Professionals who diagnose ADHD use the diagnostic criteria set forth by the American Psychiatric Association (1994) in the Diagnostic and Statistical Manual of Mental Disorders. The fourth edition of this manual, known as the DSM-IV, was released in May 1994. The criteria in the DSM-IV (discussed below) and the other essential diagnostic features listed in "Defining Attention-Deficit/Hyperactivity Disorder" are the signs of ADHD. As can be seen, the primary features associated with the disability are inattention, hyperactivity, and impulsivity. The discussion below describes each of these features and lists their symptoms, as given in the DSM-IV.

Defining Attention-Deficit/Hyperactivity Disorder*

Instead of a single list of 14 possible symptoms as listed in the prior edition of the DSM (the DSM-III-R), the DSM-IV categorically sorts the symptoms into three subtypes of the disorder:

1. Combined Type -- multiple symptoms of inattention, impulsivity, and hyperactivity;

2. Predominantly Inattentive Type -- multiple symptoms of inattention with few, if any, of hyperactivity-impulsivity;

3. Predominantly Hyperactive-Impulsive Type -- multiple symptoms of hyperactivity-impulsivity with few, if any, of inattention.

Other essential diagnostic features of ADHD include:

• Symptoms of inattention, hyperactivity, or impulsivity must persist for at least six months and be maladaptive and inconsistent with developmental levels;

• Some of the symptoms causing impairment must be present before age seven years; Some impairment from the symptoms is present in two or more settings (e.g., at school/work, and at home);

• Evidence of clinically significant impairment is present in social, academic, or occupational functioning;

• Symptoms do not occur exclusively during the course of 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 Personality Disorder).

Inattention

A child with ADHD is usually described as having a short attention span and as being distractible. In actuality, distractibility and inattentiveness are not synonymous. Distractibility refers to the short attention span and the ease with which some children can be pulled off-task. Attention, on the other hand, is a process that has different parts. We focus (pick something on which to pay attention), we select (pick something that needs attention at that moment), and we sustain (pay attention for as long as is needed). We also resist (avoid things that remove our attention from where it needs to be), and we shift (move our attention to something else when needed).

When we refer to someone as distractible, we are saying that a part of that person's attention process is disrupted. Children with ADHD can have difficulty with one or all parts of the attention process. Some children may have difficulty concentrating on tasks (particularly on tasks that are routine or boring). Others may have trouble knowing where to start a task. Still others may get lost in the directions along the way. A careful observer can watch and see where the attention process breaks down for a particular child. Symptoms of inattention, as listed in the DSM-IV, are

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities;

• Often has difficulty sustaining attention in tasks or play activities;

• Often does not seem to listen when spoken to directly;

• 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);

• Often has difficulty organizing tasks and activities;

• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);

• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools);

• Often easily distracted by extraneous stimuli;

• Often forgetful in daily activities. (American Psychiatric Association, 1994, pp. 83-84)

Hyperactivity

Excessive activity is the most visible sign of ADHD. The hyperactive toddler/preschooler is generally described as "always on the go" or "motor driven". With age, activity levels may diminish. By adolescence and adulthood, the overactivity may appear as restless, fidgety behavior (American Psychiatric Association, 1994). Symptoms of hyperactivity, as listed in the DSM-IV, are:

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

• Often leaves seat in classroom or in other situations in which remaining seated is expected;

• 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);

• Often has difficulty playing or engaging in leisure activities quietly;

• Often "on the go" or often act as if "driven by a motor";

• Often talks excessively. (APA, 1994, p. 84)

Impulsivity

When people think of impulsivity, they most often think about cognitive impulsivity, which is acting without thinking. The impulsivity of children with ADHD is slightly different. These children act before thinking, because they have difficulty waiting or delaying gratification. The impulsivity leads these children to speak out of turn, interrupt others, and engage in what looks like risk-taking behavior. The child may run across the street without looking or climb to the top of very tall trees. Although such behavior is risky, the child is not really a risk-taker but, rather, a child who has great difficulty controlling impulse. Often, the child is surprised to discover that he or she has gotten into a dangerous situation and has no idea of how to get out of it.

Symptoms of impulsivity, as listed in the DSM-IV (p. 84), are:

• Often blurts out answers before questions have been completed;

• Often has difficulty awaiting turn;

• Often interrupts or intrudes on others (e.g., butts into conversations or games).

It is important to note that, in the DSM-IV, hyperactivity and impulsivity are no longer considered as separate features. According to Barkley (1990), hyperactivity-impulsivity is a pattern stemming from an overall difficulty in inhibiting behavior. In addition to problems with inattention or hyperactivity-impulsivity, the disorder is often seen with associated features. Depending on the child's age and developmental stage, parents and teachers may see low frustration tolerance, temper outburts, bossiness, difficulty in following rules, disorganization, social rejection, poor self-esteem, academic underachievement, and inadequate self-application (American Psychiatric Association, 1994).

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*Drawn from the American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders (4th ed.), pp. 83-85.
Reprinted with permission.