How should attention‑deficit/hyperactivity disorder be screened in children, adolescents, and adults?

ADHD Screening in Children, Adolescents, and Adults

Primary Care Clinicians Should Initiate ADHD Evaluation

Primary care clinicians should initiate an ADHD evaluation for any child or adolescent aged 4–18 years who presents with academic or behavioral problems accompanied by symptoms of inattention, hyperactivity, or impulsivity. 1 This represents a proactive screening approach rather than waiting for families to request evaluation.

Age-Specific Screening Thresholds

• Children 4–18 years: Screen when academic underperformance, classroom behavioral concerns, or parent-reported difficulties with task completion, organization, or impulse control are present 1
• Adults: Screen when patients report chronic difficulties with work performance, relationship instability, task completion, time management, or have a history suggesting childhood ADHD symptoms 2
• Children under 4 years: The American Academy of Pediatrics guidelines do not support routine ADHD screening or diagnosis in this age group due to normal developmental variation that mimics ADHD 1, 3

Multi-Informant Data Collection Is Mandatory

To establish an ADHD diagnosis, clinicians must obtain structured information from multiple observers across at least two distinct settings—home, school, and/or work—using validated rating scales. 1

Recommended Screening Tools by Age

Children Ages 6–12 Years

• Vanderbilt ADHD Rating Scales (parent and teacher versions) are the primary recommended tools by the American Academy of Pediatrics 3
• Both parent and teacher forms must show at least six symptoms rated "often" or "very often" in either the inattentive or hyperactive-impulsive domain to meet diagnostic thresholds 3
• Alternative acceptable tools include the ADHD Rating Scale-5 or Conners Rating Scales when Vanderbilt forms are unavailable 3

Adolescents Ages 12–18 Years

• Continue using Vanderbilt scales or age-appropriate Conners versions 3
• Obtain reports from multiple teachers when adolescents have several instructors 3
• Include adolescent self-report alongside parent and teacher observations 1

Adults

• Adult ADHD Self-Report Scale (ASRS) is the most commonly used screening tool 2, 4
• Conners Adult ADHD Rating Scales (CAARS) provide comprehensive symptom assessment 3, 2
• Critical caveat: The ASRS has a positive predictive value of only ~11.5% in general populations, resulting in 7–10 times over-identification of ADHD 4

Common Pitfall: Over-Reliance on Screening Tools

Rating scales systematically collect symptom information but do not diagnose ADHD by themselves. 3 A positive screen must be followed by comprehensive clinical interview, verification of symptom onset before age 12, documentation of cross-setting impairment, and exclusion of alternative explanations 1, 3

Verify DSM-5 Diagnostic Criteria

After positive screening, clinicians must confirm:

• Symptom onset before age 12 years (not age 7 as in older DSM-IV criteria) 1, 3
• Functional impairment documented in two or more settings (home, school, work, social relationships) 1, 3
• Symptoms persist for at least 6 months 3
• Symptoms are not better explained by another condition 1

For Adults Specifically

• Obtain collateral information from parents, partners, or others who knew the patient in childhood to verify symptom onset before age 12 5, 2
• Document current functional impairment in occupational, social, or academic domains 2
• Recognize that hyperactive-impulsive symptoms typically diminish while inattentive symptoms persist into adulthood 6

Mandatory Comorbidity Screening

Every ADHD evaluation must include systematic screening for conditions that frequently co-occur with or mimic ADHD. 1

Essential Comorbidity Screens

• Emotional/behavioral conditions: Anxiety disorders (present in 14% of children with ADHD), depression (9%), oppositional defiant disorder, conduct disorders, substance use 1, 3, 6
• Developmental conditions: Learning disabilities, language disorders, autism spectrum disorders 1, 3
• Physical conditions: Sleep disorders (especially obstructive sleep apnea), tic disorders 1, 3

Why This Matters

The majority of children and adolescents with ADHD meet criteria for at least one additional mental disorder 6, and untreated comorbidities significantly worsen functional outcomes 3, 6

Rule Out Conditions That Mimic ADHD

Before finalizing an ADHD diagnosis, systematically exclude:

• Sleep disorders: Obtain detailed sleep history including snoring, witnessed apneas, sleep duration, and bedtime routines—sleep deprivation and obstructive sleep apnea frequently present with inattention and hyperactivity 5
• Anxiety and depression: These conditions cause restlessness, concentration difficulties, and irritability that mimic ADHD 5, 6
• Trauma exposure: Post-traumatic stress produces hypervigilance, concentration problems, and behavioral dysregulation resembling ADHD 5, 6
• Language disorders: Expressive or receptive language delays cause apparent inattention when children cannot follow verbal instructions 5
• Autism spectrum disorder: Frequently co-occurs with hyperactivity and inattention but includes core social-communication deficits 5
• Substance use (adolescents/adults): Cannabis, stimulants, and alcohol can produce or worsen inattention and impulsivity 6, 2

Clinical Interview Components

Beyond rating scales, the diagnostic evaluation requires:

• Detailed developmental history documenting when symptoms first appeared and their progression 1
• Academic history including grades, teacher comments, need for extra help, grade retention 1
• Social functioning assessment covering peer relationships, family conflicts, and extracurricular participation 1
• Occupational history (adults) documenting job changes, terminations, performance reviews 2
• Family psychiatric history given ADHD's strong genetic component 7

When Single-Setting Symptoms Appear

If symptoms are reported in only one setting (e.g., solely at home or solely at school), this pattern often reflects situational or contextual problems rather than true ADHD. 5 Before ruling out ADHD, obtain more comprehensive information from additional observers and settings 5

Special Considerations for Preschool Children (Ages 4–5)

• DSM-5 criteria can appropriately identify ADHD in preschool-aged children 5
• Determining cross-setting symptoms is particularly challenging when children do not attend preschool or childcare 5
• Consider parent training in behavior management even when diagnosis remains uncertain, as this intervention does not require a formal diagnosis to benefit families 5

Documentation Requirements

To support an ADHD diagnosis, medical records should contain:

• Completed parent and teacher (or work supervisor for adults) rating scales showing elevated symptom counts 1, 3
• Clinical interview notes documenting symptom onset before age 12 1, 3
• Specific examples of functional impairment in at least two settings 1
• Results of comorbidity screening 1
• Rationale for excluding alternative diagnoses 1

Screening Frequency and Ongoing Monitoring

ADHD should be recognized as a chronic condition requiring ongoing monitoring following chronic care model principles. 1 After initial diagnosis:

• Monitor for emergence of new comorbid conditions throughout development, particularly depression and substance use as children approach adolescence 3, 6
• Reassess symptom severity and functional impairment at regular intervals 1, 8
• Approximately 50–70% of individuals diagnosed in childhood retain clinically significant symptoms into adulthood 6