Attention-deficit/hyperactivity disorder (ADHD)

ADHD is characterized by a persistent pattern of difficulties sustaining attention and/or

impulsiveness and excessive or exaggerated motor activity. All of us have had lapses in attention
or periods of excess energy during childhood; however, in order to meet criteria for ADHD these
problems have to be numerous, persistent, and causing impairment at home, school, or the
workplace.

Perhaps partially due to their behavioral problems, children with ADHD often score approximately
7 to 15 points lower on intelligence quotient (IQ) tests (Barkley, 1997) and show deficits on
neuropsychological testing that are related to poor academic functioning (Biederman et al., 2004).

They often show specific learning disabilities such as difficulties in reading or learning other basic
school subjects. Children and adolescents with ADHD also are at significantly higher risk of a
range of school problems including suspension and repeating a grade, and these effects appear to
be due in large part to disruptive behavior problems (Kessler et al., 2014).

In addition to academic problems, symptoms of ADHD also can lead to significant social
impairment. Hyperactive children often have great difficulty getting along with their parents
because they often fail to obey rules. Their behavior problems also can result in their being viewed
negatively by their peers (Hoza et al., 2005).

DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with

functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a
degree that is inconsistent with developmental level and that negatively impacts directly on social
and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility,
or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older),
at least five symptoms are required.
a. 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).

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

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

d. 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).

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

f. 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).

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

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

i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents
and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level and that negatively impacts
directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility,
or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older),
at least five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. 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 other situations that require remaining in
place).

c. Often runs about or climbs in situations where it is inappropriate.

(Note: In adolescents or adults, may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.

e. 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).

f. Often talks excessively.

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

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

i. 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).

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

C. 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).

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

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
ADHD is fairly prevalent, occurring in approximately 9 percent of children and adolescents
(Merikangas et al., 2010). Although it is not the most prevalent disorder among U.S. children and
adolescents (specific phobia is seen in 19 percent of youth), it is the one that is most frequently
diagnosed by health professionals (Ryan-Krause et al., 2010).

The reason for this difference is that parents are much more likely to bring a child with ADHD in
for treatment than they are a child with a less disruptive disorder such as specific phobia.

The rate of ADHD is much higher in boys (13 percent) than in girls (4 percent) (Merikangas et al.,
2010) and is commonly comorbid with other externalizing disorders such as ODD and CD
(Beauchaine et al., 2010; Frick & Nigg, 2012).

ADHD is seen in cultures all around the world. For example, one study of 1,573 children from 10
European countries reported that ADHD symptoms are similarly recognized across all countries
studied and that the children have significant impairments across a wide range of domains
(Bauermeister et al., 2010).

ADHD Beyond Adolescence

Although ADHD has long been thought of as a disorder that occurs only during childhood and
adolescence, studies done in the United States and internationally suggest that approximately half
of children with ADHD will continue to meet criteria in adulthood (Kessler, Green, et al., 2010;
Lara et al., 2008).

Interestingly, however, most cases of adult ADHD are characterized by symptoms of inattention
(95 percent), whereas a much smaller percentage are characterized by hyperactivity (35 percent)
(Kessler, Green, et al., 2010).

It is estimated that approximately 4 percent of U.S. adults meet criteria for ADHD, with higher
rates among those who are male, divorced, and unemployed (Kessler, Adler, et al., 2006). The
association with unemployment may be due to trouble finding work but may also be the result of
poor work performance or absenteeism.
One recent study showed that those with ADHD miss significantly more days of work
(approximately 22 more days each year) than those without ADHD (de Graaf et al., 2008),
highlighting the long-term impairment associated with this disorder.

Causal Factors in ADHD

The specific causes of ADHD have been widely debated.

As with most disorders, available evidence points to both genetic (Ilott et al., 2010; Sharp et al.,
2009) and social-environmental factors (e.g., prenatal alcohol exposure; Ware et al., 2012).

But how do genetic variations and social-environmental events produce the particular constellation
of symptoms of ADHD that we see in children and adults?

Research on the neurobiology of ADHD suggests that the answer may lie, at least in part, in the
way that the brain develops in those with ADHD.

Children with ADHD have smaller total brain volumes than those without ADHD (Castellanos et
al., 2002), and their brains appear to mature approximately 3 years more slowly than those without
ADHD (Shaw et al., 2007).

Interestingly, these maturational delays are most prominent in prefrontal brain regions involved in
attention and impulsiveness.

Findings like these are exciting steps toward understanding this disorder, but questions remain
about how and why these differences arise. Answering these questions will likely lead not just to
better understanding, but to the development of more effective treatments.