What is the recommended approach to assess for Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Assessment: Evidence-Based Approach

Primary care clinicians should initiate ADHD evaluation for any child or adolescent aged 4-18 years presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity, using DSM-5 criteria verified through standardized rating scales from multiple informants (parents and at least 2 teachers), combined with clinical interview and systematic screening for comorbid conditions. 1, 2, 3

Core Diagnostic Requirements

The diagnosis requires meeting ALL of the following DSM-5 criteria 2, 4:

• At least 6 symptoms of inattention and/or hyperactivity-impulsivity persisting for ≥6 months 4
• Symptom onset before age 12 years (must be documented, even when evaluating adolescents or adults) 2, 4
• Functional impairment documented in ≥2 major settings (home, school, work, social relationships) 2, 4, 3
• Alternative causes ruled out through clinical interview and examination 2, 4

Systematic Assessment Process

Step 1: Multi-Informant Rating Scales (Essential Foundation)

Use DSM-based standardized rating scales from both parents AND teachers - this is the most efficient and evidence-based assessment method 2, 5:

• Ages 6-12 years: Vanderbilt ADHD Rating Scales (parent and teacher versions) are specifically recommended by the American Academy of Pediatrics 2
• Ages 4-5 years: Use Conners Rating Scale-IV Preschool Version or ADHD Rating Scale-IV with preschool normative data 1, 2
• Ages 12-18 years: Obtain information from at least 2 teachers, coaches, school counselors, or community activity leaders (adolescents minimize their own symptoms) 1

Critical point: Rating scales systematically collect symptom information but do NOT diagnose ADHD by themselves - they must be combined with clinical interview and impairment documentation 2, 5

Step 2: Clinical Interview (Cornerstone of Assessment)

Conduct structured clinical interviews with 6, 7:

• Parents/caregivers: Document specific examples of symptoms in home setting, onset timing, developmental history, and family psychiatric history 6
• Child/adolescent: Direct observation of behavior, assessment of insight into difficulties, and for adolescents specifically screen for substance use, depression, anxiety, and risky sexual behaviors 1
• Verify impairment: Obtain concrete examples of academic struggles (grades, homework completion, teacher feedback), social difficulties (peer relationships, extracurricular participation), and family conflicts 2, 3

Step 3: Mandatory Comorbidity Screening

The American Academy of Pediatrics strongly recommends systematic screening for coexisting conditions that alter treatment approach 1, 2:

Emotional/Behavioral conditions 1, 2:

• Anxiety disorders
• Depression
• Oppositional defiant disorder
• Conduct disorder
• Substance use (especially in adolescents - screen BEFORE treating ADHD if positive) 1

Developmental conditions 1, 2:

• Learning disabilities (reading, math, written expression)
• Language disorders
• Autism spectrum disorder

Physical conditions 1, 2:

• Tic disorders
• Sleep disorders (sleep apnea, insomnia)
• Seizure disorders

Use the AAP Task Force on Mental Health toolkit for systematic comorbidity assessment 1

Age-Specific Assessment Modifications

Preschool-Aged Children (4-5 years)

• Challenge: Observing symptoms across multiple settings when child doesn't attend preschool/daycare 1
• Solution: Refer to early intervention programs or enroll in parent-administered behavior therapy BEFORE finalizing diagnosis - evaluators can serve as additional observers 1
• Recommendation: Complete parent-administered behavior therapy first, then reassess with rating scales, as intervention results inform diagnostic evaluation 1

Adolescents (12-18 years)

• Challenge: Multiple teachers, less parental observation, adolescents minimize symptoms, hyperactivity becomes less overt 1
• Solution: Obtain information from ≥2 teachers plus coaches/counselors/activity leaders; do NOT rely on adolescent self-report alone 1
• Critical screening: Unusual for adolescents with attention/behavior problems to have NO prior ADHD concerns - establish why younger manifestations were missed and strongly consider substance use, depression, anxiety as alternative or co-occurring diagnoses 1

Common Diagnostic Pitfalls to Avoid

• Relying solely on questionnaire scores without clinical interview and multi-informant data 2
• Failing to gather information from multiple settings (home AND school minimum) 2, 4
• Not screening for comorbid conditions that may complicate or contraindicate standard treatment 1, 2, 4
• Underdiagnosing girls who present with predominantly inattentive symptoms rather than hyperactivity 4
• Missing substance abuse in adolescents - when present, addiction treatment must precede or be carefully coordinated with ADHD treatment 1

When to Refer to Subspecialists

Refer to child psychiatrists, developmental-behavioral pediatricians, or child psychologists when 1:

• Severe mood or anxiety disorders coexist
• Diagnostic uncertainty after comprehensive primary care evaluation
• Multiple complex comorbidities requiring specialized management
• Treatment resistance to standard interventions

Chronic Care Management Framework

Recognize ADHD as a chronic condition requiring ongoing coordinated care following medical home principles 1, 3:

• Establish continuous systematic follow-up
• Develop communication systems with schools
• Monitor treatment response using the same rating scales for consistency 2
• Address comorbid conditions through treatment or appropriate referral 3