What is the optimal approach to obtain a comprehensive history for an adult with suspected attention‑deficit/hyperactivity disorder, including example interview questions?

How to Take a Detailed History in Adult ADHD

Core Diagnostic Requirements

A comprehensive ADHD history must establish three critical elements: (1) presence of at least 5 inattentive and/or hyperactive-impulsive symptoms for ≥6 months, (2) symptom onset before age 12, and (3) functional impairment in at least two settings (work, home, social). 1

Structured Screening as Entry Point

Begin with the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A, which takes 3-5 minutes to complete. 1, 2 A positive screen occurs when the patient endorses "often" or "very often" for 4 or more of the 6 questions. 1 This screening tool provides an efficient gateway to more detailed assessment but does not replace comprehensive clinical interview. 3

Essential Interview Components

Current Symptom Assessment

Ask specific questions targeting the DSM-5 criteria, requiring at least 5 symptoms in adults (6 if under age 17): 1

Inattentive symptoms:

• "Do you frequently make careless mistakes in your work or miss important details?"
• "How often do you have difficulty sustaining attention during tasks or conversations?"
• "Do people tell you that you seem preoccupied or don't listen when spoken to directly?"
• "How often do you start tasks but get distracted or side-tracked before completing them?"
• "Tell me about your organizational challenges—are you chronically late for appointments or deadlines? Is your workspace messy or disorganized?"
• "Do you avoid tasks that require sustained mental effort, like preparing reports or reviewing lengthy documents?"
• "How often do you lose important items like keys, wallet, phone, or paperwork?"
• "Are you easily distracted by external stimuli or unrelated thoughts?"
• "Do you frequently forget daily activities, appointments, or return calls?" 1

Hyperactive-impulsive symptoms:

• "Do you fidget frequently—tapping your desk, bouncing your leg, or playing with objects?"
• "Can you sit still for prolonged periods, or do you feel restless?"
• "Do you experience inner restlessness or agitation even when sitting?"
• "Are you often loud or disruptive in social or work settings?"
• "Do others describe you as 'always on the go' or difficult to keep up with?"
• "Do you talk excessively?"
• "Do you blurt out answers before questions are completed or finish others' sentences?"
• "How difficult is it for you to wait your turn in conversations or lines?"
• "Do you interrupt or intrude on others' activities?" 1

Childhood Onset Documentation

Establishing symptom onset before age 12 is mandatory but often challenging in adults who were never diagnosed as children. 1, 3 Ask:

• "Thinking back to elementary school, did teachers comment on your attention, behavior, or ability to complete work?"
• "Did you struggle with homework completion, organization, or sitting still in class?"
• "Were you described as a 'daydreamer,' 'space cadet,' or 'always moving'?"
• "Did you have difficulty following multi-step instructions as a child?"
• "What were your report cards like—did they mention attention or behavior issues?" 3

Obtain collateral information from parents, siblings, or old school records whenever possible, as adults often have poor insight into their childhood symptoms. 3

Functional Impairment Assessment

Document specific impairment in at least two domains (work, home, social/interpersonal) with concrete examples: 1

• "How has this affected your job performance—missed deadlines, errors, job loss, underemployment relative to intelligence?"
• "What impact has this had on your relationships—conflicts with partners, friends, or family?"
• "How does this affect your home life—unpaid bills, household disorganization, forgotten commitments?"
• "Have you experienced academic underachievement despite adequate intelligence?"
• "What risky behaviors have resulted—motor vehicle accidents, substance use, impulsive financial decisions?" 3

Around 10% of adults with recurrent depression or anxiety have undiagnosed ADHD, and functional impairment often persists despite treatment of mood symptoms alone. 1

Differential Diagnosis and Comorbidity Screening

ADHD symptoms must not be better explained by another mental disorder, and aggressive screening for comorbidities is essential because they occur in the majority of adults with ADHD. 1, 4

Rule Out Alternative Explanations

Ask about:

