ADHD Diagnostic Evaluation and Treatment
Diagnostic Evaluation Process
The ADHD diagnostic evaluation requires DSM-5 criteria verification through standardized rating scales from multiple informants (parents and at least 2 teachers for children/adolescents), combined with clinical interview to document functional impairment in ≥2 settings and systematic screening for comorbid conditions. 1
Core Diagnostic Requirements
Meet ALL DSM-5 criteria: At least 6 symptoms of inattention and/or hyperactivity-impulsivity persisting ≥6 months, symptom onset before age 12 years, functional impairment documented in ≥2 major settings (home, school/work, social), and alternative causes ruled out through clinical interview 1
For adults: Documented or reliably reported manifestations of inattention or hyperactivity/impulsivity before age 12 years must be established, using collateral childhood information from parents or siblings 2, 3
Rating scales alone cannot diagnose ADHD - they must be combined with clinical interviews and multi-informant reports 3
Multi-Informant Assessment
Obtain standardized DSM-based rating scales from parents AND at least 2 teachers (or coaches/counselors/activity leaders for adolescents) 1
For preschool children (ages 4-5), use Conners Rating Scale-IV Preschool Version or ADHD Rating Scale-IV with preschool normative data 1
Clinical interview remains the cornerstone to verify DSM-5 criteria, establish symptom onset, and document functional impairment across multiple settings 3, 1
Mandatory Comorbidity Screening
Screen systematically for coexisting conditions that alter treatment approach, including: 4, 1
Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 4
Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 4
Physical conditions: tics, sleep apnea, seizures 4
For adolescents (ages 12-18): At minimum, assess for substance use, anxiety, depression, and learning disabilities - all 4 are common comorbidities that affect treatment sequencing 4
Critical Diagnostic Pitfalls to Avoid
Never rely solely on questionnaire scores without clinical interview and multi-informant data 1
Never fail to gather information from multiple settings - impairment must be documented in ≥2 major settings 1
Never skip comorbidity screening - the majority of patients with ADHD meet criteria for another mental disorder, which alters treatment approach 4
For adolescents presenting for first diagnosis: Rule out substance use (marijuana can mimic ADHD), depression, and anxiety as primary causes, and verify symptoms existed before age 12 4
Treatment Approach
ADHD must be managed as a chronic condition requiring long-term management following chronic care model principles within a medical home framework. 4, 3
Age-Specific Treatment Recommendations
Preschool children (ages 4-5): Evidence-based parent/teacher behavior therapy as first-line treatment 3
Elementary school children and adolescents: FDA-approved medications and/or evidence-based behavior therapy 3
Adults: Prioritize treatment of active substance use disorders before initiating stimulants, and address severe mood symptoms requiring stabilization 2, 3
Treatment Sequencing for Comorbidities
When substance use disorder is present: Treat active substance use disorders BEFORE initiating stimulants 2
When severe mood symptoms exist: Stabilize mood symptoms before or concurrent with ADHD treatment 2
Monitor for stimulant abuse risk in patients with substance use history throughout treatment 2
Chronic Care Management Requirements
Establish continuous systematic follow-up using the same rating scales for consistency in monitoring treatment response 1
Develop bidirectional communication systems with schools and mental health clinicians involved in the patient's care 4
Address comorbid conditions through treatment or appropriate referral, as these alter the treatment approach 1
Recognize that treatment discontinuation places patients at higher risk for catastrophic outcomes including motor vehicle crashes, criminality, depression, and other injuries 4
Medication Considerations
For children and adolescents up to 70 kg: Atomoxetine (non-stimulant option) should be initiated at 0.5 mg/kg/day and increased after minimum 3 days to target dose of 1.2 mg/kg/day, with maximum daily dose not exceeding 1.4 mg/kg/day or 100 mg 5
Black box warning for atomoxetine: Increased risk of suicidal ideation in children/adolescents (0.4% vs 0% placebo) - monitor closely for suicidality, clinical worsening, or unusual behavioral changes 5
Atomoxetine can be administered once daily in the morning or as divided doses morning and late afternoon/early evening 5