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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[@tarakann7181]

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

[@russellbarkleyphd2023]

Thanks for commenting. It was very kind of you. I appreciate your watching these lectures. Be well.

[@yarntoast]

I’m 48 and this is my experience as well. Initially I thought it was struggling with parenthood causing so many mood and brain fog issues. I had my first child at 39 and my second at 44. My ADHD diagnosis was at 46 and treatment started when I stopped nursing my second child at 47. Although stimulant medication helped with ADHD symptoms it was being prescribed a transdermal estradiol patch last winter that has helped me with mood and brain fog. Bonus, it helps a ton with joint pain and nighttime wakefulness too!

[@user-bd4bo4tb8u]

I've been having the same problem, but my doctor will not increase my dose. I'm at 60 mg of Adderall, the max, and have been taking that dose for over ten years. I think I've built some tolerance to it, but with the added hormonal changes, I struggle to do the basics and feel awful. I'm not sure what to do. I'm afraid if I ask her again, I'll be labeled a drug seeker.

[@leeannsnyder804]

@@user-bd4bo4tb8umaybe it’s time to find a new doctor that listens to you vs dismisses what you are telling them

[@Myperfectshell]

@@user-bd4bo4tb8uhave you ever tried a ketogenic diet? I know it’s kind of trendy/buzzwordy and myself, I feel sheepish even recommending it because I’ve not been able to stick with it. But it’s almost as good as medication for both ADHD symptoms and hormonal imbalance. Just my own experience. I am going to try to get back on it. I never feel quite as good as when I’m on this particular diet, I only go back to a regular diet because I have a very active social and family life and I get drawn to comfort foods at social gatherings and then I’ve just gotten out of it. I look forward to going back, though.

[@biffjerky8094]

ADHD diagnosed med student here-great lecture. Love the professional shade against the DSM’s diagnostic criteria 😂

[@irunamuk]

Can I ask you exactly how much education an MD gets on adhd in school?

[@jonathanberry9502]

🎯 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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[@moritzkolb1425]

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.

[@jbonkerz]

Interesting, my brain finds it distracting when everything is too organized. I start thinking about how I can use the space. *I too am clinically diagnosed with ADHD*

[@launacasey6513]

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.

[@thomaspeterson5745]

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.

[@martineyles]

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

[@irunamuk]

I heard someone say if it’s “often” enough to have an adverse effect on your life

[@Freakattaker]

@@irunamuk What qualifies as adverse

[@StevenWernerCS]

@@Freakattaker if you try to hide aspects of yourself to fit in and are in fear of being seen as broken/dumb/slow then it that would be sufficiently adverse.

[@chrisj320ac3]

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.

[@charmdud9]

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

[@russellbarkleyphd2023]

Thanks so much. Very kind of you. Happy New Year to you and yours. Russ

[@ikeworkman4449]

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.

[@sharonaumani8827]

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-cf5yn]

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

[@jadejago7664]

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

[@shadowmystery5613]

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

[@myaltaccount7651]

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?

[@shocolatf9275]

Thank you very much for your presentation ❤❤

[@chrisj320ac3]

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.

[@Plasmafox]

I think a lot of us are in this position because children's first contact with psychiatry often comes from the perspective of parents and teachers- "how do we make this kid quiet/compliant" rather than looking out for the child's future. Diagnoses come and go quickly and so do the pills; reported side effects or ineffectiveness are immediately dismissed as anosognosia. It destroys the person's trust in the system, so when it becomes their responsibility they put it off for years or decades because they expect more of the same.

[@chrisj320ac3]

@Plasmafox Facts. I'm now on vyvanse 30 MG. But besides the first day all its really done is take away my appetite and give me slightly more focus. Probably gonna need to go through a few different dose amounts to get it where I need it.

[@annetteka]

“leaves seat in classroom inappropriately” as part of the diagnostic criteria applied to all, also Adults… talk about non-correlation!

[@HaroldSchranz]

I would like to hear his opinion, that given it is possible to acquire ADHD by brain injury, is it also possible to affect the severity and type of pre-existing ADHD symptoms by some form of brain injury, such as a prolonged episode of hypercalcemia (parathyroid carcinoma)? Or considering a premature infant exposed to EBV infection (e.g. unscreened post-natal blood transfusion) would that be a likely causal link for ADHD development (given the same infant had Hodgkin lymphoma at the age of 2)? Wondering then if all ADHD is acquired in a sense, in infancy, given existing genetics but requiring some environmental effect to modulate the epigenetic expression? Or is EBV involved in a more direct pathway; part of the EBV virus structure resembles myelin-like structures in the CNS - which includes the brain. The immune system in attacking EBV infection could also attack parts of the brain ... leading to brain injury and ADHD-like symptoms?

[@rynezuzinec688]

Hi Dr. Barkley is there somewhere I can get a copy of this slideshow along with resources?

[@Lechuza_Chicana]

THANK YOU FOR THIS 🙏 But how do you ask your doctor about this ? I feel uncomfortable bringing it up . . . You asked to be screened ?

