ADHD diagnosis, signs, and symptoms

Principles of the diagnostic approach 

The principles of the approach to diagnosing attention deficit disorder, with or without hyperactivity, are as follows: 

• Observing signs consistent with ADHD at the time of examination;
• Reporting current signs consistent with ADHD (in the past six months) and during childhood, i.e. before the age of 12 and for at least 6 months, by the patient and/or their immediate family members. 

Diagnosis requires symptoms to be present from childhood: it is therefore widely accepted that there is no onset of ADHD in adulthood. 

In addition, each sign must be frequent, persistent, and have a clinically significant impact in several areas of life: professional, emotional, academic, and/or familial. 

There are two categories of signs listed by international classifications (such as DSM-5, the diagnostic and statistics manual of mental disorders, the standard reference for diagnosis): 

1. Inattention
2. Hyperactivity/impulsivity

What behaviors may indicate clinically significant inattention? 

A person with clinically significant inattention may exhibit the following behaviors: 

• Neglects or forgets details or makes careless mistakes in schoolwork, work or other activities
• Often has difficulty maintaining attention at work or in games, concentrating during class, a conversation, or when reading a long text
• Often appears not to be listening when spoken to directly, even in the absence of external distraction
• Does not follow instructions and is unable to fully complete their schoolwork, household chores or professional obligations. Often loses track during activities and is easily distracted
• Often has difficulty organizing their work or activities, has difficulties managing sequential tasks, keeping their personal affairs and tools in order, manages their time poorly and does not meet deadlines.
• Avoids and dislikes tasks that require sustained mental effort
• such as schoolwork, chores, writing reports or filling out forms in the case of adolescents and adults.
• Often loses items they need for their work or activities, school materials, pencils, books, tools, wallet, keys, papers, glasses, mobile phone
• Is easily distracted by external stimuli, has a tendency towards abrupt changes of subject Frequent forgetfulness in daily life, cleaning, shopping, answering calls, paying bills, keeping appointments. 

Quels comportements peuvent traduire une hyperactivité et / ou une impulsivité cliniquement significative ?

A hyperactive or impulsive person may exhibit the following behaviors:  

• Moves their hands or feet often or fidgets in their seat.
• Gets up often in class or in other situations where they are expected to stay seated Runs or climbs everywhere in situations where this is inappropriate
• Often has trouble staying still in games or leisure activities.
• Is incapable of or uncomfortable staying still for long periods, such as in restaurants and meetings; may be perceived by others as restless or difficult to follow
• Often talks too much.
• Often blurts out the answer to a question that has not yet been fully asked, and/or completes the other person’s sentence
• Often finds it difficult to wait their turn in a queue or in a conversation (e.g. when standing in line)
• Often interrupts others or speaks over them, breaks into conversations, games or activities; may begin using other people’s property without asking or receiving permission 

Children are diagnosed if at least 6 symptoms of inattention and/or 6 symptoms of hyperactivity/impulsivity are observed. 

In adults 5 symptoms in one or both dimensions must be present. 

We now know that these outward signs and their symptoms are not stable throughout life, and differ between the sexes. 

Young boys more often present with combined type ADHD (two-dimensional ADHD, where it is combined with another disorder), or are more hyperactive compared to young girls. These variations explain, for example, the high rate of under-diagnosis in young girls (with symptoms without hyperactivity being considered less “visible”). 

Note that the ADHD phenotype tends more towards “inattentive’ as patients age. 

Improving diagnosis 

The importance of friends and relatives in making an ADHD diagnosis 

For the most accurate assessment, it is frequently recommended that friends and relatives who have been involved in the patient’s education (parents, siblings and teachers) are consulted if possible. 

The importance of ruling out other disorders similar to ADHD 

Before making a definitive ADHD diagnosis, it is important to rule out other disorders that may cause similar signs and symptoms, such as mood disorders (unipolar and bipolar), anxiety disorders, and learning disorders. 

These other disorders must therefore be ruled out or at least diagnosed. Diagnosing ADHD is therefore a differential clinical diagnosis and can only be made by a specialist doctor. 

What psychiatric comorbidities are associated with ADHD? 

ADHD is also a disorder associated with psychiatric comorbidities. A greater frequency of anxiety, mood, sleep, and bipolar disorders and addiction is observed in people with ADHD. 

Early treatment can significantly reduce the likelihood of negative psychological, educational, familial and social consequences for the child. It can also help prevent the development of associated disorders.