The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child’s life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.
Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child’s self-control. A child who “can’t sit still” or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a “discipline problem,” while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child’s hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.
According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders2 (DSM-IV-TR), there are three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive far more than others of their age. Or they may show all three types of behavior. This means that there are three subtypes of ADHD recognized by professionals. These are the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD—an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).
Hyperactive children always seem to be “on the go” or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They often report needing to stay busy and may try to do several things at once.
Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of
their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they’re upset. Even as teenagers or adults, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity are:
- Feeling restless, often fidgeting with hands or feet, or squirming while seated
- Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
- Blurting out answers before hearing the whole question
- Having difficulty waiting in line or taking turns.
Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:
- Often becoming easily distracted by irrelevant sights and sounds
- Often failing to pay attention to details and making careless mistakes
- Rarely following instructions carefully and completely losing or forgetting things like toys, or pencils, books, and tools needed for a task
- Often skipping from one uncompleted activity to another.
Children diagnosed with the Predominantly Inattentive Type of ADHD are seldom impulsive or hyperactive, yet they have significant problems paying attention. They appear to be daydreaming, “spacey,” easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions.
These children don’t show significant problems with impulsivity and over-activity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of ADHD, and they may not have the same sorts of social problems so common with the combined type of ADHD. So often their problems with inattention are overlooked. But they need help just as much as children with other types of ADHD, who cause more obvious problems in the classroom.
Is It Really ADHD?
Not everyone who is overly hyperactive, inattentive, or impulsive has ADHD. Since most people sometimes blurt out things they didn’t mean to say, or jump from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD?
Because everyone shows some of these behaviors at times, the diagnosis requires that such behavior be demonstrated to a degree that is inappropriate for the person’s age. The diagnostic guidelines also contain specific requirements for determining when the symptoms indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least 6 months. Above all, the behaviors must create a real handicap in at least two areas of a person’s life such as in the schoolroom, on the playground, at home, in the community, or in social settings. So someone who shows some symptoms but whose schoolwork or friendships
are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or in the schoolroom? The person’s pattern of behavior is compared against a set of criteria and characteristics of the disorder as listed in the DSM-IV-TR.[Above information excerpted from Attention Deficit Hyperactivity Disorder a publication of National Institute for Mental Health (2006) NIH Publication No. 3572]
Problems Associated with ADHD Children
The list below contains symptoms, behavior and conditions often found in children with Attention Deficit Hyperactivity Disorder. Not all of these are considered to be diagnostic of ADHD. These are presented to help parents and teachers recognize that problems they are observing in a child may be the related to this disorder. If a child has been diagnosed by a health professional with this disorder, it may help to explain why the child is displaying the symptoms or behavior. On the other hand, if a child is exhibiting a number of symptoms on this list, an evaluation by a health care professional (family doctor, pediatrician, child psychiatrist or child psychologist) may be of value.
- Short attention span
- Poor impulse control
- Poor peer relations
- Noncompliance to commands
- Belligerent and disrespectful language
- Poor self control/high risk taking
- Poor social problem solving skills
- Immature self speech (integral language)
- Poor perspective on future consequences of behavior
- Underachievement for intelligence
- Specific learning disabilities
- Low grades
- Poor work habits
- Missing assignments
- Immature emotional control
- Excessive frustration
- Unpredictable/variable moods
- Immature physical size
- Immature bone growth
- Increased upper respiratory infections
- Increased frequency of otitis media
- Increased frequency of allergies
- Greater number of minor physical anomalies
- Underactive central nervous system
- Short sleep cycles
- High pain tolerance
- Poor motor coordination
(These are not diagnostic symptoms. These are physical conditions that are found to occur more frequently in ADHD kids than the general population. Having any of these conditions does not mean your child may have ADHD.)
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder
The following is the diagnostic criteria contained in the publication of the American Psychiatric Association known as the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV).
A. Either (1) or (2)
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to Oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(2) six (or more) of the following symptoms of hyperactivity-Impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often “on the go” or often acts as if “driven by a motor”
(f) often talks excessively
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g. butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g. at school or work and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. 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.