[@watk4373]

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?

[@hanskraut2018]

He has way better ones. The best by far is "adhd for parents" 2h50min video on youtube. Its gold. Should be done againa nd expanded. Maybe Russel just had one of those days of utter brilliance. Just seems to not really understand STILL eventho he understands more than anyone else the change of motivation/how things are exprieneces/discomfort/prisoners dillemas/complexity of humans adjusting facts for personal benefit/like noone can understand it if they dont had it or where forced to be next to a adhd person until they perished, and even then it does not mean its the most severe adhd. Like some people just have really hard mood swings or different perpensitiys to stay alive and some do it quite quickly. Might not ONLY be due to how much discomfort one feels who knows. Definitly would say its quite severe then tho. But to expereince how you are hated by everyone and ur emotions are gona or changed and ur just a alien and somethimes ur not and people just like you like a instinct. There is no rationality in that part but it is always thrown out as the bady with the bathwater since it can be *super easily dismissed* by saying "well you just had selfawareness problems. Then again people can be waaaaaaaay less selfaware without adhd and even many people can say you are the most selfaware person ever, but of course if your brain and working memory act like they have alzheimer/dementia/depression with cognitive slow or complete shutdown *variably* and somethimes longer and not then it can happen sure. But that part is super overlooked even by Mr Barkley AND even with him having a twin brother with adhd so i see little hope that that will be solved expect when someone exeptionally invested in adhd who preferably had it and is extrordinary attentive or noticing to such small things /sensitive can treat themselfes successfully with lots of help and then go for it. I would do it but without my brian working absolutely amazing as i expereinced before i see little chance. Its not even that i need it to be good just give me the selfmotivation/drive to do all the pursuits (dopamine) of the things needed to get there. Intelligence is overrated, look at the iqs or what billionaries and millionaires say and do are those the most intelligent or just the most driven and people that just "happen" to be motivated for the right things others get tortured by discomfort by? I would say the latter for sure.

[@bif53]

I can relate to that

[@Tamperkele]

The similarities in emotional dysregulation in both ADHD and BPD are something that really easily get confused. ADHD gets misdiagnosed as BPD. Then again, I can't even count how many patients I've had come in with supposed bipolar disorder and it turns out to be just regular ol' ADHD.

[@isabelapena4230]

​@@homelessrobot💅qaa

[@isabelapena4230]

W2qwww

[@rayoflightcanada]

thank you so much Dr. Russell , such an amazing lectures , I will start on Bupropion, if it does not work then she recommended to my family doctor a trial of Vyvanse, although im not typically depressed , but will try her first recommendation anyways

[@GrannyGooseOnYouTube]

Hi! I'm curious how bupropion worked for you. I've been on it for about 6 months now, and while it seemed to really be effective at first, it became less impressive as the months have gone by. Right now I pretty much feel like I'm back to baseline, with maybe a few improvements. They won't give me stimulants because I have a heart condition and a very low body weight, so bupropion was something for us to at least try.

[@rayoflightcanada]

@@GrannyGooseOnKZbin it did not work for me, it made me manic @ 150 mg, I switched to Vyvanse, its the D-Amphetamine Salts which does not impact the peripheral only works on the brain , I found it surprisingly much smoother, I also have hypertension so it did work, try it out

[@ToOffend.IsToCare]

Question from a 31 year old man, who was diagnosed with ADHD at the age of 28: To what degree is overthinking challenges (tasks at work to personal development in the area of health and habits) considered part of adult ADHD or EFDD?

[@iheart959]

Hi Dr. Barkley, my brother is trying to get a diagnosis (I was recently diagnosed with ADHD at age 25) however he does not remember much of his childhood, I only remember certain things, and our parents have a difficult time to accept ADHD. This is causing some issues in his assessment for ADHD, they told him they are not sure if he has ADHD or not because of this. Do you have any tips or advice? We went to Beyond ADHD as we are both in Canada and cannot afford a psychiatrist at the moment.

[@russellbarkleyphd2023]

While I can’t give personal advice I can recommend you contact Umesh Jain, MD in Toronto, an expert on adult ADHD and also the caddra.ca website for any advice they can give. Best wishes.

[@iheart959]

@@russellbarkleyphd2023 thank you so much for your help!

[@apotheticallyautistic73]

Could you please share some executive functioning solutions and life management and parenting for people with adhd. - single mother with adhd and asd struggling with 2 young children also adhd and asd. 😣 please and thank you. Have followed your videos on youtube for year and am so stoked you are taking control of your online identity. You have many fans in australia.

[@Plasmafox]

Here he is in another video talking about this topic: kzbin.info/www/bejne/mX-2g616mcangtU He basically says that cognitive training software like Brain Age can improve function as long as you stick with it, but the improvement fades if you stop. That lecture is ~10 years old and the ongoing research he mentions should be complete and published if you're looking for more information.

