Do's and don'ts
By M. Bruinsma and M. Reitsma, psychologists experienced in using the DIVA PsyQ, psycho-medical programs, Program Adult ADHD, The Hague, the Netherlands.
- Always use the DIVA next to an instrument for diagnostic assessment of comorbidity and for differential diagnosis
- Use the DIVA simultaneously with patient, partner and/or parents
- Ask for any available school records to see if they confirm the ADHD symptoms
- Give before the start a brief explanation of the method of administering the DIVA
- Only use the DIVA to determine whether there is ADHD, without excluding any other causes of ADHD symptoms
- Start assessment of the DIVA without any explanation beforehand
Assessment of the criteria of ADHD
- First ask questions to the patient and then ask whether partner / parents recognize the symptom
- Reed the DSM-IV criteria literally
- Longer criteria may be split up
- Repeat the question if necessary
- If the patient does not understand a question, you may explain the question in other words
- Always first ask the symptoms in adulthood, followed by in childhood
- Repeat, if necessary, the life phase concerned
- Stick to the order of the instrument
- Ask the criteria in your own words
- Be too rigid when explaining examples or criteria
- Pay too little attention to partner / parents
- Start a conversation with partner / parents while forgetting the patient
- Leave the order of the instrument which will lead to confusion and possible forgetting certain aspects of the interview
Asking examples of attention-deficit and of hyperactivity/impulsivity
- Ask whether the example is recognized and ask the patient to give concrete examples from everyday life
- Ask more questions if you are not sure whether a criterion is present or not
- If the patient mentions an example that fits well with the criterion, but is not mentioned within the standard examples, fill it in at 'Other'.
- Confront patients if they report conflicting information
- If you think the patient or the partner / parents report is unreliable, discuss this an try to find out why (shame, guilt, low memory, recognition of symptoms by themselves by the parents)
- In case of disagreement between patient and partner/parents, try to figure out why. Basically, you rely most on the information of the patient, unless you have the impression that the patient withholds information or exaggerates.
- Be too easily satisfied with an answer, e.g. scoring a criterion positive if the patient only anwers with "yes"
- Use words the patient doesn’t understand
- Fill in examples in the category "Other" that are not applicable to the criterion
Scoring of the criteria
- Score the test right away. If you don’t have enough information to decide whether a criterion is present or not, you have to ask more questions
- Decide whether the presence of the example/examples is convincing enough for the criterion to be scored as present or not One convincing example may sometimes be sufficient
- The criterion has to occur “often” If you doubt this, you may ask if the criterion occurs more often with the patient than with most other adults / children, or whether it occurs at least once a week
- Score the individual criteria after finishing the interview
- Assume that a certain number of examples must be present in order to be able to score a criterion
- First ask about all areas of functioning during adulthood and then about the areas of functioning during childhood
- Tick the examples of impairment that have already been mentioned during the investigation right away, and check the other examples by asking
- Make a diagnosis of ADHD if you have enough evidence for a childhood onset and lifetime course of ADHD symptoms and impairment in at least two areas of functioning
- In case of little impairment during childhood or adulthood, try to identify potential compensatory reasons (e.g. high intelligence, external structure given by parents or school, comorbid conditions that interfered with functioning).
- Reject the diagnosis of ADHD because there is no parent, partner or friend available to confirm the symptoms
- Reject the diagnosis of ADHD only because there seems limited (remembered) impairment in childhood
- Withold the diagnosis of ADHD because less than 6 out of 9 criteria are remembered in childhood. In this case you may choose the following procedure:
Decide whether ADHD is a likely explanation for the symptoms by considering the number of criteria in childhood and adulthood, and by considering the chronic course of symptoms and impairment. Also decide whether another diagnosis can be a better explanation for this pattern of symptoms and course. If there is no better explanation by another diagnosis, ADHD can be diagnosed when the only missing point for the diagnosis is the retrospective memory of the patient of the exact number of criteria in childhood. The retrospective memory of the patient may be the weakest part of the diagnosis, the chronic course of symptoms and impairment over time the strongest. It is necessary to explain the reasons for diagnosing ADHD in this case.