Identifying New Symptoms for
Diagnosing ADHD in Adulthood
by
Russell A. Barkley, Ph.D. and Kevin Murphy,
Ph.D
Reprinted with permission from ADHD
Report, Guilford Publications, Inc., New York, NY,
April 2006, Volume 14 No. 4
The current symptom list for ADHD in the DSM-IV
(American Psychiatric Association, 2000) was
developed on children and was only field tested
using children (Lahey, Applegate, McBurnett,
Biederman, Greenhill et al., 1994; Spitzer, Barkley,
& Davies, 1989). The utility of extending that list
to adults with ADHD is therefore an open question.
This article addresses the important issue of
whether or not better symptoms could be identified
for the adult stage of this disorder than those 18
childhood symptoms currently represented in the
DSM-IV.
We began by making a list of the most common
complaints that we had heard from adults presenting
at the Adult ADHD clinic at the University of
Massachusetts Medical Center where more than 100
adults were evaluated each year. We also went back
through previous charts of adults seen at this
clinic to identify such symptom items. We also used
the theory of executive functioning developed by
Barkley (1997) and extended to understanding ADHD in
order to generate potential symptoms that deal with
each of the five executive components of his model:
response inhibition, nonverbal working memory and
sense of time, verbal working memory,
emotional/motivation self-regulation, and planning
(generativity or reconstitution). The results of our
work on this new symptom list will appear early next
year in a new book presenting the results of an
original research project (Barkley & Murphy, 2007).
This project constitutes one of the most
comprehensive evaluations of adults with ADHD. In
this project, we extensively evaluated 146 adults
with ADHD on numerous measures of adaptive
functioning across many domains of major life
activities. We compared them to both a community
control group of 109 adults and a clinical control
group of 97 adults seen at the same ADHD Clinic but
not diagnosed with the disorder. These adults had a
mean age of 32-37 years, depending on the group,
with 47-68% of each group being male.
A New Item Pool of Potential Symptoms for ADHD in
Adults
We developed a list of 91 new items that might have
some potential for being associated with and
predictive of ADHD at the adult stage of its
development. We included items that further
elaborated on the problems with behavioral and
cognitive inhibition that are thought to be a core
feature of ADHD (Barkley, 1997, Nigg, 2001) yet
which are represented by only three items in the
current DSM-IV list, most of which may reflect
verbal impulsiveness. And so we added items dealing
with impulsive decision making, making impulsive
comments to others, poor delay of gratification,
doing things without considering their consequences,
and so forth, that may better reflect this
construct. Other items deal with working memory
(holding information in mind that is guiding
behavior), the sense and use of time thought to be
related to it, emotional self-regulation, and
planning and forethought, all of which derived from
Barkley's theory. Still other items of a less
theoretical nature were included because they were
often voiced by adults with ADHD or had been
identified as problematic for them in previous
studies, such as excessive speeding while driving,
poor management of money, motor clumsiness, poor
handwriting, and a proneness to accidents (see
Barkley, 2006). Because most of these symptoms
originated in Barkley's theory of executive
functioning (EF), we consider this list to largely
reflect that construct.
These 91 items were collected in a structured
interview with the participants, in which case they
had to be endorsed as occurring “often” or more
frequently to be considered a positively reported
symptom. The results for these items would have the
greatest bearing on any effort to develop new
symptoms to be listed in DSM-V for ADHD in adults as
they would be of the same binary or dichotomous
nature as those in the current DSM-IV symptom list.
We also collected them with reference to the same
time period stipulated in the DSM-IV, that being the
previous 6 months as reported by participants, and
the same descriptor of symptom frequency as in
DSM-IV, that being the word “often.”
Obviously, the symptom list served its purpose
because all items occurred significantly more often
in the ADHD gropy than in the Community control
group. In that sense, all 91 potential ADHD symptoms
were problematic for the ADHD group, supporting the
developmental inappropriateness of their severity.
However, all but one of these items also occurred in
more of the Clinical control adults than in the
Community controls. To reduce this item set down to
those likely to have the greatest promise for
characterizing ADHD in adults, we imposed two
criteria. First, the item had to occur in at least
65% (roughly two-thirds) of the ADHD group. Second,
it had to occur in significantly more of the ADHD
group than in the Clinical control group. There were
43 such items. We then threw out the four items that
we believed were too close in wording to those found
in the DSM-IV and therefore likely to be redundant
with them, which left 39 items.
These 39 items constituted the pool of those
symptoms offering the greatest potential for
characterizing ADHD in adults. They were analyzed
further for their ability to accurately discriminate
among the groups using logistic regression. The
items that best discriminated the ADHD cases from
those in the Community control group were (cont):
