All That Wiggles Is Not ADHD
History, Assessment, and Diagnosis of ADHD
Jodi A. Polaha, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute, UNMC
Director, Hastings Behavioral Health Clinic
Attention-Deficit
Hyperactivity Disorder
History: Where did ADHD
come from?
“Defects in Moral Control”
George Still, M.D. (1902)
A “cluster” of behaviors which:
were more common in males
seemed to run in families
were associated with certain congenital anomalies
were not accounted for by any known neurological
deficit
Other Names/Classifications
Post-encephalic Brain Disorder
 Brain Injured Child Syndrome
 Minimal Brain Dysfunction
 Hyperkinetic Reaction of Childhood (DSM-II)
 Attention-Deficit Disorder (DSM-III, 1980)

Current Conceptualization
Attention-Deficit Hyperactivity Disorder (ADHD)
DSM-IV, 1994
Three subtypes:
Predominantly Inattentive
Predominantly Hyperactive/Impulsive
Combined
Adolescent and Adult Outcomes
Some symptoms into adolescence: 70%
 Some symptoms into adulthood: 50%
 At increased risk for:

Substance abuse
Traffic citations
Automobile accidents
Cause of ADHD
No one cause identified.
Not caused by
Diet (i.e. food additives, sugar)
Poor parenting
Other Myths/Misconceptions

ADHD is outgrown in adolescence.
Other Myths/Misconceptions
ADHD is outgrown in adolescence.
 Girls are not hyperactive.

Other Myths/Misconceptions
ADHD is outgrown in adolescence.
 Girls are not hyperactive.
 There is a single test for ADHD.

Other Myths/Misconceptions
ADHD is outgrown in adolescence.
 Girls are not hyperactive.
 There is a single test for ADHD.
 Stimulant medication can “diagnose”
ADHD.

Other Myths/Misconceptions
ADHD is outgrown in adolescence.
 Girls are not hyperactive.
 There is a single test for ADHD.
 Stimulant medication can “diagnose” ADHD.
 There is a “cure” for ADHD.

Prevalence of ADHD
Best current estimate:
3%-5% school age population are affected.
Attention-Deficit Hyperactivity Disorder
Diagnosis:
Who has ADHD?
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion A:
Six or more symptoms from one or both of
these lists:
 Inattentive Type
 Hyperactive/Impulsive Type
…have been present for at least 6 months.
Symptom Lists
Inattentive Type









fails to attend to details, makes
careless mistakes
difficulty sustaining attention in
play or work
does not listen when spoken to
does not follow through
difficulty organizing tasks
avoids task requiring sustained
mental effort
loses things needed
distracted by extraneous stimuli
often forgetful
Hyper/Impulsive Type









often fidgets hands/feet or squirms
often leaves seat when sitting is expected
runs about or climbs excessively
difficulty playing or engaging in leisure
activities quietly
often “on the go”/ “driven by motor”
talks excessively
blurts out answers before questions
completed
difficulty awaiting turn
interrupts or intrudes on others
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion B:
Some of the symptoms were present before
the age of seven years.
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion C:
Some impairment from the symptoms is
present in two or more settings (e.g., home,
and school or work).
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion D:
There is evidence of clinically significant
impairment in social, academic, or
occupational functioning.
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion E:
The identified symptoms are not better
accounted for by another mental disorder.
Attention-Deficit
Hyperactivity Disorder
Assessment:
All that wiggles is not ADHD
Comprehensive Diagnosis for ADHD
There is no single test or laboratory measure
which can reliably detect ADHD.
Comprehensive Diagnosis for ADHD
Information gained by qualified clinician:
From family
 standardized, norm-referenced ratings
 detailed history
Comprehensive Diagnosis for ADHD
Information gained by qualified clinician:
From family
 standardized, norm-referenced ratings
 detailed history
From school
 standardized, norm-refernced ratings
 academic history
 in-class observations
Comprehensive Diagnosis for ADHD
Information gained by qualified clinician:
From family
 standardized, norm-referenced ratings
 detailed history
From school
 standardized, norm-referenced ratings
 academic history
 in-class observations
From clinician
 observations
Other Common Causes of
Concentration Problems

Depression/anxiety
Other Common Causes of
Concentration Problems
Depression/anxiety
 Drug/alcohol use

