Diagnosis

Clinical Guide to Diagnosis

Pediatrics:

The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.

To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria have been met.

Information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care.

In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions.

The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home.

Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age.

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. American Academy of Pediatrics, 2011.

Adults:

ADHD often lasts into adulthood, and the basic approach to diagnosis is similar, with a few caveats:

Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

Information is obtained primarily by self-report using validated measures; Sometimes spouses, family members, and other close personal contacts provide supportive information.

Typically symptoms have been present for a prolonged period of time. Sudden onset of symptoms in adulthood is not consistent with ADHD and should prompt evaluation for other causes.

Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. The American Academy of Family Physicians.

DSM-5 Criteria for ADHD

Inattention (Criterion A1): Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted.
Is often forgetful in daily activities.

Hyperactivity and Impulsivity (Criterion A2) : Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often “on the go” acting as if “driven by a motor”.
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting their turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).

In addition, the following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).

There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better-explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Attention Deficit / Hyperactivity Disorder 314.0X (F90.X)

It is important to specify the type of presenting symptoms, when possible:

314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2(hyperactivity-impulsivity) are met for the past 6 months.

314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.

314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity- impulsivity) is met but Criterion A1 (inattention) is not met over the past 6 months.

It is also important to specify the severity of symptoms in context of functional impairments:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in only minor functional impairments.

Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

Note: Symptoms are dynamic and can change over time, thus the presentation type and severity may change over time as well. Changes might be related to treatment, or the natural evolution of the disorder; Regardless, re-evaluation of symptoms and severity is important in order to best guide patient management.

In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.