What is the recommended approach for managing Attention Deficit Hyperactivity Disorder (ADHD) in individuals across the lifespan, considering their medical history, current medications, and potential comorbid conditions?

Understanding the DIVA Questionnaire for ADHD Assessment

What is the DIVA?

The DIVA (Diagnostic Interview for ADHD in adults) is a structured diagnostic tool specifically designed to assess ADHD symptoms across the lifespan, with particular emphasis on establishing childhood onset and current adult manifestations. 1

The questionnaire systematically evaluates both retrospective childhood symptoms (before age 7, now updated to age 12 in DSM-5) and current adult functioning across multiple domains. 1

Core Components of ADHD Assessment Using DIVA

Childhood Symptom Documentation

• The DIVA requires documentation that core ADHD symptoms (inattention, hyperactivity, impulsivity) were present before age 7 years, as this childhood onset is essential for diagnosis. 1
• At least 6 symptoms from either the inattentive or hyperactive-impulsive domain must have persisted for at least 6 months during childhood. 2
• For inattentive type: lack of attention to details/careless mistakes, lack of sustained attention, poor listener, failure to follow through on tasks, poor organization, avoids tasks requiring sustained mental effort, loses things, easily distracted, forgetful. 2
• For hyperactive-impulsive type: fidgeting/squirming, leaving seat, inappropriate running/climbing, difficulty with quiet activities, "on the go," excessive talking, blurting answers, can't wait turn, intrusive. 1

Current Adult Functioning Assessment

• Adults with ADHD often have notoriously poor insight and underestimate the severity of their ADHD symptoms and resulting impairments, making collateral information from a spouse, parent, or friend essential. 1
• The DIVA assesses current impairment across at least two different settings (work, home, social relationships). 2
• Symptoms must cause clinically significant impairment in social, academic, or occupational functioning. 2

Critical Diagnostic Considerations

Differential Diagnosis Requirements

• A complete psychiatric evaluation is required to rule out conditions that may masquerade as ADHD, including bipolar disorder, depression, Axis II personality disorders, learning disabilities, narcolepsy, and undiagnosed borderline intellectual functioning. 1
• Medical history, physical examination, and screening laboratory tests help exclude medical conditions mimicking ADHD. 1

Substance Abuse Screening

• Because of the high rate of comorbid substance abuse, a detailed history of drug and alcohol use must be undertaken, with consideration of obtaining a urine drug screen. 1
• This is particularly important as adults with ADHD have elevated rates of substance use disorders. 1

Complementary Rating Scales

Beyond the DIVA, structured rating scales that have been found useful include:

• The Wender Parent's Rating Scale and Wender Utah Rating Scales for retrospective childhood symptoms. 1
• The Brown Attention-Deficit Disorder Scale for Adults for current symptom assessment. 1
• The Conners Adult ADHD Rating Scale for comprehensive evaluation. 1

Common Pitfalls to Avoid

• Do not rely solely on patient self-report, as adults with ADHD are unreliable reporters of their own behaviors—always obtain collateral information from family members or close contacts. 1
• Do not diagnose ADHD based solely on current symptoms without establishing childhood onset, as this is a core diagnostic criterion. 1, 2
• Do not overlook comorbid conditions, particularly mood disorders, anxiety disorders, and substance use disorders, which frequently co-occur with ADHD and require separate assessment and treatment. 1
• Do not assume symptoms are better accounted for by another mental disorder without thorough evaluation, as the differential diagnosis is complex. 2

Clinical Implications

• The diagnosis must be based upon a complete history and evaluation of the patient and not solely on the presence of the required number of DSM-IV characteristics. 2
• Adequate diagnosis requires the use not only of medical resources but also special psychological, educational, and social resources. 2
• The DIVA serves as a structured framework to ensure comprehensive assessment across all required diagnostic domains while minimizing the risk of overlooking critical historical or current information. 1