Attention Deficit Hyperactivity Disorder: Richard Sloves, Psy.D

Attention Deficit
Hyperactivity Disorder
RICHARD SLOVES, PSY.D.
Signs and Symptoms of ADHD: Attention Deficit Hyperactivity
Disorder
• Careless in School or Work

• Distractibility and Problems Sustaining Your Attention
• Procrastination and Lack of Follow Through
• Messy Desk or Office
• Can’t Sit Still
• Losing Track of Things, Instructions or Shopping Lists
• Fidgety and Restless
• On the Go, Hyperactive
Age of Onset
Based on data from the NSCH, the median age of onset for children with current
ADHD was 6 years.
More severe cases of ADHD in children, as described by parents, were diagnosed

earlier.
• The median age of diagnosis for severe ADHD was 4 years.

• The median age of diagnosis for moderate ADHD was 6 years.
• The median age of diagnosis for mild ADHD was 7 years.
Approximately one-third of children diagnosed with ADHD retain the diagnosis

into adulthood.
Prevalence of ADHD Among Adolescents
Based on diagnostic interview data from National Comorbidity Survey–

Adolescent Supplement (NCS-A):
• The lifetime prevalence of ADHD was 8.7%.
• Nearly half of all cases showed severe impairment (4.2%).
• ADHD affected three times as many males (13.0%) as females (4.2%).

Inattention
Six or more symptoms of inattention for children up to age 16 years

Five or more for adolescents age 17 years and older and adults
Symptoms of inattention have been present for at least 6 months, and they are
inappropriate for developmental level
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with
other activities.
• Often has trouble holding attention on 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 (e.g., loses focus, side-tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
(such as schoolwork or homework).
• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets,
keys, paperwork, eyeglasses, mobile telephones).
• Is often easily distracted
• Is often forgetful in daily activities
Hyperactivity and Impulsivity
Six or more symptoms of hyperactivity-impulsivity for children up to age 16

years
Five or more for adolescents age 17 years and older and adults
Symptoms of hyperactivity-impulsivity have been present for at least 6 months to
an extent that is disruptive and inappropriate for the person’s developmental
level:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults
may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”.
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting their turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
 Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

 Several symptoms are present in two or more settings, (such as at home, school or work;
with friends or relatives; in other activities).
 There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
school, or work functioning.
 The symptoms are not better explained by another mental disorder (such as a mood
disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do
not happen only during the course of schizophrenia or another psychotic disorder.
Three kinds (presentations) of ADHD can occur.
 Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-

impulsivity were present for the past 6 months
 Predominantly Inattentive Presentation: if enough symptoms of inattention, but not

hyperactivity-impulsivity, were present for the past six months
 Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of

hyperactivity-impulsivity, but not inattention, were present for the past six months.
Diagnosing ADHD in Adults
• ADHD often lasts into adulthood
• To diagnose ADHD in adults and adolescents age 17 years or older, only 5

symptoms are needed instead of the 6 needed for younger children
• Symptoms might look different at older ages. For example, in adults,

hyperactivity may appear as extreme restlessness or wearing others out with
their activity.
Differential DX
ADHD and Bipolar Disorder

Some experts feel that children with
• severe irritability,
• emotional instability, and
• severe temper outbursts
are, in fact, suffering from bipolar disorder as it appears in childhood and should be treated accordingly.
Other experts feel this approach will lead to the overdiagnosis of children who in fact suffer from disorders other
than bipolar disorder. These experts argue for a narrower definition of bipolar disorder which includes
• episodic mood swings,
• elevated or expansive mood—not just irritable mood—and
• grandiosity or inappropriate euphoria (extreme joyfulness).
There are also other factors that can seriously complicate the diagnosis of bipolar disorder in
children. A history of severe emotional trauma such as physical or sexual abuse can lead to mood
swings, emotional outbursts, hallucinations, and extremely severe behavioral problems, including
sexualized behaviors that can resemble bipolar disorder.
Kids might exhibit distractibility, talkativeness, difficulty maintaining attention, and loss of social
functioning. Clinicians must assess whether it is one condition or whether the disorders are co-
occurring.
A child may have both ADHD and bipolar disorder if they experience behavioral outbursts, severe
mood swings, and impulsive behaviors.
If a child has already been diagnosed with ADHD and they exhibit an inflated sense of self, risky
sexual behavior, lack of need for sleep, and self-harming behaviors, then they also may be
experiencing mania associated with bipolar disorder.
• ADHD in children usually does not involve mood symptoms such as depression and euphoria to
the extent seen in bipolar disorder.
• ADHD symptoms usually first appear early in childhood while the onset of bipolar disorder
appears to occur later in childhood or adolescence.
• ADHD also usually involves normal sleep, at least once a child has settled down in bed and is
ready for sleep.
• Mania, in contrast, involves decreased need for sleep with the individual still “raring to go” the
next day despite little sleep. The family history can be helpful, as both disorders appear to run in
families.
Symptoms of Mania in Children
• acting unusually silly or happy
• having a short temper
• hyperactivity
• irritability
• talking with rapid speech
• trouble sleeping or needing less sleep
• trouble concentrating
• talking excessively about sex
• engaging in risky behaviors
Disruptive Behavior
Most kids learn that refusing to listen to a parent, throwing tantrums and hitting
people have consequences. But some kids act angry, defiant and aggressive in
spite of the consequences. If this behavior is severe and continues for six months
or more, it can be a sign of disruptive behavior disorder.
There are two main disruptive behavior disorders—conduct disorder (CD) and
oppositional defiant disorder (ODD). They’re different from each other,
although kids with CD may also have ODD.
Oppositional Defiant Disorder: ODD
Symptoms of ODD typically show up before age 8. Although the symptoms usually
appear in multiple settings (such as home and school) they may be more noticeable
in one setting than others. Signs of ODD include:
• Being uncooperative on purpose

