Documentation necessary to substantiate the Attention-Deficit/Hyperactivity Disorder must be comprehensive

Because ADHD is, by definition, first exhibited in childhood (although it may not have been formally diagnosed) and in more than one setting, objective, relevant, historical information is essential. Information verifying a chronic course of ADHD symptoms from childhood through adolescence to adulthood, such as educational transcripts, report cards, teacher comments, tutoring evaluations, job assessments and the like are necessary.

1.       The evaluator is expected to review and discuss DSM-IV diagnostic criteria for ADHD and describe the extent to which the patient meets these criteria. The report must include information about the specific symptoms exhibited and document that the patient meets criteria for long-standing history, impairment and pervasiveness.

2.       A history of the individual’s presenting symptoms must be provided, including evidence of ongoing impulsive/hyperactive or inattentive behaviors (as specified in DSM-IV) that significantly impair functioning in two or more settings.

3.       The information collected by the evaluator must consist of more than self-report. Information from third party sources is critical in the diagnosis of adult ADHD. Information gathered in the diagnostic interview and reported in the evaluation should include, but not necessarily be limited to, the following:

·         History of presenting attentional symptoms, including evidence of ongoing impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time;

·         Developmental history;

·         Family history for presence of ADHD and other educational, learning, physical or psychological difficulties deemed relevant by the examiner;

·         Relevant medical and medication history, including the absence of a medical basis for the symptoms being evaluated;

·         Relevant psychosocial history and any relevant interventions;

·         A thorough academic history of elementary, secondary and postsecondary education;

·         Review of psychoeducational test reports to determine if a pattern of strengths or weaknesses is supportive of attention or learning problems;

·         Evidence of impairment in several life settings (home, school, work, etc.) and evidence that the disorder significantly restricts one or more major life activities.

·         Relevant employment history;

·         Description of current functional limitations relative to an educational setting and toUSMLE in particular that are presumably a direct result of the described problems with attention;

·         A discussion of the differential diagnosis, including alternative or co-existing mood, behavioral, neurological and/or personality disorders that may confound the diagnosis of ADHD;

·         Exploration of possible alternative diagnoses that may mimic ADHD; and

·         Age norms where available.

Source: http://usmleworldwide.com/blog/?p=828