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Attention Deficit/Hyperactivity Disorder as listed in the DSM-III-R

314.01 Attention-deficit Hyperactivity Disorder (ADHD)

The essential features of this disorder are developmentally inappropriate degrees of inattention, impulsiveness and hyperactivity. People with the disorder generally display some disturbance in each of these areas, but to varying degrees.

Manifestations of the disorder usually appear in most situations, including at home, in school, at work and in social situations, but to varying degrees. Some people, however, show signs of the disorder in only one setting, such as at home or at school. Symptoms typically worsen in situations requiring sustained attention, such as listening to a teacher in a classroom, attending meetings or doing class assignments or chores at home. Signs of the disorder may be minimal or absent when the person is receiving frequent reinforcement or very strict control or is in a novel setting or a one-to-one situation (e.g., being examined in the clinician's office or interacting with a videogame).

In the classroom or workplace, inattention and impulsiveness are evidenced by not sticking with tasks sufficiently to finish them and by having difficulty organizing and completing work correctly. The person often gives the impression that he or she is not listening or has not heard what has been said. Work is often messy and performed carelessly and impulsively.

Impulsiveness is often demonstrated by blurting out answers to questions before they are completed, making comments out of turn, failing to await one's turn in group tasks, failing to heed directions fully before beginning to respond to assignments, interrupting the teacher during a lesson and interrupting or talking to other children during quiet work periods.

Hyperactivity may be evidenced by difficulty remaining seated, excessive jumping about, running in classroom, fidgeting, manipulating objects and twisting and wiggling in one's seat.

At home, inattention may be displayed in failure to follow through on other requests and instructions an in frequent shifts from one uncompleted activity to another. Problems with impulsiveness are often expressed by interrupting or intruding on other family members and by accident-prone behavior, such as grabbing a hot pan from the stove or carelessly knocking over a pitcher. Hyperactivity may be evidenced by an inability to remain seated when expected to do so (situations in which this is the case vary greatly from home to home) and by excessively noisy activities.

With peers, inattention is evident in failure to follow the rules of structured games or to listen to other children. Impulsiveness is frequently demonstrated by failing to await one's turn in games, interrupting, grabbing objects (not with malevolent intent) and engaging in potentially dangerous activities without considering the possible consequences, e.g., riding a skateboard over extremely rough terrain. Hyperactivity may be shown by excessive talking and by an inability to play quietly and t regulate one's activity to conform to the demands of the game (e.g., in playing "Simon Says," the child keeps moving about and talking to peers when he or she is expected to be quiet).

Age-specific features. In preschool children, the most prominent features are generally signs of gross motor overactivity, such as excessive running or climbing. The child is often described as being on the go and "always having his motor running." Inattention and impulsiveness are likely to be shown by frequently shifting from one activity to another. In older children and adolescents, the most prominent features tend to be excessive fidgeting and restlessness rather than gross motor overactivity. Inattention and impulsiveness may contribute to failure to complete assigned tasks or instructions or careless performance of assigned work. In adolescents, impulsiveness is often displayed in social activities, such as initiating a diverting activity on the spur of the moment instead of attending to a previous commitment (e.g., joy riding instead of doing homework).

Associated features. Associated features vary as a function of age and include low self-esteem, mood lability, low frustration tolerance and temper outbursts. Academic underachievement is characteristic of most children with this disorder.

In clinic samples, some or all of the symptoms of Oppositional Defiant Disorder, Conduct Disorder and Specific Developmental Disorders are often present. Functional Encopresis and Functional Enuresis are sometimes seen. Although Tourette's Disorder is relatively rare in children with ADHD, in clinic samples many children with Tourette's Disorder are found to have ADHD as well.

Nonlocalized, "soft," neurologic signs and motor-perceptual dysfunctions (e.g., poor eye-hand coordination) may be present.

Age at onset. In approximately half of the cases, onset of the disorder is before age four. Frequently the disorder is not recognized until the child enters school.

Course. In the majority of cases manifestations of the disorder persist throughout childhood. Oppositional Defiant Disorder or Conduct Disorder often develops later in childhood in those with ADHD. Among those who develop Conduct Disorder, a significant number are found to have Antisocial Personality Disorder in adulthood. Follow-up studies of clinic samples indicate that approximately one-third of children with ADHD continue to show some signs of the disorder in adulthood. Studies have indicated that the following features predict a poor course: coexisting Conduct Disorder, low IQ and severe mental disorder in the parents.

