Name: Date: Email address:
by Edward M. Hallowell, M.D. and John J. Ratey, M.D.
The following criteria are suggested only. They are based upon our clinical experience and constitute what we consider to be the most commonly encountered symptoms in adults with ADD. These criteria have not been validated by field trials, and should be regarded only as a clinical guide.
NOTE: Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.
(A) A chronic disturbance in which a least twelve of the following are present
1. a sense of underachievement, of not meeting one's goals (regardless of how much one has actually accomplished). We put this symptom first because it is the most common reason an adult seeks help. "I just can't get my act together", is the frequent refrain. The person may be highly accomplished by objective standards, or may be floundering, stuck with a sense of being lost in a maze, unable to capitalize on innate potential.
2. difficulty getting organized. A major problem for most adults with ADD. Without the structure of school, without parents around to get things organized for him or her, the adults may stagger under the organizational demands of everyday obstacles. For the want of a proverbial nail--a missed appointment, a lost check, a forgotten deadline--their kingdom may be lost.
3. chronic procrastination or trouble getting started. Adults with ADD associate so much anxiety with beginning a task, due to their fears that they won't do it right, that they put it off, which, of course, only adds to the anxiety around the task.
4. many projects going simultaneously; trouble with follow-through. A corollary of #3. As one task is put off, another is taken up. By the end of the day, or week or year countless projects have been undertaken, while few have found completion.
5. tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark. Like the child with ADD in the classroom, the adult with ADD gets carried away in enthusiasm. An idea comes and it must be spoken.
6. a restive search for high stimulation. The adult with ADD is always on the lookout for something novel, something engaging, something in the outside world that can catch up with the whirlwind that's rushing inside.
7. a tendency to be easily bored. A corollary of #6. Boredom surrounds the adult with ADD like a sink-hole, ever ready to drain off energy and leave the individual hungry for more stimulation. This can easily be misinterpreted as a lack of interest; actually it is a relative inability to sustain interest over time. As much as the person cares, his battery pack runs low quickly.
8. easy distractibility, trouble focusing attention, tendency to tune out or drift away in the middle of a page or conversation, often coupled with an ability to hyperfocus is also usually present, emphasizing the fact that this is a syndrome not of attention deficit but of attention inconsistency.
9. often creative, intuitive, highly intelligent. Not a symptom, but a trait deserving a mention. Adults with ADD often have unusually creative minds. In the midst of their disorganization and distractibility, they show flashes of brilliance. Capturing this "special something" is one of the goals of treatment.
10. trouble in going through established channels, following proper procedure. Contrary to what one might think, this is not due to some unresolved problem with authority figures. Rather, it is a manifestation of boredom and frustration: boredom with routine ways of doing things and excitement around novel approaches, and frustration with being unable to do things the way they're supposed to be done.
11. impatient; low tolerance for frustration. Frustration of any sort reminds the adult with ADD of all the failures in the past. "Oh no", he thinks, "here we go again". So he gets angry or withdraws. The impatience has to do with the need for stimulation and can lead others to think of the individuals as immature or insatiable.
12. impulsive, either verbally or in action, as in impulsive spending of money, changing plans, enacting new schemes or career plans, and the like. This is one of the more dangerous of the adult symptoms, or, depending on the impulse, one of the more advantageous.
13. tendency to worry needlessly, endlessly; tendency to scan the horizon looking for something to worry about alternating with inattention to or disregard for actual dangers. Worry becomes what attention turns into when it isn't focused on some task.
14. sense of impending doom, in-security, alternating with high-risk-taking. This symptom is related to both tendency to worry needlessly and the tendency to be impulsive.
15. mood swings, depression, especially when disengaged from a person or a project. Adults with ADD, more than children, are given to unstable moods. Much of this is due to their experience of frustration and/or failure, while some of it is due to the biology of the disorder.
16. restlessness. One usually does not see, in an adult, the full-blown hyperactivity seen in a child. Instead one sees what looks like "nervous energy": pacing, drumming of fingers, shifting position wile sitting, leaving a table or room frequently, feeling edgy while at rest.
17. tendency toward addictive behavior. The addiction may be to a substance such as alcohol or cocaine, or to an activity such as gambling, or shopping, or eating, or overwork.
