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Rapid Screening for Attention Deficit

Hyperactivity Disorder in Adults
Manuel Matas, MD, FRCPC1, Douglas Staley, MA2

There has been an explosion of interest in attention deficit hyperactivity disorder (ADHD) in recent years. This
condition was formerly known as minimal brain dysfunction (MBD). The Bureau of Drug Surveillance at
Health Canada has reported a 3- to 4-fold increase in the number of methylphenidate (Ritalin) prescriptions in
Canada between 1990 and 1995. Ritalin is the preferred drug treatment for ADHD.
In adults, ADHD is usually called attention deficit disorder (ADD). As the ADHD child matures into adulthood,
the hyperactivity often wanes and dissipates, but the afflicted individual may be left with extreme restlessness
and the other hallmark symptomsa short attention span, impulsivity, and distractibility. There are often many
secondary symptoms as well, such as anxiety, depression, substance use disorders, poor school or work
performance, extreme disorganization, procrastination, difficulties with interpersonal relationships, and low selfesteem.
At one time, it was thought that children would outgrow this condition. It was routine practice for physicians to
stop prescribing Ritalin for ADHD children once they reached puberty. We now know, as the result of several
recently published long-term follow-up studies (14), that a significant percentage of children with ADHD will
continue to have residual symptoms throughout adolescence and adulthood (estimates range from 30% to 70%).
The DSM-IV has subdivided ADHD into the predominantly hyperactive type and the predominantly inattentive
type. Girls and women are more likely to be the predominantly inattentive type; boys and men are more likely to
be the predominantly hyperactiveimpulsive type.
There are a number of adults with this disorder who were never diagnosed as children. This is especially true of
women with the predominantly inattentive type of ADHD. Since they were quiet and daydreamed in class but
were not disruptive, they did not receive early identification of their disorder as often as boys did.
There are now many adults, especially adult women, who are requesting an assessment for ADHD after one or
more of their children has been diagnosed with ADHD because they notice many similar symptoms in
themselves. This is to be expected because ADHD is known to have a familial and genetic basis (57).
Family studies, twin studies, and adoption studies all point to a genetic predisposition to ADHD, most likely
mediated by an aberration of catecholamine metabolism (8,9). First-degree relatives of ADHD children have 4
to 5 times the rate of ADHD compared with first-degree relatives of controls. Furthermore, the fathers of ADHD
children have a higher rate of substance use disorders and antisocial personality disorders, while the mothers of
ADHD children have a higher than expected rate of somatization disorder (Briquets syndrome). The
relationship between ADHD and Briquets syndrome is not fully understood, but there is some evidence for
assortative mating of people with somatization disorder and antisocial or alcoholic spouses, which would
increase both genetic and environmental risk factors for ADHD in the offspring, especially if the alcoholic or
antisocial fathers also have ADHD (1012).

Psychiatrists are therefore faced with the dilemma of making a retrospective diagnosis of a condition for which
the sine qua non is that hyperactiveimpulsive or inattentive symptoms were present before the age of 7. While
a review of report cards can be helpful, they are not always available. Collateral history from spouses or parents
is often very useful.
In order to supplement the DSM-IV diagnostic criteria for ADHD, we have been using 2 brief screening
questionnairesthe Attention Deficit Hyperactivity Disorder-Checklist (ADHD-CL), developed by Barkley and
colleagues (13), and the Wender Utah Rating Scale (WURS), whose authors claim to be able to make a
retrospective childhood diagnosis of ADHD using this scale (14).
The WURS is a 61-item scale that can be given to adults to describe their own childhood behaviour. The authors
identified 25 items on the scale that showed the greatest difference between patients with ADHD and 2
comparison groupsnormal adults and psychiatric adult outpatients with unipolar depression. The patients
with ADHD had significantly higher mean scores on all 25 items than the 2 comparison groups. A cutoff score
of 46 or higher correctly identified 86% of the patients with ADHD, 99% of the normal subjects, and 81% of
the depressed subjects. A cutoff score of 36 or higher correctly identified 96% of the adults with ADHD and
96% of the normal subjects. The higher cutoff of 46 is thus more specific, but there may be some loss of
sensitivity.
The WURS can be filled out by the patient in the doctors waiting room. Some patients may want to take it
home with them, however, and discuss some of the items regarding their childhood behaviour with their parents.
The ADHD-CL is an 18-item questionnaire that can be filled out by the patient in a few minutes. We found that
patients who score more than 30 on the ADHD-CL are likely to meet the Utah Criteria for ADHD (15).
The Utah Criteria for ADHD are the following traits: 1) A childhood history of ADHDfidgety, restless, always
on the go, talking excessively, attention deficit, behaviour problem in school, impulsivity, overexcitability, and
temper outbursts. 2) The adult features of ADHD are: persistent motor hyperactivity, attention deficits, affective
lability, inability to complete tasks, hot temper, explosive short-lived outbursts, impulsivity, and stress tolerance.
We administered the 2 rating scales to 2 groups of patients. The first group consisted of patients diagnosed with
ADHD based on DSM-IV criteria. Where the diagnosis was in doubt, psychological testing was administered
(Conners Continuous Performance Test, WAIS-R, California Verbal Learning Test, and the Wisconsin Card
Sorting Test). While psychological testing can be helpful to identify the neuropsychological abnormalities
typically associated with ADHD, these tests are not definitive. The control group consisted of a random sample
of adult psychiatric outpatients who were referred for a variety of other non-ADHD conditions, including major
depression, bipolar disorder, dissociative disorder, posttraumatic stress disorder, schizophrenia, and social
phobia.
The results are presented in Table 1. There were no significant differences between the 2 groups in terms of
gender or age, but the ADHD group scored significantly higher on both the ADHD-CL and WURS scales
compared with the control group.

