Keywords

Introduction

Mood and affect problems and symptoms of inattention, hyperactivity, and impulsivity are common in society, and particularly in mental health and primary care settings. Such problems impair patients’ relationships with family and friends, their academic and occupational function, and ultimately the course of their lives. Careful and comprehensive assessment can lay the groundwork for effective treatments that can be life-changing. The list of differential diagnoses is long, and includes mood disorders, anxiety disorders, substance use disorders, personality disorders, and disruptive behavioral disorders, any of which can also have organic or substance-related etiologies. An effective initial interview will consider each of these groups of potential causes for the presenting symptoms, but may require multiple additional steps to gather more information. Sources of such information will include the patient and often other collateral informants , but may also include old medical, mental health, employment and academic evaluations, and sometimes behavioral comments on old report cards. Much of this information can be assimilated prior to the clinician’s evaluation.

Often the clinician must integrate incomplete, potentially inaccurate, and sometimes contradictory information from different informants , and carefully weigh such informants’ potential accuracy, biases, and motivations. Patients with ADHD, by definition, are inattentive, hyperactive or impulsive, and may give inaccurate answers, whether intentional or not. Patients or family members may underreport the patient’s symptoms due to denial, poor insight, skepticism about mental illnesses, discomfort with the patient being “labeled,” or simply to defy whichever party requested the evaluation without their blessing. In children or adolescents, such discordance may reflect parental conflicts with each other, with the patient, or with the school. Patients with ADHD often tend to overestimate their competence in various areas, a trait known as “positive illusory bias ” [1, 2]. On the other hand, patients or family members may overreport the patient’s symptoms when anxious or depressed [3], to seek academic or occupational accommodations or a medical excuse, or to obtain medications they hope will be therapeutic for the patient, or that they may divert or misuse. The late US president, Ronald Reagan, when asked about his confidence that his Russian counterparts would comply with a historical treaty intended to reduce both countries’ nuclear arsenals, stated simply that he would “trust, but verify.” Clinicians should use the same approach with information provided by patients and other informants , especially when their clinical observations and gut feelings raise doubts.

History of Present Illness, Past History, Family History, and Staging the Interview

For patients of all ages, proper psychiatric assessment will often require several stages [4,5,6]. The first stage will generally include brief introductions with the patient and other informants to review basic identifying information, chief complaints, goals for the evaluation, and further stages. At that time, the clinician can review aspects and limits of confidentiality. The next stages in the case of child or adolescent patients involve interviewing the child/adolescent and parent separately. This gives each party the chance to confidentially discuss their side of the story about the reported problems, as well as other potentially sensitive issues, and for the clinician to observe how reports, behaviors, and attitudes change when the other informant is no longer present. This also gives the clinician the chance to compare each party’s answers to similar questions. The time spent with each party will vary, depending on the chief complaints, each party’s willingness to participate in a separate interview, and the clinician’s opinion about the relative reliability of each party in reporting their clinical concerns [6].

As a general rule, the proportion of time the clinician spends with a child or adolescent patient will generally increase with the patient’s age, assuming he or she is cooperative and judged to be a good informant [4,5,6]. However, even brief interviews with younger children can provide useful observations about their activity level, mood and affect, developmental level, speech and language skills, and ability to handle a brief separation from their parent or other caregiver [4]. Clinicians should adjust their style and language level to the patient’s maturity, intelligence and language skills [4, 5]. In young patients, it is particularly important to “break the ice” by adopting a comfortable and reassuring demeanor and asking less probing questions first, perhaps about hobbies, activities, friendships, experiences in school, and relationships with family [4, 5]. Any suggested problems can then be followed up with questions about mood, anxiety, obsessive compulsive, psychotic, and behavioral symptoms, and how those impact such activities. The individual interview also provides the chance to ask about trauma exposure, sexual activity, drug/alcohol use, suicidal ideations and behaviors, and other risky behaviors or potential safety concerns. Reassuring patients that these are routine questions asked of all patients can make them more forthcoming in disclosing their problems and concerns. Above all, close observation of the patient’s mood, affect, and behaviors during the interview is critical. Feelings the patient evokes in the examiner (e.g., sadness, anxiousness, hopelessness, pity, irritation) often provide important clues about patients’ underlying mood and thoughts [4, 5].

A similar approach in interviewing adult patients can be equally helpful, assuming they have age-appropriate maturity, communication and cognitive skills. Finding the proper balance between developing an alliance with the patient, and maintaining proper boundaries and a neutral perspective can be especially important but tricky. In adult patients who are the persons of interest, they should be allowed greater say regarding what happens during the diagnostic process and the degree that other informants may participate. The clinician, however, can also set limits when necessary, especially since the diagnosis of ADHD requires such collateral information , and when the patient’s thoughts and behaviors represent potential safety concerns.

How patients present themselves in the interview can also be quite informative. Do they seem sincere and trustworthy? Are they appropriately dressed, with good hygiene, or seem disorganized or disheveled? Do they seem distracted, spacey, or forgetful? Do they show signs of hyperactivity such as fidgetiness, or impulsivity such as answering questions prematurely? Do they report cognitive and vegetative symptoms of depression or any signs and symptoms suggestive of mania or psychosis? What kind of feelings do they evoke in you as the clinician through their behaviors and interactions: sympathy, irritation, anxiety, skepticism, fear? Do they have appropriate feelings about their presenting complaints?

