ADHD Assessment: Evidence-Based Approach
Initial Evaluation Criteria
Initiate an ADHD evaluation for any child or adolescent aged 4-18 years presenting with academic or behavioral problems accompanied by symptoms of inattention, hyperactivity, or impulsivity. 1
Diagnostic Requirements
Core Diagnostic Elements
Confirm DSM-IV/DSM-5 criteria are met, including documentation of impairment in more than one major setting (home, school, work, or social environments). 1, 2
Gather information from multiple informants: parents/guardians, teachers, other school personnel, and mental health clinicians involved in the patient's care. 1, 2 The clinical interview remains the cornerstone of diagnosis, but cannot stand alone. 3
Rule out alternative causes for symptoms before confirming ADHD diagnosis. 1
Use standardized behavior rating scales to systematically assess ADHD symptoms across settings, though these alone have adequate sensitivity but poor specificity and must be combined with clinical interview. 4, 5
Critical Pitfall to Avoid
Do not rely on clinical interview or rating scales alone—both have poor specificity when used in isolation. 5 The combination of structured interview, multi-informant rating scales, and assessment of functional impairment significantly improves diagnostic accuracy.
Mandatory Comorbidity Screening
Screen for coexisting conditions in every ADHD evaluation, as these alter treatment planning and are frequently present. 1, 2
Psychiatric Comorbidities to Assess
- Anxiety disorders and depression 1, 2, 6
- Oppositional defiant disorder and conduct disorders 1, 2, 6
- Substance use disorders (particularly critical in adolescents, who face higher risk when ADHD is untreated) 1, 2
Developmental and Learning Disorders
- Learning disabilities and language disorders 1, 2, 6
- Autism spectrum disorders and other neurodevelopmental conditions 2, 6
Physical Conditions
- Sleep disorders (especially sleep apnea, which can mimic and exacerbate ADHD symptoms) 1, 2
- Tic disorders 1, 2
- Seizure disorders 1, 2
The presence of comorbid conditions may alter ADHD treatment approach and may require subspecialist referral (child psychiatry, developmental-behavioral pediatrics, neurodevelopmental disability, child neurology, or psychology). 1
Age-Specific Assessment and Treatment Approaches
Preschool-Aged Children (4-5 years)
First-line treatment: Evidence-based parent training in behavior management (PTBM) and/or behavioral classroom interventions. 1, 2 This is a strong recommendation with quality of evidence A. 1
Consider methylphenidate only if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continuing functional disturbance. 1 This is quality of evidence B. 1
In areas lacking evidence-based behavioral treatments, weigh the risks of early medication initiation against the harm of delaying diagnosis and treatment. 1
Elementary School-Aged Children (6-11 years)
Prescribe FDA-approved ADHD medications (quality of evidence A, strong recommendation) AND/OR evidence-based parent/teacher-administered behavior therapy, preferably both. 1, 2
Medication hierarchy by evidence strength: Stimulant medications have the strongest evidence, followed by atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order). 1
The school environment and educational programming must be part of any treatment plan. 1
Adolescents (12-18 years)
Prescribe FDA-approved ADHD medications with the adolescent's assent (quality of evidence A, strong recommendation). 1, 2
May prescribe behavior therapy (quality of evidence C, recommendation), preferably both medication and therapy combined. 1
Mandatory substance use assessment: Adolescents with newly diagnosed ADHD must be screened for substance abuse symptoms and signs. 1, 2 When present, evaluation and treatment for addiction should precede ADHD treatment when possible, or careful concurrent treatment can begin if necessary. 1
Screen specifically for: anxiety, depression, learning disabilities, and substance use, as these are common adolescent comorbidities affecting treatment approach. 2
Chronic Disease Management Framework
Recognize ADHD as a chronic condition requiring ongoing management following chronic care model and medical home principles. 1, 2 This is a strong recommendation with quality of evidence B. 1
Medication Management
Titrate medication doses to achieve maximum benefit with minimum adverse effects. 1 This is quality of evidence B, strong recommendation. 1
Atomoxetine demonstrated statistically significant improvement in ADHD symptoms compared to placebo in multiple controlled trials, with mean final doses of approximately 1.6 mg/kg/day in children and 95 mg/day in adults. 7
Long-Term Monitoring Considerations
Untreated ADHD carries serious risks: increased early mortality, suicide risk, psychiatric comorbidity, lower educational achievement, and increased incarceration rates. 2
Treatment is frequently not maintained over time, and impairments often persist into adulthood. 2
Parents with ADHD themselves may need extra support to maintain consistent medication and behavioral program schedules. 2
Special Considerations for Adults
For adults presenting with suspected ADHD:
Obtain collateral information about childhood symptoms from parents or siblings to establish childhood onset. 3, 8
Assess current symptoms and impairment in at least two realms (home, work, social interactions) as required by DSM-IV criteria. 3
Use Wender Utah diagnostic criteria to address adult characteristics of the disorder. 8
Combine behavior rating scales with cognitive testing to significantly improve diagnostic specificity, as neither alone is sufficient. 5
Include symptom validity testing to detect invalid symptom presentation (reasonable sensitivity, very good specificity). 5
Poor psychosocial outcomes often result from unrecognized, untreated disorder and can serve as diagnostic indicators. 3