Attention-deficit/hyperactivity disorder

ADHD shows up on case exams whenever a client of any age reports poor focus, and the hinge is almost always onset and pervasiveness, not the symptom list itself.

Criteria at exam depth. Two symptom domains, nine symptoms each: inattention (careless mistakes, trouble sustaining attention, seems not to listen, poor follow-through, disorganization, avoids sustained mental effort, loses things, easily distracted, forgetful) and hyperactivity-impulsivity (fidgets, leaves seat, restlessness, can't do leisure quietly, constantly on the go, talks excessively, blurts answers, can't wait turn, interrupts). A child needs six or more in a domain; from age 17 on, five or more. Symptoms persist at least 6 months, are inconsistent with developmental level, several were present before age 12, several appear in two or more settings (home, school, work), and clearly interfere with functioning. They are not explained by a psychotic, mood, anxiety, dissociative, personality or substance disorder. Specify the presentation for the past 6 months: combined, predominantly inattentive, or predominantly hyperactive/impulsive; also partial remission and mild/moderate/severe.

Hinge differentials.

• Anxiety disorders: concentration problems are driven by worry and rise and fall with anxiety rather than forming a stable pattern across settings.
• Trauma/PTSD: hypervigilance and poor focus follow a traumatic event; ask about exposure before labeling a distractible child.
• Specific learning disorder: inattention is limited to the weak academic skill; focus is fine in other subjects.
• Sleep problems: daytime inattention resolves when sleep is corrected.
• Bipolar disorder: distractibility comes in discrete episodes with elevated mood and reduced need for sleep; ADHD is chronic and trait-like.
• Substance use: symptom onset tracks use, often after adolescence.

On the NCMHCE. The counselor gathers a developmental history and multi-informant data (parents, teachers, partners, old report cards) and uses standardized rating scales from more than one setting. For an adult first reporting symptoms, the missing piece is usually evidence of childhood onset. Rule out vision/hearing, sleep and medical causes and screen for co-occurring anxiety, depression, learning disorders and substance use. First-line approaches include behavioral parent training and classroom supports for younger children, skills-based CBT and organizational coaching for adults, and referral for medication evaluation (stimulant and nonstimulant classes). Watch for bias: cultural expectations about activity level shape how adults describe a child.

Clinical Pearl: Without several symptoms before 12 and in two or more settings, look elsewhere. Inattention that comes and goes with mood or worry is not ADHD.