DIVA 2.

Sandra Kooij MD PhD

Psychiatrist
Program Adult ADHD
PsyQ, psycho-medical programs
The Hague, The Netherlands www.divacenter.eu
 Conflict of interest JJS Kooij
Pharmaceutical industry: Non - profit:

• Speaker for Janssen, Chair DIVA Foundation

Shire, Eli Lilly, HB Chair European Network
Pharma Adult ADHD
• Unrestricted research Member Dutch ADHD
grants Shire, Janssen Network
• Unrestricted educational
grants Shire, Janssen, Royalties
Eli Lilly, Eurocept
Springer, book Adult ADHD
 Topics

• Development of DIVA 2.0

• Translations and DIVA 2.0 App
• DIVA Foundation & Board members
• Validation
• DIVA Training
 Clinical picture of ADHD
Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder:

• Inattention: distracted, chaotic, forgetful, late, difficulty

making decisions, organising and planning, no sense of
time, procrastination
• Hyperactive: (inner) restlessness, tense, talkative, busy;
coping by: excessive sporting/alcohol abuse/avoiding
meetings
• Impulsive: acting before thinking, impatient, difficulty
awaiting turn, jobhopping, binge eating, sensation seeking

In addition in 90% of adults, lifetime:

• Moodswings (5x/day) and Anger outbursts

APA 1994; Kooij 2001; Conners 1996

 Decrease of hyperactivity

Hyperactivity is adjusted, compensated for, or experienced as more

‘inner restlessness’:

• Avoiding meetings where you have to sit stil

• Excessive sporting
• Hectic job full of change
• Cannabis / alcohol / tranquillisers against restlessness
• Talkativeness, inner restlessness

The decrease in marked outward visible hyperactivity has presumably

been the reason why we mistakenly have thought that ADHD was
outgrown
 Inattention most invalidating
symptom in adults
Adults need more attention than children:

• Procrastination
• Chaos
• Difficulty organising
• Being late
• Difficulty reading and remembering
• Forgetting things or appointments
• Using no watch or agenda!
 ADHD in DSM-IV
• Attention-deficit/hyperactivity disorder
• 18 criteria: 9 attention problems (A) and 9
hyperactive/impulsive criteria (HI)
• Diagnosis in childhood from 6/9 of one or both
domains
3 subtypes:
• ADHD, inattentive type (also ADD) (10-15%)
• ADHD, hyperactive/impulsive type (3%)
• ADHD, combined type (85%)
 Impairment in adult ADHD
In clinical as well as epidemiological samples compared to NCs:

• Learning problems (60%)

• Less graduated
• Lower education
• Lower income
• Less employed, more sickness leave
• More job changes (longest job 5 yrs)
• More often arrested, divorced and more social problems
• More driving accidents, teenage pregnancies, suicide
attempts
• Higher (mental) health care costs

Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, in prep 2008
 ADHD is a clinical diagnosis
• Interview patient and partner: lifetime symptoms
and impairment of ADHD and comorbid
disorders
• Schoolreports if available
• If possible, parents/sibs about childhood onset
• Patient is best informant, though tends to
underreport severity
• No neuropsychological diagnostic test (battery)
• No validated instruments in Europe

Kooij 2003, 2008; Ferdinand 2004

 Dilemmas using childhood
DSM-IV criteria in adults
• Formulation not applicable to adults
• Self report in stead of informant report (parent)
• Cutoff may be lower in adults
• Age of onset criterium (< age 7) never validated in
children and unreliable in adults
• Current criteria lead to under-identification of adults
• Age referenced criteria have to be developed and
validated
• DSM-V will use broader age of onset (before age 12 or
16) and probably different criteria for different age
groups
Barkley 2002; Kooij 2005; Faraone 2000, 2004, 2006;
www.dsm5.org
Outline Diagnostic Assessment
• Early onset in life
• Chronic persistent course
• Chronic impairment or compensation/coping
causing secondary impairment

Mainstay of ADHD diagnosis is:

CHRONICITY

The period that ADHD symptoms are

remembered will be longest in older adults
Comorbidity in adults with ADHD

ADHD comes seldom alone:

• 75% at least one other disorder

• 33% two or more

Mean: 3 comorbid disorders

Biederman 1993; Kooij 2001, 2004

 Comorbidity in ADHD?
• Depression (60% SAD) 20-55%
• Bipolar Disorder (88% BP II) 10%
• Anxiety Disorders 20-30%
• SUD 25-45%
• Smoking 40%
• Cluster B Pers. Disorders 6-25%
• Sleeping Problems (DSPS) 75%
• Muscle, joint, neck- and backpain ??

Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij

2001, 2004; van Veen 2010; Amons 2006
The other way round: ADHD is comorbid
in 20% of psychiatric patients

• SUD: 20% (Trimbos Institute)

• Anxiety disorders: 20% (PsyQ)
• Bipolar II: 20% (PsyQ)
• Borderline PD: 35% (Radboud University)

And in accordance to epidemiological data USA: 20%

vd Glind 2005; Rops 2010 in prep; Roodbergen 2010 in prep;

Fones 2004; van Dijk 2010 in prep; Kessler APA 2007; Fayyad
2007
 Semi-structured Diagnostic Interviews
for Adult ADHD
• Only 2 Semi-structured Diagnostic Interviews based on
DSM-IV: CAADID and DIVA 2.0
• CAADID: expensive in use and the editor requires validation
studies by the translator of other languages
• We wanted to lower the thresholds for proper diagnostic
assessment of ADHD in adults
• DIVA 2.0 is online available free of charge, now in Dutch,
Danish, English, Finnish, French, German, Norwegian,
Spanish and Swedish
• Another 14 translations are underway …
• New: DIVA 2.0 App available in App store and Google Play
store (price 7.99 euro for extended use)
www.divacenter.eu
Ultrashort screening of adult ADHD

1. Are you usually restless?

2. Are you usually easily distracted or chaotic?
3. Do you usually do things before thinking?

If 1 of 3 answers = yes:

4. Did you have this symptom all your life?

If yes, further diagnostic assessment

of ADHD

Kooij 2006
 Development of DIVA 2.0
• The DIVA was first developed in Dutch by J.J.S.
Kooij and M.H. Francken in 2007
• October 2010: slightly adjusted version with an
improved introduction of the DIVA available
(DIVA 2.0) in Dutch and English
• The DIVA was developed because there is a
need for a structured diagnostic instrument in
the field that is easily available for free, in many
different languages, for research and clinical
assessment purposes.
What does DIVA 2.0 look for?
• The DIVA investigates the DSM-IV criteria of ADHD in
childhood and adulthood, as well as impairment in five
areas of functioning in both life periods.
• In order to facilitate understanding of the criteria in daily
life in both childhood and adulthood, every DSM-IV
criterion is accompanied by several examples that can
be probed.
• The same is true for the five areas of impairment:
education, work, social relationships, social
activities/leisure time, partner/family relationships and
self-esteem.
Translation of DIVA 2.0
in 23 languages supported
by the European Network
Adult ADHD

Now available in 9
languages:
Danish, Dutch, English,
Finnish, French, German,
Norwegian, Spanish, and
Swedish

Almost ready:
• Portugese
• Hebrew
• Turkish

www.divacenter.eu
 DIVA 2.0 App

The DIVA 2.0 App is now available in 8 languages in both App store
as at Google Play, for Iphone, Android and Ipad!

The DIVA 2.0 App adds the total number of DSM-IV criteria for ADHD
in both child- and adulthood, and the number or areas of impairment.
Data are not stored, but sent via email, both as text and as SPSS file.
Costs: 7.99 euro for extended use.
Adult ADHD
Diagnostic Assessment and Treatment
Formal reference of DIVA 2.0

JJS Kooij, 3rd edition

December 2012

www.springer.com
Search for ‘Adult ADHD’
 DIVA Foundation
• The DIVA foundation is the responsible legal
body taking charge of the quality, coordination
and distribution of the translations of DIVA 2.0
• The DIVA Foundation is a non-profit
organization that is independent from
pharmaceutical industry. Every representative of
a language pays an entrance fee for the set up
of the DIVA Foundation and website
• Commercial companies and industry pay
royalties for use of DIVA 2.0
DIVA Board 2011
 Process of translations
• In 2009, clinicians and researchers asked for translations
of DIVA 2.0. All were made from the original Dutch
version in order to prevent bias.
• We are grateful for the support by Janssen for the first
translations from Dutch into English, German, Swedish,
and Spanish. Translations into other languages were
supported by mental health organisations or individual
professionals.
• For proper wording and formulations used in clinical
psychiatric practice, experienced clinicians are asked to
check and improve the first translations of the DIVA.
• After verification of the back translations into Dutch, the
final translations are authorised by the authors of the
DIVA.
 Future of DIVA 2.0
• DSM5 is expected May 2013
• ADHD criteria for adults will change
• Age of onset will change to < 12 years
• Number of symptoms needed in adulthood
will be 4 or more (?)
• Examples of the criteria that apply to all
age groups will be given
• There will be a need for DIVA 3.0 …

www.dsm5.org
 Validation studies

• Validation studies of DIVA 2.0 are

necessary and are performed in Spain
first, because they have a formal validated
and translated CAADID in Spanish to
compare with DIVA 2.0
 DIVA 2.0
• DIVA 2.0 has been developed to facilitate
appropriate and careful diagnostic
assessment of ADHD in adults
• This semi-structured diagnostic instrument
still needs interpretation by a (trained)
clinician
• DIVA 2.0 should therefore not be used by
patients for self report
 Set-up of DIVA 2.0
DSM-IV Criterion A
Part 1) The 9 criteria for Attention Deficit (A1)
Part 2) The 9 criteria for Hyperactivity-Impulsivity (A2)

