Diagnostic Assessment — Attention Deficit Hyperactivity Disorder
Example 1 of 1 · fictitious patient (Veteran AC)
Diagnostic Assessment
Attention Deficit Hyperactivity Disorder
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran AC, date of birth 22 September 1986, Australian Army, Rifleman (Infantry), later Breacher and Range Weapons Instructor, enlisted 16 January 2006, medically discharged 04 June 2019. Operational service: Afghanistan, 10 February 2011 to 25 October 2011 (warlike); Middle East Area of Operations, 15 February 2017 to 30 September 2017 (warlike).
Occupational History
Infantry soldiers are exposed to repeated blast from explosive breaching, shoulder-fired anti-armour weapons, mortars and improvised explosive devices, and to head impacts in training, contact sports and vehicle incidents. Breachers and weapons instructors receive the highest repeated blast overpressure exposure in the Army because they set and fire charges, and fire anti-armour weapons, many times a day on courses and ranges.
Range instructors also inhale lead fume and dust from primers and projectiles, particularly on poorly ventilated indoor and covered ranges, and weapon maintenance involves daily use of organic solvent cleaners and degreasers. On deployment soldiers were tasked with secondary duties such as spraying insecticides for vector control at patrol bases, lived in improvised accommodation run on generators, and worked long night shifts with chronic sleep restriction.
History
Veteran AC, an infantry soldier, breacher and range weapons instructor in the Australian Army, developed attention deficit hyperactivity disorder of clinical severity in March 2012, after a moderate traumatic brain injury in an improvised explosive device blast and carbon monoxide poisoning in Afghanistan in 2011, on a background of repeated concussions, blast overpressure, lead, solvent and organophosphate exposure. The condition was diagnosed by a psychiatrist in September 2013 and worsened in 2017 during a deployment to the Middle East, where his stimulant medication could not be supplied.
Timeline
- 12 Nov 2010 — Health surveillance as a range weapons instructor on a covered small arms range showed a blood lead concentration of 0.72 micromol/L (15 microg/dL), following 0.64 micromol/L on 14 May 2010. A repeat on 20 January 2011, after pre-deployment range practices, was 0.81 micromol/L. He was advised to improve hygiene but remained on range duties until he deployed. Earlier records documented concussions playing for an Army rugby team on 03 May 2008 and during explosive breaching training on 19 March 2009. "blood lead 0.72 micromol/L"
- 14 Jul 2011 — During warlike service in Afghanistan the veteran's patrol was struck by an improvised explosive device. He lost consciousness for about 45 minutes, had a Glasgow Coma Scale score of 11 at the role 3 hospital and post-traumatic amnesia of 36 hours. CT showed bifrontal contusions. He had a third concussion on 22 April 2011 when a rocket-propelled grenade detonated near his position. He returned to light duties in Afghanistan after six weeks. "moderate TBI, bifrontal contusions"
- 18 Sep 2011 — Found drowsy and confused in a shipping-container sleeping quarters at a patrol base, where a generator exhaust had been vented next to the air inlet. He briefly lost consciousness. Carboxyhaemoglobin was 24 per cent at the role 2 facility and he was treated with high-flow oxygen. Two other soldiers were affected. During this deployment he also sprayed organophosphate insecticides around the patrol base two to three times a week as the unit pest control operator. "CO poisoning, COHb 24 per cent"
- 02 Apr 2012 — Presentation to the garrison medical officer after failing a junior leadership course. He described, since mid-March, losing equipment, missing appointments, being unable to finish written work, drifting off in lectures, interrupting others and making impulsive decisions. His post-operational psychological screen of 02 February 2012 had recorded no concentration complaints. Primary school reports he brought described him as dreamy and easily distracted but performing at average level. Referral to neuropsychology. "inattention, disorganised, failed course"
- 10 Sep 2013 — A consultant psychiatrist, using the DIVA-5 structured interview, collateral history from his partner and the neuropsychology report of 14 June 2013, diagnosed attention deficit hyperactivity disorder, combined presentation, with clinically significant onset following his service brain injuries. Adult ADHD Self-Report Scale Part A 5 of 6. Dexamfetamine 5 mg twice daily was commenced and increased to 10 mg twice daily, with good response. "ADHD combined, dexamfetamine commenced"
- 22 May 2014 — The psychiatrist diagnosed posttraumatic stress disorder related to the 2011 blast, with nightmares, hypervigilance and sleep of four to five hours a night. Sertraline was commenced, with quetiapine 50 mg and temazepam 10 mg at night for sleep. Alcohol intake was recorded at about six standard drinks (60 grams) a day. "PTSD, quetiapine and temazepam nocte"
- 20 Oct 2017 — Review by the psychiatrist after seven months in the Middle East. Dexamfetamine, a Schedule 8 drug, could not be supplied on deployment and was ceased on 15 February 2017. He worked twelve-hour night shifts in an operations centre, sleeping four to five hours a day, and continued to drink heavily on rest days and after return. His ASRS score had risen from 31 to 58, he had received two formal warnings for missed tasks, and his partner reported marked irritability and impulsive spending. Dexamfetamine was recommenced and atomoxetine added. "worse off stimulant, ASRS 58"
Symptoms
At onset the veteran had persistent inattention, distractibility, forgetfulness, losing equipment, difficulty organising and completing tasks, restlessness, talking over others and impulsive decisions, causing failure of a promotion course and problems at home. Symptoms occurred in every setting and were present every day.
