Statistical Manual of Mental Disorders (DSM IV), 4th
edition, 1994
American Psychiatric Association
Attention-Deficit/Hyperactivity Disorder
Diagnostic Features
Criteria:
A: The essential feature of Attention-Deficit/Hyperactiviry Disorder is a
persistent pattern of inattention and/or hyperactivity-impulsivity that is more
frequent and severe than typically observed in individuals at a comparable level
of development.
B: Some hyperactive-impulsive or inattentive symptoms that cause impairment must
have been present before age 7 years, although many individuals are diagnosed
after the symptoms have been present for a number of years.
C: Some impairment from the symptoms must be present in at least two settings (e.g.,
at home and at school or work).
D: There must be clear evidence of interference with developmentally appropriate
social, academic, or occupational functioning.
E: The disturbance does not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder and is not
better accounted for another mental disorder (e.g., a Mood Disorder, Anxiety
Disorder, Dissociative Disorder, Personality Disorder)..
Inattention
- Inattention may be manifest in academic, occupational, or social situations.
Individuals with this disorder may fail to give close attention to details or
may make mistakes in schoolwork or other tasks (Criterion Ala).
- Work is often messy and performed carelessly and without considered thought.
Individuals often have difficulty sustaining attention in tasks or play
activities and find it hard to persist with completion (Criterion Alb).
- They often appear as if their mind is elsewhere or are not listening or did
not hear what has just been said (Criterion A1c).
- There may be frequent shifts from one uncompleted activity to another.
Individuals diagnosed with this disorder may begin a task, move on to another,
then turn to yet something else prior to completing any one task. They often do
not follow through on requests or instructions and fail to complete schoolwork,
chores, or other duties (Criterion A1d).
- Failure to complete tasks should be considered in making this diagnosis only
if it is due to inattention as opposed to other possible reasons (e.g., a
failure to understand instructions). These individuals often have difficulties
organizing tasks and activities (Criterion Ale).
- Tasks that require sustained mental effort are experienced as unpleasant and
markedly aversive. As a result, these individuals typically avoid or have
dislike for activities that demand sustained self-application and mental effort
or that require organizational demands or close concentration (e.g., homework or
paperwork (Criterion Alf).
- This avoidance must be due to the person's difficulties with attention and not
due to a primary oppositional attitude, although secondary oppositionalism may
also occur. Work habits are often disorganized and the materials necessary for
doing the task are often scattered, lost, or carelessly handled and damaged (Criterion
Alg).
- Individuals with this disorder are easily distracted by irrelevant stimuli and
frequently interrupt ongoing tasks to attend to trivial noises or events that
are usually and easily others (e.g., a car honking, a background conversation) (Criterion
Alh).
- They are often forgetful in daily activities (e.g., missing appointments,
forgetting to bring lunch) (Criterion A1i).
In social situations, inattention may be expressed as frequent shifts in
conversation, not listening to others, not keeping one's mind on conversations,
and not following details or rules of games or activities.
Hyperacvity
Hyperacvity may be manifested by
. fidgetiness or squirming in one's seat (Criterion A2a),
. not remaining seated when expected to do so (Criterion A2b),
. excessive running or climbing in situations where it is inappropriate (Criterion
A2c),
. having difficulty playing or engaging quietly in leisure activities (Criterion
A2d),
. appearing "on the go" or as if "driven by a, motor" (Criterion A2e),
. or talking excessively (Criterion A2f).
Hyperactivity may vary with the individual's age and developmental level, and
the diagnosis should be made cautiously in young children. Toddlers and
preschoolers with this disorder differ from normally active young children by
being constantly on the go and into everything; they dart back and forth, they
are "out of door before their coat is on," jump or climb on furniture, run
through the house, and have difficulty participating in sedentary group
activities in preschool classes (e.g., listening to a story). School-age
children display similar behaviors but usually with less frequency and intensity
than toddlers and preschoolers. They have difficulty remaining seated, get up
frequently, and squirm in, or hang on to the edge of, their seat. They fidget
with objects, tap their hands, and shake their feet or legs excessively. They
often get up from the table during meals, while watching television, or while
doing homework; they talk excessively; and they make excessive noise during
quiet activities. In adolescents and adults, symptoms of hyperactivity take the
form of feelings of restlessness and difficulty engaging in quiet sedentary
activities.
