ADHD History Taking | CASC Article and Video

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When establishing a diagnosis of ADHD, seek to corroborate childhood symptoms and assess current functional impairment across multiple settings.

Key Knowledge

What is Attention Deficit Hyperactivity Disorder (ADHD)?

ICD-11 defines ADHD (6A05) as a neurodevelopmental disorder defined by a persistent pattern (≥6 months) of:
● Inattention: Difficulty sustaining attention, distractibility, disorganisation and forgetfulness,
and/or
● Hyperactivity: Excessive motor activity, restlessness, difficulty remaining still (sense of physical discomfort)
● Impulsivity: Acting without thinking, interrupting others, difficulty waiting, impulsive decisions.

Other key diagnostic features include:
● Symptoms must have started before age 12, though may not be recognised until later.
Manifestations must be present in multiple settings (work, home, social) but are likely to vary according to the structure or demand of the setting.
● Symptoms must cause significant impairment in academic, occupational, or social functioning.
Not better explained by another mental, behavioural, or neurodevelopmental disorder, or by substance misuse or medication.
● ICD-11 recognises three presentations: predominantly inattentive, predominantly hyperactive-impulsive, and combined type.

Differential Diagnosis for ADHD

Autism spectrum disorder
● In ADHD alone, there are no social/communication difficulties or restricted interests
Mood or anxiety disorder
● In ADHD there should be a persistent pattern of behaviour since childhood. Anxiety is not the primary cause of restlessness.
Substance use or medication
● Certain anticonvulsants, antipsychotics, bronchodilators and thyroid replacement medication, for example, can be associated with ADHD symptoms. 
Note: Co-morbidity with other developmental or psychiatric disorders is common. 

Risk Assessment in ADHD

Communication Tips

● Explore both current and childhood symptoms of the core symptoms
● Gently probe for impact on work, home, and relationships
● Screen for comorbidities (mood, anxiety, substance use)
● Validate the patient’s experiences and recognize and build on strengths
 
Eliciting symptoms (examples given below for a collateral history of a child with suspected ADHD):
Inattention
● ‘You mentioned he/she struggles to focus. Can you tell me a bit more about that?
‘Does he/she make careless mistakes, or find it hard to pay close attention to details?’
 ● ‘In longer lessons or activities, what happens? Does he/she get distracted easily?’
● ‘Does he/she find it hard to follow through on instructions? Do you often have to repeat yourself?’
● ‘Does he/she have problems with keeping their things organised? Does he/she often lose things like his phone or lunchbox?’
Hyperactivity
● ‘Does he/she fidget a lot? Does he/she have trouble staying seated at school or during dinner?’
● ‘How would you describe his/her overall energy level?
● ‘Does he/she talk excessively, or find it hard to wait his/her turn to speak?’
Impulsivity
● ‘Does he/she often blurt out answers or interrupt others in conversations?’
● ‘Does he/she find it hard to wait his/her turn in games or activities?’
● ‘Has he/she ever acted without thinking or recklessly, like running across the road without looking?’

CASC Practice Scenarios

Scenario 1: ADHD Presentation

Candidate Instructions
You are working in an outpatient clinic and have been asked to review Mr. Ravi Patel, a 25-year-old customer service team manager struggling with poor organisation and frequent conflicts at work. Take a history with a view to forming an initial diagnosis.

Actor Instructions
You are Ravi Patel, a 25-year-old man. You are friendly and eager to engage, but you seem restless—fidgeting, tapping your foot, and sometimes appear distracted and lose your train of thought. 
You have always been a “people” person, but after being promoted at work to a managerial position, you are finding it almost impossible to keep track of tasks and manage your responsibilities. You forget meetings, misplace documents, and struggle to sit through long discussions.
Colleagues say you interrupt, jump between topics, and sometimes seem impatient or blunt. You’ve recently been put on a performance improvement plan and are worried about your job.

Looking back, you recall being labelled “distracted” and “hyper” at school—always forgetting homework, losing things, and getting told off for talking or fidgeting. You never got into fights or serious trouble, but had lots of detentions for not listening or finishing work. You had no difficulty making friends and no particular ‘special interests’.

