Clinical process and ‘pearls’ in the diagnosis of ADHD: Implementation of guidelines and expert consensus
| Schedule several office visits to complete the diagnostic evaluation. |
| Obtain detailed information on prenatal/perinatal events, medical and mental health history. |
| Obtain developmental/behavioural history (motor, language, social milestones and behaviour, including temperament/emotional regulation and attachment). (Assessment of developmental milestones is particularly important for diagnosing preschool children because impaired attention and hyperactivity may also be features of a neurodevelopmental disorder.) |
| Evaluate family medical and mental health, family functioning and coping styles of primary caregivers. Ask about genetic disorders. Evaluate for comorbid disorder(s) (psychiatric, neurodevelopmental and physical). (Do comorbid symptoms meet criteria for a separate disorder that is the main diagnosis OR exist in tandem with ADHD as the main diagnosis OR are they secondary symptoms [stemming from the ADHD]?) |
| Review academic progress (e.g., report cards, sample assignments) and look for symptoms of a learning disorder (69). Clinical impressions and use of standardized scales are still the most effective practices for evaluating ADHD symptomatology. |
| Obtain standardized behaviour rating scale(s) that evaluate DSM-5 criteria from primary caregivers, teachers and the adolescent being assessed. For a list of screening tools and rating scales to assess impairment, see: www.cps.ca/en/tools-outils/mental-health-screening-tools-and-rating-scales (Rating scales are not diagnostic of ADHD but they provide subjective impressions to help quantify the degree to which a behaviour may deviate from the norm and can be used to evaluate the effects of interventions in home or school [70].) |
| Unless indicated by history and physical examination, do NOT: • order laboratory tests, genetic testing, EEG or neuroimaging. • order psychological (standardized assessment of intellectual function and academic achievement skills) neuropsychological or speech-language assessments. • use psychological tests (e.g., TEACH, Continuous Performance Tests [CPT]) or measures of executive function to diagnose ADHD and/or as a means to monitor symptom or functional improvement in daily activities. |
| Refer to DSM-5 criteria for core symptoms and characteristics of ADHD: 1. Symptoms are severe, persistent (i.e., present before 12 years of age and continuing >6 months), and inappropriate for the patient’s age and developmental level. • Consider the demands and expectations being placed on the child and what the child’s innate capabilities are to meet these expectations. What will this child look like over time? • The abilities to self-control attention, activity and impulses emerge in a developmental process (70). The DSM does not provide for developmental level differences, which may lead to overdiagnosis of ADHD in young preschool-aged children. 2. Symptoms are associated with impairment in academic achievement, peer and family relations and adaptive skills. • 'Impairment' implies greater severity and frequency of symptoms that interfere with ability to function across major life domains. 3. If there is a discrepancy of symptoms across settings, it is important to identify why the discrepancy exists. 4. Specify the type of ADHD presentation as per the DSM-5: i) Combined presentation (criteria are met for inattention, hyperactivity-impulsivity) ii) Predominantly inattentive presentation (criteria are met for inattention) iii) Predominantly hyperactive-impulsive presentation (criteria are met for hyperactivity-impulsivity) 5. Specify current severity (mild, moderate or severe) based on the symptoms and degree of functional impairment. |
| Medical examinations: Perform thorough physical, neurological and dysmorphology assessments (71). |
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