Screening for ADHD
Primary care clinicians should initiate an ADHD evaluation for any child or adolescent age 4 through 18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. 1
Who Should Be Screened
- Children and adolescents (ages 4-18 years) presenting with academic difficulties, behavioral problems, or symptoms of inattention, hyperactivity, or impulsivity warrant formal ADHD evaluation 1
- Adults may be evaluated if they report documented or reliably recalled manifestations of inattention or hyperactivity/impulsivity before age 12 years 2, 3
- There is insufficient evidence to recommend routine screening in children younger than 4 years, though parent training in behavior management may be considered for significant impairment 1
Diagnostic Process
The diagnosis requires meeting DSM-5 criteria with documentation of symptoms AND functional impairment in more than one major setting (home, school, work, social). 1, 2
Essential Diagnostic Components
- Symptom criteria: At least 6 symptoms of inattention and/or hyperactivity-impulsivity persisting for at least 6 months 2
- Age of onset: Symptoms must have been present before age 12 years 2, 3
- Multiple informants: Obtain information primarily from parents/guardians, teachers, other school personnel, and mental health clinicians involved in the patient's care 1
- Functional impairment: Document impairment in more than one major setting (social, academic, or occupational) 1, 2
- Rule out alternative causes: Exclude other medical, developmental, or psychiatric conditions that could explain symptoms 1
Screening Tools
- Behavior rating scales remain the standard of care for assessing diagnostic criteria 1
- Use validated screening tools completed by parents, teachers, or other adults to aid diagnosis 4
- For adults, retrospective assessment tools (such as the Wender-Utah Rating Scale) and current symptom inventories (such as CAARS or ASRS) can be helpful 5, 6
Comorbidity Screening
The evaluation must include systematic screening for comorbid conditions, as these are extremely common in ADHD. 1
Screen for:
- Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 2
- Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 1, 2
- Physical conditions: tics, sleep apnea 1, 2
Common Pitfalls to Avoid
- Failing to gather information from multiple sources and contexts (home AND school AND other settings) 2
- Neglecting to screen for comorbid conditions, which occur in a substantial percentage of ADHD patients 2
- Underdiagnosing girls who more commonly present with predominantly inattentive symptoms rather than hyperactive symptoms 2
- Inappropriately diagnosing ADHD when symptoms are better explained by another condition (anxiety, depression, learning disability, sleep disorder) 1
- In adults, failing to document childhood onset of symptoms before age 12 years 2, 3
Management Framework
ADHD should be recognized as a chronic condition requiring long-term management following chronic care model principles and the medical home approach. 1, 3