Attention Deficit/Hyperactivity Disorder (ADHD) is a neuro-psychiatric condition characterised by problems with:
- Inattention and organisational skills.
- Activity levels.
This often presents with easy distractibility, low tolerance for frustrational boredom, greater tendency to say whatever comes to one’s mind (impulsivity), and in some a predilection for situations with high intensity.
There are three clinical groups that have been identified earlier, i.e.
- The hyperactive group where increased activity and impulsivity is the major factor.
- The combined group, which have symptoms of all three the domains, and
- The inattentive group, where problems are mostly with organisational skills and inattention.
With the new DSM V criteria the clinical subgroups is not so important, as they may change over a persons lifespan.
Occasionally they may all have difficulty with the above-mentioned symptoms. If the patient has ADHD though, these problems become pervasive and persistent and it affects their ability to function effectively in daily life. We find that it affects;
- School and learning situations. In adulthood it may also affect work situations.
- Socialisation and personal interaction is affected.
- Home and family life is sometimes compromised.
This is a condition that persists into adulthood. In many sufferers, they are able to manage and control the symptoms by developing specific skills, but in a group some of these problems may still have a functional impact. The importance is thus to evaluate each patient individually.
The diagnosis is made according to the DSM V criteria. The DSM IV criteria was revised and re-evaluated and the new DSM V criteria was brought out in 2015. The basic criteria for the diagnosis is still the same, but the descriptions have been widened to ensure that there is better representation of all age-groups.
Diagnosis is made according to the criteria of which there are nine (9) specific symptoms for inattention and organisational skills. Five (5) for increased activity and three (3) for impulsivity. These have been changed slightly and have been qualified to ensure that adults can also relate to these symptoms.
Changes that have been made from DSM IV to DSM V is that the age when symptoms should have appeared is not that clear, as there is no scientific proof that the age of seven (7) is important.
We do know that we have to have a specific number of symptoms that must have been persisting for a period longer than six (6) months before a diagnosis can be made.
Symptoms must occur in:
• At least two different settings for example with children at school and at home.
• The symptoms must cause significant impairment in social and academic functioning.
• The symptoms must also not be caused by another condition.
To thus make the diagnosis of ADHD a comprehensive evaluation is needed. This includes a full history, collateral information from the School and other caretakers as well as from the parents. It is still very much a clinical diagnosis. It is an assessment that takes time.
It is necessary to rule out:
- Any other causes for these possible symptoms, i.e. anxiety, poor cognitive function or emotional disorders.
- We need to establish whether there are co-existing conditions, which influence the clinical picture of ADHD and also complicate the management. In 30% of patients with ADHD we basically have ADHD as their primary problem, but in the other 70%, there is often a co-existing condition, which can modify the clinical picture as well as complicate management.
To make the diagnosis a full evaluation should be done by a Psychologist and a Medical Practitioner, i.e. a Paediatrician or a Psychiatrist or a Neurologist/Developmentalist. It is important to realise that the diagnosis cannot only be made with the use of a specific check-list (like Connor forms). These forms play an important role in monitoring the symptomatology, but are not an absolute for the diagnosis.
There is no single test to diagnose ADHD. There are certain tests that would help with;
- Clarification of the possibility of the diagnosis being present.
- A fair sensitivity in picking up the condition. At this stage it is agreed that none of these tests are absolute in making the diagnosis and that the clinical diagnosis is still the better one.
Tests that have shown some value are:
- The QEEG.
- There are certain tests which work on executive function, which are used to check patients’ response when doing some activities and to see how often they make impulsive decisions and/or certain mistakes.
These tests must be seen as additional proof. Clinical diagnosis and evaluation is still the most important.
Before reaching a diagnosis it is also important to look for conditions that could;
- Manifest similar symptoms.
- Mimic the clinical picture.
- Be co-existing and thus cloud the clinical picture and the management.
- Emotional difficulties/Social and environmental problems. Problems with anxiety and depression are extremely important here.
- Developmental issues;
• Low muscle tone plays a role with some of these kids, but is not the cause for distractibility. It depends on how good their control of their muscles are, whether they will have problems with fidgetiness.
• Fine motor coordination difficulties. This often leads to problems with task completion and the quality of work presented. It also sometimes causes problems with motor planning, especially if praxis problems are present. it often co-exists in patients with ADHD.
• Sensory modulation disorders. These patients are hypersensitive to either sound, touch or other factors in their environment. They then battle to ignore some of the normal stimuli that happen in the environment and will have difficulty blocking these out, which then leads to problems with them paying attention and/or reacting to their environment.
- Global Developmental Delay with poor cognitive functioning can also affect concentration. Here it is important to evaluate their concentration and functioning according to their functional, not chronological age.
- Specific learning problems. Patients will often present with difficulty in reading or mathematics and it is important to ensure that these be recognised and/or distinguished as they will need specific remedial input.
- Absence Epilepsy. This is a form of epilepsy; which has short episodes of clouding of awareness. These often present between ages 6 – 10-years. It also has a very specific treatment.
- Visual and hearing problems must be evaluated and ensured that it is managed according to the specific needs.
- A patient’s physical health should be good. Should there be chronic problems, these need to be managed effectively before a specific diagnosis of ADHD can be made. Sleep and eating disorders must be assessed.
- Psychiatric conditions: Anxiety, depression and a host of psychiatric conditions needs to be identified and/or excluded.
(Reviewed by Dr A van der Walt, MMed (Paed) BSc Hon (Human Genetics),
May 2007, July 2010 and January 2015)