Diagnosis and Assessment of Disease
ADHD Diagnostic Algorithm
Screening
> As part of a mental health assessment, regardless of presenting complaint, ask parents/caregiver specific questions concerning major symptoms of ADHD in the patient
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and if causing
functional impairment in family, peer, and/or school/daycare domains:
` Inattention
` Hyperactivity
` Impulsivity
> If positive response, schedule evaluation of the patient for ADHD
Evaluation
> Perform detailed interview with parents/caregiver concerning each of the 18 ADHD symptoms listed in DSM-IV-TR (Table 1) to determine:
` Presence and duration, severity, and frequency
` Age of onset
` Circumstances of occurrences
` Settings in which functional impairment occurs (as distinguished from presence of symptoms)
> Review with parents/caregiver symptoms of other common childhood psychiatric disorders (eg, oppositional defiant disorder, conduct disorder, depression, mania, anxiety disorders, tic
disorders, psychosis, substance abuse)
> Have parents/caregiver complete a standardized behavior rating scale (Table 2); if possible, obtain rating scale from appropriate teacher(s) or schoolwork samples, report cards
> Assess family history, structure, functioning, social interaction
> Review patient's perinatal, medical, mental health histories, developmental milestones
> Interview patient to identify signs/symptoms inconsistent with ADHD or suggestive of other comorbid disorders and to assess age-appropriateness of vocabulary, thought processes, and
content of thought
> If patient's medical history is unremarkable, laboratory tests or neurological studies are not indicated
> Psychological and neuropsychological testing are not mandatory for diagnosis of ADHD but should be performed if patient's history suggests low achievement in language or mathematics
relative to intellectual ability
> Patient meets DSM-IV-TR criteria for ADHD (Table 1)
Integrate data from Evaluation for presence of comorbid disorder symptoms to determine whether:
> Symptoms meet full DSM criteria for separate comorbid disorder(s) in addition to ADHD:
` Oppositional defiant disorder or conduct disorder (usually present concurrently in young children)
` Major depressive disorder or specific anxiety disorder (usually occurs several years after onset of A DHD)
` Mania (severe mood lability/elation/irritability, thought disturbances, severe aggressive outbursts, decreased need for sleep, age-inappropriate levels of sexual interest)
> Comorbid disorder is the primary disorder and patient's ADHD symptoms are directly caused by it and occur after childhood
> Symptoms do not meet DSM criteria for separate comorbid disorder(s) but are secondary symptoms stemming from ADHD and may dissipate once ADHD is successfully treated
Select treatment regimen (Treatment Algorithm)
> Choice of treatment regimen, especially pharmacologic intervention, is often influenced by nature of patient's comorbid disorder(s)
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Patient refers to any minor (preschooler, 3-5 yr; child, 6-12 yr; adolescent, 13-17 yr).