18. chronic problems with self esteem. These are the direct and unhappy results of years of conditioning: years of being told one is a klutz, a spaceout, and underachiever, lazy, weird, different, out of it, and the like. Years of frustration, failure, or of just not getting it right do lead to problems with self-esteem. What is impressive is how resilient most adults are, despite all the setbacks.
19. inaccurate self-observation. People with ADD are poor self-observers. They do not accurately gauge the impact they have on other people. This can often lead to big misunderstandings and deeply hurt feelings.
20. family history of ADD or manic-depressive illness or depression or substance abuse or other disorders of impulse control or mood. Since ADD is genetically transmitted and related to the other conditions mentioned it is not uncommon (but not necessary) to find such a family history.
(B) Childhood history of ADD (It may not have been formally diagnosed, but in reviewing the history the signs and symptoms were there.).
(C) Situation not explained by other medical or psychiatric condition.
(Drs. Hallowell/Ratey are on staff at Harvard Med. School and are co-authors of Driven to Distraction, soon to be released. {Pantheon Books}. Both doctors are ADDults.)
This is one of the more useful diagnostic criteria for the diagnosis of Attention Deficit Disorder in Adults (ADD). Follow the instructions below to evaluate an individual concerning whether they fulfill the criteria for ADD in adults.
A. Childhood history consistent with attention deficit disorder (ADD) of childhood based on either narrow criteria as described in the DSM-III or broad criteria described below (including both characteristics #1 and #2, and one characteristic of #3 through #6).
(1) More active than other children, unable to sit still, fidgetiness, restlessness, always on the go, talking excessively
(2) Attention deficits, sometimes described as "short attention span," characterized by inattentiveness, distractibility, inability to finish school work
(3) Behavior problems in school
(4) Impulsivity
(5) Over-excitability
(6) Temper outbursts
B. Presence in adulthood of both characteristics #1 and #2 -which the patient observes or says others observe about him -together with two of characteristics #3 through #7.
(1) Persistent motor hyperactivity: Restlessness, inability to relax, "nervousness" (meaning inability to settle down -- not anticipatory anxiety), inability to persist in sedentary activities (eg, watching movies, television, reading newspaper), being always on the go, dysphoria when inactive.
(2) Attention deficits: Inability to keep mind on conversation, distractibility (being aware of other stimuli when attempts are made to filter them out); inability to keep mind on reading materials; difficulty keeping mind on job; frequent "forgetfulness" -- "often losing or misplacing things, forgetting plans, etc.; "mind frequently somewhere else."
(3) Affective lability: Usually described as antedating adolescence, and in some instances as far back as the patient can remember. Shifts from a normal mood to depression or mild euphoria or excitement; depression described as "down," "bored," or "discontented"; mood shifts usually last hours to a few days at most and are present without significant physiologic concomitants. Mood shifts may be spontaneous or reactive.
(4) Inability to complete tasks: The subject reports lack of organization in job, running household, or performing school work; tasks frequently not completed; subject switches from one task to another in haphazard fashion; disorganization in activities, problem solving, allotting time.
(5) Hot temper, explosive short-lived outbursts: Subject reports he may have transient loss of control and be frightened by his own behavior. Easily provoked or constant irritability. Temper problems interfere with personal relationships.
(6) Impulsivity: Subject makes decisions quickly, without reflection, often on the basis of insufficient information and to his own disadvantage. Inability to delay acting without experiencing discomfort. Manifestations include poor occupational performance; abrupt initiation or termination of relationships (eg, multiple marriages, separations, divorce); antisocial behavior (eg, job-riding, shoplifting); excessive involvement in pleasurable activities (eg, buying sprees, foolish business investments, reckless driving) without recognizing risks of painful consequences.
(7) Stress intolerance: Subject cannot take ordinary stresses in stride and reacts excessively or inappropriately with depression, confusion, uncertainty, anxiety, anger. Emotional responses interfere with appropriate problem solving. Subject experiences repeated crises in dealing with routine life stresses.
C. Absence of signs and symptoms of schizophrenia, schizoaffective disorder, or primary affective disorder.
D. Absence of the following characteristics of schizotypal or borderline personality disorders:
Associated features of ADD,RT: Marital instability; academic and vocational success less then expected on the basis of intelligence and education; alcohol or drug abuse, atypical responses to psychoactive medications; familial history of similar characteristics; family histories of ADD in childhood, alcoholism, drug abuse, antisocial personality and Tourquet's syndrome.
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