The core symptoms in childhood ADHD are inattention, impulse control problems and motor hyperactivity, but impulse control problems and motor hyperactivity generally soften (or change) by adolescence, although inattention remains.
We likely miss many patients who have only the inattentive symptoms of ADHD, such as being shy or withdrawn, or being “daydreamers.” As a general rule, patients who have only the inattentive symptoms are female. They also tend to have more internalizing symptoms, so separating ADHD from a mood disorder is more difficult.
The associated symptoms of ADHD can be problematic for the person, but they are not part of the diagnostic criteria. Associated symptoms in adults include:
- procrastination and poor time-management skills
- poor organizational skills
- feelings of being rushed or missing the subtleties of information
- problems in interpersonal relationships, including parenting skills
- appearing not to take responsibility for themselves
- difficulty delivering on promises (e.g., missed deadlines)
- difficulty paying bills, completing reports or assignments (paperwork is “kryptonite” to someone with ADHD).
Do NOT use the following clinical observations to dismiss a diagnosis of ADHD:
- You do not observe hyperactivity in the office.
- The patient reports a great deal of problems with organization, time management and executive function, but is reliable in keeping appointments, filling out forms and paying for treatment.
- The patient has read about ADHD and thinks he or she has this problem.
- There is no family history.
- A partner or parent suggests symptoms of ADHD, which the patient dismisses.
- The patient is well-educated or employed in a high-level position.
- The patient is very bright, and early school report cards do not describe problems with attention or behaviour. Other patients may, on further exploration, give a very convincing account of unusual coping strategies, such as excess time on homework or increased need for assistance.
- The patient was clearly hyperactive, impulsive and inattentive when younger, but currently has difficulty with only a few residual symptoms.
- The patient does not remember or denies symptoms in childhood, and school report cards are not available. Usually, a careful developmental history will reveal evidence of the impact of the disorder, even if the patient did not have insight, either at the time or now, into the symptoms that provoked these consequences. The symptoms must be present before age 12. (This age requirement has changed from the earlier DSM-IV, which indicated age 7, because many adults cannot remember what they were like at that young age.)
Consider ADHD if any of the following situations apply to the patient:
- Any first-degree family member was diagnosed with ADHD (i.e., the patient’s child, parent or sibling).
- The patient was diagnosed with ADHD as a child or adolescent.
- The patient felt a calming, focused sensation on a psychostimulant, energy drink, cannabis or cocaine.
- The patient had psychometric testing as a child or adolescent that suggested they had a learning disability, particularly a problem with working memory.
- The patient or a family member might say, “I think I [they] have ADHD.”
- The patient has a current diagnosis of depression or anxiety.
If any of these situations apply, have the patient complete the Adult ADHD Self-Report Scale from the eToolkit that accompanies the Canadian ADHD Practice Guidelines developed by CADDRA–Canadian ADHD Resource Alliance (CADDRA; 2018, 2019). The tool does not make the diagnosis and does not have a threshold marker, but it helps you decide whether to consider ADHD if a patient answers “yes” to most of the questions. It might also help to have the patient’s partner complete the tool.