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13 Sep 2019

Schneider BC et al. J Atten Disord 2019; Epub ahead of print

Despite several national guidelines and increasing clinician awareness, adult ADHD remains under-diagnosed in many countries. This study aimed to identify diagnostic methods used by clinicians in Germany to diagnose adult ADHD, collect data regarding clinician training in ADHD assessment, and understand clinicians’ concept of core symptoms of ADHD in adulthood.

Clinicians who regularly performed assessments of adult ADHD completed an online survey between February 2015 and 2016, and were asked a series of questions regarding their experiences* and opinions on the challenges associated with these assessments.

In total, 178 participants completed the survey: 144 (80.9%) were psychologists, 32 (18.0%) were physicians and 2 (1.1%) were occupational therapists. In terms of further qualifications, 58.1% (n = 100) were psychotherapists, 24.3% (n = 42) were neuropsychologists, 13.9% (n = 24) were neurologists and 3.4% (n = 6) were doctors of psychosomatic medicine. Mean (standard deviation [SD]) ADHD assessments per month were higher for physicians (6.28 [7.39]) compared with neuropsychologists (2.92 [3.85]) or psychotherapists (1.33 [1.89]). Most participants (28.4%) had received ‘a few hours’ of ADHD-specific training and 6.0% reported ‘extensive training’.

Clinicians’ opinions of clinical characteristics central to adult ADHD

  • There was relative consensus regarding impairments in concentration (62.9%), problem solving and planning (29.7%) and organisation (33.1%) as a core feature of adult ADHD.
  • 21.3% felt that psychomotor activity had ‘little relevance’ but 26.2% endorsed it as a core feature.
  • 53.0% felt that impairments in social behaviour/aggression had ‘little relevance’, whereas 35.8% indicated this was ‘relevant’.
  • There was significant discrepancy between physicians and psychologists regarding the relevance of impairments in social behaviour/aggression (56.0% vs 29.9%, p = 0.04), distractibility from external stimuli (31.3% vs 55.0%, p = 0.03) and impaired divided attention (40.0% vs 55.6%, p = 0.01) as characteristics of adult ADHD.
  • Almost all participants (90.1%) endorsed the presence of ADHD symptoms prior to 12 years as a feature of ADHD in adults.
  • Work-related impairments were rated as ‘important/essential’ for 87.8% of clinicians when making an adult ADHD diagnosis.
  • Meeting the cut-off on a self-report measure of current and childhood ADHD symptoms was viewed as ‘essential/important’ for making a diagnosis of ADHD by 69.2% and 64.2% of clinicians, respectively; collateral report scales were seen as slightly less important for current (56.0%) and childhood (56.7%) symptoms.
  • Social problems (68.8%), undergoing a successful trial of stimulants (54.9%), the presence of psychiatric comorbidities (47.1%) and neuroimaging findings (15.3%) were also endorsed as being ‘important/essential’ sources of information.

Clinical practices in the assessment of ADHD in adults

  • Most clinicians indicated they ‘always/often’ used self-report scales to assess current (76.5%) and past (69.4%) symptoms of ADHD.
  • A clinical interview was ‘always/often’ used by 80.0% of clinicians; of these, 82.2% used an unstructured interview and 31.1% used a structured or semi-structured interview.
  • 54.1% indicated they ‘always/often’ consult their diagnosis with a psychiatrist, psychologist or other occupational group.

Treatment preferences

  • Cognitive behavioural therapy was recommended by most (91.9%) clinicians and 75.9% endorsed treatment with a stimulant; 81.5% recommended occupational therapy.
  • Psychologists were significantly less likely to recommend pharmacotherapy compared with physicians (67.0% vs 96.7%, p = 0.001).

Greatest challenges to diagnosing ADHD among adults

  • Psychiatric comorbidity was identified as a major challenge by 59.5% of clinicians, followed by the lack of consensus on ‘gold standard’ measure(s) (33.1%) and lack of clinicians’ knowledge and experience (31.8%).

Diagnostic certainty

  • Only 40.4% of clinicians felt ‘certain/very certain’ of their ability to diagnose adult ADHD; 20.6% felt ‘uncertain’ and 39.0% were ‘moderately certain’.
  • There was greater certainty among those who had more ADHD experience (p < 0.001), more training (p < 0.001), who were physicians (p = 0.004), who were older (p = 0.004) or who had a greater number of years of professional experience (p = 0.004).

This study had several limitations. Firstly, this survey largely comprised psychologists so may not be generalisable to physicians. Secondly, 51.5% of the participants reported having ‘little to no’ ADHD-specific training and 25.4% had not read the guidelines for the treatment and assessment of ADHD. According to the guidelines, these individuals should pursue more training prior to conducting ADHD assessments or refer patients to a specialist; therefore, it is likely these findings do not reflect clinical practice in specialised clinics. Third, this study did not examine the reasons why some guideline recommendations were not implemented by clinicians.

The authors concluded that this study suggests that guidelines may not be sufficient to ensure the accurate assessment of adult ADHD, and that further training may be required to improve clinicians’ understanding of ADHD and to align diagnostic practice with guideline recommendations.

Read more about clinical practice and opinions of adult ADHD in Germany here

 

*Questions related to: symptoms they considered to be of central relevance to adult ADHD; what sources of information they gather during their assessment; the type of interview conducted; what information is used to verify an ADHD diagnosis; how often they consult with other professionals when making a diagnosis; their perceptions of the relative importance of certain data for the verification of an ADHD diagnosis; how certain they feel in their ability to diagnose ADHD; and the amount of ADHD-specific training they had

Schneider BC, Schöttle D, Hottenrott B, et al. Assessment of adult ADHD in clinical practice: four letters – 40 opinions. J Atten Disord 2019; Epub ahead of print.

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