[@dahallagris]

I have a question: We know that ADHD has been around for centuries, but it would seem that many children born in the 1970"s and 80's s seem to suffer more from ADHD than other decades. Has there ever been a study to show a correlation between Children born with ADHD and the illicit drug use during those decades?

[@russellbarkleyphd2023]

Not that I have seen but there are a few studies showing no increase in ADHD over the last two generations one of which would include those kids who may have been drug exposed. Drug exposure, especially to alcohol, does increase risk of ADHD in offspring as shown in some studies. But parents with ADHD also drink and smoke more and use drugs more than others so the risk here is from parent genetic ADHD to child risk for ADHD and the drug use is just a marker for the disorder in parents. That is what happened when studies examined tobacco use. it was initially correlated with risk for disorder but them became nonsignificant when parental ADHD was controlled in the analyses. But we have very little research on true prevalence before the 1960s and so we really cannot say if it went up in the subsequent decades. be well

[@cjsun7871]

Dr. Barkley, I am wondering about people misdiagnosed. Since there are symptoms of ADHD that also fall under various illnesses, what would happen long term if they were given stimulants such as Adderall but actually was misdiagnosed?

[@russellbarkleyphd2023]

The stimulants produce modest improvements in most typical people at low doses, so you wouldn’t see much difference. It is the degree or magnitude of the change that is so much more obvious in ADHD because their symptoms place them so much farther from the mean or typical performance. So drug response is not helpful for diagnosis. While some symptoms of ADHD appear in other disorders, it is the no overlapping symptoms that help with differential diagnosis. But often the overlap is due to comorbidity of both disorders in the individual. Be well.

[@katarzynaturek4775]

How to adequately differeniate between ADHD and BPD (and/or other conditions)?

[@russellbarkleyphd2023]

Focus on the thinking disturbances and affective cycling in bipolar to distinguish it from ADHD. Both involve inattention. The impulsiveness and hyperactivity in BPD are episodic and associated with manic episodes. That is not the case in ADHD. But both can coexist, as is the case in 25% of BPD adults and more than twice that in kids and teens with BPD.

[@katarzynaturek4775]

@@russellbarkleyphd2023 Thank you very much! I also hear that it isn't ADHD if a complex childhood trauma was present. I assume BPD (possibly the other disorders) develop as a result of trauma (with ADHD still present there?)?

[@russellbarkleyphd2023]

if you mean borderline personality and not bipolar disorder, then, yes, some significant trauma has usually preceded it but having ADHD that goes on to conduct disorder is also a predisposing pathway to BPD

[@bluewisdomtriforce]

this makes me wonder could someone have "good" working memory in the sense that the person can remember what they were in the middle of and just not be motivated by that what so ever for example could one be in the middle of vacuuming their living room walk away "remember" they are technically in the middle of vacuuming and just not go back to it? or would that be something else entirely

[@bluewisdomtriforce]

I should have watched further, because you did mention how the clinical functioning tests are flawed

[@obelixpfeifenreiniger2863]

dont get fooled by the term "memory". its more like not being to handle more than one thing at any time. you would not get back to vaccuming because something else got your attention, and now your focus switched to that other thing. out of sight, out of mind. apply that one thing at a time and out of sight thing, and you have total chaos.

[@StevenWernerCS]

have you heard of 'justice sensitivity'? when I witness something I deem unjust I get (apparently unreasonably) infuriated instantly and outwardly, and the rage subsides fairly quickly after outward expression or action. It commonly presents itself while driving since there is a constant stream of infractions from rude or careless drivers.

[@russellbarkleyphd2023]

I think this specific issue is part of the larger problem with emotional self-regulation that is a well established component of ADHD. Thanks for watching.

[@MisterCJR]

I just wanted to say this is a give struggle of mine as well!

[@StevenWernerCS]

@@MisterCJR 38, just got diagnosed with ADHD.. its crazy how many people live with all these struggles for years. creating compensatory mechanisms and masking to get by. I'm (slowly) getting my masters in Applied Cognition and Neuroscience and only found out through school. I have a Computer Science undergrad and became good at harnessing hyperfocus, but at the cost of extreme stress and letting every other component of life suffer that isn't what I'm trying to focus on.

[@sinan_islam]

KZbin audio is 100% Computer audio is 100% I can hardly hear anything!

[@RelentlessBoater]

skill issue

[@sheezle3]

Buy some good headphones, you won't have these issues anymore

[@zavierlee695]

Bro I can't afford a therapist doing all this extra crap to me lol

[@grantwiersum7394]

38:12 my brother and I call it "monkey brain" - when you start rifling through drawers and milling about because you're not being engaged

[@BartAssink]

pfff, I need some cute animal clips after hearing the truth from somebody else.

[@irunamuk]

Wait. So if I don’t have a ton of people who knew me as a child im expected to have notes sent home from school for this assessment? Are you kidding??

[@carlo.m5233]

Not really... It depends on how your doctor wants to assess you. My psychiatrist did not require a school report. He did ask my parents to answer some questions but I told him that my parents report will not be accurate.