ADHD Diagnostic criteria Flashcards
Inattentive presentation
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention.
Does not appear to listen.
Struggles to follow through on instructions.
Has difficulty with organization.
Avoids or dislikes tasks requiring a lot of thinking.
Loses things.
Is easily distracted.
Is forgetful in daily activities.
Hyperactive-impulsive presentation
Fidgets with hands or feet or squirms in chair.
Has difficulty remaining seated.
Runs about or climbs excessively in children; extreme restlessness in adults.
Difficulty engaging in activities quietly.
Acts as if driven by a motor; adults will often feel inside like they were driven by a motor.
Talks excessively.
Blurts out answers before questions have been completed.
Difficulty waiting or taking turns.
Interrupts or intrudes upon others.
Minimum number of symptoms to make diagnosis
6 in children, 5 in adults (17 and above)
Duration symptoms must be present to diagnose ADHD
6 months, to a degree that is judged to be inconsistent with an individual’s developmental level.
When symptoms must start, according to DSM-5.
Several inattentive or hyperactive-impulsive symptoms must be present prior to 12 years. (They do not need to be impairing, just present).
Where symptoms must be observed, according to DSM-5
“Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.” This differs from DSM-IV which stated symptoms must be impairing in 2 or more settings.
Examples of lack of attention to detail
Overlooks or misses details, work is inaccurate, careless mistakes
Examples of trouble sustaining focus
Difficulty remaining focused during lectures
Conversations
Lengthy reading
Not listening when spoken to directly
Mind seems elsewhere, even in the absence of any obvious distraction
Examples of “does not follow through on instructions”
Starts tasks but quickly loses focus and is easily sidetracked:
Schoolwork
Chores
Workplace duties
Examples of difficulty with organization
Difficulty managing sequential tasks
Difficulty keeping materials and belongings in order
Messy, disorganized work
Poor time management
Fails to meet deadlines
Examples of “often avoids or is reluctant to engage in tasks that require sustained mental effort”
Avoids schoolwork or homework
Preparing reports
Completing forms
Reviewing lengthy papers
Examples of “often loses things necessary for tasks or activities”
School materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones.
Forgetting to bring things needed for the day.
Examples of “often easily distracted by extraneous stimuli”
Noises
Distractions in the environment
For older adolescents and adults may include unrelated thoughts (looking things up online)
Examples of “forgetful in daily activities”
Doing chores, running errands
Returning calls
Paying bills
Keeping appointments
Examples of fidgeting
Taps hands or squirms in seat
Examples of leaving seat in situation where remaining seated is accepted
Leaves his place in the classroom
Office or other workplace
Church
Family dinners
Running or climbing
May be limited to feeling restless in adults or adolescents
Examples of “often unable to play or engage in leisure activities quietly”
Talking too much when doing a quiet activity
Can’t watch a movie - standing up, talking, doing other things
Examples of blurting out answers
Completes people’s sentences
Cannot wait for turn in conversation
Answer questions prematurely
Examples of difficulties awaiting turn
Trouble waiting in line
Traffic
Waiting for things to arrive in the mail
Examples of interrupting or intruding on others
Butts into conversations,games, or activities.
Using other people’s things without asking or receiving permission
Adolescents and adults: may intrude into or take over what others are doing
“Too bossy”
Interrupting in conversations
Other Specified ADHD in DSM-5
When full criteria are not met
Clinically significant distress or impairment in functioning
The clinician chooses to convey why full criteria are not met (e.g. Other Specified ADHD with insufficient inattention symptoms)
Unspecified ADHD in DSM-5
Full symptom criteria are not met
Symptoms are clinically impairing
The clinician chooses not to specify the reason that full criteria are not met and making a more specific diagnosis is not possible.
How should the information re: diagnostic criteria be obtained per DSM-5?
No specified sources of information or diagnostic tests required.
ADHD remains a clinical judgment that clinicians make based on the information they obtain using the methods they choose to obtain it.
Situations where symptoms may be minimal or absent
Individual is receiving frequent rewards for appropriate behaviour
Close supervision
Novel setting
Especially interesting activities
consistent external stimulation (e.g. electronic screens)
Interacting one-on-one
Associated features
Mild delays in language, motor, or social development
Low frustration tolerance
Irritability
Mood lability
Basis of the diagnostic criteria for ADHD in DSM-5.
Hundreds of studies (literature review), expert consensus opinion, survey of rating scales and factor structure, field trial. (Barkley 2015). The factor analysis involved behavioral ratings of over 60,000 children. Cutoff for # of symptoms based on field trial.
Age of onset in DSM-5
Age 12; this is a rough guideline (Barkley 2015) so clinicians should be flexible in imposing an age of onset, recognizing that recall of onset is unreliable.
Degree of agreement between parents and teachers…
… is modest for most dimensions of behavior (between 0.3 and 0.5). Thus there is a low ceiling for level of agreement that can be expected between two informants.
How should information from informants be weighted?
This information should be interpreted as providing information on children in that particular context and nothing more. When complete agreement across parent, teacher, and clinician is required for diagnosis, it severely reduces diagnosis. There is no empirical basis for requiring reports from multiple informants so evidence of a history of symptoms in multiple settings should be accepted.
Validity of the DSM-5 diagnostic criteria in adults.
The DSM-5 has parenthetical clarifications but these have not been tested for accuracy in discriminating teens or adults with ADHD.
Alternative diagnostic criteria for adults
Developed by Barkley 2008; better items than those in the DSM-5 exist for diagnosing or predicting impairment in adults. 9 items (6 or more needed)
- easily distracted
- often make decisions impulsively
- difficulty stopping activities or behaviour when they should do so
- Starts a project or task without reading or listening to directions carefully
- Often shows poor follow-through
- Often trouble doing things in their proper order or sequence.
- Often likely to speed (or trouble doing leisure activities quietly)
- Often difficulty sustaining attention in tasks or leisure activities.
- Difficulty organizing tasks and activities.
What is the standard of impairment in ADHD?
The DSM-5 specifies the symptoms interfere with, or reduce, the quality of social, academic or occupational functioning. It does not specify the standard of comparison. Barkley (2015) et al believe it should be judged against the “average person” to be considered a disorder.
Validity of ADHD diagnostic criteria in women and girls.
Females in general show fewer ADHD symptoms than males in the general population. Therefore females need to meet a higher threshold relative to other females to be diagnosed with ADHD than do males relative to other males. Females with ADHD show equally if not more engative functional outcomes compared to male counterparts.
