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ADHD Diagnosis The Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM), used in the USA and the rest of the world for the formal diagnosis of attention-deficit hyperactivity disorder (ADHD), was released by the American Psychiatric Association in 2013 and replaces the previous version (Diagnostic and Statistical Manual of Mental Disorders – 4th Edition [DSM-IV]).1,2 The DSM-5TM defines ADHD as a persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, has symptoms presenting in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities), and negatively impacts directly on social, academic or occupational functioning. Several symptoms must have been present before age 12 years.1 -impulsivity that interferes with functioning or development Six or more of the symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. yperactive-impulsive symptoms were present prior to age 12 years -impulsive symptoms are present in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities) evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal) Whilst the fundamental diagnostic criteria for ADHD have not changed in the DSM5TM compared with the previous version, the DSM-5TM has been updated to more accurately characterize the experience of adolescents and adults with ADHD. This has been achieved with the inclusion of additional examples to illustrate the types of ADHD-related behaviors that adolescents and adults with ADHD may exhibit, as well as ADHD-related behaviors that children may exhibit.1 Furthermore, adults and adolescents (aged ≥17) are required to present with a minimum of five (rather than six) symptoms, and symptoms should have been present before age 12 (not before age 7), recognizing that adult recall of precise childhood onset is difficult.1,2 A pervasive developmental disorder (autism spectrum disorder) is no longer an exclusion criterion.1 ADHD is now listed in the new category of ‘Neurodevelopmental Disorders’, acknowledging the growing body of scientific evidence supporting brain development correlates with ADHD.3 The DSM-5TM notes that although motor symptoms of hyperactivity become less obvious in adolescence and adulthood, difficulties persist with restlessness, inattention, poor planning, and impulsivity. The DSM-5TM also acknowledges that a substantial proportion of children remain relatively impaired into adulthood.1 Presentations of ADHD Individuals with ADHD may present with both inattention and hyperactivity/impulsivity, or one symptom pattern may predominate. Three presentations of ADHD are commonly referred to: combined-type, inattentive-type and hyperactive/impulsive-type (Table 1). According to the DSM-5TM classification system, the appropriate presentation of ADHD should be indicated based on the predominant symptom pattern for the last six months. Combined All three core features are present and ADHD is diagnosed when ≥6 symptoms of hyperactivity/impulsivity and ≥6 symptoms of inattention have been observed for ≥6 months – Inattentive Diagnosed if ≥6 symptoms of inattention (but <6 symptoms of hyperactivity/impulsivity) have persisted for ≥6 months Hyperactive/impulsive Diagnosed if ≥6 symptoms of hyperactivity/impulsivity (but <6 symptoms of inattention) have been present for ≥6 months Furthermore, the DSM-5TM also states that it must be specified whether the individual with ADHD is in “partial remission” (when partial ADHD criteria have been met for the past six months with full criteria met previously, and the symptoms still result in impairment in social, academic or occupational functioning); and the current severity of the disease (Table 2).1 Table 2: Current severity of ADHD Mild Current Severity of ADHD Moderate Few, if any, symptoms in Symptoms or functional excess of those required to impairment between “mild” make the diagnosis are and “severe” are present present, and symptoms result in no more than minor impairments in social or occupational functioning Severe Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present; or the symptoms result in marked impairment in social or occupational functioning Symptoms of ADHD Three key features define attention-deficit hyperactivity disorder (ADHD)1 or hyperkinetic disorder (HKD)2 – inattention, hyperactivity and impulsivity – and the contribution of each to an individual’s presentation of ADHD varies from patient to patient.1 In some individuals, two or more features may contribute in equal measure; in others, one feature may predominate.1 As different features of ADHD can impair functioning and quality of life in different ways, it is important to accurately evaluate each patient’s unique symptomatic characteristics, using medical classification systems such as the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM) or the International Classification of Mental and Behavioral Disorders 10th revision (ICD10).1,2 Whereas the ICD-10 characterizes HKD by its “cardinal features” of impaired inattention and overactivity, the DSM-5TM categorizes patients with ADHD by three main presentations: combinedtype, predominantly inattentive-type and predominantly hyperactive-impulsive-type.1 Inattention is characterized as an individual moving between tasks without completing any one activity, seemingly losing interest in one task because they become diverted to another.1,2 Individuals with inattention are often easily distracted and forgetful, and experience difficulties when organizing activities. At school, children with ADHD may struggle to listen and be frequently distracted; in the workplace, adults with ADHD may appear as if their mind is elsewhere and their work may be messy and performed carelessly (Figure 1).1 Hyperactivity refers to excessive motor activity,1,2 and may present differently depending on the patient’s age.1 In children, it may present as the child running and jumping around at inappropriate times, getting up from a seat when he or she is supposed to remain seated, fidgeting and wriggling, or excessive talkativeness and noisiness.1,2 In adolescents and adults, hyperactivity may manifest as inner feelings of extreme restlessness and wearing others out with their activity (Figure 2).1 Impulsivity Individuals with impulsive tendencies can be reckless and appear impatient, and are often disinhibited in social situations. They may find it difficult to wait their turn, intruding on or interrupting others’ activities or blurting out answers to a question before it has been completed (Figure 3).1,2 –