuals with ADHD may experience a "racing" of ideas, reflecting a lack of top-down executive regulation.
- Impulsive decisions and a lack of contemplation about future outcomes are hallmarks of ADHD.
34:48 🎯 *Motivational Disinhibition in ADHD*
- People with ADHD often struggle with self-motivation, leading to procrastination and difficulty achieving long-term goals.
- There's a diminished value placed on delayed rewards or consequences, emphasizing immediate gratification.
- While individuals with ADHD may set sincere goals for the future, they often struggle to act upon them due to a lack of motivational weight.
01:00:42 🧠 *ADHD and Sluggish Cognitive Tempo (SCT)*
- Discussion on Sluggish Cognitive Tempo (SCT) as distinct from ADHD.
- SCT often coexists with ADHD, but it can also be a standalone condition associated with depression, anxiety, and PTSD.
- Dr. Barkley hints at the renaming of SCT to something more appropriate and less stigmatizing.
01:02:05 📊 *Neuropsychological Testing Limitations*
- Emphasis on the inefficacy of neuropsychological testing in diagnosing adult ADHD.
- Highlighting the flawed nature of executive function tests and their inability to predict real-world impairments.
- Warning against using these tests for high-stakes decisions like special education services or disability support.
01:06:10 🚫 *Tests vs. Real-life Functioning*
- Detailed analysis showcasing the discrepancy between test results and real-life executive functioning.
- Refutation of the claim that these tests can provide insights for treatment planning.
- Discussion on the harm caused by relying on these tests for crucial life decisions, with evidence from various studies.
01:14:46 🕵️‍♂️ *Issues in Diagnosis*
- Exploring the challenges of underreporting and overreporting of ADHD symptoms in adults.
- Delving into issues of retrospective recall, where individuals may not accurately remember their childhood symptoms.
- The importance of corroborating symptoms through multiple sources and considering potential malingering in specific contexts.
01:23:57 🎯 *Differential Diagnosis and Severity*
- Highlighting how ADHD symptoms and their impact differentiate from other disorders like anxiety, depression, and learning disorders.
- Emphasis on the chronic and unremitting nature of ADHD symptoms in contrast to episodic disorders.
- Discussion on the severity of ADHD's impact on multiple life domains, including education, work, relationships, and health.
01:28:35 📋 *ADHD Assessment Overview*
- Dr. Barkley outlines the comprehensive process of assessing ADHD in adults.
- Overview of the three-tiered interview process: open-ended, semi-structured, and structured interviews.
- Emphasis on the importance of considering the history, onset, and course of the disorder.
- Mention of the role of DSM criteria, rating scales, and collecting collateral information for a thorough evaluation.
01:29:50 🧠 *Executive Functioning and Evaluation*
- Dr. Barkley delves into the significance of executive functioning in ADHD assessment.
- ADHD is described as an executive functioning deficit disorder (EFDD).
- Highlighting the critical areas of executive functioning affected: time management, inhibition, self-awareness, emotion regulation, and planning.
- Mention of the limitations of using executive functioning tests for ADHD detection.
01:30:58 📝 *Beyond DSM: Holistic ADHD Assessment*
- The presentation concludes with an emphasis on a holistic approach to ADHD assessment beyond just DSM criteria.
- Need for amending and expanding DSM criteria considering the oversights and shortcomings.
- Importance of recognizing ADHD as a self-regulation deficit disorder (SRDD).
- Stress on evaluating comorbid disorders, differential diagnosis, and considering resources for treatment.

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[Le_montrealais]

I'm getting my diagnosis this week as a 20 year old. My mom and her mom were diagnosed over 30 year old, which explains a lot about her past inability to fulfill the same tasks and role as a parent compared with neurotypical parents. Your videos give me so much insights and perspective on myself as someone who struggle a lot with university and living alone task affiliated. Thanks for that!

[dylikestories]

You’re my favourite source of adhd information. You give very unbiased and truthful information about what adhd really is. I’m currently under assessment for it and after telling a few people about it they’re always surprised because they never thought I had issues with attention. I particularly like that you’d rather the disorder be called Executive dysfunction disorder (or something close to that I forgot the specific name sorry). I’ve learned so much and thank you for these lectures!

