Diagnostic Criteria for ADD/ADHD

Note: The information below is intended to familiarize you with the diagnostic criteria for ADHD/ADD. Making this diagnosis correctly requires a comprehensive evaluation, however, and should only be made by a qualified health care provider.

In the United States, ADHD is diagnosed according to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV). ADHD symptoms are divided into two groups: symptoms of inattention and symptoms of hyperactivity/impulsivity. These groups of symptoms are shown below:

In the United States, Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder is diagnosed according to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV). ADHD/ADD symptoms are divided into two groups: symptoms of inattention and symptoms of hyperactivity/impulsivity. These groups of symptoms are shown below:

Inattentive Symptoms

· often fails to give close attention to details or makes careless mistakes in schoolwork, 
  work, or other activities;

· often has difficulty sustaining attention in tasks or play activities;

· often does not seem to listen when spoken to directly;

· often does not follow through on instructions and fails to finish school work, chores, or
  duties in the work place (this failure is not due deliberately refusing to do it or not
  understanding instructions);

· often has difficulty organizing tasks or activities;

· often avoids or is reluctant to engage in tasks that require sustained mental effort;

· often loses things necessary for tasks or activities;

· is often easily distracted by extraneous stimuli;

                                                           · is often forgetful in daily activities;
 

            Hyperactive/Impulsive Symptoms

 · often fidgets with hands or squirms in seat;

· often leaves seat in classroom or in other   situations in which remaining seated is expected;

· often runs about or climbs excessively in which it is inappropriate (in adolescents and adults, may be limited to subjective feelings
  of restlessness;

· often has difficulty playing or engaging in leisure activities quietly;

· is often "on the go" or often acts as if "driven by a motor"

· often talks excessively;

· often blurts out answers before questions have been completed;

· often has difficulty awaiting turn;

· often interrupts or intrudes on others (e.g. butts into conversations or games)

To avoid diagnosing individuals who show only isolated difficulties, at least 6 inattentive symptoms and/or 6 hyperactive/impulsive symptoms must be present to possibly qualify for an ADHD/ADD diagnosis. In addition, these symptoms must have been present for at least 6 months to a degree that is considered inappropriate for the individual's age.

"Does my child have to show both kinds of symptoms to be diagnosed with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder?"

No. Many, but not all, individuals with ADHD/ADD display both inattentive and hyperactive/impulsive symptoms. Some, however, display one set of symptoms but not the other.

If 6 or more inattentive symptoms are present the diagnosis of ADHD/ADD, Predominantly Inattentive Type may apply. This is what people mean when they refer to ADD.  Technically, this term is no longer correct.

If 6 or more hyperactive/impulsive symptoms are the diagnosis of ADHD, Predominantly Hyperactive/Impulsive Type may apply;

When 6 or more of both types of symptoms are present, the diagnosis of ADHD, Combined Type may apply.

"Is deciding whether these symptoms are present the only factor involved in making the diagnosis?"

No - it is only the initial step. The following conditions must also be present:

SOME HYPERACTIVE-IMPULSIVE OR INATTENTIVE SYMPTOMS THAT CAUSED IMPAIRMENT NEED TO HAVE BEEN PRESENT BEFORE THE CHILD WAS 7.

This means that a 10 year old who suddenly begins displaying ADHD symptoms would not be diagnosed with ADHD if there was no indication of these problems when the child was younger. It is not necessary for the child's symptoms to have been as problematic at the earlier age, but there needs to be some indication that they were present. 

For example, it is not uncommon for children with inattentive symptoms, but not the hyperactive/impulsive symptoms, to do okay in the early grades when the academic demands are not very rigorous. This is especially likely for a bright child who catches on despite not attending very well. In later grades, however, when the work becomes more demanding, the child's problems with attention may begin to create real problems. Thus, although it may appear that the child's problems with attention emerged "suddenly", a careful investigation often reveals the presence of attentional difficulties earlier on.

In cases where there truly is no indication of ADHD symptoms, even at a reduced level, than ADHD would not be an appropriate diagnosis. Instead, it is likely that some other type of problem such as a mood disorder or anxiety disorder is responsible for the symptoms.

                             THE SYMPTOMS MUST CAUSE SOME IMPAIRMENT IN
                              TWO OR MORE SETTINGS (E.G. HOME AND SCHOOL).

This is a very important consideration. In order for the symptoms listed above to reflect ADHD/ADD, they must impair the individual's functioning in 2 or more settings. For children, these settings would generally be home and school. This means that if the child's symptoms are apparent in only one setting, and are not evident anyplace else, Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder is not an appropriate diagnosis. For example, if the symptoms are only evident in school, but are not present at home, Sunday school, cub scouts, little league, etc., than ADHD/ADD would not be a correct diagnosis. Similarly, if symptoms are reported by parents when the child is home, but are not observed anywhere else, than ADHD/ADD is also unlikely to apply. In these circumstances, one would look for factors unique to the setting where the symptoms are evident to try and understand what is causing them

It is important to emphasize that the intensity of ADHD symptoms can vary considerably across settings and it is not necessary that the degree of impairment from symptoms be equivalent in different settings. For example, it is not uncommon for a child's difficulties to be more prominent at school than at home. When this occurs, it is often because the demands to sustain attention and inhibit activity level are greater at school than at home. Thus, in order to satisfy the dual setting criteria, there just needs to be some indication that the problems are not exclusively confined to a single context.

THERE MUST BE CLEAR EVIDENCE OF CLINICALLY SIGNIFICANT IMPAIRMENT IN SOCIAL, ACADEMIC, OR OCCUPATIONAL FUNCTIONING.

This is another very important consideration. In order for the symptoms listed above to reflect ADHD, they must clearly impair the individual's functioning in one of these areas. For children, one would generally expect that the symptoms have a negative impact on academic performance, ability to meet appropriate behavioral expectations (e.g. following rules), and to get along with others. If the symptoms are so mild as to not create difficulties in any of these areas, than ADHD would not be diagnosed.

THE SYMPTOMS DO NOT OCCUR EXCLUSIVELY DURING THE COURSE OF A PERVASIVE DEVELOPMENTAL DISORDER, SCHIZOPHRENIA, OR OTHER PSYCHOTIC DISORDER AND ARE NOT BETTER ACCOUNTED FOR BY ANOTHER MENTAL DISORDER (E.G. MOOD DISORDER, ANXIETY DISORDER, DISSOCIATIVE DISORDER, OR A PERSONALITY DISORDER).

The purpose of this final condition is to avoid diagnosing ADHD when the symptoms reflect another psychiatric problem and not ADHD. In the conditions listed above individuals may display symptoms that are similar to those characteristic of ADHD. In diagnosing ADHD, therefore, it is necessary to confirm that it is not one of these other disorders that is responsible for the symptoms.

In reality, the first 3 disorders listed (i.e. pervasive Developmental Disorder, Schizophrenia, or some other Psychotic Disorder) are quite rare, and impair an individual's functioning to such an extent that it should be clear that something besides a simple case of ADHD is present. The remaining disorders are most likely to be the cause of ADHD symptoms when the symptoms emerged after age 7, and there was no indication of ADHD symptoms earlier on.

SUMMARY

As is hopefully clear from the above, the diagnosis of ADHD is not a simple matter. It requires that careful attention be given to a number of specific symptoms; that information about a child's functioning be collected from different sources (i.e. at least parent and teacher); that there be clear indication of impaired functioning in important life areas; and that other possible explanations for the child's symptoms are ruled out. When these detailed criteria are applied, you can be confident that the diagnostic judgment is more likely to be accurate.