Impulsivity
Impulsivity manifests itself as
. impatience, difficulty in delaying responses, blurting out answers before
questions have been completed (Criterion A2g),
. difficulty awaiting one’s turn (Criterion A2h),
. and frequently interrupting or intruding on others to the point of causing difficulties in
social, academic, or occupational settings (Criterion A2i).
Others may complain that they cannot get a word in edgewise. Individuals with
this disorder typically make comments out of turn, fail to listen to directions,
initiate conversations at inappropriate times, interrupt others excessively,
intrude on others, grab objects from others, touch things they are not supposed
to touch, and clown around. Impulsivity may lead to accidents (e.g., knocking
over objects, banging into people, grabbing a hot pan) and to engagement in
potentially dangerous activities without consideration of possible consequences
(e.g., riding a skateboard over extremely rough terrain).
Behavioral manifestations usually appear in multiple contexts, including home,
school, work, and social situations. To make the diagnosis, some impairment must
be present in least two settings.
It is very unusual for an individual to display the same level of dysfunction in
all settings or within the same setting at all times. Symptoms typically worsen
in situations that require sustained attention or mental effort, or that lack
intrinsic appeal or novelty (e.g., listening to classroom teachers, doing class
assignments, listening to or reading lengthy materials, or working on monotonous,
tasks). Signs of the disorder may be minimal or absent when the person is strict
control, is in a novel setting, is engaged in especially interesting activities,
is in a one-to-one situation (e.g., the clinician's office), or while the person
experiences frequent rewards for appropriate behavior. The symptoms are more
likely to occur in group situations (e.g., in playgroups, classrooms, or work
environments). The clinician should therefore inquire about the individual's
behavior in a variety of situations within each setting.
Subtypes
Although most individuals have symptoms of both inattention and
hyperactivity-impulsivity, there are some individuals in whom one or the other
pattern is predominant. The appropriate subtype (for a current diagnosis) should
be indicated based on the predominant symptom pattern for the past 6 months.
Attention-Deficit/Hyperactivity Disorder, Combined Type. This subtype should be
used if six (or more) symptoms of inattention and six (or more) symptoms of
hyperactivity-impulsivity have persisted for at least 6 months. Most children
and adolescents with the disorder have the Combined Type. It is not known
whether the same is true of adults with the disorder.
Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. This
subtype should be used if six (or more) symptoms of inattention (but fewer than
six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months.
Attention-Deficit/Hyperactivity Disorder, Predominantly
Hyperactive-ImpulsiveType. This subtype should be used if six (or more) symptoms
of hyperactivity-impulsivity (but fewer than six symptoms of inattention) have
persisted for at least 6 months. Inattention may often still be a significant
clinical featture in such cases.
Recording Procedures
Individuals who at an earlier stage of the disorder had the Predominantly
Inattentive Type or the Predominantly Hyperactive-Impulsive Type may go on to
develop the Combined Type and vice versa. The appropriate subtype (for a current
diagnosis) should be indicated based on the predominant symptom pattern for the
past 6 months. If clinically significant symptoms remain but criteria are no
longer met for any of the subtypes, the appropriate diagnosis is
Attention-Deficit/Hyperactivity Disorder, in Partial Remission. When an
individual's symptoms do not currently meet full criteria for the disorder and
it is unclear whether criteria for the disorder have previously been met,
Attention-Deficit/Hyperactivity Disorder not Otherwise Specified should be
diagnosed.
Associated Features and Disorders
Associated descriptive features and mental disorders.
Associated features vary depending on age and developmental stage and may
include low frustration tolerance, temper outbursts, bossiness, stubbornness,
excessive and frequent insistence that requests be met, mood lability,
demoralization, dysphoria, rejection by peers, and poor self-esteem. Academic
achievement is often impaired and devalued, typically leading to conflict with
the family and school authorities. Inadequate self-application to tasks that
require sustained effort is often interpreted by others as indicating laziness,
a poor sense of responsibility, and oppositional hehavior. Family relationships
are often characterized by resentment and antagonism, especially because
variability in the individual's symptomatic status often leads parents to
believe that all the troublesome behavior is willful. Individuals with
Attention-Deficit/Hyperactivity Disorder may obtain less schooling than their
peers and have poorer vocational achievement. Intellectual development, as
assessed by individual IQ tests, appears to be somewhat lower in children with
this disorder. In its severe form, the disorder is very impairing, affecting
social, familial, and scholastic adjustment. A substantial proportion of
children referred to clinics with Attention-Deficit/Hyperactivity Disorder also
have Oppositional Defiant Disorder or Conduct Disorder. There may be a higher
prevalence of Mood Disorders, Anxiety Disorders, Learning Disorders, and
Communication Disorders in children with Attention-Deficit/Hyperactivity
Disorder. This disorder is not infrequent among individuals with Tourette's
Disorder; when the two disorders coexist, the onset of Attention-Deficit/
Hyperactivity Disorder often precedes the onset of the Tourette's Disorder.
