Diagnosis, Evaluation, and Screening
In 2019, the American Academy of Pediatrics (AAP) produced evidence-based guidelines for the evaluation and treatment of ADHD.13 For evaluation and diagnosis, AAP recommends:
- Any child or adolescent 4 to 18 years of age exhibiting academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated for ADHD.
- DSM-5 criteria must be met and an alternative etiology of symptoms must be ruled out for a diagnosis to be made.
- Evaluation must include screening for comorbid conditions, such as emotional/behavioral conditions, developmental conditions, and physical conditions.
Validated screening tools are recommended for assessment and ongoing monitoring of ADHD symptoms. To fully determine an ADHD diagnosis, multiple informants should administer these screening tools across environments (home, school, work). The tools evaluate DSM-5 subscales of inattention and hyperactivity-impulsivity, as well as some element of functional impairment in relationships with others, academic functioning, and behavioral functioning.
Although some behaviors are on a continuum and common in healthy children, in individuals with ADHD, these behaviors are noticeably more frequent than expected for their age. Screening tools are based on symptoms that have occurred over the previous 6 months. The tools recommended here are available in the public domain and often used in primary care settings. As with all screening tools and scales, professional judgment, including interviews and synthesis of data, is required to make a full diagnosis.
Vanderbilt ADHD Parent Rating Scale (VADPRS)
VADPRS is a time- and cost-efficient screening tool to identify ADHD symptoms and comorbidities. The scale includes the domains and symptoms of ADHD that are in alignment with DSM-5 criteria as well as an evaluation of academic performance and peer relationships. It specifically collects information about the emotional/behavioral conditions of oppositional defiant disorder (ODD), conduct disorder, anxiety, and depression.14 Moreover, the scale has a parent follow-up scale that is helpful and important for repeated measurement over time. A Spanish version of the parent scale also is available.
Swanson, Nolan and Pelham Teacher and Parent Rating Scale (SNAP-IV)
This questionnaire has been revised to include items evaluating the inattention and hyperactivity/impulsivity domains, as well as symptoms of ODD.15 The SNAP-IV evaluates functioning as it relates to classroom behavior; it provides both parent and teacher rating scales and has shown reliable psychometric properties. A clinical interview is needed to determine onset, progression, and functional impairment.15
Adult ADHD Self Report Screening Scale for DSM 5 (ASRS-5)
The ASRS-5 is a short screening tool to determine the presence of ADHD symptoms in individuals older than 18 years.16 It is used in combination with the ASRS symptom checklist. A clinical interview to evaluate symptoms and review of differential diagnosis and comorbid conditions are recommended.
When evaluating patients for ADHD, clinicians should evaluate for the presence of comorbidities and consider the patient’s overall mental health. The significant prevalence of depression, anxiety, SUD, and suicide among patients with ADHD requires repeated, ongoing assessment and measurement of these conditions (preferably monthly) to facilitate early recognition and treatment and to track progress.16
There are several general mental health screening tools available to assist in identifying comorbid conditions. Examples of these include the Weiss Symptom Record (WSR),17 Patient Health Questionnaire (PHQ-9),18 Generalized Anxiety Disorder Item-7 (GAD-7),19 Screen for Child Anxiety Related Disorder (SCARED),20 Alcohol Use Disorders Identification Test (AUDIT),21 and Suicide Assessment Five-Step Evaluation and Triage with the Columbia-Suicide Severity Rating Scale (SAFE-T with C-SSRS).22