Deciding if a child has ADHD is a several-step process. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms. Thus, diagnosing ADHD should be done only by trained health care providers.
What is ADHD?
ADHD is a neurodevelopmental disorder affecting both children and adults. It is described as a “persistent” or on-going pattern of inattention and/or hyperactivity-impulsivity that gets in the way of daily life or typical development. Individuals with ADHD may also have difficulties with maintaining attention, executive function (or the brain’s ability to begin an activity, organize itself and manage tasks) and working memory.
There are three presentations of ADHD:
- Combined inattentive & hyperactive-impulsive
What is the DSM-5?
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), published by the American Psychiatric Association is the guide that lays out the criteria to be used by doctors, mental health professionals, and other qualified clinicians when making a diagnosis of ADHD. The DSM-5 was published in 2013 and made changes to the definition of ADHD that affect how the disorder is diagnosed in children and in adults.
What about ADHD has changed with the DSM-5?
Adult ADHD: For many years, the diagnostic criteria for ADHD stated that it was children who were diagnosed with the disorder. That meant that teens and adults with symptoms of the disorder, and who may have been struggling for many years but didn’t know why, couldn’t officially be diagnosed with ADHD. The DSM-5 has changed this; adults and teens can now be officially diagnosed with the disorder. The diagnostic criteria mentions and gives examples of how the disorder appears in adults and teens.
- In diagnosing ADHD in adults, clinicians now look back to middle childhood (age 12) and the teen years when making a diagnosis for the beginning of symptoms, not all the way back to childhood (age 7).
- In the previous edition, DSM-IV TR*, the three types of ADHD were referring to as “subtypes.” This has changed; subtypes are now referred to as “presentations.” Furthermore, a person can change “presentations” during their lifetime. This change better describes how the disorder affects an individual at different points of life.
- A person with ADHD can have mild, moderate or severe ADHD. This will generally depend on how many symptoms a person has, and how difficult those symptoms make daily life.
In making the diagnosis, children still should have six or more symptoms of the disorder. In older teens and adults the DSM-5 states they should have at least five symptoms.
The criteria of symptoms for a diagnosis of ADHD:
- 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.
- 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.
Combined inattentive & hyperactive-impulsive presentation:
- Has symptoms from both of the above presentations.
Reference: American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5), Washington, D.C.: American Psychiatric Association
Prepared by the National Resource Center on ADHD: A Program of CHADD (NRC). The NRC is supported through Cooperative Agreement Number CDC-RFA-DD13-1302 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
Does my child have to show both kinds of symptoms to be diagnosed with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder?
No. Some individuals display one set of symptoms but not the other set. There are three types of presentations that may apply within the ADHD/ADD diagnosis.
- Predominantly Inattentive presentation – applies to an individual with enough inattentive, but not hyperactivity-impulsivity symptoms present for the past six months. This is what people mean when they refer to ADD. Technically, this term is no longer correct.
- Predominantly Hyperactive/Impulsive presentation – applies to individuals with enough hyperactive/impulsive but not inattention symptoms present for the past six months.
- Combined presentation – applies to individuals with enough symptoms of both criteria inattention and hyperactivity-impulsivity present for the past six months
Because symptoms can change over time, the presentation may change over time as well.
Is deciding whether these symptoms are present the only factor involved in making the diagnosis?
No, it is only an initial step. The following conditions must also be present.
- Some hyperactive-impulsive or inattentive symptoms that caused impairment need to have been present before the child was 12.
This means that a 14 year old who suddenly begins displaying ADHD symptoms would not meet the criteria for ADHD diagnosis. It is not necessary for the child’s symptoms to have been as problematic at an earlier age, but there needs to be some indication that they were at least present before age 12. For example, it is not uncommon for children with inattentive symptoms, but not the hyperactive/impulsive symptoms, to get by in early grades. In later grades, however, when the work becomes more rigorous, a child’s attention problems may become problematic. In cases where there is no indication of ADHD symptoms before age 12, even at a reduced level, than ADHD would not be an appropriate diagnosis. Instead, it is likely that some other type of problem such as a mood disorder or anxiety disorder is responsible for the symptoms.
- The symptoms must cause some impairment in two or more settings (e.g. home and school).
In order for the symptoms to reflect ADHD/ADD, they must impair the individuals functioning in at least 2 settings. For children, these settings tend to be at home and school. If the symptoms are only evident at school but not present at home, a diagnosis of ADHD/ADD would not be appropriate. Similarly, if the symptoms are reported at home and not observed anywhere else, ADHD/ADD would not be the correct diagnosis. In situations such as these, factors unique to the settings where the symptoms are evident would be investigated in order to understand what was causing them.
It is not necessary that the degree of impairment from symptoms be equivalent in different settings because the intensity of ADHD symptoms can vary considerably across settings. For example, it is not uncommon for a child’s difficulties to be more prominent at school than at home. When this occurs, it is often because the demands to sustain attention and inhibit activity level are greater at school than at home. Thus, in order to satisfy the dual setting criteria, there just needs to be some indication that the problems are not exclusively confined to a single context.
- There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
In order for the symptoms to reflect ADHD/ADD, they must clearly interfere with an individual’s functioning in one of these areas. For children, the problems are usually observed in their academic performance, their ability to meet appropriate behavioural expectations (for eg. following rules) and their capacity to get along with others. If the symptoms are so mild as to not create problems in any of these areas, than ADHD/ADD would not be an appropriate diagnosis.
- 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).
The purpose of this final condition is to avoid diagnosing ADHD/ADD when the symptoms reflect another problem. In these conditions, individuals may display symptoms that are similar to those characteristic of ADHD. It is necessary to confirm that it is not one of these other disorders that are responsible for the ADHD symptoms.
In reality, the first 3 disorders listed (i.e. pervasive Developmental Disorder, Schizophrenia, or some other Psychotic Disorder) are quite rare, and impair an individual’s functioning to such an extent that it should be clear that something besides a simple case of ADHD is present. The remaining disorders are most likely to be the cause of ADHD symptoms when the symptoms emerged after age 12.