You have always struggled with organisation—your home is cluttered, you start hobbies but rarely finish, and you sometimes make impulsive purchases you regret. You have had a few minor car accidents due to “not paying attention.”

You drink alcohol socially, don’t use drugs, and have no criminal history. You have never had periods of being “too happy” or “high,” nor experienced hallucinations or paranoia. Sometimes you feel low or anxious when things go wrong, but your mood is generally stable. You have never considered harming yourself.

You have a partner, and she is sometimes frustrated by your forgetfulness and impulsiveness. You have argued over your spending. You have never spoken to a mental health professional before.

Feedback for Scenario 1

Scenario 2: History Taking for ADHD

Candidate Instructions: 
You are the psychiatry registrar in an adult CMHT service. Ms. Sophie Taylor, a 27-year-old freelance photographer, has been referred by her GP after her partner raised concerns about ‘problems at home.’
 
Take a focused psychiatric history to clarify the diagnosis.

Actor Instructions: 
You are Sophie Taylor, a 27-year-old woman who has come to see you after your partner told you to ‘get checked for ADHD’ after watching a TV documentary about it. You arrive a few minutes late, apologising and looking flustered, after forgetting your appointment time and almost leaving your bag on the bus. Throughout the conversation, you seem restless and occasionally glance down at your phone to make sure you haven’t missed any messages.
 
You explain that you have always found it hard to keep on top of things at home. Your flat is usually messy, with piles of laundry and unopened post. You often start tidying up but get distracted halfway through, moving on to something else before finishing.
 
Cooking is a challenge – you frequently forget you’ve put something on the stove until you smell burning, and you’ve left the oven on more than once. You have missed paying bills several times, and last month your electricity was briefly cut off.
 
You live with your boyfriend, who you say is “incredibly patient, but understandably frustrated.” He often has to remind you about chores or appointments, and you admit that you do argue a lot, for example if you forget to pass on important messages or pick up food shopping, and he says you never seem to listen, even when you’re trying your best. You’ve also started to avoid making plans with friends because you’re embarrassed about always being late or forgetting to show up.
 
You work part-time as a freelance photographer. While you love the creative side, you struggle to keep track of deadlines and emails, and you often leave projects until the last minute, working late into the night to finish them. You’ve lost clients because of missed deadlines or mistakes, and you sometimes feel like you’re “constantly letting people down.” However, you don’t think you could ever manage an “office job”.
 
Looking back, you remember being called “scatterbrained” and “away with the fairies” as a child. Teachers often wrote in your school reports that you were bright but never finished your work, and your desk was always messy. You were never disruptive in class, but you daydreamed a lot and lost your belongings regularly. You have never been in trouble with the police and have never used drugs. You drink socially but not excessively.
 
You have never felt “high” or out of control, nor have you experienced hallucinations or paranoia. You sometimes feel anxious and overwhelmed, especially when things pile up, but you don’t think you have ever been depressed for more than a few days at a time. You have never thought about harming yourself.
 
You have never seen a mental health professional before, and you admit you feel embarrassed to be here, worried that you’re just  “bad at adulting.” However, you are desperate for things to improve, especially as your relationship is under strain and you worry you might lose your partner if things don’t change.
 
If the interviewer is kind and patient, you become more open about how much your difficulties affect your self-esteem and how lonely and ashamed you sometimes feel. If the interviewer is brisk or judgmental, you become defensive and downplay your struggles.

Feedback for Scenario 2

Scenario 3: Example Video

Candidate Instructions: 
You are working in a community child and adolescent mental health service (CAMHS). You have been asked to take a collateral history from Mr Anish Gill , father of 13-year-old Daniel Gill, who has been referred by his school due to behavioural concerns at school.

Please take a history from Mr. Gill to gather information on Daniel with a view to establishing a diagnosis.

Authors/Reviewers

Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.

References and Resources

1. World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
2. National Institute for Health and Care Excellence (NICE). (2018). Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline [NG87]. Retrieved from https://www.nice.org.uk/guidance/ng87

Disclaimer:

This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
 
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.

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