After the 2017 worsening the symptoms were more severe, with formal warnings at work, impulsive spending, irritability and road rage. He now reports partial control on stimulant medication but continues to lose track of appointments and bills, cannot sustain attention on reading or paperwork and has difficulty holding civilian employment. He has lost two civilian jobs since discharge because of missed deadlines and conflict with supervisors, relies on his partner to manage household finances and has had his driver licence suspended for speeding offences.
Imaging
- 14 Jul 2011 — CT brain: "Bifrontal cortical contusions, larger on the right, with small volume subarachnoid blood. No mass effect."
- 28 Jun 2012 — MRI brain with susceptibility-weighted imaging: "Gliosis and encephalomalacia in the right orbitofrontal region at the site of prior contusion. Several microhaemorrhages at the grey-white junction of both frontal lobes and in the corpus callosum, consistent with diffuse axonal injury."
Onset Date
The most likely date of onset of this condition is 15 Mar 2012.
At that date the veteran was serving full time with an infantry battalion in Australia and had begun a junior leadership course. He had returned from warlike service in Afghanistan on 25 October 2011, where he sustained a moderate traumatic brain injury on 14 July 2011 and carbon monoxide poisoning on 18 September 2011. From mid-March 2012 he could not keep up with course work, lost equipment and made impulsive errors, and he failed the course.
This date is appropriate because his post-operational psychological screen of 02 February 2012 recorded no concentration or organisational complaints, and he first presented with the symptoms on 02 April 2012, about two weeks after they became evident. Several inattentive traits were described on primary school reports, but they caused no impairment at school, in his trade training or in five years of service before the injuries. It falls within uninterrupted full-time service.
For the moderate traumatic brain injury and carbon monoxide factors, the 2 years before onset run from 15 Mar 2010 to 15 Mar 2012; the brain injury occurred on 14 Jul 2011 and the poisoning on 18 Sep 2011. For the repeated concussion, blast overpressure, lead and organophosphate factors, the 5 years before onset run from 15 Mar 2007 to 15 Mar 2012; his concussions were on 03 May 2008, 19 Mar 2009 and 22 Apr 2011, he fired more than 700 breaching charges and anti-armour rounds from 2008 to 2011, his blood lead was above 0.48 micromol/L from May 2010 to January 2011, and he sprayed organophosphates from February to October 2011. For the solvent factor, the 10 years before onset run from 15 Mar 2002 to 15 Mar 2012, and his solvent exposure ran from 2006 to 2012.
For the worsening factors, the condition was diagnosed on 10 Sep 2013 and treated. The worsening is documented on 20 Oct 2017. The 3 months before the worsening run from 20 Jul 2017 to 20 Oct 2017, during which he worked night shifts with less than 5 hours of sleep and took quetiapine and temazepam nightly. The 6 months before the worsening run from 20 Apr 2017 to 20 Oct 2017, during which he drank an average of about 60 grams of alcohol a day. Posttraumatic stress disorder, diagnosed on 22 May 2014, was present at the worsening. Dexamfetamine was unavailable from 15 Feb 2017 to his return.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Attention Deficit Hyperactivity Disorder, combined presentation (ICD-10-AM F90.0), with clinically significant onset in adulthood following service-related brain injury. No Statement of Principles has been determined for this condition.
Attention deficit hyperactivity disorder is a disorder of attention, impulse control and activity level, with persistent inattention and/or hyperactivity-impulsivity that interferes with functioning in more than one setting. The frontal and frontostriatal networks that control attention and executive function are central to the disorder. While it usually becomes evident in childhood, the medical literature recognises that acquired brain injury, toxic exposures and hypoxic injury can cause or bring to clinical significance ADHD in adults (secondary or acquired ADHD), and that sleep loss, posttraumatic stress disorder, alcohol and sedating medication make it worse.
