27th October 2023

Attention Deficit Hyperactivity Disorder (ADHD)

Classification 

What was referred to in the ICD-10 as ‘hyperkinetic disorder’ is now classified under the ICD-11 and DSM-V as attention deficit hyperactivity disorder (ADHD).

The ICD-11 and DSM-V share many key diagnostic features, including:

• Symptoms of inattention and/or hyperactivity-impulsivity – either class may predominate.
• Symptoms must be present before 12 years.
• Persistent for at least 6 months.
• Present in 2 or more settings.

However, the DSM-V is more stringent with the number of symptoms, specifying the need for 6 or more in each domain to frequently be present to satisfy the diagnosis of a combined presentation.

The DSM-V also states that if assessed older than 17 years of age, then only 5 symptoms in each domain are required, and highlights the importance of symptoms not being solely attributable to oppositional behaviour or a failure to understand instructions, which might point more towards oppositional defiant disorder/conduct disorder or ID / ASD respectively (although does not of course rule out dual diagnosis).

Oppositional defiant disorder is another NDD that encompasses a profile of irritability, defiant and vindictive behaviour occurring at least once a week for at least 6 months. A child who frequently loses their temper, argues with or intentionally annoys authority figures and blames others for their mistakes should raise suspicions for ODD.

Conduct disorder (conduct dissocial disorder in the ICD-11) is similar to ODD and may develop from it but with a greater predominance of aggression, violence, destruction of property, deceitfulness and theft, and truancy for at least 6 months. It may begin as a child (<10yrs) or adolescent (>10yrs) and may remit or develop into enduring personality problems.

Assessment 

ADHD is a clinical diagnosis – based upon an interview and possible observation, but NICE guidelines state that rating scales such as the Conners’ rating scales and the Strengths and Difficulties questionnaire can be used as adjuncts (NICE, 2018). The Royal College of Psychiatrists also has a document that includes a list of rating scales and diagnostic interviews for adults, e.g. the Diagnostic interview for ADHD in adults (DIVA), which takes 1.5hrs to complete and includes a retrospective assessment of childhood behaviours too (Royal College of Psychiatrists, 2023).

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• The National Institute for Health and Care Excellence (2018). Attention deficit hyperactivity disorder: diagnosis and management (NICE guideline NG87)
• Royal College of Psychiatrists (2023) College Report CR235 ADHD in adults: Good practice guidance
• World Health Organisation. (2019). Neurodevelopmental disorders. International statistical classification of diseases and related health problems (11th ed.).