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7 Apr 2017

Ustun B et al. JAMA Psychiatry 2017; 74: 520-526

Adult ADHD is usually undiagnosed and untreated, despite availability of effective evidence-based treatments. Current adult ADHD screening scales are typically calibrated to the Diagnostic and Statistical Manual of Mental Disorders – 4th edition (DSM-IV), but in fact the 5th edition (DSM-5TM) provides a wider scope for screening criteria. This study aimed to update the World Health Organization Adult ADHD Self-Report Scale (ASRS) to more closely align with the expanded criteria of DSM-5TM.

The ASRS scale was developed with support from Shire Pharmaceuticals

The study was based on two general population samples and one clinical sample.

  • Household sample of participants in the National Comorbidity Sample Replication (NCS-R) who completed face-to-face surveys (2001–2003): 119 respondents aged 18–44 years were divided into four sampling strata* based on the retrospective assessment of childhood ADHD and included in the present study
  • Managed care sample of subscribers to a large managed healthcare plan who completed telephone surveys (2004–2005) and were re-interviewed 6 months later: 218 respondents were included in the present study
  • NYU Langone sample of patients who were either obtaining a free evaluation through an adult ADHD programme (2011–2012) or were controls from a primary care waiting room near the NYU Langone campus (2015–2016): 300 patients were included in the present study.

All participants completed the ASRS (developed based on DSM-IV criteria) and a blinded, semi-structured diagnostic interview for DSM-5TM using version 1.2 of the Adult ADHD Clinical Diagnostic Scale (ACDS).

The interview consisted of an initial retrospective assessment of childhood ADHD, followed by an assessment of symptoms over the past 6 months. Diagnosis of adult ADHD required 6–9 childhood and 5–9 adult DSM-5TM A1 or A2 symptoms (Criterion A), ≥1 symptom before 12 years of age (Criterion B), ADHD-related impairment in ≥2 domains of functioning in the past 6 months (Criterion C) and clinically significant ADHD-related impairment in the past 6 months (Criterion D). Criterion E (symptoms do not occur exclusively during the course of a pervasive developmental disorder or psychotic disorder and are not better accounted for by another mental disorder) was measured indirectly using probing interview questions. A DSM-5TM ASRS screening scale with an additive scale (each response option being a number from 0–5) was created using a machine-learning algorithm, RiskSLIM.

For unweighted samples, the prevalence of DSM-5TM/ACDS adult ADHD was 37.0% in the household sample (n=44), 23.4% in the managed care sample (n=51) and 57.7% in the NYU Langone sample (n=173). For the weighted samples (to adjust for oversampling), prevalence was 6.5% in the household sample and 9.2% in the managed care sample. Of the respondents meeting the diagnostic criteria, 45.9% (n=123) were male with a mean (standard deviation) age of 33.1 (11.4) years.

A screening scale based only on responses to the six questions in DSM-IV/ACDS screening scale was built using RiskSLIM, and the operating characteristics were used to predict DSM-5TM adult ADHD by optimising response scores. In doing so, it was demonstrated that the DSM-IV detected most DSM-5TM cases (sensitivity: NYU Langone, 79.8%; general population samples, 84.2%). A low false-positive rate, but an increasingly biased prevalence rate, was observed.

Several limitations exist within this study. General population samples were both small in participant numbers and number of sample cohorts, and they were also limited to patients aged 18–44 years (NCS-R) or members of a managed healthcare plan. Furthermore, the diagnostic interviews did not provide a means for detection of exclusionary comorbidities, nor inclusion of informant reports, which may improve detection of those lacking insight into their condition. Finally, the application of the ACDS scale has not been validated.

The authors conclude that, not only does the new adult ADHD screening scale for DSM-5TM offer the potential for discrimination between patients presenting for speciality treatment, but that it is a short process that is easily scored.

Read more about the new adult ADHD self-report screening scale here

*Four sampling groups consisted of those refusing childhood ADHD symptoms, those with childhood ADHD symptoms not meeting full eligibility criteria, those with childhood ADHD symptoms but refusal of current symptoms and those with both childhood and adult ADHD symptoms
The ASRS screening scale item pool, developed by psychiatrists in collaboration with the World Health Organization, consists of one fully structured question for each DSM-IV criterion (A1–A2) symptom of inattention and hyperactivity/impulsivity, in addition to 11 non–DSM-IV symptoms thought to be associated with adult ADHD (and similar to the Utah Criteria for adult ADHD)
Questions in the optimal RiskSLIM DSM-5TM ASRS screening scale included: ‘How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?’ (DSM-5TM A1c); ‘How often do you leave your seat in meetings or other situations in which you are expected to remain seated?’ (DSM-5TM A2b); ‘How often do you have difficulty unwinding and relaxing when you have time to yourself?’ (DSM-5TM A2d); ‘When you’re in conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?’ (DSM-5TM A2g); ‘How often do you put things off until the last minute?’ (non–DSM-5TM); and ‘How often do you depend on others to keep your life in order and attend to details?’ (non–DSM-5TM)

Ustun B, Adler LA, Rudin C, et al. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry 2017; 74: 520-526.

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