Neobook — clinical reference

The accurate diagnosis of ADHD is a crucial factor in the successful management of this common, but often under- or misdiagnosed condition. The diagnosis should ideally be made by a specialist healthcare professional with appropriate expertise and training in diagnosing ADHD, such as a child psychiatrist, a paediatric neurologist or a neurodevelopmental paediatrician. For a diagnosis of ADHD to be made, symptoms according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria need to be present (Box 1).¹⁴

The diagnosis requires the presence of developmentally inappropriate levels of the triad of hyperactive, impulsive and inattentive symptoms for at least 6 months. Symptoms need to occur in two or more different settings (e.g. home and school), should cause impairment in functioning or development across social, academic or occupational settings and at least some symptoms need to have been present before the age of twelve.

Based on these criteria, three types of ADHD are identified:

Attention-deficit/hyperactivity disorder combined type: If both criteria A1 and A2 have been met for the past 6 months.
Attention-deficit/hyperactivity disorder predominantly inattentive type: If criterion A1 has been met, but criterion A2 has not been met for the past 6 months.
Attention-deficit/hyperactivity disorder predominantly hyperactive-impulsive type: If criterion A2 has been met, but criterion A1 has not been met for the past 6 months.

Further distinctions are made about severity:

Mild: Few, if any, symptoms above those required to make the diagnosis are present, resulting 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 above those required to make the diagnosis or several particularly severe symptoms are present or the symptoms result in marked impairment in social or occupational functioning.

Screening

As ADHD is a common neurodevelopmental disorder that presents in early childhood, ideally screening for ADHD symptoms in children in preschool or early primary school would assist in preventing the consequences of delayed or missed diagnosis; however, the practicality of this in South Africa is limited. It is important to note that the agreed minimally acceptable balance of sensitivity and specificity for screening tools is 0.8. Systematic reviews and meta-analysis of screening tools for ADHD have indicated that most acknowledged tools have good overall diagnostic accuracy, but that a single measure completed by a single reporter is unlikely to have sufficient sensitivity and specificity for clinical use or population screening.¹⁵

Once children are referred to a specialist, screening for ADHD should occur as part of the psychiatric diagnostic history taking in all patients regardless of the referred complaint. In conjunction with the clinical history, rating scales screening for ADHD are often used. These cannot be used alone to diagnose ADHD; positive screens can prompt full diagnostic evaluations.

In South Africa, the most used screening instruments are the Conners’ Parent Rating Scale (CPRS) and the Conners’ Teacher Rating Scale (CTRS),¹⁶ the Swanson, Nolan and Pelham Rating Scale (SNAP-IV) for Teachers and Parents,¹⁷ the Vanderbilt ADHD Diagnostic Rating Scale for teachers (VADTRS) and parents (VADPRS)¹⁸ and the Copeland Symptom Checklist.¹⁹

A study comparing a semi-structured interview versus CTRS/CPRS found sensitivity and specificity values to be high for the diagnostic interviews (91.8% and 70.7%, respectively), while sensitivity of the CTRS/CPRS was relatively high (83.5%), but specificity was poor (35.7%).^8,20

A systematic review of tools for the diagnosis of ADHD in children and adolescents, indicated the sensitivity of the SNAP-IV for parents as ranging from 96% to 100%, with a 4%–38% specificity in clinical samples. The SNAP-IV for teachers sensitivity ranged from 40% to 97%, with specificity ranging from 26% to 71%. ²¹ The SNAP is therefore sensitive for picking up ADHD symptoms, but not accurate in distinguishing whether the symptoms are specific to ADHD or not. In general, parent scores showed a stronger association with ADHD than teacher scores. Teachers’ scores were specifically poor in detecting inattentiveness.²²

BOX 1: Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria for attention-deficit/hyperactivity disorder.

A. A persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development, as characterised by: (1) inattention and (2) hyperactivity and impulsivity:

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental levels and negatively impacts social academic and occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms are required:

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or during other activities (e.g. overlooks or misses details, work is inaccurate).
Often has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focussed during lectures, conversations or lengthy reading).
Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction).
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (e.g. starts tasks but quickly loses focus and easily side tracked).
Often has difficulty organising tasks and activities (e.g. difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganised work; has poor time management and fails to meet deadlines).
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework; for older adolescents and adults, preparing reports, completing forms and reviewing lengthy papers).
Often loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses and mobile telephones).
Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, returning calls, paying bills and keeping appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental levels and negatively impacts directly on social, academic and occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or a failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms are required.

Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected (e.g. leaves his or her place in the classroom, in the office or other workplace or in other situations that require remaining in place).
Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults it may be limited to feeling restless.)
Often unable to play or engage in leisure activities quietly.
Is often ‘on the go’, acting as if ‘driven by a motor’ (e.g. is unable to be or uncomfortable being still for an extended time, as in restaurants or meetings; may be experienced by others as being restless or difficult to keep up with).
Often talks excessively.
Often blurts out an answer before a question has been completed (e.g. completes people’s sentences; cannot wait for his or her turn in conversation).
Often has difficulty waiting his or her turn (e.g. while waiting in line).
Often interrupts or intrudes on others (e.g. butts into conversations, games or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to 12 years of age.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school or work, with friends or relatives or in other activities).

D. There is clear evidence that the symptoms interfere with or reduce the quality of social, academic or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or other psychotic disorders and are not better explained by other mental disorders (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Source: American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. c2013¹⁴

The VADTRS and VADPRS are freely available in the public domain, making it an accessible screening instrument. Studies indicated Cronbach’s alpha reliability for the VADPRS of 0.93–0.95 in clinical study samples, while the reliability for the VATRS ranged from 0.9 to 0.92 in school screens and 0.93–0.94 in clinical study samples.¹⁹ A small South African study of 100 children between the ages of 6 and 12 found acceptable reliability of the VADRS with all subscale alphas above 0.7. However, the study found that contextual factors impact significantly on how the child was rated and need to be considered when interpreting findings.²³

Rating scales are also useful for monitoring intervention responses and comparing them to baseline symptoms.

Clinical evaluation

The clinical interview remains the cornerstone of the assessment process in diagnosing ADHD. In assessing a child, a full clinical and psychosocial history should be obtained from parents or caregivers, and the child or adolescent themselves where appropriate. Collateral information from schools, such as report cards and rating scales completed by teachers, is also invaluable. Collateral information and assessment reports from therapists involved with the patient, such as educational psychologists, occupational therapists (OT), optometrists and speech and language pathologists, should also be reviewed. Certain conditions or circumstances may point to an increased risk for ADHD, such as premature birth or a complicated neonatal course, neurodevelopmental disorders (including intellectual disability, autism spectrum disorders (ASD), specific learning disabilities, tic disorders and congenital syndromes), the presence of oppositional defiant symptoms or behavioural challenges, mood and anxiety disorders, epilepsy, traumatic brain injury, substance abuse, the presence of ADHD in a close relative and children in foster or alternative care arrangements.^24,25

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Belsham B, Kelly L, Schoeman R_The SASOP/PsychMg child and adolescent attention-deficit/hyperactivity disorder guidelines_South African Journal of Psychiatry; 25 February 2025