• Mood disorders: "Have you experienced periods of persistently low mood, loss of interest, or elevated/irritable mood lasting weeks?" (Depression and bipolar disorder can mimic inattention) 1
• Anxiety disorders: "Do you experience excessive worry, panic attacks, or avoidance that could explain concentration difficulties?" 1
• Psychotic disorders: "Have you experienced hallucinations, delusions, or disorganized thinking?" 1
• Substance use: "What is your current and past use of alcohol, cannabis, stimulants, or other substances?" (Intoxication/withdrawal can mimic ADHD) 1
• Sleep disorders: "Do you snore, stop breathing at night, or have restless legs? How many hours of quality sleep do you get?" (Sleep deprivation causes inattention) 1

Screen for Common Comorbidities

Depression and anxiety co-occur in approximately 50% of adults with ADHD, and substance use disorders are significantly elevated. 4, 5 Ask:

• "Have you been diagnosed with or treated for depression, anxiety, bipolar disorder, or substance abuse?"
• "Do you have learning disabilities or were you in special education?"
• "Have you been told you have oppositional defiant disorder or conduct problems?"
• "Do you have chronic sleep problems or a sleep disorder diagnosis?"
• "Have you experienced trauma or been diagnosed with PTSD?" 4

Medication and Treatment History

Document all prior ADHD-related treatments with specific details: 1

• "What ADHD medications have you tried—stimulants (methylphenidate, amphetamines), atomoxetine, guanfacine, clonidine?"
• "What doses were used and for how long?"
• "What was your response—did symptoms improve?"
• "What side effects did you experience?"
• "Why was each medication stopped?"
• "What was your adherence like—did you take it as prescribed?" 1

Cardiovascular and Safety Screening

Before considering stimulant therapy, obtain a detailed cardiac history: 1

• "Have you ever experienced syncope, chest pain, palpitations, or exercise intolerance?"
• "Is there a family history of premature cardiovascular death, arrhythmias, or structural heart disease?"
• "Do you have hypertension, hyperthyroidism, glaucoma, or symptomatic cardiovascular disease?" (These are contraindications to stimulants) 1

Measure baseline blood pressure and pulse. 1

Substance Use Risk Assessment

Screen adolescents and adults for substance use risk, as ADHD significantly increases vulnerability and stimulants are controlled substances. 1, 4

• "Have you ever misused prescription medications, including stimulants?"
• "Do you have a history of substance use disorder or are you in recovery?"
• "Have family members struggled with addiction?"
• "Do you have access to your medications or concerns about diversion?" 1

If substance use disorder is present or in recent remission, consider long-acting stimulant formulations with lower abuse potential (e.g., lisdexamfetamine, OROS-methylphenidate) or non-stimulants (atomoxetine, guanfacine, clonidine) as first-line. 1, 6

Collateral Information

Gathering information from family, friends, coworkers, or partners significantly improves diagnostic accuracy, as adults with ADHD often have poor self-awareness of their symptoms. 2, 3

Ask the patient: "May I speak with someone who knows you well—a spouse, parent, or close friend—to get their perspective on your attention and behavior?" 3

Questions for collateral sources:

• "Have you noticed [patient] being easily distracted, forgetful, or disorganized?"
• "Does [patient] interrupt conversations, talk excessively, or seem restless?"
• "What impact have you seen on [patient's] work, relationships, or daily functioning?"
• "Do you recall [patient] having these difficulties as a child?" 3

Documentation of Impairment Across Settings

Symptoms must be present in at least two settings (e.g., work and home, or work and social). 1 Systematically document:

• Work/school: Specific examples of missed deadlines, errors, conflicts with supervisors, job loss, academic underachievement 3
• Home: Unpaid bills, household chaos, forgotten appointments, relationship conflicts 3
• Social: Difficulty maintaining friendships, interrupting others, social isolation 3

Common Diagnostic Pitfalls to Avoid

• Do not assume mood lability or irritability automatically indicates bipolar disorder—these are common in ADHD and often improve with stimulant treatment. 1
• Do not diagnose ADHD based on screening scales alone—the clinical interview remains the cornerstone of diagnosis. 3
• Do not overlook childhood onset—if symptoms only began in adulthood, consider alternative diagnoses like depression, anxiety, or cognitive disorders. 1
• Do not miss comorbid conditions—untreated depression, anxiety, or substance use will undermine ADHD treatment and must be addressed concurrently. 4, 5
• Do not rely solely on patient self-report—collateral information dramatically improves diagnostic accuracy. 3