Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is a behavioural disorder, usually first diagnosed in childhood, characterized by inattention, impulsivity, and sometimes hyperactivity. These symptoms usually occur together; however, one may occur without the other(s).

ADHD and Diagnostic Creep

ADHD is overdiagnosed.[1][2][3] The most recent research has also called into question the validity of adult-onset ADHD diagnoses itself.[4] It is important to be aware of diagnostic creep and overdiagnosis! True ADHD is a debilitating condition that presents largely in childhood and absolutely should be treated, but we are likely in a culture of overdiagnosis right now, especially with the ease of prescribing and short assessments in primary care settings. Consider the role of stimulant diversion and abuse.[5][6] Finally, consider also how the role of technology and the Internet could be shaping and changing our attention spans.[7][8] (See also: Washington Post: Is the Internet giving us all ADHD?)

For more on overdiagnosis and cognitive errors see the article: Cognitive Bias, Diagnostic Error, and Overdiagnosis
Criterion A
  • A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by the (1) inattention category and/or (2) hyperactivity and impulsivity category:
Inattention

At least 6 of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

  1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
  2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading)
  3. Often does not seem to listen when spoken to directly (e.g., mind seems else where, even in the absence of any obvious distraction)
  4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
  5. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
  6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
  7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
  8. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
  9. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least 5 symptoms are required.
Hyperactivity and Impulsivity

At least 6 of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

  1. Often fidgets with or taps hands or feet or squirms in seat.
  2. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
  3. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
  4. Often unable to play or engage in leisure activities quietly
  5. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with)
  6. Often talks excessively
  7. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
  8. Often has difficulty waiting his or her turn (e.g., while waiting in line).
  9. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving per mission; for adolescents and adults, may intrude into or take over what others are doing).
Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least 5 symptoms are required.
Criterion B

Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

Criterion C

Several inattentive or hyperactive-impulsive symptoms are present in at least 2 settings (e.g. - home, school, work, with friends or relatives, in other activities).

Criterion D

There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

Criterion E

The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.

Mnemonic

When the child is inattentive, you CALL FOR FRED, this can be used to remember the inattention criteria. When the child is impulsive and hyperactive, he or she RUNS FASTT, this can be used to remember the hyperactivity-impulsivity criteria.[9]

Inattention Criteria

  • C Careless mistakes
  • A Attention difficulty
  • L Listening problem
  • L Loses things
  • F Fails to finish what he/ she starts
  • O Organizational skills lacking
  • R Reluctance to do tasks that require a sustained mental effort
  • FR Forgetful in routine activities
  • ED Easily distracted

Hyperactivity-Impulsivity Criteria

  • R Runs or is restless
  • U Unable to wait for his or her turn
  • N Not able to play quietly
  • S Slow?- oh no! On the go!
  • F Fidgets with hands or feet
  • A Answers are blurted out
  • S Staying seated is difficult
  • T Talks excessively
  • T Tends to interrupt

Recent research has shown that there are bilateral amygdala, accumbens, and hippocampus reductions in ADHD.[10] However, these findings have been scrutinized and remain under debate.[11][12]

Stimulants

Supplements

There is some evidence that supplementing diets of pediatric ADHD patients with fatty fish high in omega-3s or commercial preparations containing at least 500 mg of EPA can reduce symptoms.[13]

References

9. Child and Adolescent Psychiatry (Practical Guides in Psychiatry) 1st Edition, pg. 58, Dorothy Stubbe, MD