Diagnostic Evaluation and Treatment Approach for ADHD
The diagnostic evaluation for ADHD requires a comprehensive clinical assessment using DSM-5 criteria with standardized rating scales from multiple informants (parents, teachers) across different settings, followed by treatment with FDA-approved medications (strongest evidence for stimulants) and/or evidence-based behavioral therapy, with the specific approach determined by age. 1
Diagnostic Evaluation
Core Assessment Components
- Use standardized DSM-5-based rating scales such as SNAP-IV or ADHD Rating Scale-IV 1
- Confirm symptoms cause significant impairment in at least two major settings (social, academic, or occupational) 1
- Collect reports from both parents and teachers due to low agreement between observers 1
- For adolescents, obtain multiple teacher reports as they typically have several teachers 1
DSM-5 Diagnostic Criteria
| Presentation | Symptoms Required | Evidence of Impairment |
|---|---|---|
| Inattentive | ≥6 inattention symptoms, <6 hyperactivity/impulsivity symptoms | Yes |
| Hyperactive/Impulsive | <6 inattention symptoms, ≥6 hyperactivity/impulsivity symptoms | Yes |
| Combined | ≥6 inattention symptoms, ≥6 hyperactivity/impulsivity symptoms | Yes |
Screening for Comorbidities
- Essential step: Screen for common comorbid conditions that can affect treatment approach 2, 1:
- Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use
- Developmental conditions: learning disabilities, language disorders, autism spectrum disorders
- Physical conditions: tics, sleep disorders, seizure disorders
Treatment Approach by Age Group
Preschool Children (4-5 years)
- First-line: Evidence-based parent training in behavior management (PTBM) 2, 1
- Second-line: Consider methylphenidate only if:
School-Age Children (6-11 years)
- Medication: Prescribe FDA-approved ADHD medications 2, 1
- Behavioral therapy: Implement parent and/or teacher-administered behavior therapy 2, 1
- Preferably use both medication and behavioral interventions 2
- Include educational interventions and supports as part of treatment plan 1
Adolescents (12-18 years)
- Medication: Prescribe FDA-approved ADHD medications with adolescent's assent 2, 1
- Behavioral therapy: May prescribe behavior therapy as treatment 2
- Special considerations:
Long-term Management
- Recognize ADHD as a chronic condition requiring ongoing care 2, 1
- Follow principles of the chronic care model and medical home approach 2
- Titrate medication doses to achieve maximum benefit with minimum adverse effects 2
- Maintain communication with school personnel and mental health clinicians 1
- Monitor for persistence of symptoms and functional impairment over time 1
Common Pitfalls to Avoid
- Inadequate assessment: Failing to gather information from multiple sources and settings
- Overlooking comorbidities: Missing common co-occurring conditions that affect treatment
- Premature treatment discontinuation: Increases risk for adverse outcomes including motor vehicle crashes, substance use disorders, depression, academic underachievement, and legal issues 1
- Insufficient monitoring: Not regularly evaluating response to treatment and adjusting as needed
- Focusing only on medication: Not implementing behavioral and educational interventions as part of comprehensive treatment
By following this structured approach to diagnosis and treatment, clinicians can effectively manage ADHD and improve outcomes for patients across the lifespan.