Other Common Causes of
Concentration Problems
Depression/anxiety
 Drug/alcohol use
 Poor fit between academic demands and
individual’s capabilities

Other Common Causes of
Concentration Problems
Depression/anxiety
 Drug/alcohol use
 Poor fit between academic demands and
individual’s capabilities
 Physical illness

Other Common Causes of
Concentration Problems
Depression/anxiety
 Drug/alcohol use
 Poor fit between academic demands and
individual’s capabilities
 Physical illness
 Adjustment

Associated Problems

Learning Disability: 25 - 30%
Associated Problems
Learning Disability: 25 - 30%
 Oppositional Defiant Disorder: 35 - 65%

Oppositional Defiant Disorder
Pattern of negative, hostile, and defiant behavior:








Often loses temper
Often argues with adults
Often actively defies or refuses to comply with adults’ requests or rules
Often deliberately annoys people
Often blames others for his/her mistakes or behavior
Often touchy or easily annoyed by others
Often angry or resentful
Often spiteful or vindictive
Associated Problems
Learning Disability: 25 - 30%
 Oppositional Defiant Disorder: 35 - 65%
 Variable academic quality

Associated Problems
Learning Disability: 25 - 30%
 Oppositional Defiant Disorder: 35 - 65%
 Variable academic quality
 Poor social skills, peer relationships

Who Has ADHD?
Percent
100
90
80
70
60
50
40
30
20
10
0
Extremely
Attentive
3-5%
Average
Attentiveness
Extremely
Inattentive
Who Has ADHD?
Percent
100
90
80
70
60
50
40
30
20
10
0
Extremely
Attentive
3-15%?
3-5%
Average
Attentiveness
Extremely
Inattentive
ADHD as Heterogeneous Disorder
Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes
difficulty sustaining attention in play or work
does not listen when spoken to
does not follow through
difficulty organizing tasks
avoids task requiring sustained mental effort
loses things needed
distracted by extraneous stimuli
often forgetful
often fidgets hands/feet or squirms
often leaves seat when sitting is expected
runs about or climbs excessively
difficulty playing or engaging in leisure
often “on the go”/ “driven by motor”
talks excessively
blurts out answers before questions completed
difficulty awaiting turn
interrupts or intrudes on others
Associated Problems
Learning Disability
Oppositional Defiant Disorder
Variable academic quality
Poor social skills, peer relationships
ADHD as Heterogeneous Disorder
Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes
difficulty sustaining attention in play or work
does not listen when spoken to
does not follow through
difficulty organizing tasks
avoids task requiring sustained mental effort
loses things needed
distracted by extraneous stimuli
often forgetful
often fidgets hands/feet or squirms
often leaves seat when sitting is expected
runs about or climbs excessively
difficulty playing or engaging in leisure
often “on the go”/ “driven by motor”
talks excessively
blurts out answers before questions completed
difficulty awaiting turn
interrupts or intrudes on others
Associated Problems
Learning Disability
Oppositional Defiant Disorder
Variable academic quality
Poor social skills, peer relationships
ADHD as Heterogeneous Disorder
Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes
difficulty sustaining attention in play or work
does not listen when spoken to
does not follow through
difficulty organizing tasks
avoids task requiring sustained mental effort
loses things needed
distracted by extraneous stimuli
often forgetful
often fidgets hands/feet or squirms
often leaves seat when sitting is expected
runs about or climbs excessively
difficulty playing or engaging in leisure
often “on the go”/ “driven by motor”
talks excessively
blurts out answers before questions completed
difficulty awaiting turn
interrupts or intrudes on others
Child with ADHD
Associated Problems
Learning Disability
Oppositional Defiant Disorder
Variable academic quality
Poor social skills, peer relationships
Child with ADHD
Importance of Diagnosis




Can help schools document need for
additional services.
Research purposes.
Professional communication.
But it doesn’t help individualize a treatment
strategy!
Importance of Diagnosis
More important than a diagnosis:
is a comprehensive, functional assessment
of the child’s impairment in daily life
•
•
•
•
with peers.
with teachers.
with siblings.
with parents.
New Conceptualization of ADHD
Dr. Russell Barkley:
“ADHD is a delay in the development of
behavioral inhibition.”