DSM-IV Criteria B, C and D

Part 3) The Age of Onset and Impairment accounted
for by the ADHD symptoms

Summary form
Score form
 Order of questioning
Part 1 and 2
• Always first read the full DSM-IV criterion aloud,
ask if it is recognised in adulthood, and if yes to
give (an) example(s)
• The frequency of behaviour has to be often
• The duration of current symptoms needs to be at
least 6 months
• ‘Often’ is not operationalised, but refers to a
symptom being more severe and/or frequent
compared to an age and IQ matched group, or
to be closely linked to impairment
• Tick the examples mentioned
 Order of questioning II
• If no examples are given, read the examples that belong
to the criterion and tick those that apply

• Start always with the adult symptom (> 6 months),

continue with the childhood presentation of the same
symptom (between 5-12 yrs)

• It is not necessary to have many examples per criterion,

also one convincing example may be enough for the
investigator to be able to decide about the absence or
presence of the criterion
 Order of questionning III
• If spouse and/or parent/sibs are present, ask them after
the patient about the same symptom in resp. adulthood
and childhood
• In case of disagreement, the patient usually is the best
informant in clinical settings
• The more outward visible hyperactive behaviour is i.e.
better remembered than inattention by family members
• Collateral information serves as additional information
about severity, chronicity and impairment
• The investigator weighs all information and decides per
criterion whether it applies

Kooij ea, 2008

 No collateral information
• The patient can be the sole informant to make the
diagnosis
• Collateral information serves only to get a more
complete picture, but may as well induce doubt in case
of disagreement
• Disagreement about the symptoms is common in ADHD
families…
• School reports may be helpful if the behaviour is
described, but cannot be used to reject the diagnosis if
no remark was made
• Former reports of diagnostic assessments may be useful
regarding descriptions of the same symptoms earlier in
time
 Part 3: Criterion B
Criterion B: Age of onset

• Have you always had these symptoms of attention deficit

and/or hyperactivity/impulsivity?

• ❑ Yes (a number of symptoms were present prior to the

7th year of age)
• ❑ No

• If no is answered above, starting as from …. year of

age.
 Part 3: Criterion C and D
Criterion C: Clinical significant impairment of which
many examples are given in 5 specified areas in
adulthood as well as childhood:

• Work/ education
• Relationship/ family
• Social contacts
• Free time/ hobby
• Self-confidence/ self-image

Conclude if there is clinical significant impairment in 2 or more areas

 Summary form

• Count the total number of criteria met for

inattention (A) and hyperactivity/impulsivity
(HI), in both adulthood and childhood
 Score form
Answer the questions on the Score form on:

1. Sufficient number of symptoms in adulthood (≥4) and

childhood (≥6)*
2. A lifetime pattern of symptoms and limitations (rather
than a strict age of onset!)
3. Symptoms and impairment manifest in 2 or more areas
4. No better explanation of the symptoms by other
psychiatric disorders
5. Level of support for the diagnosis by collateral
information
6. Diagnosis and subtype***
 Trying to find the adult cutoff *

Composite measure of impairment by number of

symptoms with GHQ-28 as covariate
0.30 0.30
(5,4,3,2,1,0)
(3,2,1,0)
0.25 0.25

(2,1,0)
(3,2,1,0)
(2,1,0) 0.20
0.20 (3,2,1,0)

0.16
0.16

0.11
0.11

0.06
0.06 >=6 5 4 3 2 1 0
>=6 5 4 3 2 1 0
number of hyperactive/impulsive symptoms
number of inattentive symptoms

Kooij 2005
 Cutoff current
DSM-IV criteria in adults?
Epidemiological study (n=1800): adults were significantly
more impaired starting from 4/9 current ADHD criteria:

• of inattention as well as hyperactivity/impulsivity

• in both genders, and in young and old people
• effect remained significant after controlling for impairment due
to comorbidity (GHQ)
• ADHD proved to have its own contribution to impairment,
independent of comorbidity

C/ 6/9 symptoms in childhood and 4 or more current DSM-IV

symptoms may lead to diagnosis of ADHD in adulthood

Kooij 2005; Barkley 1997; www.dsm5.org

 Different subtypes in
child- and adulthood***

Score Form:

*** If the established sub-types differ in

childhood and adulthood, the current adult
sub-type prevails for the diagnosis
Training DIVA 2.0
yourself
• You are now a certified
DIVA 2.0 trainer!
• To train those who want
to use DIVA 2.0 in your language
• These slides can be used for trainings and
can be send to you all (please write your
email address)