Diagnostic Issues

Hyperactivity, or ADHD, is a condition that has been recognized for many years and has been quite extensively researched, but the diagnostic criteria and treatment continue to be controversial. The symptoms of ADHD were first described by a German physician, Heinrich Hoffman, in a children's book written in 1848. The symptoms were represented by two children, Harry, who looks in the air (inattention), and Fidgety Phil (hyperactivity). In 1902, George Still presented a lecture in England about 20 children who were aggressive, defiant, excessively emotional and lacking inhibitory volition, and who were also noted to have impaired attention and over-activity. A more etiological conceptualization of the condition did not occur until after World War I.

Symptoms of hyperactivity and inattention were suspected to be caused by the influenza epidemic that occurred after World War I, when postencephalitic behavior manifestations in children included extreme examples of hyperactivity and inattention. This led to the suggestion that these symptoms were due to organic brain damage. The concept of inattention and hyperactivity being part of a spectrum with less intense manifestations secondary to subtle injuries became known as the syndrome of 'minimal brain damage' in the 1960s. However, the lack of clear evidence for brain damage eventually resulted in a shift to a more descriptive labeling of the disorder. This is reflected in the American Psychiatric Association classification system (DSM) defining the 'hyperkinetic reaction of childhood.' The same disorder was similarly described in the United Kingdom, as reflected in the World Health Organization (WHO) classification. However, the conditions described differed in that the British disorder included more severe symptomatology and required that the symptoms had to be present in all settings.

In 1980, the US characterization of inattention and hyperactivity was changed in several ways. It was conceptually defined by three symptom dimensions: inattention, impulsiveness, and hyperactivity, with inattention playing a more prominent role. In addition, to address the heterogeneity within the disorder, two subtypes ('attention deficit disorder with hyperactivity' and 'attention deficit disorder without hyperactivity') were defined. Again, different from the British criteria, the symptoms were only required to be present in one setting such as school. Retaining the concept that the major contributions to the symptoms were related to innate characteristics in the child rather than to environmental influences, the symptoms were required to have been present before the age of 7 years and to have lasted for at least 6 months. The British system continued to use the term 'hyperkinetic syndrome of childhood' and to include the pervasive nature of the symptoms.

The most recent changes in diagnostic criteria used by the American Psychiatric Association (DSM-IV) and the WHO have moved the definitions closer to agreement. Considering the most recent studies, there is evidence to support two dimensions. In DSM, the first dimension, inattention, is characterized by the 'often' occurrence of at least six of nine of the inattentive behaviors presented in Table 1. The second dimension consists of both hyperactivity and impulsiveness and is characterized by the 'often' occurrence of at least six of nine of the hyperactive and/or impulsive behaviors presented in Table 1. The WHO definitions are similar but do not attempt to quantify the specific behaviors and do not include impulsiveness in the hyperactivity dimension.

In DSM, the two dimensions define three subtypes: predominantly inattentive type (meeting criteria on the inattentive dimension), predominantly hyperactive/impulsive type (meeting criteria on the hyperactive/impulsive dimension), and combined type (meeting criteria on both dimensions). In addition, there are other general criteria including the onset of symptoms before 7 years of age, the presence of symptoms for at least 6 months, the presence of symptoms in two or more settings (e.g., home, school, or work), and evidence that

Table 1 DSM-IV behaviors for ADHD

Inattention

Careless mistakes Difficulty sustaining attention Seems not to listen Fails to finish tasks Difficulty organizing

Avoids tasks requiring sustained attention Loses things Easily distracted Forgetful

Hyperactivity

Fidgeting

Unable to stay seated

Moving excessively (restless)

Difficulty engaging in leisure activities quietly

Talking excessively

Impulsiveness

Blurting answers before questions completed Difficulty awaiting turn Interrupting/intruding upon others the symptoms cause significant clinical impairment in social, academic, or occupational functioning. The WHO condition has been renamed 'disturbances of activity and attention.'

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