In this veteran several inattentive traits were present in childhood without impairment. The disorder became clinically significant on 15 March 2012 after the 2011 brain injury and carbon monoxide poisoning, was diagnosed on 10 September 2013, and worsened in 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 March 2012.
When did the veteran first present to a health / medical provider for this condition?
02 April 2012.
When was the condition confirmed / formally diagnosed?
10 September 2013.
When did the veteran first present to you (or your practice) for this condition?
07 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by a consultant psychiatrist on 10 September 2013 against the DSM-5 criteria, using the DIVA-5 structured diagnostic interview, collateral history from his partner, primary school reports and the Adult ADHD Self-Report Scale. He had seven inattentive and six hyperactive-impulsive symptoms for more than six months, present at work and at home, with clear impairment. Several inattentive symptoms were present before the age of 12 on school reports.
Neuropsychological assessment on 14 June 2013 showed impaired sustained attention (Conners Continuous Performance Test), slowed processing speed and executive dysfunction, with intact general intellect and valid effort testing. MRI showed right orbitofrontal injury and diffuse axonal injury. The response to dexamfetamine supports the diagnosis, as does the clear worsening when it was withdrawn in 2017. Posttraumatic stress disorder, sleep disorder and substance use were considered and are recognised comorbidities that do not account for the full picture.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 15 March 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. No Statement of Principles has been determined for attention deficit hyperactivity disorder, so the claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits of a Statement of Principles. The reasonable hypothesis standard applies to the veteran's warlike service in Afghanistan in 2011, where the brain injury, carbon monoxide poisoning and organophosphate exposure occurred, and in the Middle East in 2017, where the condition worsened. The balance of probabilities standard applies to peacetime service.
Each cause must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having a moderate or severe traumatic brain injury within the 2 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- On 14 July 2011, during warlike service in Afghanistan, the veteran's patrol was struck by an improvised explosive device. He lost consciousness for about 45 minutes, had a Glasgow Coma Scale score of 11 and post-traumatic amnesia of 36 hours, and CT showed bifrontal contusions, a moderate traumatic brain injury. This was 8 months before the onset on 15 March 2012. Injury to the orbitofrontal and frontostriatal networks is the best-established cause of secondary ADHD in adults.
Cause 2: having at least three episodes of mild traumatic brain injury within the 5 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- The veteran had documented concussions playing for an Army rugby team on 03 May 2008, during explosive breaching training on 19 March 2009 and from a nearby rocket-propelled grenade detonation in Afghanistan on 22 April 2011, each with brief loss of consciousness or confusion and post-concussive symptoms. All three fell within the 5 years before onset, from 15 March 2007 to 15 March 2012, and all occurred in service.
Cause 3: being exposed to repeated low-level blast overpressure from explosive breaching or the firing of heavy weapons on at least 500 occasions within the 5 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- As a qualified breacher and range weapons instructor from 2008 to 2011 the veteran set and fired more than 400 explosive breaching charges and fired more than 300 rounds from shoulder-fired anti-armour weapons on courses, ranges and pre-deployment training, as recorded in his course and range logs. All of this was within the 5 years before onset and was part of his duties.
Cause 4: having a blood lead concentration of at least 0.48 micromoles per litre for at least 6 months within the 5 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- Health surveillance showed blood lead concentrations of 0.64 micromol/L on 14 May 2010, 0.72 micromol/L on 12 November 2010 and 0.81 micromol/L on 20 January 2011. His blood lead therefore stayed above 0.48 micromol/L for at least 8 months, from May 2010 to January 2011, within the 5 years before onset. The lead was absorbed from primer and projectile fume and dust on a covered small arms range where he instructed daily.
Cause 5: being exposed to organophosphate insecticides for at least 200 hours within the 5 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- From February to October 2011, during warlike service in Afghanistan, the veteran was the unit pest control operator and sprayed organophosphate insecticides around the patrol base for vector control two to three times a week, for two to three hours each time, with a cloth mask only. This amounts to about 250 hours of exposure, all within the 5 years before onset.
Cause 6: being exposed to organic solvents for at least 1,000 hours within the 10 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- From 2006 to 2012 the veteran cleaned and degreased weapons for one to two hours on most working days, and as a range instructor he cleaned the section and range weapons after each practice, using aromatic hydrocarbon solvent cleaners in a poorly ventilated armoury. His exposure exceeded 1,500 hours, all within the 10 years before onset, from 15 March 2002 to 15 March 2012.
