What is the next step in managing a patient with a moderately high score on the Attention Deficit Hyperactivity Disorder (ADHD) questionnaire and an average score on the Quiet Brain (QB) test?

ADHD Diagnosis with Discordant Screening Results

When ADHD questionnaire scores are moderately high but objective testing (QB test) is average, proceed with comprehensive clinical evaluation using DSM-5 criteria, gathering collateral information from multiple settings, as the diagnosis of ADHD is fundamentally clinical and does not depend on computerized test results. 1

Understanding the Discordance

The QB test has demonstrated poor diagnostic validity for ADHD, particularly in adolescent populations with neurodevelopmental concerns. Research shows the QB test achieved area under curve (AUC) scores of only 0.48-0.64, indicating random to poor validity, and failed to differentiate ADHD from other neurodevelopmental conditions. 2 Clinicians should be aware that computerized tests like the QB have dubious discriminating power and should not override clinical judgment. 2

Rating scales and computerized tests serve only to systematically collect symptom information—they do not diagnose ADHD by themselves. 3 The American Academy of Pediatrics explicitly states that diagnosis requires a comprehensive evaluation beyond questionnaire scores. 3

Next Steps in Diagnostic Evaluation

Verify DSM-5 Criteria

Determine whether DSM-5 criteria are met, including documentation of impairment in more than one major setting (home, school, work, social). 1, 3 This requires:

• Symptoms present before age 12 years and persisting for at least 6 months 3
• Five or more symptoms of inattention and/or hyperactivity-impulsivity (for those under 17 years; four or more for adults 17+) 1
• Functional impairment documented in at least two settings through information from parents, teachers, and other observers 1, 3

Gather Multi-Informant Data

Obtain information from multiple sources across different settings, as this is essential for proper diagnosis. 1 Specifically:

• Complete Part B of the ASRS (Adult ADHD Self-Report Scale) to further elucidate symptoms 1
• Have someone who knows the patient well (parent, spouse, teacher) complete the ASRS with the patient in mind 1
• Use teacher ratings of ADHD symptoms using validated, age- and sex-normed instruments 1
• Obtain Vanderbilt ADHD Rating Scales from both parents and teachers for children ages 6-12 3

Assess Functional Impairment

Use a functional impairment scale such as the Weiss Functional Impairment Rating Scale-Self (WFIRS-S), which was specifically developed and validated to measure ADHD-specific impairment. 1 Adults with ADHD often display difficulties in:

• Managing home responsibilities (cooking, cleaning) 1
• Keeping track of appointments 1
• Planning and organization 1
• Time management 1

Screen for Comorbid Conditions

Systematically assess for comorbid conditions that may alter treatment approach or explain symptoms. 1, 3 Essential screening includes:

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 3
• Developmental conditions: learning and language disorders, autism spectrum disorders 1, 3
• Physical conditions: tics, sleep disorders 1, 3

The majority of individuals with ADHD meet diagnostic criteria for another mental disorder, making this screening critical. 1

Rule Out Alternative Causes

Conduct clinical interview and examination to rule out alternative explanations for symptoms. 1, 3 QB test scores may correlate with IQ and other cognitive factors rather than ADHD specifically. 2

Clinical Decision-Making

If DSM-5 criteria are met with documented impairment in multiple settings, make the ADHD diagnosis regardless of QB test results. 1, 3 The diagnosis is clinical, not test-based. 4

If criteria are not fully met, consider:

• Subthreshold ADHD (problem-level inattention or hyperactivity/impulsivity) that may still benefit from chronic illness management principles 1
• Alternative diagnoses that better explain the symptom pattern
• Comorbid conditions masquerading as or exacerbating attention problems 1

Treatment Initiation (Once Diagnosed)

For patients meeting full diagnostic criteria with moderate-to-severe impairment:

Age-Specific Recommendations

• Ages 6-11 years: Prescribe FDA-approved medications for ADHD along with parent-administered behavior therapy and/or behavioral classroom intervention (preferably both) 1, 3
• Ages 12-18 years: Prescribe FDA-approved medications with the adolescent's assent, combined with evidence-based behavioral interventions if available 1, 3
• Adults: Prescribe FDA-approved stimulant medications, as approximately 60% show moderate-to-marked improvement compared with 10% on placebo 5

Medication Options

Stimulant medications (methylphenidate, amphetamine) are first-line with strongest evidence. 1, 6 Atomoxetine is an alternative non-stimulant option with sufficient but less strong evidence. 1, 6

Common Pitfalls to Avoid

• Relying solely on computerized test results like the QB test for diagnosis 2, 4
• Failing to gather information from multiple sources and settings 3
• Not screening for comorbid conditions that complicate the clinical picture 1, 3
• Delaying treatment in patients with documented significant impairment while pursuing additional testing 1
• Overlooking functional impairment assessment beyond symptom counts 1