Instructions how to use DIVA
According to the DSM-IV, ascertaining the diagnosis of ADHD in adults involves determining the presence of ADHD symptoms during both childhood and adulthood.
The main requirements for the diagnosis are that the onset of ADHD symptoms occurred during childhood and that this was followed by a lifelong persistence of the characteristic symptoms to the time of the current evaluation.
The symptoms need to be associated with significant clinical or psychosocial impairments that affect the individual in two or more life situations1. Because ADHD in adults is a lifelong condition that starts in childhood, it is necessary to evaluate the symptoms, course and level of associated impairment in childhood, using a retrospective interview for childhood behaviours. Whenever possible the information should be gathered from the patient and supplemented by information from informants that knew the person as a child (usually parents or close relatives).
The Diagnostic Interview for ADHD in Adults (DIVA)
The DIVA is based on the DSM-IV criteria and is the first structured Dutch interview for ADHD in adults. The DIVA has been developed by J.J.S. Kooij and M.H. Francken and is the successor of the earlier Semi-Structured Interview for ADHD in adults2,3. In order to simplify the evaluation of each of the 18 symptom criteria for ADHD, in childhood and adulthood, the interview provides a list of concrete and realistic examples, for both current and retrospective (childhood) behaviour. The examples are based on the common descriptions provided by adult patients in clinical practice. Examples are also provided of the types of impairments that are commonly associated with the symptoms in five areas of everyday life: work and education; relationships and family life; social contacts; free time and hobbies; self-confidence and self-image.
Whenever possible the DIVA should be completed with adults in the presence of a partner and/or family member, to enable retrospective and collateral information to be ascertained at the same time. The DIVA usually takes around one and a half hours to complete.
The DIVA only asks about the core symptoms of ADHD required to make the DSM-IV diagnosis of ADHD, and does not ask about other co-occurring psychiatric symptoms, syndromes or disorders. However comorbidity is commonly seen in both children and adults with ADHD, in around 75% of cases. For this reason, it is important to complete a general psychiatric assessment to enquire about commonly co-occurring symptoms, syndromes and disorders. The most common mental health problems that accompany ADHD include anxiety, depression, bipolar disorder, substance abuse disorders and addiction, sleep problems and personality disorders, and all these should be investigated. This is needed to understand the full range of symptoms experienced by the individual with ADHD; and also for the differential diagnosis, to exclude other major psychiatric disorders as the primary cause of ‘ADHD symptoms’ in adults.
The DIVA is divided into three parts that are each applied to both childhood and adulthood:
(1) The criteria for Attention Deficit (A1)
(2) The criteria for Hyperactivity-Impulsivity (A2)
(3) The Age of Onset and Impairment accounted for by ADHD symptoms
Start with the first set of DSM-IV criteria for attention deficit (A1), followed by the second set of criteria for hyperactivity/impulsivity (A2). Ask about each of the 18 criteria in turn. For each item take the following approach: First ask about adulthood (symptoms present in the last 6-months or more) and then ask about the same symptom in childhood (symptoms between the ages of 5 to 12 years). Read each question fully and ask the person being interviewed whether they recognise this problem and to provide examples. Patients will often give the same examples as those provided in the DIVA, which can then be ticked off as present. If they do not recognise the symptoms or you are not sure if their response is specific to the item in question, then use the examples, asking about each example in turn.
For a problem behaviour or symptom to be scored as present, the problem should occur more frequently or at a more severe level than is usual in an age and IQ matched peer group, or to be closely associated with impairments. Tick off each of the examples that are described by the patient. If alternative examples that fit the criteria are given, make a note of these under “other”. To score an item as present it is not necessary to score all the examples as present, rather the aim is for the investigator to obtain a clear picture of the presence or absence of each criterion.
For each criterion, ask whether the partner or family member agrees with this or can give further examples of problems that relate to each item. As a rule, the partner would report on adulthood and the family member (usually parent or older relative) on childhood. The clinician has to use clinical judgement in order to determine the most accurate answer. If the answers conflict with one another, the rule of thumb is that the patient is usually the best informant7. The information received from the partner and family is mainly intended to supplement the information obtained from the patient and to obtain an accurate account of both current and childhood behaviour; the informant information is particularly useful for childhood since many patients have difficulty recalling their own behaviour retrospectively. Many people have a good recall for behaviour from around the age of 10-12 years of age, but have difficulty for the pre-school years.
