This article was written by
Benny Stein

Wouldn’t it be wonderful if there was a smartphone app that could diagnose and monitor teens with ADHD?

Most physicians find making a conclusive diagnosis of ADHD daunting, particularly in adolescents: Would it not be wonderful if there was a smartphone app that could diagnose and monitor teens with ADHD?

As with many mental and behavioural conditions, there is as yet no single biological test or marker available for ADHD. It is a condition that exists in a particular social and educational milieu, and we cannot deny that the diagnostic threshold is influenced by the availability of safe and effective treatments. The diagnosis may confer certain advantages and disadvantages, and therefore a special responsibility rests upon the diagnosing clinician.

The process relies almost entirely on reported symptoms. Even when these symptoms are accurately reported by teachers, parents or the patient, they remain only indirect indicators of ADHD. Teenagers have more insight than younger children and are therefore prone to either under- or over-reporting symptoms, depending on their perception of what the implications of a diagnosis may be.

The clinician needs to exclude other conditions that may present with executive dysfunction (e.g.mania or early onset psychosis); and recognise comorbid conditions such as mood and conduct disorders. On top of this the diagnosis requires clinical evidence of “significant scholastic and social impairment”, but what constitutes significant is left to the clinician’s judgement. Clinicians not specialising in the field of psychiatry may find this level of ambiguity uncomfortable, and social controversy over medication and special allowances for extra time in examinations adds to the complexity. Fortunately, listening to our patients and sharing experiences with other clinicians, helps to build confidence in making an accurate diagnosis.

Through the years some tools for supporting and enhancing the clinical interview have been developed, but are we any closer to an objective test for ADHD? What are the latest developments in attempts to make the process of diagnoses more objective? There are a number of tests that a clinician can use to support his/her diagnosis. It is however important to understand the shortcomings of such measurements and that none of them can really replace assessment by an experienced clinician.

Rating Scales

The diagnostic process is time-consuming and requires a full clinical history with the adolescent and family, supported by rating scales e.g. the Connors’ Teacher Rating Scale or Brown ADD Scales for adolescents (multiple informants).

Rating scales are systematic and quantitative, but they are not objective. They are prone to “halo” effects – if an informant thinks a young person needs medication, they are more likely to score every item as “severe”. Inter-rater reliability is poor, even between parents. Adolescents are less likely to be closely monitored by teacher than younger learners, and there self-report questionnaires are essential, but subject to bias as mentioned above.

Rating scales are therefore a necessary component of diagnosis, but cannot stand alone without a clinical evaluation.

Psychologicol testing

A conventional cognitive test like the WISC or SA-WAIS elicits the young person’s relative strengths and weaknesses in different tasks. ADHD sufferers may struggle with auditory memory tasks like Digit Span and they may score relatively low on Working Memory and Processing Speed scores.

There are two problems with psychological testing. One is the cost, and the second is that it may yield a false negative finding as it is only an indirect measure of ADHD:  ADHD symptoms may be missed in the artificial environment of a small room, one-on-one with an adult examiner.

Computerised tests

Computerised test of continuous performance (CPT), like the TOVA, may yield false positives and do not display good inter-test reliability. Moreover, they are not sensitive enough to accurately monitor dose response or duration (e.g. hours into the afternoon) and are at best helpful as an adjunct to diagnosis and clinical monitoring.

Physiologicol tests of limited use

A wide range of physiological tests have been brought to bear on the problem of ADHD. Accelerometers are motion sensors worn like a wristwatch to monitor hyperactivity, but attempts to use it for diagnosis have been disappointing. Although SPECT and qEEG are not deemed to have clinical utility by mainstream ADHD clinicians, the idea of reading the brain’s activity for clues to diagnosis is gaining ground. In July 2013 the FDA approved the first scan for ADHD: the Neba device relies on a 20 minute EEG-based test to support the diagnosis. In the author’s opinion, it has limited value and is likely to escalate costs of an assessment.

A high prevalence of ADHD has been reported in patients with bipolar disorder – up to 85%, while the rate of bipolar disorder in patients with ADHD reached 22%.

Major depressive disorder frequently co-occurs in adolescents with substance use disorders and attention deficit hyperactivity disorder (ADHD). Such youth may require interventions targeting depression.

Learning disorder(s)

Reading disorders are common in ADHD; about 25-40% with ADHD has major reading and writing difficulties.

