What is the recommended approach for evaluating and treating an adult patient presenting for an Attention Deficit Hyperactivity Disorder (ADHD) evaluation?

ADHD Evaluation in Adults

Begin with the Adult ADHD Self-Report Scale (ASRS) as your initial screening tool, then confirm diagnosis using DSM-5 criteria requiring documentation of symptoms causing impairment in at least two settings (work, home, social), with evidence of symptom onset before age 12. 1

Initial Screening Approach

• Use the ASRS screener which can be completed in 3-5 minutes to identify adults who warrant full diagnostic evaluation 2
• The ASRS Part A serves as the initial screen; if positive, proceed to Part B for comprehensive symptom assessment 1
• Consider additional validated scales including Conners' Adult ADHD Rating Scales or Brown Attention-Deficit Disorder Scale for Adults to supplement clinical assessment 3
• Important caveat: Self-report scales have high sensitivity (78-92%) but poor specificity, incorrectly identifying 36-67% of non-ADHD patients as positive, so never diagnose based on screening tools alone 4

Comprehensive Diagnostic Evaluation

Establish DSM-5 Criteria

You must document all of the following 1:

• Five or more symptoms of inattention and/or hyperactivity-impulsivity persisting for at least 6 months
• Symptom onset before age 12 - obtain childhood report cards, speak with parents, or review documented history 1
• Impairment in at least two settings (occupational, social, academic) - gather information from multiple sources 1
• Symptoms directly cause functional impairment and are not better explained by another mental disorder 1

Collateral Information is Essential

• Obtain reports from someone who knows the patient well (spouse, parent, close friend) by having them complete the ASRS with the patient in mind 1
• Request information from employers, coworkers, or review work performance evaluations when possible 2
• Use the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) to measure ADHD-specific impairment in daily functioning 1

Critical Differential Diagnosis and Comorbidity Screening

Screen for these conditions that commonly mimic or co-occur with ADHD 1:

Psychiatric Comorbidities (Present in Majority of ADHD Adults)

• Depression and anxiety disorders - symptoms overlap substantially with ADHD inattention 1, 5
• Substance use disorders - both active use and history, as substances can mimic ADHD symptoms 1
• Bipolar disorder - stimulants can precipitate manic episodes if misdiagnosed 6
• Personality disorders - particularly borderline and antisocial patterns 5

Medical Conditions to Rule Out

• Sleep disorders (sleep apnea, insomnia) - cause daytime inattention and fatigue 1
• Thyroid dysfunction - can present with concentration difficulties 5
• Traumatic brain injury or neurological conditions 5

Key Clinical Interview Elements

• Establish childhood onset by asking: "Can you describe what you were like as a child in school? Did teachers comment on your attention or behavior?" 1
• Document chronicity: "Have these symptoms been present continuously since childhood, or did they start recently?" 1
• Assess functional impairment: "How do these symptoms affect your job performance, relationships, and daily responsibilities?" 1
• Rule out recent stressors: New-onset symptoms in adulthood suggest alternative diagnoses like adjustment disorder or depression 5

Common Diagnostic Pitfalls to Avoid

• Do not diagnose ADHD based solely on self-report scales - they lack specificity and cannot differentiate ADHD from anxiety/depression 4, 7
• Do not use neuropsychological testing routinely - it does not improve diagnostic accuracy for ADHD, though it may clarify learning strengths/weaknesses 1
• Do not overlook substance use - marijuana and stimulant misuse can mimic or mask ADHD symptoms 1
• Do not assume adult-onset symptoms are ADHD - true ADHD requires childhood onset before age 12; new symptoms suggest mood/anxiety disorders 1
• Beware of patients seeking stimulants for performance enhancement rather than genuine impairment 1

Documentation Requirements for Diagnosis

Document the following in your evaluation 1:

• Specific DSM-5 symptoms present (list which of the 18 symptoms are endorsed)
• Age of onset with supporting evidence from childhood
• Settings where impairment occurs with concrete examples
• Degree of functional impairment in work, relationships, daily activities
• Comorbid conditions identified or ruled out
• Collateral information sources and their observations

When to Refer to Psychiatry

Consider referral for 1, 6:

• Diagnostic uncertainty after comprehensive evaluation
• Multiple comorbid psychiatric conditions requiring complex medication management
• Treatment-resistant cases or previous medication failures
• Active suicidal ideation or severe mood symptoms
• Suspected bipolar disorder or psychotic features
• Active substance use disorder requiring specialized treatment