6. Guidelines for diagnostics

The most important guideline for ADHD diagnosis in Germany is the Interdisciplinary evidence- and consensus-based S3 guideline “Attention Deficit Hyperactivity Disorder (ADHD) in children, adolescents and adults (AWMF 028045).
Guidelines for the diagnosis of ADHD recommend the following diagnostic procedure:¹

Additions by ADxS are shown in italics.

• 1. Psychiatric anamnesis
• 2. Differential diagnosis
  • 2.1. Exclusion of organic causes
  • 2.2. Exclusion of other psychological causes
  • 2.3. Exclusion of simulation / non-medical drug abuse
• 3. Interview with parents/confidants
• 4. Existence of symptoms in childhood
• 5. Standardized survey of ADHD symptoms
• 6. Test psychological performance diagnostics

1. Psychiatric anamnesis¶

Assessment of the individual problem situation, taking into account comorbid disorders, the developmental history of the person with ADHD and their family.

2. Differential diagnosis¶

2.1. Exclusion of organic causes¶

A differential diagnosis should be carried out in parallel to the ADHD diagnosis to ensure that symptoms do not result from other dominant organic causes.
More on this at ⇒ Differential diagnosis of ADHD

2.2. Exclusion of other psychological causes¶

For the differential diagnosis of depression, see ⇒ Depression and dysphoria in ADHD

2.3. Exclusion of simulation / non-medical drug abuse¶

ADHD medications can be abused as drugs (though there are substances that work much better as drugs for less money and effort in every disco and behind every train station) or resold for this purpose (which only makes sense if the insurance company pays for the prescription). The lifetime abuse rate of ADHD stimulants in the US is 8.1%, well behind painkillers (24.6%), tranquilizers (15.6%), and sleep aids (9.9%). Within the ADHD stimulants, there were clear differences which, in cases of doubt, make Lisdexamfetamine or MPH Ganzagesretards appear advantageous (cases of abuse among adults per 100,000 prescriptions)²
Ritalin: 1.62
Adderall; 1.61
Adderall XR: 0.62
Concerta: 0.19
Lisdexamfetamine: 0.13

The self-treatment effect must be taken into account here. Among patients of addiction centers, 21 to 23% of people with ADHD are found in serial ADHD studies³, which corresponds to a 4.6 to 9.2-fold prevalence with an adult ADHD population prevalence of 2.5 to 5%

Stimulants can also be abused by pupils or students during stressful exam phases. A study in the USA found that 4.3% of 18- to 25-year-olds and 1.3% of 26- to 49-year-olds reported taking stimulants without medical indication.⁴ This is in addition to the fact that many students who abuse stimulants for exams have increased ADHD symptoms.⁵⁶⁷ In addition, exam times can mean severe stress, which can temporarily increase or trigger subclinical ADHD symptoms due to stress

Unlike ASRS 1.1 (which can only be used for screening anyway), Brown Attention-Deficit Disorder Scale (BADDS), Wender Utah Rating Scale (WURS) and Barkley Adult ADHD Rating Scale (BAARS-IV), the Conners Adult Rating Scale (CAARS) has two embedded validity indices:⁸

• CAARS Infrequency Index (CII; items that are rarely reported by people with ADHD as well as those not affected)⁹
• Exaggeration Index (EI; combines items from the CAARS with items from the Dissociative Experiences Scale (DES), which are rarely reported by people with ADHD¹⁰
• in development: ADHD Credibility Index (ACI)¹¹

The ADxS symptom test (not validated for diagnosis and only used for screening) and the ADxS external assessment test are equipped with redundancies that measure inconsistent information; a reference value is given.

3. Interview with parents/confidants¶

Interviews on retrospective and current symptoms and the use of standardized assessment scales can help to record current symptoms and symptoms in childhood.

The ADxS symptom test (which is not validated for diagnostic purposes and is only used for screening) has an identical question structure to the ADxS external assessment test (V5: 168 questions) and can be completed online by any number of third parties. The evaluations for the doctor make it transparent which questions and answers score for which symptom

4. Existence of symptoms in childhood¶

People with ADHD often have a poor long-term memory and therefore have few tangible memories of their childhood.

The head marks / behavioral marks / individual assessments in primary school reports are often helpful in reconstructing the behavior of people with ADHD in childhood. It is by no means appropriate to rule out a diagnosis solely on the basis of inconspicuous or even missing primary school reports.
We have received alarming reports that some doctors have refused to diagnose such cases. Of course, this is in no way acceptable:

• DSM and ICD require first symptoms by the age of 12, which is outside primary school age. Barkley assumes a possible first onset up to the completion of brain development, which occurs up to the age of 25, and therefore recommends interpreting the criterion correspondingly broadly.
• Some people with ADHD no longer have their primary school certificates.
• A high level of intelligence or a high compensatory willingness to perform can make people with ADHD appear inconspicuous in elementary school.
• Girls are also more adapted and often do not stand out as people with ADHD. Women often develop psychological problems at a later age than boys due to their different sex hormone development. More on this under Gender differences in ADHD.
• In our opinion, the current DSM and ICD criteria still overrepresent a classic boy’s ADHD with hyperactivity.
• In addition, some teachers formulated their assessments in a rather friendly way. At the time, no teacher was aware that their assessment would be used as a diagnostic measure at some point.

As an alternative to primary school reports, reports from parents, relatives, school friends or graduation newspapers (which often contain very accurate characterizations of the persons by classmates) can also help.
The absence of primary school reports must never be the (sole) reason for refusing a diagnosis, as no one is obliged to keep these reports. Accordingly, primary school reports should be viewed with caution. In both positive and negative cases, they are an indication that contributes to the overall picture, but are by no means mandatory “proof”.

5. Standardized survey of ADHD symptoms¶

Use of standardized procedures for the detailed assessment of relevant symptoms and their severity.

6. Test psychological performance diagnostics¶

Use of procedures to determine the general cognitive performance level.
See above for a warning about this.