What are the diagnostic criteria and follow-up assessment for a patient suspected of having Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Diagnostic Criteria for Follow-Up Assessment

For follow-up ADHD assessments, document the presence of at least 5 symptoms (adults) or 6 symptoms (children/adolescents under 17) in either the inattention or hyperactivity-impulsivity domain that have persisted for at least 6 months, verify functional impairment in at least two independent settings, confirm symptom onset before age 12, and systematically screen for comorbid conditions including anxiety, depression, substance use, and trauma. 1, 2

Core Diagnostic Requirements

Symptom Thresholds by Age

• Children and adolescents (under 17 years): At least 6 symptoms of inattention and/or 6 symptoms of hyperactivity-impulsivity 1, 3
• Adults (17 years and older): At least 5 symptoms of inattention and/or 5 symptoms of hyperactivity-impulsivity 2
• Symptoms must persist for at least 6 months and be present before age 12 1, 2, 4

Inattention Symptoms (Document Which Are Present)

1. Difficulty paying attention to details or makes careless mistakes 5
2. Difficulty sustaining attention during tasks or activities 5
3. Does not seem to listen when spoken to directly 5, 4
4. Difficulty completing tasks, gets distracted or side-tracked 5
5. Organizational challenges resulting in chronic lateness, messiness, or disorganized work 5
6. Avoids or is reluctant to engage in tasks requiring sustained mental effort 5, 4
7. Loses things necessary for tasks or activities 5, 4
8. Easily distracted by extraneous stimuli 5, 4
9. Frequently forgetful in daily activities 5, 4

Hyperactivity-Impulsivity Symptoms (Document Which Are Present)

1. Fidgets with hands or feet, squirms in seat 5, 4
2. Leaves seat in situations where remaining seated is expected 5, 4
3. Runs about or climbs inappropriately (or feelings of restlessness in adults) 5, 4
4. Difficulty engaging in leisure activities quietly, often loud and disruptive 5
5. Always "on the go," difficult for others to keep up 5, 4
6. Talks excessively 5, 4
7. Blurts out answers before questions are completed, frequently interrupts others 5, 4
8. Difficulty waiting turn, highly impatient 5, 4
9. Intrudes into others' activities or conversations 5, 4

Subtype Classification

Document the specific presentation type based on symptom pattern:

• Predominantly Inattentive Type: 5+ symptoms of inattention (adults) or 6+ (children) for at least 6 months, but fewer than 5 (adults) or 6 (children) symptoms of hyperactivity-impulsivity 5, 3
• Predominantly Hyperactive-Impulsive Type: 5+ symptoms of hyperactivity-impulsivity (adults) or 6+ (children) for at least 6 months, but fewer than 5 (adults) or 6 (children) symptoms of inattention 5, 3
• Combined Type: 5+ symptoms in BOTH domains (adults) or 6+ in BOTH domains (children) for at least 6 months 5, 3

Functional Impairment Documentation (Required)

You must document clear evidence of functional impairment in at least two independent settings 1, 2, 4:

Settings to Assess

• Work/occupational functioning: Difficulty meeting deadlines, disorganization, job performance issues 2
• Home environment: Difficulty managing household tasks, cooking, cleaning, keeping track of appointments 5
• Social relationships: Impact on friendships, romantic relationships, family dynamics 2
• Academic performance: Grades, completion of assignments, classroom behavior 1, 3

Tools for Functional Assessment

• Weiss Functional Impairment Rating Scale-Self (WFIRS-S): Validated specifically for ADHD-related functional impairment across multiple life domains 5, 3
• Vanderbilt scales (for children): Collect from both parents and teachers for comprehensive behavioral information 3
• Adult ADHD Self-Report Scale (ASRS) Part B: Further elucidates symptoms and their impact 5

Information from Multiple Sources (Critical)

Gather collateral information from at least one additional informant who knows the patient well 1, 2, 6:

• For children: Parents, teachers, coaches, or other caregivers 1, 3
• For adults: Spouse, partner, close friends, or family members 2, 6
• Have collateral informants complete the same rating scales with the patient in mind 5, 2
• Review old report cards, school records, or prior evaluations to establish childhood onset 2

