Attention Deficit: Diagnosing

1. Differential Diagnosis

2. DSM IV

3. Diagnostic Tools

4. dsm4part2

Contents

1. Differential Diagnosis
As many as 50-60% of children with ADHD have one or more comorbid conditions including learning disabilities, oppositional defiant disorder, conduct disorder, depression and anxiety disorder. The symptoms of ADHD can overlap with these disorders, and it may be difficult to determine whether the ADHD, the comorbid condition, or both are responsible for the symptoms.
Other conditions to consider in children with symptoms of inattention and/or hyperactivity/impulsivity include cognitive problems (mental retardation, fragile X syndrome), environmental factors (stressful home environment with or without PTSD, inappropriate educational setting), and various medical conditions such as hearing or visual impairment, diabetes mellitus, asthma treatments, fetal alcohol syndrome, thyroid abnormalities, sleep disorder, and seizure disorder. These medical conditions usually can be differentiated from ADHD because the symptoms fluctuate with the course of disease. In contrast, the symptoms in ADHD are persistent and pervasive.

2. DSM IV Criteria

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

  1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  2. Often has trouble keeping attention on tasks or play activities.
  3. Often does not seem to listen when spoken to directly.
  4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  5. Often has trouble organizing activities.
  6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  8. Is often easily distracted.
  9. Is often forgetful in daily activities.

B.   Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

  1. Often fidgets with hands or feet or squirms in seat.
  2. Often gets up from seat when remaining in seat is expected.
  3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  4. Often has trouble playing or enjoying leisure activities quietly.
  5. Is often "on the go" or often acts as if "driven by a motor".
  6. Often talks excessively.

Impulsivity

  1. Often blurts out answers before questions have been finished.
  2. Often has trouble waiting one's turn.
  3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

II.  Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V.  The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

  1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
  2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 
  3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

*Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

3. Diagnostic Tools:

The diagnosis of ADHD requires that a child meet DSM-IV criteria in 2 or more settings, for more than 6 months, and have functional impairment. High scores on the following screening tools are therefore not diagnostic, but can be useful to establish risk for ADHD and comorbid conditions, as well as to follow ADHD symptoms.

Neuropsychological testing may be a valuable adjunct to the evaluation of ADHD. Though it is not required for the routine diagnosis of ADHD it can uncover learning disabilities and shed light on the specific type of deficit that makes a child with ADHD susceptible to school failure, i.e. executive functioning deficits, delayed processing skills, language disorders, and other learning disabilities. (Link to Diagnosing learning problems). Neuropsychologic testing alone however, does not distinguish children with and without ADHD.1

SNAP IV Parent & Teacher ENGLISH

SNAP IV Parent & Teacher SPANISH

SNAP IV Scoring Instructions

Vanderbilt Parent version, ENGLISH

Vanderbilt Parent version, SPANISH

Vanderbilt Teacher version

Vanderbilt Scoring Instructions

4. dsm4part2:

1. Doyle AE, et al. Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit-hyperactivity disorder. J Consult Clin Psychol, 2000 Jun:68(3):477-88