Neobook — clinical reference

The core triad of ADHD is a persistent pattern of inattention or hyperactivity–impulsivity that interferes with functioning. This is accompanied by associated behavioural, cognitive, emotional and social problems which can lead to workrelated and interpersonal difficulties (see Box 1 for The Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) criteria for ADHD).³⁶

Inattention manifests behaviourally in ADHD as difficulty sustaining focus, wandering off tasks, lacking persistence, paralysing procrastination, poor time management, inefficiency and being disorganised.

Hyperactivity refers to excessive motor activity when it is not appropriate or excessive fidgeting, tapping or talkativeness. In adults, hyperactivity may manifest as extreme restlessness or wearing others out with their activity, being a workaholic, excessive talkativeness, being overscheduled and feeling overwhelmed.

BOX 1: DSM-5 criteria for ADHD.

A. A persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development, as characterised by (1) and (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental levels and negatively impacts directly on social and academic or occupational activities:

Note:
The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms are required:

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or during other activities (e.g. overlooks or misses details, work is inaccurate).
Often has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, conversations or lengthy reading).
Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction).
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (e.g. starts tasks but quickly loses focus and easily side tracked).
Often has difficulty organising tasks and activities (e.g. difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganised work; has poor time management; fails to meet deadlines).
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework; for older adolescents and adults, preparing reports, completing forms and reviewing lengthy papers).
Often loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses and mobile telephones).
Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, returning calls, paying bills and keeping appointments)

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental levels and negatively impacts directly on social and academic or occupational activities:

Note:
The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or a failure to understand tasks or instructions. For older adolescents and adults (age 17 years and older), at least five symptoms are required:

Often fidgets with or taps hands or feet or squirms in seat.
Often leaves seat in situations when remaining seated is expected (e.g. leaves his or her place in the classroom, in the office or other workplace or in other situations that require remaining in place).
Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults it may be limited to feeling restless.)
Often unable to play or engage in leisure activities quietly.
Is often ‘on the go’, acting as if ‘driven by a motor’ (e.g. is unable to be or uncomfortable being still for extended time, as in restaurants or meetings; may be experienced by others as being restless or difficult to keep up with).
Often talks excessively.
Often blurts out an answer before a question has been completed (e.g. completes people’s sentences; cannot wait for his or her turn in conversation).
Often has difficulty waiting his or her turn (e.g. while waiting in line).
Often interrupts or intrudes on others (e.g. butts into conversations, games or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to 12 years of age.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school or work, with friends or relatives, in other activities).

D. There is clear evidence that the symptoms interfere with or reduce the quality of social, academic or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorders and are not better explained by another mental disorders (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Source: American Psychiatric Association (APA)³⁶

Impulsivity refers to hasty actions that occur in the moment without forethought and could have a high potential for harm to the individual. This may reflect reward dependence and a need for immediate gratification. Impulsive behaviours may manifest as social intrusiveness, a low frustration tolerance, mood lability and losing one’s temper, making important decisions without consideration of long-term consequences (e.g. taking a job without adequate information, or impulsively quitting a job, ending relationships, or driving too fast) and addictive behaviours.

These core symptoms should be evident since childhood, with evidence of several symptoms being present since before the age of 12 years. Also, substantial symptoms causing significant impairment should be present in more than one setting (e.g. home, school and work). Some of the impairments related to adult ADHD include job failure or under-employment, complications such as drug dependence, driving accidents, unwanted pregnancies and sexually transmitted diseases, and even a life of perpetual failure.

Typically, symptoms vary depending on context within a given setting. Adult recall of childhood symptoms tends to be unreliable. Confirmation of the presence of symptoms and the impact thereof across various settings typically cannot be done accurately without consulting informants who have seen the individual in those settings. Obtaining collateral information is therefore beneficial – if not crucial.

Symptoms often appear to decrease over time – in number and in severity. However, adults are often more adept at managing these symptoms. Some adults compensate for ADHD-related impairment by choosing lifestyles and careers that suit them. Although they may appear to function well, high amounts of energy and time are used to accomplish tasks.

A field trial in a representative large sample (N = 4000) of 18–19-year-old adults14,15 indicated a 27% increase (from 2.8% to 3.55%) in the expected prevalence of ADHD when comparing DSM-IV to DSM-5 criteria. However, the study supported lowering the symptomatic threshold for diagnosing ADHD in adults, with the best symptomatic cutoff in the number of symptoms for predicting impairment being five symptoms of inattention and four symptoms of hyperactivity-impulsivity.

Based on these criteria, three types of ADHD are identified:

ADHD combined type: If both criteria 1A and 1B are met for the past 6 months.
ADHD predominantly inattentive type: If criterion 1A is met, but criterion 1B is not met for the past 6 months.
ADHD predominantly hyperactive-impulsive type: If criterion 1B is met, but criterion 1A is not met for the past 6 months.

Further distinctions are made with regard to severity:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between ‘mild’ and ‘severe’ are present.
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.

A course specifier for partial remission is specified where full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic or occupational functioning. Furthermore, provision has been made for patients who present with symptoms characteristic to ADHD that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for ADHD. This is done by recording ‘other specified attention-deficit/hyperactivity disorder’ followed by the specific reason (‘with insufficient inattention symptoms’). If the clinician chooses not to specify the reason for partial fulfilment of criteria, or when there is insufficient information to make a more specific diagnosis, the diagnosis will be ‘unspecified attention-deficit/hyperactivity disorder’.

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Click here for the ADHD Treatment Armamentarium in South Africa

Schoeman R, Liebenberg R. The South African Society of Psychiatrists/Psychiatry Management Group Management Guidelines for Adult Attention-Deficit/ Hyperactivity Disorder. S Afr J Psychiat. 2017;23(0), a1060. https://doi.org/10.4102/sajpsychiatry.v23i0.1060 - An Update on the ADHD Treatment Armamentarium in South Africa., Prof Renata Schoeman

South African Journal of Psychiatry; The South African Society of Psychiatrists/Psychiatry Management Group the Management Guidelines for Adult Attention-Deficit/ Hyperactivity Disorder, 28 April 2017_An Update on the ADHD Treatment Armamentarium in South Africa, 2023