[bethannsmith]

The explanation of working memory and how people with ADHD lack it was so incredibly helpful to me personally. It pretty much describes my life and helped me to understand things that puzzled me about my diagnosis and also how I function in this world.

[chrisjac]

I've been diagnosed since childhood, only been in Ritalin, Concerta (both of which made me very depressed) and Strattera which i didn't notice any difference with. I gave up on the medications after high school because nothing seemed to actually help.

I've worked in manual labor ever since, but now my back has betrayed me and I'm looking into being rediagnosed and medicated again at this point because I've begun to realize the last couple years just how my limitations have set me back in life and am now in need of a new, less physical career, which is terrifying for me because I have a hard time learning new things.

I have an appointment set up with a psychologist next month that we will hopefully be able to afford. I'm hoping that with everything that's been learned about it since i was a kid (i graduated in 06) that now at 35 maybe I'll actually get help that works.

[moritzkolb]

My room is always in perfect shape, minimalistic and in Order. Not because i dont have ADHD im clinicaly diagnosed with it.
It is a coping technique because if my room is not in order i cant do my work until it is in order and then i am no longer distracted.

[thomaspeterson]

This is an epic lecture. Such a well structured, thoroughly substantiated, and professionally delivered critique and commentary on ADHD assessment. This is brilliance on display.

[launacasey]

I'd like to hear his opinion on C-PTSD. I know that it's not technically in the DSM-V but many of the symptoms tend to overlap. Also a person can have both as well as many other personality disorders that come about in order to compensate for the ADHD, for example, Obsessive compulsive personality disorder.

[ikeworkman]

This video was extremely validating as well as informative. I was brought to tears many times upon being so accurately described. Thank you for all your work in the field.

[martineyles]

The hardest thing to decide is what counts as "often"

[firehinoe]

Happy Birthday Dr Barkley! Busy watching all your YouTube videos! Absolutely mind-blowing & so enlightening. Cant thank you enough. Greetings from South Africa!

[sharonaumani]

I am studying this, taking notes....I am going to have lots of questions for you, specifically related to your rating scales for executive functioning and how you determine the separate disorder of SCT [of which I am convinced IS, given much of my own experience, it seems].

[JM-cfyn]

Wonderful lecture! Very comprehensive, informative, and insightful. Thank you as always

[myaltaccount]

22:07: "Cutoff would be either 4 of first 7 or 6 of all 9 symptoms" -- You can't have "6 of all 9" without first meeting "4 of first 7", so the two "optional" ones are moot. Unless I misunderstood something?

[Chiiisecake]

Thank you so much Dr. Barkley for all this condensed and amazing-quality information. I am very much interested in the concept of "lacking attention to the future" and your advocacy for the inclusion of more EFs in the diagnostic criteria.

May I ask for your opinions on "goal-management training" for individuals with ADHD? Also, what could be helpful in assessment or treatment process to identify or counter this inattention related to goal-orientation?

[chrisjac]

I've got my first psychological appointment tomorrow at 35 y/o after quitting all medication after high school.

Nothing ever did what it was supposed to for me growing up. Ritalin, Concerta and Strattera are what i had been given up to that point. The first two only ever made me depressed and Strattera did nothing noticeable. So id given up.


Now I'm out of the Manual labor market due to back issues and need to learn something new to find a new career and I'm looking to try again.


You've helped me in part reach this point, though a lot of self analyzing the last few years was making me think about it before i found your lectures.

Thank you Dr. Barkley. I hope they are able to help me.

[watk]

This is gold! Hands down best ADHD lecture I've heard including all the conferences I've been to. Curious on your thoughts on the utility of the BRIEF vs BDEFS in assessing executive dysfunction in ADHD?

[shadowmystery]

I definitely don't have an overly positive bias about myself, in fact I have that in reverse. I often feel like I am too dumb for anything while ordinary people try to convince me I'm good at doing things xD I can't even tell who's right - me who's experienced a lot of negative things like forgetting things, mental shutdowns, being shamed, ridiculed and being yelled at - or ordinary people who experience that I can recall to a good detail how an RBMK-reactor explodes so they think I am smart and able XD

[jadejago]

Much like their homes or bedrooms.... I'm so called out!