Attention-Deficit/Hyperactivity Disorder (ADHD)

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).

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).

ADHD is likely overdiagnosed.^{[4][5][6][7][8]} 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. However, we are likely in a culture of overdiagnosis right now, especially with the ease of prescribing stimulants and short assessments in primary care settings. A short or incomplete assessment means a thorough differential diagnosis has not been considered! Since individuals both with and without ADHD can experience improved attention and decreased restlessness while taking stimulants, medication response alone is not a basis for diagnosing the disorder.^[9] However, this is often a common diagnostic fallacy that many clinicians make.

Although many ADHD guidelines continue to suggest that prevalence rates are stable, and that overdiagnosis is not occurring, the epidemiological data is increasingly showing the opposite. A 2015 systematic review and meta-analysis (the most comprehensive to date) provided a conservative benchmark overall pooled estimate prevalence of 7.2% using 36 years of ADHD studies^[11] In the United States, from 1997 to 2016, the estimated prevalence of diagnosed attention-deficit/hyperactivity disorder in US children and adolescents increased from 6.1% in 1997 to 10.2% in 2016.^[12] This far exceeds the baseline estimated prevalence rates from the systematic review, suggesting that overdiagnosis may be occurring.

Psychiatric

• Oppositional defiant disorder (ODD)
• Conduct disorder
• Disruptive mood dysregulation disorder (DMDD)
• Specific learning disorder
• Generalized anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Major depressive disorder (MDD)
  • Moderate to severe depression should be treated first and suicide must be assessed in all cases
• Autism spectrum disorder (ASD)
• Bipolar I disorder or Bipolar II disorder
• Psychotic disorders
• Substance use disorders

Medication-related

• Medication with cognitive dulling side effect
  • Think about mood stabilizers and antipsychotics
• Medication with psychomotor activation
  • Think about decongestants and beta agonists

Other Factors

• Unsafe or disruptive learning environment
• Family dysfunction or poor parenting
• Child abuse or neglect
• Attachment disorders

General Medical Conditions

• Sleep disorders
  • Insomnia disorder
  • Obstructive sleep apnea or central sleep apnea
• Traumatic brain injury
  • Since underlying ADHD can increase risk for head trauma, it is important to look for timing of cognitive symptoms apparition (present before, or appeared or worsened after head trauma).
• Seizure disorders
• Hearing impairment or vision impairment
  • Order audiology and vision assessment if there are any concerns
• Thyroid disorders
  • Order TSH levels to check for hypothyroidism or hyperthyroidism
• Hypoglycemia
  • Check blood glucose levels
• Anemia
  • Order CBC
• Lead poisoning
  • Order blood lead levels
• Fragile X syndrome (FXS)
  • Molecular genetic testing for the FMR-1 gene confirms the diagnosis of Fragile X.
• Phenylketonuria
• Neurofibromatosis
• Fetal alcohol spectrum disorder (FASD) and Intellectual disability
  • Consider the presence of intellectual disability and FASD by observing for growth deficiency and facial features and FASD. Ask a thorough developmental history around prenatal alcohol exposure risk. Further psychoeducational testing may also be helpful.