What are the steps to assess and screen for Attention Deficit Hyperactivity Disorder (ADHD)?

Steps to Assess and Screen for Attention Deficit Hyperactivity Disorder (ADHD)

The primary care clinician should follow a structured, evidence-based approach to assess for ADHD, including standardized rating scales, comprehensive evaluation of symptoms in multiple settings, and screening for comorbid conditions. 1, 2

Step 1: Initial Screening and Identification

• Initiate evaluation for any child or adolescent (4-18 years) presenting with:

  • Academic or behavioral problems
  • Symptoms of inattention, hyperactivity, or impulsivity 1
  • Poor school or social functioning 3

• Use age-appropriate standardized ADHD rating scales based on DSM-5 criteria:

  • For children: Vanderbilt, Conners, or SNAP-IV scales
  • For adolescents: Conners Adult ADHD Rating Scale or Adult ADHD Self-Report Scale (ASRS) 2
  • Collect ratings from multiple sources (parents, teachers, other caregivers)

Step 2: Comprehensive Clinical Evaluation

• Conduct a detailed clinical interview documenting:

  • Core ADHD symptoms (inattention, hyperactivity, impulsivity)
  • Age of onset (symptoms must be present before age 12) 2
  • Duration of symptoms (at least 6 months)
  • Severity and frequency of symptoms
  • Functional impairment across multiple settings (home, school, social)
  • Family history of ADHD or other psychiatric disorders 1, 2

• Obtain information from multiple sources:

  • Parents/guardians (required)
  • Teachers/school personnel (at least 2 teachers for school-aged children)
  • Mental health clinicians involved in the child's care 1
  • For adolescents: self-report and reports from multiple teachers 1

Step 3: Screen for Comorbid Conditions

• Screen for emotional/behavioral comorbidities:

  • Anxiety disorders
  • Depression
  • Oppositional defiant disorder
  • Conduct disorders
  • Substance use (especially in adolescents) 1, 2

• Screen for developmental comorbidities:

  • Learning disabilities
  • Language disorders
  • Autism spectrum disorders 1

• Screen for physical comorbidities:

  • Tic disorders
  • Sleep disorders (including sleep apnea)
  • Seizure disorders 1

Step 4: Rule Out Alternative Causes

• Medical conditions that may mimic ADHD:

  • Thyroid disorders
  • Lead toxicity
  • Hearing or vision problems
  • Seizure disorders

• Psychiatric conditions that may mimic ADHD:

  • Anxiety disorders
  • Mood disorders (including bipolar disorder)
  • Post-traumatic stress disorder
  • Substance use disorders 1, 2

Step 5: Confirm Diagnosis Using DSM-5 Criteria

• Verify that DSM-5 criteria are met:
  • Six or more symptoms of inattention and/or hyperactivity-impulsivity (5+ for adolescents ≥17 years)
  • Symptoms present in two or more settings
  • Clear evidence of functional impairment
  • Symptoms not better explained by another disorder 1, 2

Special Considerations for Different Age Groups

Preschool Children (4-5 years)

• More emphasis on behavioral observation
• Greater caution in diagnosis
• Consider developmental appropriateness of behaviors 1

School-Age Children (6-12 years)

• Obtain detailed school reports
• Document academic performance and classroom behavior
• Assess impact on peer relationships 1

Adolescents (12-18 years)

• Be aware that hyperactive symptoms may be less apparent
• Screen specifically for substance use, anxiety, depression, and learning disabilities
• Verify presence of symptoms before age 12
• Be alert to possibility of symptom feigning to obtain stimulant medication 1, 2

Documentation Requirements

• Document all of the following:
  • DSM-5 criteria fulfillment
  • Evidence of symptoms in multiple settings
  • Age of onset
  • Duration of symptoms
  • Degree of functional impairment
  • Alternative explanations considered and ruled out
  • Comorbid conditions identified 1

Common Pitfalls to Avoid

• Relying solely on parent or teacher reports without cross-verification
• Failing to screen for comorbid conditions that may alter treatment approach
• Diagnosing based on response to medication trials
• Using screening tools alone without comprehensive clinical evaluation 2
• Overlooking age-specific manifestations of symptoms (especially in adolescents) 1
• Misdiagnosing comorbid conditions, leading to inappropriate treatment 1

Following this structured approach ensures accurate diagnosis of ADHD, which is essential for developing appropriate treatment plans and improving long-term outcomes for affected individuals.