Diagnostic Criteria of ADHD

DSM-5 Diagnostic Criteria for ADHD

Criterion A: Pattern of Inattention and/or Hyperactivity-Impulsivity

At least 6 symptoms from either (or both) categories, persisting for at least 6 months:

(For adolescents 17+ and adults, at least 5 symptoms required)

A1. Inattention (6 or more symptoms):

  1. Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

  2. Difficulty sustaining attention in tasks or play activities (e.g., lectures, conversations, lengthy reading)

  3. Does not seem to listen when spoken to directly (mind seems elsewhere, even without obvious distraction)

  4. Does not follow through on instructions and fails to finish work (starts tasks but quickly loses focus)

  5. Difficulty organizing tasks and activities (difficulty managing sequential tasks, keeping materials organized, messy work, poor time management)

  6. Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (schoolwork, homework, preparing reports, completing forms)

  7. Loses things necessary for tasks or activities (school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile phones)

  8. Easily distracted by extraneous stimuli (for older adolescents/adults, may include unrelated thoughts)

  9. Forgetful in daily activities (doing chores, running errands, returning calls, paying bills, keeping appointments)

A2. Hyperactivity and Impulsivity (6 or more symptoms):

Hyperactivity:

  1. Fidgets with or taps hands or feet, or squirms in seat

  2. Leaves seat in situations when remaining seated is expected (classroom, office, workplace)

  3. Runs about or climbs in situations where inappropriate (in adolescents/adults, may be limited to feeling restless)

  4. Unable to play or engage in leisure activities quietly

  5. “On the go” acting as if “driven by a motor” (uncomfortable being still for extended time, others may find them restless or difficult to keep up with)

  6. Talks excessively

Impulsivity:

  1. Blurts out answers before questions completed (completes people’s sentences, can’t wait for turn in conversation)

  2. Difficulty waiting their turn (waiting in line)

  3. Interrupts or intrudes on others (butts into conversations, games, or activities; may start using others’ things without asking; adolescents/adults may intrude or take over what others are doing)

Criterion B: Onset

Several inattentive or hyperactive-impulsive symptoms were present before age 12 years

Note:

  • Symptoms don’t have to be diagnosed before age 12
  • But must have been present (based on history)
  • Many adults diagnosed later recall symptoms in childhood

Criterion C: Multiple Settings

Several symptoms present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities)

Why this matters: Distinguishes ADHD from situational behavior problems

Criterion D: Functional Impairment

Clear evidence that symptoms interfere with, or reduce quality of social, academic, or occupational functioning

Examples:

  • Poor school/work performance
  • Relationship problems
  • Difficulty completing responsibilities
  • Social rejection

Criterion E: Exclusion

Symptoms do not occur exclusively during course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication/withdrawal)

Specify Presentation Type

Combined Presentation

  • Criteria A1 (Inattention) AND A2 (Hyperactivity-Impulsivity) met for past 6 months
  • Most common presentation

Predominantly Inattentive Presentation

  • Criterion A1 (Inattention) met
  • Criterion A2 (Hyperactivity-Impulsivity) NOT met for past 6 months
  • More common in girls

Predominantly Hyperactive-Impulsive Presentation

  • Criterion A2 (Hyperactivity-Impulsivity) met
  • Criterion A1 (Inattention) NOT met for past 6 months
  • More common in young children

Note: Presentation can change over time as symptoms change

Specify Current Severity

Mild: Few symptoms beyond required, minor impairment

Moderate: Symptoms or functional impairment between “mild” and “severe”

Severe: Many symptoms beyond required, or symptoms produce marked impairment

Specify If:

In Partial Remission: Full criteria previously met, but fewer than full criteria met for past 6 months, with symptoms still resulting in impairment

Additional Diagnostic Considerations

Age-Specific Manifestations

Preschool Children:

  • Hyperactivity more obvious
  • Difficulty sitting during meals, story time
  • Constantly moving, climbing
  • Dangerous behavior (no sense of danger)

School-Age Children:

  • Inattention becomes problematic academically
  • Difficulty completing homework
  • Forgetfulness, disorganization
  • Social problems emerge

Adolescents:

  • Hyperactivity may decrease or become internalized (restlessness)
  • Executive function problems more apparent
  • Risk-taking behavior
  • Academic underachievement

Adults:

  • Hyperactivity often internal (feeling restless)
  • Chronic lateness, disorganization
  • Job problems, relationship difficulties
  • May have learned compensatory strategies
  • Often multiple job changes

Cultural Considerations

  • Symptoms may be viewed differently across cultures
  • Diagnostic threshold should consider cultural context
  • Activity level norms vary by culture
  • Teacher/parent tolerance for activity varies

Gender Differences

Males:

  • More hyperactive-impulsive symptoms
  • More behavioral problems
  • Diagnosed earlier and more often

Females:

  • More inattentive symptoms
  • May be overlooked (“daydreamers”)
  • Fewer behavioral problems
  • Often diagnosed later
  • May internalize symptoms (anxiety, low self-esteem)

Differential Diagnosis

Must Rule Out:

Normal High Activity: Some children naturally more active; not impairing

Oppositional Defiant Disorder: Defiant behavior may seem like not listening; can co-occur

Anxiety Disorders: Worry can cause distraction; agitation may seem like hyperactivity

Depression: Poor concentration common in depression

Learning Disorders: Inattention may be secondary to frustration with academics

Autism Spectrum Disorder: Social deficits different from ADHD; can co-occur

Intellectual Disability: Inattention may be appropriate for mental age

Sleep Disorders: Sleep deprivation causes inattention, hyperactivity

Substance Use: Intoxication or withdrawal can mimic ADHD

Medical Conditions: Thyroid problems, seizures, lead poisoning

Medication Side Effects: Some medications cause inattention or hyperactivity

Comorbidity

ADHD commonly co-occurs with:

  • Learning disorders (30-50%)
  • Oppositional Defiant Disorder (40-60%)
  • Conduct Disorder (15-20%)
  • Anxiety disorders (25-35%)
  • Depression (15-20%)
  • Substance use disorders (adolescents/adults)
  • Tic disorders

Assessment Methods

Comprehensive Evaluation Includes:

  1. Clinical Interview:

    • Developmental history
    • Current symptoms
    • Functional impairment
    • Multiple settings

  2. Rating Scales:

    • Parent/teacher rating scales (Conners, Vanderbilt)
    • Self-report (for adolescents/adults)
    • Standardized and normed

  3. Behavioral Observations:

    • Clinic observation
    • School observation if possible

  4. Psychological Testing:

    • IQ testing (rule out intellectual disability)
    • Achievement tests (check for learning disorders)
    • Continuous performance tests (measure attention)

  5. Medical Examination:

    • Rule out medical causes
    • Check vision/hearing
    • Medication review

  6. School Records:

    • Report cards
    • Teacher comments
    • Disciplinary records

  7. Collateral Information:

    • Multiple informants (parents, teachers, spouse)
    • Information from multiple settings

Important Notes

Cannot Diagnose Based On:

  • Single setting (e.g., only at school)
  • Brief observation
  • Rating scale alone
  • Computer test alone

Requires:

  • Comprehensive evaluation
  • Information from multiple sources
  • Evidence of impairment
  • Rule out other causes

Key Diagnostic Points for Exams

  1. Three presentations: Combined, Predominantly Inattentive, Predominantly Hyperactive-Impulsive
  2. Symptom count: 6+ symptoms (5+ for ages 17+) for at least 6 months
  3. Two symptom categories: Inattention AND/OR Hyperactivity-Impulsivity
  4. Age of onset: Several symptoms present before age 12
  5. Multiple settings: Symptoms in 2+ settings required
  6. Functional impairment: Must interfere with functioning
  7. Developmentally inappropriate: Symptoms inconsistent with developmental level
  8. Not better explained: Must rule out other disorders
  9. High comorbidity: Especially learning disorders, ODD, anxiety
  10. Comprehensive assessment: Multiple methods, sources, settings needed