Table 1. Comparison of ADHD and Control Groups: gender:N (percentage)

other variables: mean score SD (range)

Variable

ADHD (n = 23)

Control (n = 23)

Significance

Gender

M = 14 (60.9%)
F = 9 (39.1%)

M = 18 (78.3%)
F = 5 (21.7%)

c2 = 1.64
NS

34.26 764)

38.70 10.56 (2162)

t (44) = 1.31; NS

Age

ADHD-Checklist

40.1 151)

18.6 8.9 (137)

t (44) = 8.99
P< 0.0001

Wender Utah Rating Scale

65.6 093)

36.1 14.5(462)

t (44) = 5.82
P< 0.0001

Both results are highly significant statistically. We conclude, therefore, that both the ADHD-CL and the WURS
are useful screening questionnaires to distinguish ADHD adults from a non-ADHD population of psychiatric
outpatients. It is important to remember, however, that these are only screening instruments, and it is still
essential to take a thorough clinical history, including a family history, for every patient.

References
1. Weiss G, Hechtman LT. Hyperactive children grown up. 2nd ed. New York: Guilford Press; 1993.
2. Denckla MB. Attention deficit hyperactivity disorder residual type. J Child Neurol 1991;6(6 Suppl):44S50S.
3. Klein RG, Mannuzza S. Long term outcome of hyperactive children: a review. J Am Acad Child Adolesc Psychiatry 1991;30:3837.
4. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and
psychiatric status. Arch Gen Psychiatry 1993;50:56576.
5. Faraone SV, Biederman J, Lehman BK, Keenan K, Norman D, Seidman LJ, and others. Evidence for the independent familial transmission of
attention deficit hyperactivity disorder and learning disabilities: results from a family genetic study. Am J Psychiatry 1993;150:8915.
6. Cantwell DP. Genetic studies of hyperactive children. In: Fievel RR, Rosenthal D, Brill H, editors. Genetic research in psychiatry. Baltimore (MD):
Johns Hopkins University Press; 1975.
7. Welner Z, Welner A, Stewart M, Palkes H, Wish E. A controlled study of siblings of hyperactive children. J Nerv Ment Dis 1977;165:110.
8. Shaywitz BA, Cohen DJ, Bowers Jr MD. CSF monoamine metabolism in children with minimal brain dysfunction: evidence of alteration of brain
dopamine. J Pediatr 1977;90:67.
9. Shetty T, Chase TN. Central monoamines and hyperactivity of childhood. Neurology 1976;26:1000.
10. Cantwell DP. Psychiatric illness in the families of hyperactive children. Arch Gen Psychiatry 1972;27:4147.
11. Livingston R. Children of people with somatization disorder. J Am Acad Child Adolesc Psychiatry 1993;32: 53644.
12. Merikangas KR. Assortative mating for psychiatric disorders and psychological traits. Arch Gen Psychiatry 1982;39:14015.
13. Barkley RA. Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment. New York: Guilford Press; 1990.
14. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood ADHD. Am J Psychiatry
1993;150:88590.
15. Wender P, Reimherr F, Wood DR. Attention deficit disorder (minimal brain dysfunction) in adults. Arch Gen Psychiatry 1981;38:44956.