Mandatory Comorbidity Screening

Systematically screen for the following conditions, as they are highly comorbid with ADHD and may influence treatment decisions 1, 2, 3:

Psychiatric Comorbidities

• Anxiety disorders: Present in high rates, particularly in girls with ADHD 1, 3
• Depression: Must be optimized before confirming ADHD diagnosis if symptoms overlap 2, 3
• Oppositional defiant disorder and conduct disorder: Common in children 1, 3
• Substance use disorders: Especially alcohol, marijuana, and stimulants in adults; can produce identical symptoms to ADHD 2, 7
• PTSD/trauma history: Can cause hypervigilance, concentration problems, and emotional dysregulation that mimic ADHD 2

Medical Conditions

• Sleep disorders: Can cause inattention and behavioral problems 3
• Thyroid disease: Can mimic ADHD symptoms 7
• Tic disorders: Common comorbidity 3

Developmental Conditions (Children)

• Learning disorders: Consider referral for psychoeducational testing if suspected 3
• Language disorders 3
• Autism spectrum disorders: Can now be diagnosed concurrently with ADHD 8

Differential Diagnosis Algorithm

Before confirming ADHD diagnosis, systematically exclude alternative explanations 2, 4:

1. Active substance use: Reassess after sustained abstinence if marijuana, stimulants, or other substances are being used 2
2. Untreated trauma/PTSD: Treat PTSD first, then reassess attention symptoms 2
3. Mood and anxiety disorders: Optimize treatment before diagnosing ADHD if symptoms are better explained by these conditions 2
4. Medication side effects: Steroids, antihistamines, anticonvulsants, caffeine, and nicotine can mimic ADHD 7
5. Environmental factors: Symptoms secondary to environmental stressors do not warrant ADHD diagnosis 4

Critical Diagnostic Pitfalls to Avoid

• Relying solely on self-report without collateral information: Adults often minimize symptoms 2
• Failing to establish childhood onset before age 12: This is non-negotiable for diagnosis 1, 2
• Using rating scale scores alone without comprehensive clinical interview: Rating scales are screening tools, not diagnostic instruments 2, 3
• Underdiagnosing girls: They more commonly present with predominantly inattentive symptoms rather than hyperactive symptoms 1, 3
• Diagnosing ADHD when symptoms are better explained by substance use, trauma, or mood disorders 2
• Failing to gather information from multiple settings: Information from only one context is insufficient 1, 3

Follow-Up Assessment Structure

At Each Follow-Up Visit, Document:

1. Current symptom count and severity in both inattention and hyperactivity-impulsivity domains using standardized rating scales 1, 3
2. Functional impairment levels across work, home, social, and academic settings using WFIRS-S or similar tools 5, 3
3. Treatment response: Medication efficacy, side effects, and adherence 2, 7
4. Comorbid condition status: Changes in anxiety, depression, substance use, or other psychiatric symptoms 1, 2
5. Collateral information updates: Recent feedback from family members, teachers, or employers 2, 3
6. Substance use screening: Random urine drug screening may be appropriate for adults on stimulants 7

Reassessment Timing

• Initial follow-up: Within 2-4 weeks of starting medication to assess response and side effects 7
• Ongoing monitoring: Regular follow-up visits to assess treatment response, functional outcomes, and adjust treatment as needed 2
• Annual comprehensive reassessment: Full symptom and functional impairment evaluation to document ongoing need for treatment 1

Special Populations Considerations

Pregnancy and Postpartum

• ADHD symptoms may interfere with managing medical appointments, preparing for baby, and adhering to treatment regimens for conditions like gestational diabetes 5
• Parents with ADHD experience greater parental distress in the first year postpartum 5
• Review pharmacologic and non-pharmacologic treatment options before pregnancy 5

Preschool-Age Children (4-5 years)

• Evidence is insufficient to recommend routine diagnosis in this age group 1
• Parent training in behavior management should be recommended before assigning an ADHD diagnosis 3

Adolescents

• Consider substance abuse, depression, and anxiety as alternative or comorbid diagnoses 1
• Note that hyperactive symptoms typically decline while inattentive symptoms persist into adulthood 2