Evaluation

A thorough evaluation is essential to make a diagnosis of ADHD.

  • There are currently no medical or psychological tests to make such a diagnosis.
  • Instead, the health care provider must evaluate the presence of symptoms; determine if they pose impairment; and judge they are not better accounted for by another diagnosis.23
  • A comprehensive patient history, including gathering information from the patient, parents, care providers, and teachers is necessary to gather complete diagnostic data.16
  • Physical or neurological exams may be performed to rule out other conditions and a psychological evaluation is conducted to rule out learning problems and determine comorbid mental health issues.15
  • The primary care physician should initiate evaluation for ADHD for any child ages 4 through 18 if the patient presents with inattention, hyperactivity or impulsivity.1
  • Diagnostic and Statistical Manual of Mental Disorders criteria are applied to make the ADHD diagnosis. Criteria from DSM-5, originally published in 2013 are summarized in Table 1. Updates to ADHD diagnosis in the DSM-5 more accurately characterize the experiences of affected adults and aims to ensure that children with ADHD can continue to get care, as needed, thorough their lives. DSM-5 notes that although motor symptoms of hyperactivity become less obvious in adolescence and adulthood, difficulties persist with restlessness, inattention, poor planning and impulsivity. DSM-5 also acknowledges that a substantial proportion of children remain relatively impaired into adulthood.14 Specific examples of changes from the DSM-IV include: those over 17 years of age need only present 5 symptoms vs. 6 for younger children; examples of behaviors older adolescents and adults might exhibit are included; and symptoms must be present prior to age 12 vs. age 7.14
Table 1. Diagnostic Criteria for ADHD.13

These symptoms represent subtype I of ADHD - Primarily Inattentive.
For children, six or more of the following symptoms of inattention that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. For older adolescents and adults, (age 7 and older) five or more symptoms are required.

Inattention

  • Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other 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.
  • Often has difficulty organizing tasks and activities.
  • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
  • Often loses things necessary for tasks or activities.
  • Often distracted by extraneous stimuli.
  • Often forgetful in daily activities.

These symptoms represent subtype II of ADHD - Primarily hyperactive/impulsive.
For children, six or more of the following symptoms of hyperactivity-impulsivity that have persisted for at least 6 months to a degree that it is maladaptive and inconsistent with developmental level. For older adolescents and adults (age 7 and older) five or more symptoms are required.

Hyperactivity

  • Often fidgets with hands or feet or squirms in seat.
  • Often leaves seat in classroom or in other situations in which remaining in seat is expected.
  • Often runs about or climbs excessively in situations in which it is inappropriate. In adolescents or adults, may be limited to subjective feelings of restlessness.
  • Often has difficulty playing or engaging in leisure activities quietly.
  • Often ‘on the go’ or acts as if ‘driven by a motor’.
  • Often talks excessively.

Impulsivity

  • Often blurts out answers before questions have been completed.
  • Often has difficulty awaiting turn.
  • Often interrupts or intrudes on others.

For subtype III of ADHD called combined, symptoms of both subtypes I and II as described above are present.

For subtype IV of ADHD called inattentive (restrictive), the criterion for inattention is met but no more than 2 symptoms from hyperactivity-impulsivity have been present for the past 6 months.

In addition, the following criteria must also be met for all subtypes:

Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 12.

Some impairment from the symptoms is present in 2 or more settings (home, work, school, social).

There must be clear evidence of clinically significant impairment in social, academic or occupational functioning

The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.

The severity of symptoms should also be specified:

Mild - Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.

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.