ADHD is considered a mental health disorder. Only a licensed professional, such as a pediatrician, psychologist, neurologist, psychiatrist, or clinical social worker, can make the diagnosis that a child, teen, or adult has ADHD. These professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV-TR) as a guide (APA, 2000).
Over the last 10 years, public awareness about ADHD has led to more children and adults being diagnosed with the disorder. Some people have expressed concern that the condition is being overdiagnosed. The American Medical Association (AMA) took a serious look into these claims. According to AMA's Special Council Report, however, there is little evidence of widespread overdiagnosis of ADHD or over-prescription of medication for the disorder (Goldman et al., 1998).
In order to be diagnosed with ADHD, children and youth must meet the specific diagnostic criteria set forth in the DSM-IV-TR. These criteria are primarily associated with the main features of the disability: inattention, hyperactivity, and impulsivity. Let's take a closer look at the specific types of behavior that must be evident in order for a diagnosis of ADHD to be made.
Attention is a process. When we pay attention:
we initiate (direct our attention to where it is needed or desired at the moment);
we sustain (pay attention for as long as needed);
we inhibit (avoid focusing on something that removes our attention from where it needs to be); and finally
we shift (move our attention to other things as needed).
Children with ADHD can pay attention. Their problems have to do with what they are paying attention to, for how long, and under what circumstances. It's not enough to say that a child has a problem paying attention. We need to know where the process is breaking down for the child so that appropriate individualized remedies can be created.
With ADHD, we see three common areas of inattention problems:
sustaining attention long enough, especially to boring, tedious, or repetitious tasks;
resisting distractions, especially to things that are more interesting or that fill in the gaps when sustained attention quits; and
not paying sufficient attention, especially to details and organization.
These attention difficulties result in incomplete assignments, careless errors, and messy work. Children with ADHD often tune out activities that are dull, uninteresting, or unstimulating. Their performance is inconsistent both at home and in school. Social situations are affected by frequent shifts or losing track of conversations, not listening to others, and not following directions to games or rules (APA, 2000).
Symptoms of inattention, as listed in the DSM-IV-TR*, are:
a. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities;
b. often has difficulty sustaining attention in tasks or play activities;
c. often does not seem to listen when spoken to directly;
d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions);
e. often has difficulty organizing tasks and activities;
f. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);
g. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools);
h. is often easily distracted by extraneous stimuli;
i.is often forgetful in daily activities. (APA, 2000, p. 92*)
*Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association.
Excessive activity is the most visible sign of ADHD. Studies show that these children are more active than those without the disorder, even during sleep. The greatest differences are usually seen in school settings (Barkley, 2000). Many parents find their toddlers and preschoolers quite active. Care must be given before labeling a young one as hyperactive. At this developmental stage, a comparison should be made between the child and his or her same-age peers without ADHD. In young children, usually the hyperactivity of ADHD will come across as "always on the go" or "motor driven." You may see behaviors such as darting out of the house or into the street, excessive climbing, and less time spent with any one toy. In elementary years, children with ADHD will be more fidgety and squirmy than their same-age peers who do not have the disorder. They also are up and out of their seats more. Adolescents and adults feel more restless and bothered by quiet activities. At all ages, excessive and loud talking may be apparent. (APA, 2000)
Symptoms of hyperactivity, as listed in the DSM-IV-TR*, are:
a. often fidgets with hands or feet or squirms in seat; b. often leaves seat in classroom or in other situations in which remaining seated is expected;
c. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness);
d. often has difficulty playing or engaging in leisure activities quietly;
e. is often "on the go" or often acts as if "driven by a motor;"
f. often talks excessively. (APA, 2000, p. 92*)
Children and youth with ADHD often act without fully considering the circumstances or the consequences. Actually, thinking about the potential outcomes of their actions before the fact often does not even cross their minds. Their neurobiologically caused problem with impulsivity makes it hard to delay gratification. Waiting even a little while is too much for their biological drive to have it now.
The impulsivity leads these children to speak out of turn, interrupt others, and engage in what looks like risk-taking behavior. The child may run across the street without looking or climb to the top of very tall trees. Although such behavior is risky, the child is not so much a risk-taker as a child who has great difficulty controlling impulse and anticipating consequences. Often, the child is surprised to discover that he or she has gotten into a dangerous situation and has no idea of how to get out of it. Some studies show that these children are more accident prone, particularly those youth who are somewhat stubborn or defiant (Barkley, 2000).
Symptoms of impulsivity, as listed in the DSM-IV-TR (APA, 2000, p. 92*), are:
g. often blurts out answers before questions have been completed;
h. often has difficulty awaiting turn;
i. often interrupts or intrudes on others (e.g., butts into conversations or games).
For a diagnosis of predominantly inattentive type of ADHD, six or more of the inattention symptoms must be present (see list on page 3). For a diagnosis of hyperactive/impulsive type, six or more of the hyperactivity or impulsivity symptoms must be present (see lists on this page). For a diagnosis of combined type, six or more symptoms of inattention, plus six or more symptoms of hyperactivity or impulsivity, must be present.
The word often appears before each symptom of inattention, hyperactivity, and impulsivity in the DSM-IV-TR. In order to be considered a symptom of ADHD, a behavior can't be "a once in a while" problem. Nor can it be a problem that pops up all of a sudden. According to the DSM-IV-TR, the following must be true:
"Developmentally inappropriate" is an important point. If you look again at the symptom list for the three main features of ADHD, you will notice that some of these behaviors may be fairly normal at certain ages. For instance, no one expects a two year old to keep track of toys or to stay seated for very long. So, losing things or not being able to stay in a chair for long would not be considered symptoms of ADHD at that age. These same behaviors in a ten year old, however, would be developmentally inappropriate. We don't expect a ten year old to constantly lose things. We do expect a ten year old to be able to stay seated during a half-hour of class or a family dinner.
ADHD is determined by the number of symptoms present and the extent of the difficulty these cause. Also, the number of symptoms and the problems they cause may change across the life span. In a small number of cases, ADHD does go away in adolescence or adult years. However, in most cases, the problems shift. A hyperactive-impulsive fourteen year old may be able to stay seated longer than he or she could at age nine. While problems caused by hyperactivity-impulsivity seem to lessen with age, other ADHD-related symptoms usually become more problematic. For instance, demands for longer periods of sustained attention increase with age. So, for example, even though a fourteen year old may sit still during a lengthy reading assignment, he or she may be bothered by an inability to concentrate.