Module 5: Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder

• A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) inattention and/or (2) hyperactivity and impulsivity

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

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

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

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

Inattention

• 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)

• Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading)

• Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)

• 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) 

• Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks, difficulty keeping materials and belongings in order, messy and disorganized work, has poor time management, fails to meet deadlines)

• 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)

• Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)

• Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)

Hyperactivity and Impulsivity

• Often fidgets with or taps hands or feet or squirms in seat

• 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 the other situations that require remaining in place)

• Often runs about or climbs in situations where it is inappropriate (Note: in adolescents or adults, may be limited to feeling restless)

• Often unable to play or engage in leisure activities quietly

• 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)

• Often talks excessively 

• Often blurts out an answers before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation)

• Often has  difficulty waiting his or her turn (e.g., while waiting in line)

• 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 permission; for adolescents and adults, may intrude into or take over what others are doing)

Specifiers

• Combined presentation

• Predominantly inattentive presentation

• Predominantly hyperactive/impulsive presentation

• Specify if:

  • In Partial remission

    • When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social academic, or occupational functioning

Associated Features

• Delays in language, motor, or social development are not specific to ADHD but often co-occur

• Emotional dysregulation or emotional impulsivity

• Described by others as being quick to anger, easily frustrated, and overreactive emotionally

• Minor physical abnormalities may be elevated

Development and Course

• Parents may notice excessive motor activity as early as toddlerhood, though symptoms are hard to distinguish from normal behavior before age 4

• ADHD is commonly identified during elementary school, when inattention becomes more noticeable and impairing

• The disorder is generally stable through early adolescence, though some individuals may develop antisocial behaviors

• Motor hyperactivity tends to lessen in adolescence and adulthood, yet issues with restlessness, inattention, impulsivity, and poor planning often persist 

• A significant number of children with ADHD continue to experience impairments into adulthood

Age-Specific Manifestations | Preschool

Hyperactivity is the primary symptom

Age-Specific Manifestations | Elementary School

Inattention becomes more evident

Age-Specific Manifestations | Adolescence

• Overt hyperactive behaviors (e.g., running, climbing) decline

• Restlessness may appear as fidgeting, jitteriness, or impatience

Age-Specific Manifestations | Adulthood

• Inattention and restlessness continue

• Impulsivity may remain problematic even when hyperactivity decreases

Risk and Prognostic Factors | Temperamental Factors

• Linked with reduced behavioral inhibition, effortful control, or constraint

• Associated with negative emotionality and high novelty seeking

• These traits may increase vulnerability to ADHD but are not exclusive to it

Risk and Prognostic Factors | Environmental Factors

• Very low birth weight and prematurity increases the risk of ADHD

  • The lower the weight, the  higher the risk 

•  Prenatal exposure to smoking is correlated with ADHD even after accounting for prenatal psychiatric and socioeconomic factors

• Some cases may involve reactions to certain dietary components 

• Exposure to neurotoxins (e.g., lead), infections (e.g., encephalitis), and alcohol use during pregnancy has been linked to ADHD, though causality is uncertain

Risk and Prognostic Factors | Genetic and Physiological Factors

• ADHD has a high heritability rate of approximately 74%

• Genome-wide association studies (GWAS) have identified multiple genetic loci in constrained genomic regions, loss-of-function genes, and brain-expressed regulatory areas

• No single gene causes ADHD; it is influenced by multiple genetic factors 

• Visual and hearing problems, metabolic abnormalities, and nutritional deficiencies may contribute to ADHD-like symptoms 

• Higher prevalence of ADHD is noted among individuals with idiopathic epilepsy

Sex- and Gender-Related Diagnostic Features

• ADHD occurs more frequently in males than in females

• Children

  • Approximately 2:1 male-to-female ratio

• Adults

  • Approximately 1.6:1 male-to-female ratio

• Females

  • Often present with primarily inattentive symptoms, rather than hyperactivity or impulsivity 

• Differences in symptom severity between sexes may be influenced by varying genetic and cognitive factors

Diagnostic Markers

• There are no biological markers that can definitively diagnose ADHD

• Earlier findings suggested:

  • Increased theta wave activity (4-7 Hz)

  • Decreased beta wave activity (14-30 Hz)

• Later reviews found no significant differences in these brain wave patterns between individuals with ADHD and control groups 

• Some neuroimaging studies have shown brain differences in with children but:

  • Meta-analyses reveal no consistent or reliable neuroimaging differences between individuals with ADHD and controls 

  • Variability in diagnostic criteria, sample sizes, tasks, and imaging methods may account for inconsistent findings

• Conclusion

  • Neuroimaging cannot currently be used to diagnose ADHD

Association with Suicidal Thoughts or Behavior

• ADHD increases the risk of suicidal ideation and behavior in children

• In adults, ADHD is linked to a higher risk of suicide attempts, particularly when accompanied by:

  • Mood disorders

  • Conduct disorders

  • Substance use disorders

  • (This elevated risk remains even after accounting for comorbid conditions)

