Diagnostic criteria

In DSM-IV the symptoms of ADHD (attention deficit hyperactivity disorder) are divided into two core symptoms, inattention and impulsivity-hyperactivity (see Table: Diagnostic Criteria For ADHD).7 This division reflects the growing understanding that hyperactivity and impulsivity probably have the same underlying biological substrate.

As shown in Table: Diagnostic Criteria For ADHD, nine symptoms compose each dimension. The hyperactivity-impulsivity dimension consists of six symptoms that reflect hyperactivity and three symptoms that reflect impulsivity. One of the key modifiers in each symptom description is the word often. This emphasizes that these symptoms:

• are not rare or occasional, but are persistent
• are more severe than in other children at a comparable stage of development
• result in significant functional impairment

Meeting the criteria for ADHD requires that some impairing symptoms be present before the age of 7 years, in at least two settings, and for at least 6 months. These constraints reflect the fact that ADHD is a chronic disorder and that different environmental settings may reduce or exacerbate symptoms.

DSM-IV lists subtypes of ADHD:

• In the combined type, at least six symptoms from the dimensions of both inattention and hyperactivity-impulsivity must be present.
• In the predominantly inattentive type, six or more symptoms from the inattention category and fewer than six symptoms from the hyperactivity-impulsivity list must be present.
• In the predominantly hyperactive-impulsive type, at least six symptoms from the hyperactivity-impulsivity dimension and fewer than six from the inattention symptoms must be present.

For patients who met full criteria for the disorder at some point but who no longer do so, the modifier in partial remission should be appended to the diagnosis.

For patients with prominent symptoms who do not meet the criteria for the full syndrome, the diagnosis ADHD not otherwise specified can be used.

ADHD at different ages

The core symptoms may manifest themselves differently at different stages of development. Preschoolers tend to show more hyperactive symptoms. Motor restlessness, destructive play, fearlessness, temper tantrums, sleep difficulties, and noncompliance may be the predominant symptoms. Because many of these behaviors can be seen in healthy preschoolers, however, accurately making a diagnosis of ADHD can be difficult. For this reason, it has been suggested that symptoms be noted for at least 12 months before the diagnosis is confirmed.

The DSM-IV field trials targeted children ages 5–12 years, and the criteria are clearest for this age group.8 It is during the school years that attentional issues usually are first recognized. Difficulties with peer relationships also are often present in the school-age child.

In adolescence, high-risk behaviors, disorganization, and a feeling of inner restlessness (as opposed to hyperactivity) are prominent. The greater demands of a departmentalized school system with multiple teachers and the requirement to change classrooms throughout the day can result in increasing academic difficulties and school failure.

Is ADHD outgrown?

Barkley and Biederman10 presented some cogent arguments for doing away with the age-of-onset criteria and reviewed several studies, pointing out problems with retrospective recall and demonstrating that a subgroup of patients have ADHD onset in adolescence. Clinical lore and the DSM-II reported that children outgrow the symptoms of ADHD sometime during early adolescence, but we now know that up to 65% of children with ADHD have symptoms through adulthood.

Are symptoms the same for both sexes?

The higher rate of ADHD in boys than in girls raises questions of what the symptoms of ADHD look like in girls. In a study of 42 girls in whom ADHD was diagnosed, few differences emerged when they were compared with ADHD-affected boys. Both groups were similar in age of onset, comorbidity, parent diagnosis, and response to stimulants. There was some suggestion that the girls had more severe symptoms, but this may have been a result of referral bias.9

Adapted from: Hirsch GS and Koplewicz HS. Attention-deficit hyperactivity disorder. In: Devinsky O and Westbrook LE, eds. Epilepsy and Developmental Disabilities. Boston: Butterworth-Heinemann; 2001;187–204.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised June 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.

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