What are the diagnostic criteria and assessment tools for adult Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

Adult ADHD diagnosis should be based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, which requires at least five symptoms of inattention and/or hyperactivity-impulsivity, and the use of assessment tools such as the Adult ADHD Self-Report Scale (ASRS) as the initial screening step. The diagnosis of adult Attention Deficit Hyperactivity Disorder (ADHD) involves a comprehensive evaluation of the patient's symptoms, developmental history, and functional impairment across multiple settings 1.

Diagnostic Criteria

The DSM-5 criteria for ADHD include:

• An ongoing pattern of inattentive and/or hyperactive-impulsive symptoms for at least six months
• Multiple inattentive and/or hyperactive-impulsive symptoms (five or more for adults)
• Symptoms must have been present before the age of 12
• Symptoms must be present in two or more settings (e.g., home, work)
• Evidence that symptoms interfere with or reduce the quality of functioning (e.g., interpersonal, occupational)

Assessment Tools

Common assessment tools for adult ADHD include:

• Structured clinical interviews
• Standardized rating scales like the Adult ADHD Self-Report Scale (ASRS) 1
• Conners' Adult ADHD Rating Scales (CAARS)
• The Wender Utah Rating Scale (WURS) for childhood symptoms

Evaluation Process

A comprehensive evaluation for adult ADHD typically involves:

• A clinical interview covering developmental history, current symptoms, and functional impairment across multiple settings
• Neuropsychological testing to assess executive functioning, attention, and memory
• Differential diagnosis to rule out other conditions with similar symptoms, such as anxiety, depression, or learning disorders
• Collateral information from family members or significant others who knew the person during childhood
• Medical evaluation, including physical examination and laboratory tests to rule out medical conditions that could mimic ADHD symptoms 1

Initial Screening

The initial screening step for adult ADHD should involve the use of the Adult ADHD Self-Report Scale (ASRS) part A, which asks patients to indicate the frequency of a variety of symptoms, and a screen is considered positive when a patient checks often or very often for 4 or more of the 6 questions 1. This initial screening can help identify patients who may require further evaluation for ADHD.

From the FDA Drug Label

A diagnosis of ADHD (DSM-IV) implies the presence of hyperactive-impulsive or inattentive symptoms that cause impairment and that were present before age 7 years. The symptoms must be persistent, must be more severe than is typically observed in individuals at a comparable level of development, must cause clinically significant impairment, e.g., in social, academic, or occupational functioning, and must be present in 2 or more settings, e.g., school (or work) and at home. For the Inattentive Type, at least 6 of the following symptoms must have persisted for at least 6 months: lack of attention to details/careless mistakes, lack of sustained attention, poor listener, failure to follow through on tasks, poor organization, avoids tasks requiring sustained mental effort, loses things, easily distracted, forgetful For the Hyperactive-Impulsive Type, at least 6 of the following symptoms must have persisted for at least 6 months: fidgeting/squirming, leaving seat, inappropriate running/climbing, difficulty with quiet activities, “on the go,” excessive talking, blurting answers, can’t wait turn, intrusive. For a Combined Type diagnosis, both inattentive and hyperactive-impulsive criteria must be met.

To diagnose adult ADHD, the following diagnostic criteria must be met:

• Presence of hyperactive-impulsive or inattentive symptoms that cause impairment
• Symptoms must be persistent and more severe than typically observed
• Symptoms must cause clinically significant impairment in social, academic, or occupational functioning
• Symptoms must be present in 2 or more settings The assessment tools for adult ADHD include:
• A complete history and evaluation of the patient
• Use of medical, psychological, educational, and social resources
• Evaluation of the presence of at least 6 symptoms of inattentive or hyperactive-impulsive type that have persisted for at least 6 months 2

From the Research

Diagnostic Criteria for Adult ADHD

The diagnostic criteria for Adult Attention Deficit Hyperactivity Disorder (ADHD) are primarily based on the behavior in childhood, including age-inappropriate and impairing levels of hyperactivity, impulsivity, and inattention 3. However, other symptoms such as mood instability and frustration intolerance are not included in the current criteria but are prevalent in adults with ADHD.

Assessment Tools for Adult ADHD

Several assessment tools are used to diagnose adult ADHD, including:

• Conners Adult ADHD Rating Scales (CAARS) 4, 5, 6: a self-report and observer-rated questionnaire that is considered the international standard for questionnaire assessment of ADHD.
• ASRS Screening Scale 7: a screening scale that was updated in 2017 to reflect the changes made to identify ADHD based on the DSM-5 criteria.
• Clinical interviews: a comprehensive clinical interview is essential in the diagnostic assessment of adult ADHD, including rating scales for past and present symptoms and collateral information from multiple informants 3.

Factors to Consider in Diagnostic Assessment

The diagnostic assessment of adult ADHD should consider the following factors:

• Comorbidities: ADHD is often comorbid with other psychiatric disorders, such as anxiety and personality disorders, as well as substance abuse 3.
• Neuropsychological functions: assessment of neuropsychological functions is important to understand the symptom patterns and develop targeted treatment programs 3.
• Gender and age differences: the diagnostic criteria and assessment tools should take into account the differences in symptoms and presentation between men and women, as well as across different age groups 4, 5.
• Non-credible symptom report: the use of validity indices, such as the Conners' Adult ADHD Rating Scales Infrequency Index, can help detect non-credible self-report and feigned ADHD 6.