For each criterion, the researcher should make a decision about the presence or absence in both stages of life, taking into account the information from all the parties involved. If collateral information cannot be obtained, the diagnosis should be based on the patient’s recall alone. If school reports are available, these can help to give an idea of the symptoms that were noticed in the classroom during childhood and can be used to support the diagnosis. Symptoms are considered to be clinically relevant if they occurred to a more severe degree and/or more frequently than in the peer group or if they were impairing to the individual.
Age of onset and impairment
The third section on Age of Onset and Impairment accounted for by the symptoms is an essential part of the diagnostic criteria. Find out whether the patient has always had the symptoms and, if so, whether any symptoms were present before 7-years of age. If the symptoms did not commence till later in life, record the age of onset. Then ask about the examples for the different situations in which impairment can occur, first in adulthood then in childhood. Place a tick next to the examples that the patient recognises and indicate whether the impairment is reported for two or more domains of functioning. For the disorder to be present, it should cause impairment in at least two situations, such as work and education; relationships and family life; social contacts; free time and hobbies; self-confidence and self-image, and be at least moderately impairing.
Summary of symptoms
In the Summary of Symptoms of Attention Deficit (A) and Hyperactivity-Impulsivity (HI), indicate which of the 18 symptom criteria are present in both stages of life; and sum the number of criteria for inattention and hyperactivity/impulsivity separately. Finally, indicate on the Score Form whether six or more criteria are scored for each of the symptom domains of Attention Deficit (A) and Hyperactivity-Impulsivity (HI).
For each domain, indicate whether there was evidence of a lifelong persistent course for the symptoms, whether the symptoms were associated with impairment, whether impairment occurred in at least two situations, and whether the symptoms might be better explained by another psychiatric disorder. Indicate the degree to which the collateral information, and if applicable school reports, support the diagnosis. Finally, conclude whether the diagnosis of ADHD can be made and which subtype (with DSM-IV code) applies.
Explanation to be given beforehand to the patient
This interview will be used to ask about the presence of ADHD symptoms that you experienced during your childhood and adulthood. The questions are based on the official criteria for ADHD in the DSM-IV. For each question I will ask you whether you recognise the problem. To help you during the interview I will provide some examples of each symptom, that describe the way that children and adults often experience difficulties related to each of the symptoms of ADHD. First of all, you will be asked the questions, then your partner and family members (if present) will be asked the same questions. Your partner will most likely have known you only since adulthood and will be asked questions about the period of your life that he or she knew you for; your family will have a better idea of your behaviour during childhood. Both stages of your life need to be investigated in in order to be able to establish the diagnosis of ADHD.
- American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition. Washington DC, 2000.
- Diagnostic Interview for ADHD in Adults 2.0 (DIVA 2.0), in: Kooij, JJS. Adult ADHD. Diagnostic assessment and treatment. Pearson Assessment and Information BV, Amsterdam, 2010.
- Kooij, JJS, Francken MH: Diagnostisch Interview Voor ADHD (DIVA) bij volwassenen. Online available at www.kenniscentrumadhdbijvolwassenen.nl, 2007 and published in English in reference 2.
- Applegate B, Lahey BB, Hart EL, Biederman J, Hynd GW, Barkley RA, Ollendick T, Frick PJ, Greenhill L, McBurnett K, Newcorn JH, Kerdyk L, Garfinkel B, Waldman I, Shaffer D: Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 1997; 36(9):1211-21.
- Barkley RA, Biederman J: Toward a broader definition of the age-of-onset criterion for attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1997; 36(9):1204-10.
- Faraone SV, Biederman J, Spencer T, Mick E, Murray K, Petty C, Adamson JJ, Monuteaux MC: Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry 2006; 163(10): 1720-9.
- Kooij JJS, Boonstra AM, Willemsen-Swinkels SHN, Bekker EM, Noord Id, Buitelaar JL: Reliability, validity, and utility of instruments for self-report and informant report regarding symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) in adult patients. J Atten Disorders 2008; 11(4):445-458.