Cause 7: having an episode of carbon monoxide poisoning with loss of consciousness or a carboxyhaemoglobin level of at least 20 percent within the 2 years before the clinical onset of attention deficit hyperactivity disorder; — MET
- On 18 September 2011, during warlike service in Afghanistan, generator exhaust vented beside the air inlet of his shipping-container sleeping quarters caused carbon monoxide poisoning. He briefly lost consciousness and his carboxyhaemoglobin was 24 per cent. This was 6 months before onset. Delayed neuropsychological sequelae of carbon monoxide poisoning include persisting deficits of attention and executive function.
Worsening factors
Worsening 1: having posttraumatic stress disorder at the time of the clinical worsening of attention deficit hyperactivity disorder; — MET
- A psychiatrist diagnosed posttraumatic stress disorder on 22 May 2014, arising from the blast on warlike service in Afghanistan on 14 July 2011. It was active, with nightmares and hypervigilance, at the worsening documented on 20 October 2017. Hyperarousal and intrusive symptoms add to inattention and impulsivity.
Worsening 2: having sleep restricted to less than 5 hours per day for at least the 3 months before the clinical worsening of attention deficit hyperactivity disorder; — MET
- During warlike service in the Middle East the veteran worked twelve-hour night shifts in an operations centre and slept four to five hours a day in shared accommodation, compounded by PTSD-related nightmares. This continued throughout the 3 months before the worsening, from 20 July 2017 to 20 October 2017.
Worsening 3: consuming an average of at least 40 grams of alcohol per day for at least the 6 months before the clinical worsening of attention deficit hyperactivity disorder; — MET
- The veteran drank an average of about 60 grams of alcohol a day from 2014, as recorded by the psychiatrist, to cope with his PTSD symptoms. He continued to drink at this level on rest days in the Middle East and after his return, including throughout the 6 months before the worsening, from 20 April 2017 to 20 October 2017.
Worsening 4: taking a sedating medication for at least the 3 months before the clinical worsening of attention deficit hyperactivity disorder; — MET
- The veteran took quetiapine 50 mg and temazepam 10 mg every night from 22 May 2014, prescribed for PTSD-related insomnia, and continued both throughout the 3 months before the worsening, from 20 July 2017 to 20 October 2017. Both drugs impair daytime attention and processing speed.
Worsening 5: inability to obtain appropriate clinical management for attention deficit hyperactivity disorder. — MET
- Dexamfetamine, a Schedule 8 stimulant, could not be supplied on deployment and was ceased on 15 February 2017, the day he deployed to the Middle East on warlike service. No alternative non-stimulant treatment or psychiatric review was available until his return. Over the seven months without treatment his ASRS score rose from 31 to 58. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The attention deficit hyperactivity disorder has contributed to the veteran's harmful alcohol use, his difficulty following treatment plans for posttraumatic stress disorder and his loss of civilian employment. Impulsivity has led to financial difficulty and relationship strain. These are sequelae of the condition and should be considered in any related claim.
Unintended Consequence
Met. The worsening in 2017 is in part an unintended consequence of quetiapine and temazepam, prescribed and paid for by Defence for the veteran's service-related posttraumatic stress disorder, which impair daytime attention, and of the withdrawal of his prescribed dexamfetamine when he was deployed (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From 15 February 2017 to his return from the Middle East on 30 September 2017 the veteran's diagnosed ADHD was untreated, because dexamfetamine could not be supplied on deployment and no alternative treatment or psychiatric review was arranged. His symptoms worsened, his ASRS score rose from 31 to 58 and he received two formal warnings. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational restrictions that prevent the supply of prescribed treatment amount to an inability to obtain appropriate clinical management. The delay of 17 months between his first presentation in April 2012 and the psychiatric diagnosis in September 2013 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 03 May 2008, Sports injury record, Medical Officer, Garrison health centre
- 19 Mar 2009, Training injury record, Medical Officer, Garrison health centre
- 12 Nov 2010, Lead health surveillance result, Occupational physician
- 20 Jan 2011, Lead health surveillance result, Occupational physician
- 14 Jul 2011, Trauma admission and CT brain report, Role 3 hospital, Afghanistan
- 18 Sep 2011, Role 2 medical facility record, Medical Officer, Afghanistan
- 02 Feb 2012, Post-operational psychological screen, Psychologist
- 02 Apr 2012, Outpatient health record, Medical Officer, Garrison health centre
- 28 Jun 2012, MRI brain, Radiologist
- 14 Jun 2013, Neuropsychological assessment, Clinical neuropsychologist
- 10 Sep 2013, Psychiatric assessment, Consultant psychiatrist
- 22 May 2014, Psychiatric review, Consultant psychiatrist
- 20 Oct 2017, Psychiatric review, Consultant psychiatrist
