What is the recommended approach for taking a history in a new adult patient with Attention Deficit Hyperactivity Disorder (ADHD)?

History Taking for New Adult ADHD

Begin with the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A as your initial screening tool, then conduct a comprehensive clinical interview focused on establishing DSM-5 criteria, documenting childhood onset, and obtaining collateral information from someone who knows the patient well. 1, 2

Initial Screening (3-5 minutes)

• Administer the ASRS-V1.1 Part A, which consists of 6 questions—a positive screen requires the patient to check "often" or "very often" for 4 or more questions 1, 3
• If Part A is positive, proceed to Part B for comprehensive symptom assessment 2
• This screening can be completed in as little as 3-5 minutes but is essential before proceeding with full diagnostic evaluation 4

Core Symptom Documentation

Inattentive Symptoms (Need ≥5 for adults ≥17 years)

• Poor attention to detail in work tasks, paperwork, or other activities 1
• Difficulty concentrating or sustaining attention during meetings, conversations, or reading 1
• Appearing preoccupied or not listening when spoken to directly 1
• Difficulty completing tasks or following through on instructions 1
• Organizational challenges with time management, meeting deadlines, keeping materials organized 1
• Reluctance to engage in sustained mental effort (avoiding reports, forms, reviewing lengthy documents) 1
• Forgetfulness in daily activities such as returning calls, paying bills, keeping appointments 1

Hyperactive-Impulsive Symptoms (Need ≥5 for adults ≥17 years)

• Frequent fidgeting with hands or feet, or squirming in seat 1
• Difficulty sitting still for prolonged periods during meetings or meals 1
• Feeling of inner restlessness or agitation (even if not visibly hyperactive) 1
• Often being loud and disruptive in social or work settings 1
• Always being on the go or feeling driven by a motor 1
• Talking excessively or interrupting others frequently 1

Critical Diagnostic Requirements

Establish Childhood Onset (Before Age 12)

• Obtain childhood report cards looking for comments about "not working to potential," "talks too much," "doesn't follow directions," or "disorganized" 2
• Interview parents directly about childhood behaviors, academic performance, and disciplinary issues 2, 4
• Review any documented childhood history from school records, prior medical records, or psychological evaluations 2
• Adults with ADHD are notoriously poor self-reporters and often underestimate symptom severity—collateral childhood information is essential 1

Document Functional Impairment in ≥2 Settings

• Work/occupational impairment: Missed deadlines, job changes, underemployment relative to intelligence, disciplinary actions, difficulty with paperwork 2
• Home/personal life: Disorganization affecting daily tasks, chronic lateness, difficulty managing household responsibilities 1, 2
• Social/relationship impairment: Conflict with spouse/partner, difficulty maintaining friendships, interrupting others 2
• Use the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) to systematically measure ADHD-specific impairment 2

Obtain Mandatory Collateral Information

• Have a spouse, parent, or close friend complete the ASRS with the patient in mind—their perspective often reveals impairments the patient minimizes 2
• Adults with ADHD consistently underestimate their symptoms and resulting impairments, making collateral information diagnostically essential 1
• Interview informants directly when possible about specific examples of inattention, disorganization, or impulsivity 4, 5

Essential Differential Diagnosis and Comorbidity Screening

Screen for Overlapping Psychiatric Conditions

• Depression and anxiety disorders: Symptoms overlap substantially with ADHD inattention—ask about persistent sadness, anhedonia, excessive worry, panic attacks 2
• Approximately 10% of adults with recurrent depression/anxiety have underlying ADHD, and treating depression/anxiety alone will be inadequate without addressing ADHD 1
• Bipolar disorder: Critical to identify before prescribing stimulants, which can precipitate manic episodes—ask about periods of elevated mood, decreased need for sleep, grandiosity 2
• Substance use disorders: Can mimic or mask ADHD symptoms—obtain detailed drug and alcohol history, consider urine drug screening given high comorbidity rates 1, 2
• Personality disorders: Particularly borderline and antisocial patterns, which can present with impulsivity and emotional dysregulation 2

Rule Out Medical Mimics

• Sleep disorders (sleep apnea, insomnia): Can cause daytime inattention and fatigue that mimics ADHD 2
• Thyroid dysfunction, anemia, or other medical conditions that may present with concentration difficulties 2
• Conduct a comprehensive medical history and physical examination to exclude organic causes 5

Structured Clinical Interview Components

Childhood History

• Age when symptoms first noticed and by whom 5
• Academic performance and grade retention 5
• Behavioral problems at school or home 5
• Peer relationships and social functioning 5
• Any prior ADHD evaluations or treatments 5

Current Adult Presentation

• ADHD symptoms often become more challenging as adults face increased demands of work, relationships, and parenting, even though the disorder preceded these life stages 1
• Adults predominantly present with inattentive symptoms rather than hyperactivity—hyperactivity often manifests as inner restlessness rather than overt motor activity 1
• Document specific examples of how symptoms cause problems in daily life (e.g., "I've been fired from 3 jobs for missing deadlines" vs. vague "I have trouble focusing") 2

Medication and Treatment History

• Prior stimulant or non-stimulant medication trials, doses, duration, and response 5
• Any adverse effects or reasons for discontinuation 5
• Current medications that may interact with ADHD treatments 5

Additional Validated Assessment Tools

• Wender Utah Rating Scales: Addresses adult characteristics of ADHD retrospectively 1, 6
• Brown Attention-Deficit Disorder Scale for Adults: Comprehensive symptom assessment 1
• Conners Adult ADHD Rating Scale: Standardized rating with normative data 1, 3

Documentation Requirements for Diagnosis

Your clinical documentation must include:

• Specific DSM-5 symptoms present with concrete examples from patient and collateral sources 2
• Age of onset with supporting evidence from childhood (report cards, parent interview, documented history) 2
• Settings where impairment occurs with specific examples (work, home, social) 2
• Degree of functional impairment in work, relationships, and daily activities 2
• Comorbid conditions identified or ruled out through systematic screening 2
• Collateral information sources and their specific observations 2

When to Refer to Psychiatry

Refer when you encounter:

• Diagnostic uncertainty after comprehensive evaluation 2
• Multiple comorbid psychiatric conditions requiring complex medication management 2
• Treatment-resistant cases or previous medication failures 2
• Active suicidal ideation or severe mood symptoms 2
• Active substance use disorder requiring specialized treatment 2

Common Pitfalls to Avoid

• Do not rely solely on patient self-report—adults with ADHD consistently underestimate their symptoms and impairments 1
• Do not diagnose ADHD without documenting childhood onset before age 12—this is a DSM-5 requirement that distinguishes ADHD from adult-onset attention problems 1, 2
• Do not skip collateral information gathering—informant reports often reveal impairments the patient minimizes or doesn't recognize 2
• Do not assume a single screening tool is sufficient—diagnosis requires comprehensive clinical interview, collateral information, and functional impairment documentation 2, 3
• Do not overlook comorbid conditions, particularly depression, anxiety, and substance use disorders, which are present in the majority of adults with ADHD 1, 2