“Even when the child is paying attention, is learning difficult? Are there certain subtypes that the person has extreme difficulty with? How does this person do in reading, writing, and mathematics? Has the person ever been tested for a learning disability?”

Disruptive behaviour disorder not otherwise specified

About 20-45% of children with ADHD also meet criteria for conduct disorders. “Does the adolescent lie a lot, get into physical fights or try to hurt people? Has the person ever stolen or damaged people’s property”

Substance abuse

The presence of ADHD increases the risk he or she will be a cigarette smoker by at least 3 times the level of the general population. Smoking usually begins at an earlier age and persists throughout life. Alcohol is another common type of substance abuse disorder in ADHD.

“Do you suspect this adolescent smokes, uses drugs or drinks alcohol? Why do you suspect this?”

Awareness of risk behaviour in teenage ADHD

Adolescents and young adults with ADHD histories are at risk of engaging in typically health-endangering behaviours such as substance abuse and unsafe sex, but may also be involved in risk-taking behaviours that are not inherently “deviant” or illegal- as in this case of motor sports.

Educational outlook for adolescents with ADHD is poor

Adolescents with ADHD complete fewer years of school; graduate from high school at a lower rate, and are less likely to enrol in graduate school with less success at work. Older children with ADHD display significantly greater social and homework problems than younger children.

Attention-deficit/hyperactivity disorder in substance use disorders (SUDs)

Studies assessing ADHD and other disorders in substance abusing groups have indicated that from one-quarter of adults with substance use disorders and one-half of adolescents with SUDs have ADHD.

Issues of misuse and diversion of stimulants

The majority of individuals treated for ADHD use their medications appropriately; however, studies have indicated that approximately 5% of college students have misused stimulants. The use of stimulants is appropriate for children and adolescents with ADHD when opportunities for screening, family- and child education, and counselling concerning substance abuse are consistently integrated into the ongoing treatment regime.

Motor sports involvement with heightened risk of injury

Adolescents and young adults with ADHD histories, especially those with persisting impulsivity, comorbid conduct disorder or anti-social personality disorder and heavy drinking tendencies, are more likely to engage in motor sports, which may heighten risk of injury.

Internet, video games addiction and gambling behaviour among odolescents with ADHD

Significant associations have been found between levels of ADHD symptoms and severity of internet addiction, showing that 22.5% of the students diagnosed in the study with internet addiction had ADHD (vs.1% of non-addicts).

Moreover, studies have highlighted the clinical importance of considering the subtype of ADHD among gamblers and the greater association of depressive affect and emotional problems with gambling among adolescents..

Risk of completed suicide, -ideotion and -attempt in ADHD ottention deficit hyperactivity disorder

There is a positive relationship between ADHD and risk to self. The importance of thorough risk assessment in the attention-deficit population should not be underestimated.

ADHD and nicotine addiction risk

ADHD is a serious risk factor for early smoking and nicotine dependence in adulthood. Children, adolescents and young adults with ADHD smoke at rates that are considerably higher than those of the general population or of healthy controls.

Interventions that work with ADHD teenagers with comorbidity and high risk behaviour

Combined strategies for ADHD to reduce severe behaviour problems

  • Parent management training
  • Cognitive behavioural therapy with problem solving skills training
  • Psycho-education for children and families
  • School based intervention programmes.

Pharmacological interventions

  • Long-term medication use does improve the academic outcomes of youth with attention-deficit/hyperactivity disorder. Studies demonstrated that long-term medication use is associated with improvements in standardized achievement scores in youth with ADHD.
  • In adolescents with bipolar disorder and ADHD, it is safe and effective to stabilize the irritable or manic mood first with a first-line anti-manic medication, like risperidone; followed by stimulant treatment for the comorbid attention-deficit/hyperactivity disorder (ADHD). Small dosages (0.5-2.5mg) were as effective as high dosages to treat acute mania with fewer side effects. Adolescents seem to be especially sensitive to second generation anti-psychotic metabolic side effects.

Conclusion

The assessment of the adolescent with possible ADHD should include a comprehensive history (school and developmental) with a thorough mental status examination; identification of teenage ADHD symptoms; ADHD comorbidity and exploration of possible risk behaviours. This approach may be helpful to assist in the development of a patient-centred management plan to improve treatment outcome.