• Individuals with ADHD report more frequent suicidal thoughts compared to those without ADHD

• ADHD has been found to predict the persistence of suicidal thoughts in US Army soldiers

Functional Consequences of ADHD | Academic and School-Related Impacts

• Reduced school performance and lower academic attainment

• Inattention is strongly linked to academic difficulties, school problems, and peer neglect

• Hyperactivity and impulsivity are more associated with peer rejection and accidental injuries

• Inconsistent self-application to tasks requiring effort may be perceived by others as laziness, irresponsibility, or lack of cooperation

Functional Consequences of ADHD | Occupational and Adult Functioning

• Young adults with ADHD experience poor job stability

• Adults show reduced occupational performance, lower achievement, poor attendance, and higher risk of unemployment

• Increased interpersonal conflicts in the workplace

• Individuals with ADHD tend to achieve less education, have poorer vocational outcomes, and score lower on intellectual tests compared with peers, though outcomes vary widely

• Severe ADHD significantly impairs social, family, and occupational functioning

Functional Consequences of ADHD | Family and Social Relationships

• Family dynamics often include conflict and negative interactions 

• Individuals with ADHD typically have lower self-esteem than peers

• Peer relationships are commonly disrupted by rejection, neglect, or teasing

Functional Consequences of ADHD | Psychiatric and Behavioral Risks

• Children with ADHD are at icnreased risk of developing conduct disorder during adolescence 

• Higher likelihood of antisocial personality disorder in adulthood

• Elevated risk of substance use disorders and incarceration, particularly when conduct or antisocial traits emerge

Functional Consequences of ADHD | Safety, Health, and Mortality

• Greater likelihood of injuries and trauma compared to peers

• Increased risk of PTSD following traumatic incidents

• More frequent traffic accidents and violations among drivers with ADHD

• Elevated overall mortality rate, primarily due to accidents and injuries

• Possible increased likelihood of obesity and hypertension 

Differential Diagnosis of ADHD | Oppositional Defiant Disorder (ODD)

• Resistant behavior stems from hostility, defiance, and negativity toward authority

• Must be differentiated from ADHD-related avoidance caused by difficulty sustaining effort or impulsivity

• Some individuals with ADHD may develop oppositional behaviors as a secondary reaction to repeated failures

Differential Diagnosis of ADHD | Intermittent Explosive Disorder

• Shares impulsivity with ADHD 

• Characterized by severe aggressive outbursts, unlike ADHD

• Does not involve persistent attention problems

• Rare in childhood; can be diagnosed alongside ADHD

Differential Diagnosis of ADHD | Stereotypic Movement Disorder

Displays repetitive, fixed motor behaviors (e.g., rocking, self-biting), unlike the generalized fidgetiness seen in ADHD

Differential Diagnosis of ADHD | Autism Spectrum Disorder (ASD)

• Has social disengagement and difficulty with communication cues, unlike ADHD’s impulsive or inattentive social problems

• Both may involve inattention and behavioral challenges

• ____ includes social disengagement and difficulty with transitions due to rigidity 

• ADHD-related misbehavior ste

Differential Diagnosis of ADHD | Tourette’s Disorder

Multiple tics may resemble fidgeting; requires observation to differentiate from ADHD symptoms

Differential Diagnosis of ADHD | Specific Learning Disorder

• Inattention appears only when tasks require impaired cognitive processes (e.g., working memory, processing speed)

• Attention improves when doing tasks not requiring the affected skill — unlike ADHD, where inattention is pervasive

Differential Diagnosis of ADHD | Intellectual Developmental Disorder (Intellectual Disability)

• ADHD symptoms appear only in academic settings inappropriate for mental ability 

• ADHD is diagnosed only if symptoms are excessive for mental age and present beyond academic contexts

Differential Diagnosis of ADHD | Reactive Attachment Disorder

• May show social disinhibition but lacks the full ADHD symptom cluster

• Characterized by absence of enduring relationships, which is not typical in ADHD

Differential Diagnosis of ADHD | Anxiety Disorders

Share symptoms of inattention and restlessness

Severity | Mild

Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning

Severity | Moderate

Symptoms or functional between “mild” and “severe” are present

Severity | Severe

Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present or the symptoms are result in marked impairment in social or occupational functioning

Other Specified Attention-Deficit/Hyperactivity Disorder

• This category applies to presentations in which symptoms characteristic of ADHD that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for ADHD or any of the disorders in the neurodevelopmental disorders diagnostic class. 

• The ______ is used in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for ADHD or any specific neurodevelopmental disorder. 

• This is done by recording “other specific attention-deficit/hyperactivity disorder) followed by the specific reason (e.g., “with insufficient inattention symptoms)

Unspecific Attention-Deficit/Hyperactivity Disorder

• This category applies to presentations in which symptoms of characteristic of ADHD that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for ADHD or any of the disorders in the neurodevelopmental disorders diagnostic class

• The ______ is used in situations which the clinician chooses not to specify the reason that the criteria are not met for ADHD or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis