Preventing ADHD Under- and Over-Diagnosis With the Right Screening Tools
February 7, 2024 | Dr. Joel L. Young
Mental health misdiagnosis is an ongoing problem. Research shows that ADHD is both under-diagnosed and over-diagnosed. The results can be catastrophic. Adderall works well for ADHD, but can cause worsening anxiety in a person with anxiety, and increase the risk of addiction in a person with a history of substance use disorder. Online telehealth startups are increasingly providing ADHD drugs with little or no oversight, and government regulators are beginning to crack down.
Patients are stuck in the middle. On the one hand, finding a clinician to diagnose ADHD can require a long wait. And for someone already struggling with executive dysfunction, this process can be demoralizing. On the other, people who get the wrong diagnosis get worse, and may eventually turn away altogether from mental health care.
Even when patients do find the right clinician, they may not get an accurate diagnosis. Most people turn to primary care providers for psychiatric help. General practitioners do not have specialized mental health training, resulting in a high rate of misdiagnosis. Most patients who seek assistance from a PCP do not take a validated assessment. And they may not report all symptoms to their provider, causing other conditions to go undiagnosed.
A comprehensive, quality assessment can help correct these errors, reducing the human cost of inaccurate diagnoses.
Clinicians at the Rochester Center for Behavioral Medicine conducted this research, with the aim of presenting new assessment options for clinicians well beyond our doors. A secondary goal was to optimize assessments offered via MindMetrix, an innovative new psychiatric assessment tool.
Our research explored how the combination of two tests could more accurately screen for ADHD in adults seeking a diagnosis for the first time.
Accuracy of ADHD Diagnosis Relies on Understanding Childhood Symptoms
To qualify for an ADHD diagnosis, a person must first develop symptoms in childhood. This is because many other diagnoses — depression, anxiety, burnout, substance abuse, and more — may mimic the executive dysfunction of ADHD in adulthood. Thus standard ADHD assessments in adulthood may inaccurately diagnose ADHD, delaying diagnosis and treatment of another disorder.
The Wender Utah Rating Scale (WURS) is a scientifically validated scale that assesses for signs of ADHD in adults. Most assessments are designed for children because diagnostic criteria mandate that symptoms must be present in childhood. But this scale invites adults to look back on their childhood experiences to assess for signs of ADHD.
The symptoms of ADHD intersect with many other diagnoses. For example, a child who is hyper might have ADHD, or they might be anxious. A child may struggle to complete tasks because of executive dysfunction, depression, or myriad other issues. And when adults look back on their childhood, their attributions about their experiences may be less specific. The WURS corrects for this by including symptoms that are characteristic of other mental health diagnoses.
So how can clinicians recognize adult ADHD symptoms without missing other diagnoses? Our study assessed the use of the WURS along with Conner’s Adult ADHD Rating Scale (CAARS) and Brown Executive Function/Attention Scales (Brown EF/A). CAARS is one of the most popular and well-researched adult ADHD assessment tools, and Brown EF/A is excellent at detecting executive dysfunction—a symptom of both ADHD and some other mental health diagnoses.
We theorized that using the two together would catch more ADHD cases, without over-diagnosis. This, we hypothesized, would enable us to detect adult ADHD without missing other disorders.
About the Study
For this research, clinicians referenced RCBM patient records to pull a random sample of 65 adults. Each recently underwent a psychological assessment because of suspected ADHD. Each participant had taken all three ADHD assessments: the WURS, CAARS, and Brown EF/A.
Our goal was to assess the efficacy of all three assessments for diagnosing ADHD, without either over- or under-diagnosis.
Methodology
The study drew on a random sample of 65 adults who recently took all three assessments. We then compared the results of each assessment to determine whom would get an ADHD diagnosis based on each individual assessment, as well as based on the assessments used together.
Findings
Our findings were consistent with ADHD rates in the general population.
The WURS and CAARS provided a more rigorous test of ADHD. This combination may reduce the risk of over-diagnosis, but it is unclear the extent to which it might under-diagnose.
To ensure the rigor of our testing, researchers also performed a significance test. They found that using the WURS and CAARS together provided a more rigorous test of ADHD, Pearson χ2 (1) = 29.792, p < 0.001, than using the CAARS and Brown EF/A together.
- We found a score consistent with ADHD in 20 of 65 people (31%) when we used the CAARS and Brown EF/A tests together.
- We found a score consistent with ADHD in 11 of 65 people (17%) when we used the WURS and CAARS together.
Takeaways
For some people, ADHD symptoms disappear in adulthood. But for many, it is a lifelong disorder. Some adults do not get an accurate diagnosis in childhood, depriving them of treatment that could improve quality of life.
An assessment that combines reflections on ADHD in childhood with a measure of ADHD in adulthood is a more accurate diagnostic tool, than using just one or the other. Clinicians who use a rating scale such as the WURS in addition to their assessment of current symptoms are less likely to over-diagnose ADHD, or to mistake another diagnosis for ADHD. This may improve treatment outcomes.