What are the appropriate tests for diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in children?

Appropriate Testing for Diagnosing ADHD in Children

The primary care clinician should diagnose ADHD using DSM-5 criteria, with documentation of symptoms and impairment in more than one setting (social, academic, or occupational), obtaining information primarily from parents/guardians, teachers, and other school personnel through standardized rating scales and interviews. 1

Diagnostic Approach for ADHD

Core Assessment Components

• Initiate evaluation for any child 4-18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity 1
• Determine that DSM-5 criteria have been met, documenting symptoms and impairment in more than one major setting 1
• Rule out alternative causes for symptoms before confirming ADHD diagnosis 1
• Collect information from multiple sources including parents/guardians, teachers, and other school personnel 1

Recommended Assessment Tools

• DSM-5-based ADHD rating scales completed by parents and teachers are the most efficient and effective assessment method 1, 2
• Both parent and teacher ratings are necessary for accurate clinical diagnosis 3
• Common validated rating scales include:
  • ADHD Rating Scale-5 1
  • Conners' Parent Rating Scale (CPRS) 2, 4
  • Conners' Teacher Rating Scale (CTRS) 2, 4
  • Child Behavior Checklist (CBCL) 2

Important Considerations by Age Group

• For preschool-aged children (4-5 years):

  • Conduct clinical interview with parents 1
  • Examine and observe the child 1
  • Use DSM-based ADHD rating scales with preschool norms when available 1
  • Be aware of challenges in determining symptoms across multiple settings, especially for children not in preschool or childcare 1

• For school-aged children (6-12 years) and adolescents (12-18 years):

  • Obtain information from both parents and teachers using standardized rating scales 1, 5
  • For adolescents, include self-report measures and assessment for substance use 5
  • Parent ratings of childhood ADHD symptoms are particularly important for accurate diagnosis 6

Screening for Comorbid Conditions

• Assessment for other conditions that might coexist with ADHD is essential 1, 5
• Screen for emotional or behavioral disorders:
  • Anxiety disorders 5
  • Depression 5
  • Oppositional defiant disorder 5
  • Conduct disorder 5
• Evaluate for developmental and learning disorders:
  • Learning disabilities 5
  • Language disorders 5
  • Other neurodevelopmental disorders 5
• Assess for physical conditions:
  • Sleep disorders, particularly sleep apnea 5
  • Tics 5
  • Seizures 5

Common Pitfalls to Avoid

• Relying solely on rating scales without comprehensive assessment - rating scales have high sensitivity (83.5%) but poor specificity (35.7%) when used alone 4
• Failing to obtain information from multiple sources (parents, teachers, and other observers) 1
• Not assessing for comorbid conditions that can mimic or exacerbate ADHD symptoms 5, 7
• Using neuropsychological testing for diagnosis - this has not been found to improve diagnostic accuracy in most cases 1
• Neglecting to document impairment across multiple settings as required by DSM-5 1

Diagnostic Algorithm

1. Collect information using DSM-5-based rating scales from both parents and teachers 1
2. Conduct clinical interviews with parents to assess symptoms, developmental history, and functioning 1
3. Examine the child and observe behavior when possible 1
4. Screen for comorbid conditions that may mimic or coexist with ADHD 5
5. Rule out alternative causes for symptoms 1
6. Confirm that DSM-5 criteria are met with symptoms present in more than one setting 1
7. Document specific impairments in social, academic, or occupational functioning 1

The evidence strongly supports that proper diagnosis requires systematic collection of information from multiple sources using standardized rating scales based on DSM-5 criteria, with careful attention to documenting impairment across settings and ruling out alternative explanations for symptoms 1, 3.