Impairment. Some impairment in social and school functioning is common.

Complications. School failure is the major complication.

Predisposing factors. Central nervous system abnormalities, such as the presence of neurotoxins, cerebral palsy, epilepsy and other neurologic disorders, are thought to be predisposing factors. Disorganized or chaotic environments and child abuse or neglect may be predisposing factors in some cases.

Prevalence. The disorder is common; it may occur in as many as 3% of children.

Sex ratio. In clinic samples, the disorder is from six to nine times more common in males than in females. In community samples, multiple signs of the disorder occur only three times more often in males than in females.

Familial pattern. The disorder is believed to be more common in first-degree biologic relatives of people with the disorder than in the general population. Among family members, the following disorders are thought to be overrepresented: Specific Developmental Disorders, Alcohol Dependence or Abuse, Conduct Disorder and Antisocial Personality Disorder.

Differential diagnosis. Age-appropriate overactivity, as is seen in some particularly active children, does not have the haphazard and poorly organized quality characteristic of the behavior of children with Attention-deficit Hyperactivity Disorder. Children in inadequate, disorganized or chaotic environments may appear to have difficulty in sustaining attention and in goal-directed behavior. In such cases it may be impossible to determine whether the disorganized behavior is primarily a function of the chaotic environment or whether it is due largely to the child's psychopathology (in which case the diagnosis of Attention-deficit Hyperactivity Disorder may be warranted).

In Mental Retardation there may be many of the features of ADHD because of the generalized delay in intellectual development. The additional diagnosis of ADHD is made only if the relevant symptoms are excessive for the child's mental age.

Symptoms characteristic of ADHD are often observed in Pervasive Developmental Disorders; in these cases a diagnosis of ADHD is preempted.

In Mood Disorders there may be psychomotor agitation and difficulty in concentration that are difficult to distinguish from the hyperactivity and attentional difficulties seen in Attention-deficit Hyperactivity Disorder. Therefore, it is important to consider the diagnosis of Mood Disorder before making the diagnosis of Attention-deficit Hyperactivity Disorder.

Signs of impulsiveness and hyperactivity are not present in Undifferentiated Attention-deficit Disorder.

Diagnostic criteria for 314.01 Attention-deficit Hyperactivity Disorder
Note: Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.

  • A disturbance of at least six months during which at least eight of the following are present:
    1. often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)
    2. has difficulty remaining seated when required to do so
    3. is easily distracted by extraneous stimuli
    4. has difficulty awaiting turn in games or group situations
    5. often blurts out answers to questions before they have been completed
    6. had difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension), e.g., fails to finish chores
    7. has difficulty sustaining attention in tasks or play activities
    8. often shifts from one uncompleted activity to another
    9. has difficulty playing quietly
    10. often talks excessively
    11. often interrupts or intrudes on others, e.g., butts into other children's games
    12. often does not seem to listen to what is being said to him or her
    13. often loses things necessary for tasks or activities at school or at home (e.g., toys, pencils, books, assignments)
    14. often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking

    Note: The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-III-R criteria for Disruptive Behavior Disorders.

  • Onset before the age of seven.

  • Does not meet the criteria for a Pervasive Developmental Disorder.

Criteria for severity of Attention-deficit Hyperactivity Disorder:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis and only minimal or no impairment in school and social functioning.

Moderate: Symptoms or functional impairment intermediate between "mild" and "severe."

Severe: Many symptoms in excess of those required to make the diagnosis and significant and pervasive impairment in functioning at home and school and with peers.

314.00 Undifferentiated Attention-deficit Disorder

This is a residual category for disturbances in which the predominant feature is the persistence of developmentally inappropriate and marked inattention that is not a symptom of another disorder, such as Mental Retardation or Attention-deficit Hyperactivity Disorder or of a disorganized and chaotic environment. Some of the disturbances that in DSM-III would have been categorized as Attention Deficit Disorder without Hyperactivity would be included in this category. Research is necessary to determine if this is a valid diagnostic category and, if so, how it should be defined.