From the Guidelines
The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in adults should be approached with a comprehensive clinical evaluation, starting with the Adult ADHD Self-Report Scale (ASRS-V1.1) to screen for symptoms, followed by a thorough clinical interview and assessment of functional impairment across different settings, as recommended by the most recent guidelines 1. The process of diagnosing ADHD in adults involves several key steps, including:
- A thorough clinical interview to explore current symptoms, developmental history, and functional impairment across different settings
- The use of standardized rating scales, such as the ASRS-V1.1, to provide valuable supplementary information
- Assessment for the presence of core ADHD symptoms (inattention, hyperactivity, impulsivity) that have persisted since childhood
- Review of educational, occupational, and relationship history to identify patterns of impairment
- Careful examination of medical and psychiatric history to rule out other conditions that might better explain the symptoms Key diagnostic criteria for ADHD, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, include:
- An ongoing pattern of inattentive and/or hyperactive-impulsive symptoms—at least 6 months
- Multiple inattentive and/or hyperactive-impulsive symptoms—5 or more (for age 17 years; 6 or more are required for age <17 years)
- Several inattentive and/or hyperactive-impulsive symptoms with an onset before the age of 12 years
- Several inattentive and/or hyperactive-impulsive symptoms that are present in 2 or more settings (e.g., home, work)
- Evidence that inattentive and/or hyperactive-impulsive symptoms interfere with or reduce the quality of functioning (e.g., interpersonal, occupational) 1. It is essential to note that the diagnosis of ADHD in adults should be made by a qualified healthcare professional, typically a psychiatrist, psychologist, or physician with expertise in adult ADHD, and should follow established guidelines requiring symptoms to be present in multiple settings, cause significant impairment, and not be better explained by another mental disorder 1.
From the Research
Diagnosing ADHD in Adult Patients
To diagnose Attention Deficit Hyperactivity Disorder (ADHD) in adult patients, the following steps can be taken:
- Conduct a comprehensive clinical interview to review representative symptoms starting in childhood that continue to cause impairment into adulthood 2
- Use a structured diagnostic interview with the patient, and collect informant ratings from family, friends, coworkers, or school records 3
- Utilize adult-specific diagnostic scales, such as behavior rating scales, symptom validity tests, and cognitive tests, to augment the clinical interview and improve diagnostic accuracy 4
- Apply the "or rule" to integrate informant reports, and enforce the impairment criterion to provide checks and balances 3
- Chronicle a symptom timeline to understand the persistence and impact of symptoms 3
- Rule out alternative explanations for symptoms, and finalize the diagnosis based on the comprehensive evaluation 3
Assessment Measures
The following assessment measures can be used to diagnose ADHD in adult patients:
- Clinical interviews, which have adequate sensitivity but poor specificity 4
- ADHD behavior rating scales, which have adequate sensitivity but poor specificity 4
- Symptom validity tests, which have reasonably good sensitivity and very good specificity in detecting invalid symptom presentation 4
- Cognitive tests, which have inadequate sensitivity and specificity in identifying ADHD, but can be useful when used in conjunction with behavior rating scales 4
Diagnostic Procedure
A systematic, stepped diagnostic procedure can be used to diagnose ADHD in adult patients, which includes:
- A structured diagnostic interview with the patient 3
- Collection of informant ratings 3
- Casting a wide net on symptoms using the "or rule" 3
- Providing checks and balances on the "or rule" by enforcing the impairment criterion 3
- Chronicling a symptom timeline 3
- Ruling out alternative explanations for symptoms 3
- Finalizing the diagnosis 3
Treatment Options
Once a diagnosis of ADHD is made, treatment options can be considered, including:
- First-line pharmacological treatment options, such as methylphenidate and lisdexamfetamine 5
- Second-line treatments, such as atomoxetine, for those who cannot tolerate or do not respond to first-line treatments 5
- Combination pharmacotherapy, which may be necessary in certain situations, such as partial response, dose-limiting side effects, associated disorders, and comorbid diagnoses 6