Attention-Deficit/Hyperactivity Disorder Initial Assessment

Clinical Presentation

The signs and symptoms of attention-deficit/hyperactivity disorder (ADHD) include hyperactivity, acting without thinking, inattention or daydreaming, fidgetiness, restlessness, difficulty in completing tasks, excessive talking, aggressive behavior, academic underachievement, disorganization, and impulsive behavior.

History

Physical Examination

On physical examination, observe for fidgeting, inability to remain seated, loud or interruptive speech, subtle neurologic motor findings, mixed laterality or ambidexterity, and difficulties with coordination and fine-motor tasks (eg finger-to-nose testing, rapid alternating movements, finger tapping, skipping, maze tracing, and cutting paper).

Diagnosis or Diagnostic Criteria

Based on DSM-5-TR, the criteria to diagnose attention-deficit/hyperactivity disorder (ADHD) are the following:

• Presence of a continuous and constant pattern of either inattention and/or hyperactivity-impulsivity that causes significant interference or impairment in development and social, academic, or occupational functioning
• Presence of inattentiveness or hyperactive-impulsive symptoms before the age of 12 years
• Presence of inattentiveness or hyperactive-impulsive symptoms in ≥2 situations (eg school, work, or home)
• Disturbance does not occur exclusively during the course of schizophrenia or other psychotic disorder and is not better explained by any other mental disorder or substance intoxication or withdrawal
• Presence of at least five inattention and/or hyperactivity-impulsivity symptoms in patients ≥17 years old OR ≥6 symptoms in patients <17 years old that persisted for at least 6 months
  • Inattention symptoms include:
    • Often having inattention to details or making careless mistakes in schoolwork, work, or other activities
    • Often having problems sustaining attention in doing tasks or play activities
    • Often does not seem to listen when spoken to directly, even without obvious distraction
    • Often fails to carry out instructions to completion and fails to finish schoolwork, tasks, or duties at work
    • Often having problems organizing tasks and activities
    • Often avoids or strongly dislikes doing tasks that would require sustained mental effort
    • Often loses things needed to perform tasks or activities
    • Often easily distracted by extraneous stimuli
    • Often forgets daily activities
  • Hyperactivity-impulsivity symptoms include:
    • Fidgeting or tapping of hands/feet or squirming in the seat is often observed
    • Often leaves the seat in the classroom or any situation that requires it to be remained seated
    • Inappropriately runs about or climbs excessively
    • Often have an inability to be quiet while playing or engaging in leisure activities
    • Often uncomfortable or having difficulty being still for extended periods of time that others may perceive as always being “on the go” or acting like “driven by a motor”
    • Excessively talking
    • Often blurting out answers to questions before questions have been completed
    • Often having problems waiting in line or waiting for his or her turn
    • Often interrupting or intruding on others; in adults or adolescents, it is evident with intruding or taking over what others are doing

According to DSM-5-TR criteria, ADHD can be classified into subclasses:

• Predominantly inattentive, where hyperactivity symptoms were not present in the past 6 months
• Predominantly hyperactive/impulsive, wherein inattentive symptoms have not been present in the past 6 months
• Combined where both hyperactivity/impulsivity and inattentive symptoms are present in the past 6 months

Remission status should be specified as follows: 

• Partial remission is seen 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
• It can also be specified by severity based on the effect on occupational or social functioning such as:
  • Mild for minor impairment
  • Moderate if impairment is between mild and severe symptoms and functions
  • Severe if the symptoms are in excess of those necessary to meet the diagnosis or there is marked impairment