There may be a history of child abuse or neglect, multiple foster placements,
neurotoxin exposure (e.g., lead poisoning), infections (e.g., encephalitis),
drug exposure in utero, low birth weight, and Mental Retardation.
Associated laboratory findings.
There are no laboratory tests that have been established as diagnostic in the
clinical assessment of Attention-Deficit/Hyperactivity Disorder. Tests that
require effortful mental processing have been noted to be abnormal in groups of
individuals with Attention-Deficit/Hyperactivity Disorder compared with control
subjects, but it is not yet entirely clear what fundamental cognitive deficit is
responsible for this.
Associated physical examination findings and general medical conditions.
There are no specific physical features associated with Attention-Deficit/Hyperactivity
Disorder, although minor physical anomalies (e.g., hypertelorism, highly arched
palate, low-set-ears) may occur at a higher rate than in the general population. There may
also be a higher rate of physical injury.
Specific Culture, Age, and Gender Features
Attention-Deficit/Hyperactivity Disorder is known to occur in various cultures,
with variations in reported prevalence among Western countries probably arising
more from different diagnostic practices than from differences in clinical
presentation.
It is especially difficult to establish this diagnosis in children younger than
age 4 or 5 years, because their characteristic behavior is much more variable
than that of older children and may include features that are similar to
symptoms of Attention-Deficit/ Hyperactivity Disorder. Furthermore, symptoms of
inattention in toddlers or preschool children are often not readily observed
because young children typically experience few demands for sustained attention.
However, even the attention of toddlers can be held in a variety of situations (e.g.,
the average 2- or 3-year-old child can typically sit with an adult looking
through picture books). In contrast, young children with AttentionDeficit/Hyperactivity
Disorder move excessively and typically are difficult to contain. Inquiring
about a wide variety of behaviors in a young child may be helpful in ensuring
that a full clinical picture has been obtained.
As children mature, symptoms
usually become less conspicuous. By late childhood and early adolescence, signs
of excessive gross motor activity (e.g., excessive running and climbing, not
remaining seated) are less common, and hyperactivity symptoms may be confined to
fidgetiness or an inner feeling of jitteriness or restlessness. In school-age
children, symptoms of inattention affect classroom work and academic
performance. Impulsive symptoms may also lead to the breaking of familial,
interpersonal, and educational rules, especially in adolescence. In adulthood,
restlessness may lead to difficulty in participating in sedentary activities and
to avoiding pastimes or occupations that provide limited opportunity for
spontaneous movement (e.g., desk jobs).
The disorder is much more frequent in males than in females, with male-to-female
ratios ranging from 4:1 to 9:1, depending on the setting (i.e., general
population or clinics).
Prevalence
The prevalence of Attention-Deficit/Hyperactivity Disorder is estimated at 3%-5%
in school-age children. Data on prevalence in adolescence and adulthood are
limited.
Course
Most parents first observe excessive motor activity when the children are
toddlers, frequently coinciding with the development of independent locomotion.
However, because many overactive toddlers will not go on to develop
Attention-Deficit/Hyperactivity Disorder, caution should be exercised in making
this diagnosis in early years. Usually, the disorder is first diagnosed during
elementary school years, when school adjustment is compromised. In the majority
of cases seen in clinical settings, the disorder is relatively stable through
early adolescence.
In most individuals, symptoms attenuate during late
adolescence and adulthood, although a minority experience the full complement of
symptoms of Attention-Deficit/Hyperactivity Disorder into midadulthood. Other
adults may retain only some of the symptoms, in which case the diagnosis of
Attention-Deficit/Hyperactivity Disorder, in Partial Remission, should be used.
This diagnosis applies to individuals who no longer have the full disorder but
still retain some symptoms that cause functional impairment.
Familial Pattern
Attention-Deficit/Hyperactivity Disorder has been found to be more common in the
first-degree biological relatives of children with Attention-Deficit/Hyperactivity
Disorder. Studies also suggest that there is a higher prevalence of Mood and
Anxiety Disorders, Learning Disorders, Substance-Related Disorders, and
Antisocial Personality Disorder in family members of individuals with
Attention-Deficit/Hyperactivity Disorder.
Differential Diagnosis
In early childhood, it may be difficult to distinguish symptoms of
Attention-Deficit/Hyperactivity Disorder from age-appropriate behaviors in
active children (e.g., running around or being, noisy).
Symptoms of inattention are common among children with low IQ who are placed in
academic settings that are inappropriate to their intellectual ability. These
behaviors must be distinguished from similar signs in children with
Attention-Deficit/Hyperactivity Disorder. In children with Mental Retardation,
an additional diagnosis of Attention-Deficit/Hyperactivity Disorder should be
made only if the symptoms of inattention or hyperactivity are excessive for the
child's mental age. Inattention in the classroom may also occur when children
with high intelligence are placed in academically understimulating environments.
Attention-Deficit/Hyperactivity Disorder must also be distinguished from
difficulty in goal-directed behavior in children from inadequate, disorganized,
or chaotic environments.
Reports from multiple informants (e.g., babysitters,
grandparents, or parents of playmates) are helpful in providing a confluence of
observations concerning the child's inattention, hyperactivity, and capacity for
developmentally appropriate self-regulation in various settings. Individuals
with oppositional behavior may resist work or school tasks that require
self-application because of an unwillingness to conform to others' demands.
These symptoms must be differentiated from the avoidance of school tasks seen in
individuals with Attention-Deficit/Hyperactivity Disorder. Complicating the
differential diagnosis is the fact that some individuals with Attention-Deficit/Hyperactivity
Disorder develop secondary oppositional attitudes toward such tasks and devalue
their importance, often as a rationalization for their failure.
Attention-Deficit/Hyperactivity Disorder is not diagnosed if the symptoms are
better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorder, Personality Disorder, Personality Change Due to
a General Medical Condition, or a Substance-Related Disorder). In all these
disorders, the symptoms of inattention typically have an onset after age 7 years,
and the childhood history of school adjustment generally is not characterized by
disruptive behavior or teacher complaints concerning inattentive, hyperactive,
or impulsive behavior. When a Mood Disorder or Anxiety Disorder co-occurs with
Attention-Deficit/Hyperactivity Disorder, each should be diagnosed.
Attention-Deficit/Hyperactivity Disorder is not diagnosed if the symptoms of
inattention and hyperactivity occur exclusively during the course of a Pervasive
Developmental Disorder or a Psychotic Disorder. Symptoms of inattention,
hyperactivity, or impulsivity related to the use of medication (e.g.,
bronchodilators, isoniazid, akathisia from neuroleptics) in children before age
7 years are not diagnosed as Attention-Deficit/Hyperactivity Disorder but
instead are diagnosed as Other Substance-Related Disorder Not Otherwise
Specified.
Diagnostic criteria for Attention-Deficit/ Hyperactivity Disorder
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at
least 6 months to a degree that is maladaptive and inconsistent with
developmental level:
Inattention
(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
Six (or more) of the following symptoms of hyperactivityimpulsivity have
persisted for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level:
Hyperactivity
(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
Impulsivity
(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)
B. Some hyperactive-impulsive or inattentive symptoms that caused
impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g.,
at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in
social, academic, or occupational functioning.
E. 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).
Code based on type:
Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and
A2 are met for the past 6 months, 314.01
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if
Criterion A1 is met but Criterion A2 is not met for the past 6 months, 314.00
Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive
Type: if Criterion A2 is met but
Criterion A1 is not met for the past 6 months, 314.01
Coding note: For individuals (especially adolescents and adults) who currently
have symptoms that no longer meet full criteria, "in Partial Remission" should
be specified.
Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified, 314.9
This category is for disorders with prominent symptoms of inattention or
hyperactivityimpulsivity that do not meet criteria for Attention-Deficit/Hyperactivity
Disorder.
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