ADHD Assessment: Structured Diagnostic Approach
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, using DSM-5 criteria with documentation of functional impairment in more than one major setting. 1, 2
Core Diagnostic Requirements
The diagnosis requires meeting all of the following criteria 1, 2:
- DSM-5 symptom criteria documented through standardized behavior rating scales (the standard of care) 1, 2
- Age of onset before age 12 years, verified through patient report or collateral information from family members 3
- Multiple informants providing information from different settings 2, 4
- Functional impairment documented in more than one major setting (home, school, work, social relationships) 1, 2
- Rule out alternative causes through comprehensive evaluation 2, 4
Mandatory Comorbidity Screening
You must systematically screen for coexisting conditions in every ADHD evaluation, as the majority of patients with ADHD meet diagnostic criteria for another mental disorder. 1 This is a Grade B strong recommendation that fundamentally alters treatment planning. 1
Required Screening Categories
Screen for these three domains 1:
- Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1
- Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 1
- Physical conditions: tics, sleep apnea, sleep disorders 1
Critical Adolescent-Specific Screening
For adolescents (age 12-18 years), you must assess for substance use, anxiety, depression, and learning disabilities at minimum, as these four comorbid conditions fundamentally affect treatment sequencing. 1 When substance use is identified, evaluation and treatment for addiction should precede ADHD treatment when possible, or careful ADHD treatment can begin if necessary. 1
Chronic Disease Management Framework
Recognize ADHD as a chronic condition requiring long-term management following chronic care model principles and the medical home approach. 1, 2 This is a Grade B strong recommendation based on evidence that ADHD causes symptoms and dysfunction over long periods, even into adulthood, and available treatments address symptoms but are usually not curative. 1
Essential Management Components
Implement these chronic care elements 1, 2:
- Continuous coordinated care with systematic follow-up rather than episodic visits 1, 2
- Bidirectional communication systems with teachers and school personnel 1
- Treatment or referral for identified comorbid conditions 1, 2
- Subspecialist referral when severe mood disorders, anxiety disorders, or complex comorbidities are present (to child psychiatrists, developmental-behavioral pediatricians, neurodevelopmental disability physicians, child neurologists, or child/school psychologists) 1
Critical Pitfalls to Avoid
The major risk in ADHD assessment is misdiagnosing coexisting conditions and providing inappropriate care. 1 Missing comorbid substance use disorders fundamentally changes the treatment approach and requires stabilization first. 3
Treatment discontinuation places individuals with ADHD at higher risk for catastrophic outcomes including motor vehicle crashes, criminality, depression, and other injuries. 1 Untreated or undertreated ADHD carries serious risks including increased mortality, suicide, psychiatric comorbidity, lower educational achievement, and incarceration. 1, 3
Never treat ADHD as an acute, self-limited condition—it requires ongoing management like any chronic disease, as treatments are frequently not maintained over time and impairments persist into adulthood. 1, 3