A 12-Year-Old Boy With Falling Grades and Forgetful Behavior

The criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),^[12] for the diagnosis of ADHD include those for inattention and for hyperactivity and impulsivity. With regard to inattention, children as old as 16 years must show 6 or more symptoms, whereas patients aged 17 years or older must show 5 or more symptoms. In addition, the symptoms must have been present for at least 6 months and be inappropriate for the patient’s developmental level. The symptoms of inattention are as follows:^[12]

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or in 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 (eg, loses focus, sidetracked)
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 (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
Is often easily distracted
Is often forgetful in daily activities

As with the above criteria for inattention, the DSM-5’s criteria for hyperactivity-impulsivity require that children as old as 16 years show 6 or more symptoms and that patients aged 17 years or older show at least 5 symptoms. In addition, the symptoms must have been displayed for at least 6 months and be pronounced enough to be disruptive and inappropriate for the patient’s developmental level. They are as follows:^[12]

Often fidgets with or taps hands or feet or squirms in seat
Often leaves seat in situations in which 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 his/her turn
Often interrupts or intrudes on others (eg, butts into conversations or games)

The following criteria must also be met for a diagnosis of ADHD:^[12]

Several symptoms of inattention or hyperactivity-impulsivity have been present since before age 12 years
Several symptoms are present in two or more settings (eg, at home, school, or work; with friends or relatives; in other activities)
Clear evidence must suggest that the symptoms interfere with, or reduce the quality of, social, school, or work functioning
The symptoms do not happen only during the course of schizophrenia or another psychotic disorder; the symptoms are not better explained by another mental disorder (eg, mood disorder, anxiety disorders, dissociative disorder, or personality disorder)

Depending on the symptoms exhibited, the presentation of ADHD can be classified as follows (although note that because the symptoms can change over time, the presentation may change as well):^[8,12]

Combined presentation: If enough symptoms to satisfy the criteria for both inattention and hyperactivity-impulsivity have existed for at least 6 months
Predominantly inattentive presentation: If enough symptoms to satisfy the criteria for inattention, but not for hyperactivity-impulsivity, have existed for at least 6 months
Predominantly hyperactive-impulsive presentation: If enough symptoms to satisfy the criteria for hyperactivity-impulsivity, but not for inattention, have existed for at least 6 months

In diagnosing ADHD, the patient must be observed in two or more locations. Generally, the parents do so at home, while a teacher observes the patient in the classroom. The following are examples of observation charting and recording tools:

Barkley Adult ADHD Rating Scale ̶ IV (BAARS-IV)^[13]
Conners’ Rating Scales^[14]
Vanderbilt ADHD Diagnostic Teacher Rating Scale^[15]

In this case, indications for ADHD included the fact that Michael is male, had 7 of the possible symptoms for inattention and 6 for hyperactivity-impulsivity (combined presentation), demonstrated the symptoms for more than 6 months, and displayed them in two locations (home and school).

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