ADHD DIVA 2.0 - DSM-IV

DSM-IV criteria OR DIVA 2.0

Diagnostic interview for ADHD in adults

Source: DIVA Foundation J.J.S. Kooij, MD, PhD & M.H. Francken, MSc2010, 2010, DIVA Foundation, The Netherlands

PATIENT DETAILS

First Name *

Last Name *

Date of Birth *

Part 1: Symptoms of attention-deficit (DSM-IV criterion A1)

Instructions: the symptoms in adulthood have to have been present for at least 6 months. The symptoms in childhood relate to the age of 5-12 years.
For a symptom to be ascribed to ADHD ( symptom present) it should have a chronic trait-like course and should not be episodic.

A1. Do you often fail to give close attention to detail, or do you make careless mistakes in your work or during other activities? And how was that during childhood? *

YesNo

Other:

Other

Symptom present *

YesNo

Symptom present *

YesNo

A2. Do you often find it difficult to sustain your attention on tasks? And how was that during childhood? *

YesNo

*Unless the subject is found to be really interesting (e.g.computer or hobby)

Other

Symptom present: *

YesNo

Symptom present *

YesNo

A3. Does it often seem as though you are not listening when you are spoken to directly? And how was thatduring childhood? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A4. Do you often fail to follow through on instructions and do you often fail to finish jobs or fail to meet obligationsat work? And how was that during childhood (when doing schoolwork as opposed to when at work)? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A5. Do you often find it difficult to organise tasks and activities? And how was that during childhood?

A5. Do you often find it difficult to organise tasks and activities? And how was that during childhood? *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A6. Do you often avoid (or do you have an aversion to, or are you unwilling to do) tasks which requiresustained mental effort? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A7. Do you often lose things that are needed for tasks or activities? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A8. Are you often easily distracted by external stimuli? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

A9. Are you often forgetful during daily activities? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Supplement criterion A

Adulthood: Do you have more of these symptoms of attention deficit than other people, or do you experience these more frequently than other people of your age? *

YesNoNot applicable (patient is a child)

Childhood: Did you have more of these symptoms of attention deficit than other children of your age, or did you experience these more frequently than other children of your age? *

YesNo

Part 2: Symptoms of hyperactivity-impulsivity (DSM-IV criterion A2)

Instructions: the symptoms in adulthood have to have been present for at least 6 months. The symptoms in childhoodrelate to the age of 5-12 years. For a symptom to be ascribed to ADHD it should have a chronic trait-like course andshould not be episodic.

H/I 1. Do you often move your hands or feet in a restless manner, or do you often fidget in your chair?And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 2. Do you often stand up in situations where the expectation is that you should remain in your seat?And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 3. Do you often feel restless? And how was that during childhood?

Examples during adulthood: *

Feeling restless or agitated insideConstantly having the feeling that you have to be doingsomethingFinding it hard to relaxNot applicable (patient is a child)

Examples during childhood: *

Always running aroundClimbing on furniture, or jumping on the sofaClimbing in treesFeeling restless inside

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 4. Do you often find it difficult to engage in leisure activities quietly? And how was that duringchildhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 5. Are you often on the go or do you often act as if “driven by a motor”? And how was that duringchildhood?

Examples during adulthood: *

Always busy doing somethingHas too much energy, always on the moveStepping over own boundariesFinds it difficult to let things go, excessively drivenNot applicable (patient is a child)

Examples during childhood: *

Constantly busyExcessively active at school and at homeHas lots of energyAlways on the go, excessively driven

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 6. Do you often talk excessively? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 7. Do you often give the answer before questions have been completed? And how was that duringchildhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

H/I 8. Do you often find it difficult to await your turn? And how was that during childhood?

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Other:

Symptom present: *

YesNo

Symptom present: *

YesNo

Supplement criterion A

Adulthood: Do you have more of these symptoms of hyperactivity/impulsivity than other people, or do you experience these more frequently than other people?

YesNoNot applicable (patient is a child)

Childhood: Did you have more of these symptoms of hyperactivity/impulsivity than other children of your age, or did you experience these more frequently than other children of your age?

YesNo

Part 3: Impairment on account of the symptoms (DSM-IV criteria B, C and D)

Criterion B

Have you always had these symptoms of attention deficit and/or hyperactivity/impulsivity? *

Yes (a number of symptoms were present prior to the 7th year of age).No

If no is answered above, starting as from year of age.

Criterion C

In which areas do you have / have you had problems with these symptoms?

Adulthood

Childhood and adolescence

Other

Adulthood: Evidence of impairment in two or more areas? *

Yes NoNot applicable (patient is a child)

Childhood and adolescence: Evidence of impairment in two or more areas? *

Yes No

End of the interview. Please continue with the summary.

Potential details:

Summary of symptoms A and H/I (PATIENTS TO SKIP THIS PART)

Indicate which criteria were scored in parts 1 and 2 and add up

Total number of criteria Attention Deficit

--/9

Total number of criteria Hyperactivity/Impulsivity

--/9

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient Signature *

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Score form ---- OFFICE USE ONLY ----

DSM-IVcriterion A

Childhood

Is the number of A characteristics ≥ 6?

YesNo

Is the number of H/I characteristics ≥ 6?

YesNo

Adulthood

Is the number of A characteristics ≥ 6?

YesNo

Is the number of H/I characteristics ≥ 6?

YesNo

DSM-IVcriterion B

Are there signs of a lifelong pattern of symptoms and limitations?

YesNo

DSM-IVcriterion C and D

The symptoms and the impairment are expressed in at least two domains of functioning

Adulthood

YesNo

Childhood

YesNo

DSM-IVcriterion E

The symptoms cannot be (better) explained by the presence of another psychiatric disorder

YesNo

If Yes, by

Is the diagnosis supported by collateral information?

0 = none/little support

1 = some support

2 = clear support

Explaination

Diagnosis ADHD***

No

If Yes, subtype

314.01 Combined type314.00 Predominantly inattentive type314.01 Predominantly hyperactive-impulsive type

* Research has indicated that at adult age, four or more characteristics of attention problems and/or hyperactivity-impulsivity are sufficient forthe diagnosis of ADHD to be made. Kooij e.a., Internal and external validity of Attention-Deficit Hyperactivity Disorder in a population-basedsample of adults. Psychological Medicine 2005; 35(6):817-827. Barkley RA: Age dependent decline in ADHD: True recovery or statisticalillusion? The ADHD Report 1997; 5:1-5.** Indicate from whom the collateral information was taken.*** If the established sub-types differ in childhood and adulthood, the current adult sub-type prevails for the diagnosis.