What are the diagnostic criteria for Adolescent Attention Deficit Hyperactivity Disorder (ADHD)?

Diagnostic Criteria for Adolescent ADHD

For adolescents (age 12 to 18th birthday), you must document at least 5 symptoms (not 6) from either the inattentive or hyperactive-impulsive category that have persisted for at least 6 months, with symptom onset before age 12, causing impairment in at least 2 settings. 1

Core DSM-5 Diagnostic Requirements

The diagnosis requires meeting all of the following criteria simultaneously:

Symptom Threshold

• At least 5 symptoms from either inattentive OR hyperactive-impulsive categories (or both for combined type) 1
• Note: This is reduced from 6 symptoms required for children under age 17 1
• Symptoms must persist for at least 6 months 1

Age of Onset

• Several symptoms must have been present before age 12 1
• This is a critical change from DSM-IV which required onset before age 7 1
• Retrospective documentation is acceptable even when limited 2

Cross-Situational Impairment

• Symptoms must be present in 2 or more settings (home, school, work, social situations) 1
• Information must be obtained from multiple sources: parents/guardians, teachers, other school personnel, and mental health clinicians 1
• Use DSM-based ADHD rating scales from parents AND teachers to systematically document symptoms 1

Functional Impairment

• Clear evidence that symptoms interfere with or reduce quality of functioning in interpersonal, academic, or occupational domains 1
• The impairment must be clinically significant, not just mild difficulties 3, 4

Specific Symptom Categories

Inattentive Symptoms (need ≥5 for adolescents):

1. Poor attention to detail/careless mistakes 1
2. Difficulty concentrating or sustaining attention on tasks 1
3. Seems preoccupied, difficulty shifting focus even when spoken to directly 1
4. Difficulty completing tasks (gets distracted/side-tracked) 1
5. Organizational challenges (chronic lateness, messiness, disorganized work) 1
6. Reluctance to engage in tasks requiring sustained mental effort 1
7. Difficulty keeping track of personal belongings 1
8. Easily distracted 1
9. Frequently forgetful 1

Hyperactive-Impulsive Symptoms (need ≥5 for adolescents):

1. Frequent fidgeting (tapping desk) 1
2. Difficulty sitting still for prolonged periods 1
3. Feeling of inner restlessness or agitation 1
4. Often loud and disruptive 1
5. Always on the go, difficult for others to keep up 1
6. Talks excessively 1
7. Frequently interrupts others (difficulty waiting turn in conversation) 1
8. Highly impatient (difficulty waiting in line) 1
9. Often intrudes into others' activities 1

Presentation Types

Based on symptom patterns over the past 6 months:

• Predominantly Inattentive (314.00 [F90.0]): ≥5 inattentive symptoms but <5 hyperactive-impulsive symptoms 1, 5
• Predominantly Hyperactive-Impulsive (314.01 [F90.1]): ≥5 hyperactive-impulsive symptoms but <5 inattentive symptoms 1, 5
• Combined Presentation (314.01 [F90.2]): ≥5 inattentive AND ≥5 hyperactive-impulsive symptoms 1, 5
• Other Specified/Unspecified (314.01 [F90.8]): Clinically significant impairment but cannot verify full criteria 1, 2, 5

Mandatory Exclusion Criteria

Symptoms must NOT be better explained by:

• Oppositional behavior, defiance, hostility, or failure to understand tasks 1
• Another mental disorder: psychotic disorder, mood disorder, anxiety disorder, dissociative disorder, personality disorder 1
• Substance intoxication or withdrawal 1, 2

Required Comorbidity Screening

You must actively screen for comorbid conditions that may explain symptoms or coexist with ADHD 1, 2:

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1
• Developmental conditions: learning disorders, language disorders, autism spectrum disorders 1
• Physical conditions: tics, sleep apnea 1

The majority of adolescents with ADHD meet criteria for another mental disorder, making this screening essential rather than optional 2

Diagnostic Process for Adolescents

Initial Screening

• Use the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A 1
• Screen is positive when patient checks "often" or "very often" for 4 or more of 6 questions 1

Comprehensive Evaluation if Screen Positive

• Complete ASRS Part B to further elucidate symptoms 1
• Obtain collateral information from someone who knows the patient well (parent, spouse) 1
• Collect DSM-based rating scales from teachers and other school personnel 1
• Conduct clinical interview focusing on symptom onset, duration, and cross-situational impairment 1

Critical Pitfalls to Avoid

• Do not diagnose ADHD in adolescents with recent-onset symptoms after age 12, even if currently impairing 1
• Strongly consider substance use, depression, or anxiety as alternative explanations in this age group before confirming ADHD 2
• Do not rely on single-source information; you must obtain reports from multiple settings 1, 2
• Do not use the outdated term "ADD"; use "ADHD, predominantly inattentive presentation" instead 5
• Neuropsychological testing does not improve diagnostic accuracy for most cases, though it may clarify learning strengths/weaknesses 1

When Full Criteria Cannot Be Met

If clinically significant ADHD-like impairment exists but you cannot verify full criteria (insufficient information from multiple settings or cannot confirm onset before age 12), use the unspecified ADHD diagnosis (314.01 [F90.8]) 2, 5

Behavioral interventions remain beneficial even without a formal diagnosis and should not be withheld while gathering additional diagnostic information 2