Time spent with the parents or other family members, either alone or with the patient, is essential in the case of child and adolescent assessments , and often helpful in the case of adult patients too. Parents and other family members will often be more reliable reporters regarding the patient’s ADHD and other externalizing behaviors, and other potentially sensitive issues about the patient’s substance use, and social, school, work, family, or legal problems. Parents often will be better able to provide past psychiatric, medical, family, and socio-developmental history as well as relevant stressors or trauma exposure that the patient has no awareness of, or has chosen to withhold [6]. The clinician may use separate time with only the parent of a child patient to share clinical impressions and propose next steps regarding assessment and treatment of the patient. This is often a good time to discuss making sure that the parent’s or other family members’ mental health needs are also being appropriately addressed. Such time with parents and other family members helps the clinician to anticipate potential problems the patient or parent could have in both accepting and complying with the clinician’s recommendations for treatment.

Additional information about the patient’s past psychiatric history from the patient or family can also be helpful, including past diagnoses, experiences with prior therapy or pharmacological treatments, suicide attempts or self-injury, hospitalizations and the indications for them. If considering pharmacotherapy, it is important to review any prior medications tried and the patient’s response to them. Careful review of past medical history and reports of any current somatic symptoms could suggest a tendency to overreport physical complaints that could be blamed as a medication side effect, or could suggest a potential medical problem that could interfere with treatment, or at least require a medical workup and medical clearance before starting pharmacotherapy.

Information about the family history , from either the patient or parent, is also useful in understanding the patient’s current mental health issues and the environmental context in which they are occurring. Identifying past mental health issues in other family members can help to identify genetic risks for mood, ADHD, substance use, and autism spectrum disorders, as well as for suicidal behaviors. Information about family members’ responses to pharmacological treatments can be helpful in anticipating the patient’s responses to the same or similar medications. A family member at home with an active substance use problem could increase the patient’s risk of environmental adversities and trauma exposure, and is a relative contraindication to prescribing controlled substances like stimulants to the patient.

The Physical and Mental Status Examination

Obtaining vital signs, including blood pressure, pulse, weight, and height, is recommended as a routine part of psychiatric care, especially when considering a trial of a stimulant medication or other ADHD medication. If considering a trial of an atypical neuroleptic, baseline tests, such as an Abnormal Involuntary Movements Exam and measurement of waist circumference, as well as ordering a fasting blood glucose and lipids are recommended [7]. Observations of either motor or vocal tics are important to document and potentially discuss with the patient and family. When considering pharmacological treatment for ADHD, especially with a stimulant, a complete baseline physical exam is recommended , since hypertension, tachycardia, and structural or other heart problems are potential contraindications to such a trial [8, 9].

Structured Interviews and Rating Scales

As summarized in Table 2.1, there are several well-validated structured or semi-structured interviews to help clinicians’ reach more accurate diagnoses in patients of all ages. Though such interviews are considered the gold standard for mental health assessment, they are often time-consuming, impractical in clinical settings, and require training to be used validly.

Table 2.1 Structured and semi-structured diagnostic interviews
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Instead, the current standard of care for patients of all ages is a careful diagnostic interview, supplemented with collateral information from validated rating scales, screening for various diagnoses that could explain patients’ presenting complaints, or may require additional attention. Table 2.2 lists multiple different rating scales , along with relevant references. Using additional time during the interview to gather more information about symptoms reported on the questionnaires can be especially helpful. Reports by interview or rating scales about trauma exposure and other recent or ongoing stressors are especially important because they suggest contributing factors that could be targeted and mitigated with psychosocial interventions.

Table 2.2 Rating Scales and Questionnaires
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Neuropsychological, Continuous Performance, and Electroencephalogram (EEG) Tests

Although neuropsychological testing has been suggested to be an important potential component of the workup for ADHD in patients of all ages [10], such testing is often time-consuming and expensive, and not designed specifically to diagnose ADHD at any age according to both the American Academy of Pediatrics [9] and the American Academy of Child and Adolescent Psychiatry [8]. However, neuropsychological testing can be helpful in situations in which an underlying learning disorder or developmental language disorder is suspected, or when accommodations at school or in taking standardized tests are being considered. If possible, this could be done through the school’s special education team as it can be quite expensive and insurance may not cover it.

Multiple continuous performance tests have been available for years [11, 12], and are sometimes used in the assessment of potential individuals with ADHD of all ages. A recent literature review of the available options suggested they often have shown problems with retest reliability and in discriminating patients with and without ADHD, due to unacceptably high false positive and false negative tests, especially in the presence of comorbid psychiatric disorders or other brain problems [13]. Continuous performance tests are not a substitute for a good clinical interview. However, they have been treatment-sensitive in pharmacological trials of ADHD medications [14]. Table 2.2 has additional information about these too.

A test involving EEGs (known as NEBA) has recently been validated, and approved by the Food and Drug Administration, as a supplemental test for ADHD in children and adolescents [15]. The NEBA test involves an approximately 25 min EEG in which the patient’s ratio of theta to beta waves is determined. This ratio has been demonstrated to be a biomarker of ADHD [16], and may be useful in equivocal cases. See Table 2.2 for more information.

Summary and Next Steps

A careful psychiatric assessment is the cornerstone for diagnosing and effectively treating ADHD and the many disorders of moodiness associated with it. This requires a carefully staged interview of the patient and other key informants about the patient’s recent past history of mental health problems. Such interviews vary according to age, cooperativeness, and perceived ability of the patient and other informants to provide useful and accurate information about the reported problems. Rating scales about patients’ symptoms and associated impairment can help in screening, and guiding the interview, and may highlight and help to resolve contradictory reports. Once working diagnoses are determined, rating scales can be used subsequently to monitor changes in the patient’s symptoms with treatment, and to help guide further adjustments to the treatment. The next chapter will review potential organic causes of moodiness and ADHD symptoms. Later chapters will discuss assessment and treatment strategies for various potential causes of moodiness or mood problems in patients with ADHD.