• Not following the rules
• Arguing, even about small and unimportant things
• An overall irritable and negative attitude
Most kids show those symptoms once in awhile. But with ODD they last for over
six months and happen almost daily.
Disruptive mood dysregulation disorder: DMDD
Disruptive mood dysregulation disorder (DMDD) is a condition in which a child is

chronically irritable and experiences frequent, severe temper outbursts that seem
out of proportion to the situation at hand.
Children diagnosed with DMDD struggle to regulate their emotions in an age-

appropriate way. In between outbursts they are irritable most of the time.
Disruptive mood dysregulation disorder: DMDD
Disruptive mood dysregulation disorder is characterized by temper outbursts that

are frequent, severe, inconsistent with the situation at hand, and inappropriate to a
child’s developmental level.
Parents describe children with DMDD as having intense emotional responses to a

variety of triggers. They seem to experience things more powerfully than their
peers, and lack age-appropriate self-regulation skills to control those feelings.
Post Traumatic Stress Disorder: PTSD
Post Traumatic Stress Disorder results from a traumatic event or series of events
in a child’s or adult’s environment that causes changes in the brain.
Traumatic events lead to physiological, cognitive, and emotional changes in how

a person processes stressful incidents and worries.
They leave a person feeling chronically unsafe, which, in turn, causes him to
excrete higher than normal amounts of the stress hormone cortisol. They respond
easily and often to the fight/flight part of the brain called the amygdala,
becoming so consumed with his own safety that he cannot pay attention to daily
life.
Both ADHD & PTSD present symptoms of
• inattention,
• poor impulse control,
• lack of focus,
• sleeplessness,
• distractibility, impulsivity,
• irritability,
• poor memory and concentration,
• anxiety, sensitivity to sensory stimuli, and
• low self-esteem.
Evaluating for ADHD Initial Screening Full evaluation
◦ Interviews: parent, teacher(s) & child
◦ Bio-psycho-social history collection
◦ Rating scales: Pre & Post administration of medication
◦ Assessment for co-occurring conditions

Connors 3
• Full length and short versions validated for ages 6–18 years
• Conners’ Parent Rating Scale
• Conners’ Teacher Rating
• Conners-Wells’ Adolescent Self-Report Scale

The Conners 3 is composed of the following scales:
• Hyperactivity/Impulsivity
• Executive Functioning
• Learning Problems
• Aggression
• Peer Relations
• Family Relations
DSM Symptom Scales
• ADHD Hyperactive/Impulsive
• ADHD Inattentive
• ADHD Combined
• Oppositional Defiant Disorder
• Conduct Disorder

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Attention Deficit

• Careless in School or Work

More severe cases of ADHD in children, as described by parents, were diagnosed

• The median age of diagnosis for severe ADHD was 4 years.

Approximately one-third of children diagnosed with ADHD retain the diagnosis

Based on diagnostic interview data from National Comorbidity Survey–

• The lifetime prevalence of ADHD was 8.7%.

• Nearly half of all cases showed severe impairment (4.2%).

• ADHD affected three times as many males (13.0%) as females (4.2%).

Six or more symptoms of inattention for children up to age 16 years

Six or more symptoms of hyperactivity-impulsivity for children up to age 16

 Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

 Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-

 Predominantly Inattentive Presentation: if enough symptoms of inattention, but not

 Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of

• ADHD often lasts into adulthood

• To diagnose ADHD in adults and adolescents age 17 years or older, only 5

• Symptoms might look different at older ages. For example, in adults,

ADHD and Bipolar Disorder

• Being uncooperative on purpose

Disruptive mood dysregulation disorder (DMDD) is a condition in which a child is

Children diagnosed with DMDD struggle to regulate their emotions in an age-

Disruptive mood dysregulation disorder is characterized by temper outbursts that

Parents describe children with DMDD as having intense emotional responses to a

Traumatic events lead to physiological, cognitive, and emotional changes in how

◦ Interviews: parent, teacher(s) & child

◦ Bio-psycho-social history collection

◦ Rating scales: Pre & Post administration of medication

◦ Assessment for co-occurring conditions

• Conners’ Parent Rating Scale

• Conners’ Teacher Rating

• Conners-Wells’ Adolescent Self-Report Scale

• Oppositional Defiant Disorder

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