The DSM IV Diagnostic Criteria: A Closer Look

In order to be classified as ADD/ADHD, a person must meet the DSM IV criteria, which I've listed below. Whether someone meets the criteria or not is very subjective and hinges on the meaning of the term "maladaptive." All people exhibit some of the traits of ADD some of the time, but when a person exhibits the traits to a degree that is maladaptive, then a diagnosis of ADD is given. For some clinicians, "maladaptive" means failing out of school or losing job after job. For other clinicians "maladaptive" can mean a gifted student that is only getting B's, or a spirited child who is disrupting a dull classroom.

While some people have actual brain defects caused by things like exposure to toxic chemicals, or illness caused by allergies, it is entirely possible for someone to meet the criteria because of natural temperament factors rather than a brain defect. Under the current diagnostic criteria, there is NO exclusion for behavior caused by temperament, giftedness or diet. To demonstrate the relationship between temperament and ADHD, I've listed the diagnostic criteria next to quotes from MBTI temperament experts. Temperament differs from personality in that it cannot be changed. Quotes are from the book "Nurture by Nature" by Tieger and Tieger, unless otherwise noted. MBTI temperament types have been studied extensively for decades.

Children who are bright, generally happy, and who can concentrate closely on things they find interesting (like video games) are less likely to have some sort of real problem and more likely to be exhibiting behavior normal for their temperament. Children with a low IQ or children who often seem sick, cranky, have severe behavior problems, trouble sleeping, multiple allergies, or who have problems concentrating on things they like are more likely to have some type of medical problem.

If you are unfamiliar with the MBTI temperament system, there are four opposing preferences which make sixteen different temperament types. Some of these terms are referenced in the table below.

Extravert vs. Introvert (E vs. I)
Sensory vs. Intuitive (S vs. N)
Thinking vs. Feeling (T vs. F)
Judging vs. Perceiving (J vs. P)

As you will see, strong Extraverts may appear hyperactive/impulsive, while strong Intuitives and Perceivers may appear inattentive. I discovered my son and I are extremes in all three - a potent combination! For more information on MBTI temperament see Temperament.

Hyperactivity / Impulsivity If a person meets six of the following they are considered to be ADHD with hyperactivity	Related Temperament Factors: Quotes are from Nurture by Nature unless otherwise noted.
Often fidgets with hands or feet, or squirms in seat (in adults, may be replaced by feelings of restlessness).	"Most of the behavior problems Extraverted children have in school are the direct result of being confined to a chair, and required to work for an extended period of time on a paper-and-pencil activity in a room where silence must be maintained." ESTPs: "Given their naturally high energy level and relatively short attention span, it's understandable why school is usually not an ESTP's favorite experience...ESTPs characteristically have a very hard time sitting still for any length of time and are easily distracted...They are constantly scanning the environment and are usually first to notice someone at the door, the fact that it has begun to rain, or some other happening outside their classroom."
Often leaves seat in classroom or other situation where it is inappropriate.
Often has difficulty playing or engaging in leisure activities quietly.	"Left alone in a room, [Extraverts] become distracted, bored, or rambunctious as their energy drains away.They need other people around in order to keep their brains awake." ENTPs: "They seek constant interaction and engagement."
Is often 'on the go' or often acts as if 'driven by a motor.'	"Extraverted children tend to get overexcited by the onslaught of stimulation...their natural expressiveness demonstrates itself in both words and actions - with great energy, bustle, and activity in everything they do...It can be exhausting to parent Extraverted children. They can just seem like too much of a good thing, especially for more Introverted parents..." Extraverts: "Libby's parents described her as a little energy vortex - gobbling up energy from people around her and becoming more excited each moment she interacted with others. The more action and the more people around, the more wound up she would become until either she was in trouble or someone got hurt. In school, her teachers complained that she often disrupted the classroom or became aggressive with classmates. Finally, her parents suggested she be paired with a friend to complete the seat-work assignments. Libby found it much easier to get her work done when she didn't feel either exiled or like the class problem. While it was important for Libby to learn to work by herself, her parents stressed that self-control was a learning task itself. It didn't seem fair to Libby that she had to simultaneously learn the classroom curriculum and the life skill of self-control."
Often talks excessively.	"Once [Extraverts] begin to put words together, their speech seems to occur as an explosion. Many parents say that once their Extraverted children began to talk, they never stopped! In fact, they often insist that they be heard. Since they tend to think out loud, they often give quite long and involved explanations and stories. And, because they form most of what they want to say as they are saying it, it's easy for them to lose their train of thought if they are interrupted or made to wait their turn to speak. They usually find this terribly frustrating and may rage or cry when they forget what they were going to say."
Often blurts out answers before questions have been completed	"Extraverted children frequently interrupt others, unable to hold onto any thought or idea for any length of time without expressing it. When you interrupt an Extraverted child's words, you interfere with her thinking...Extraverted children do tend to think out loud, and they may simply say things to see how they sound. And in speaking before thinking, they may end up saying things that they don't mean or that are not true. ESFP: "While Tyler never intentionally disrupted his fourth-grade class, he did have trouble learning to raise his hand, wait his turn, and generally contain himself during classroom instruction or discussion. It got to be a joke between him and his parents that, almost weekly, he brought home sheets of paper with the statement 'I will not blurt out' written in his hand fifty times. His parents met with his teacher and suggested they instead try a reward system by which Tyler could earn freedom through self-control. Instead of being punished for his impetuousness, Tyler earned opportunities to run errands for the teacher or help her with chores around the classroom. At the start of each new grade, Tyler's parents made sure to explain to his teacher that they had discovered that Tyler learned best with his mouth moving and his hands on whatever he was trying to understand."
Often interrupts or intrudes on other (e.g. barges into conversations or games)
Often has difficulty awaiting turn.

Inattention Six or more of the following must be met for a diagnosis of ADD / inattentive type.	Temperament Factors: Quotes are from Nurture by Nature unless otherwise noted.
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities	"Because the Intuitive child is pulled toward the future and possible, he may seem uninvolved and inattentive to the present. When the present is a classroom lesson or parental instruction, the Intuitive child can find himself in difficulty...the Intuitive child might be daydreaming the hours away." - Keirsey/ "Please Understand Me" "Absorbed as they often are in their internal world, [Intuitives] tend miss a great deal of what's right around them -- current reality is merely a problem to be solved, or a stage of development toward some future ideal. Not only can they miss details, they can also lose track of where they are, and for instance drive right past their highway turn-off. 'It's only reality' they sometimes say, to register their relative disinterest in the merely concrete. But more than disinterest, [Intuitives] can be discontent with reality, even bothered by it, and speculate about possible ways of improving it. Because of their tenuous grasp of reality, [Intuitives] can appear to [others] as flighty, impractical, and unrealistic -- the dreamer or absent-minded professor who can't be bothered with the nitty-gritty of living." - Keirsey website. "Cognition for the NF [Intuitive-Feeling] child may be impressionistic. He tends to be satisfied with a global, diffuse grasp of learning. If he gains a general impression, glossing over details, he still believes that he has sufficient mastery of the subject." - Keirsey/ "Please Understand Me." "The Perceiving child may have to be reminded to get dressed, to come to dinner, to take out the trash, to do his homework, and so on." - Kiersey/ "Please Understand Me." "Focus and concentration do not come easily to most ENFPs. I takes great effort to stay on task." INFPs "frequently forget things like keys, homework, or their backpacks."
Is often forgetful in daily activities.
Often has difficulty sustaining attention in tasks or play activities.	Note that nearly all children identified as ADD actually focus extremely well on anything they find interesting. The problem is usually that they do not find SCHOOL interesting. This is also described as the child who likes to start things but doesn't finish them, or who bounces from toy to toy. Perceivers are defined, in part, by their preference for starting projects rather than finishing them. Intuitive types "can become bored quickly with too much repetition or routine." NTs (Intuitive-Thinkers) "are bored very quickly and need a steep learning curve to stay engaged. Once they master something, they will change interests and hobbies (and eventually jobs!) more often than any other temperament." "Homework is frequently another trouble spot for many school-aged ENFPs, who have yet to develop the work and study habits that make completing assignments easier and quicker." SPs (Sensory-Perceivers) are well known for their dislike of school work and their drive to escape from it. "As the curriculum becomes less active, the SP does not find the activity and excitement he wants. As the demand is for concentration, he becomes restless and turns to activities of his own initiation." - Keirsey/ Please Understand Me.
Often does not seem to listen when spoken to directly.	Introverted children: "John's mom knew that to others, John could appear shy and withdrawn. But she came to understand in time that, like his Introverted father, John usually had an ongoing inner dialogue or stream of thought running in his head. But breaking into that train of though could take real effort; it might require repeating herself, touching his arm to establish contact, and gently shaking him out of his reveries. John seemed to not be listening or to be intentionally ignoring her. She learned that while that might sometimes be true, most of the time he was just more engaged in his favorite world - the one inside. The outer world was so cluttered with fragments of talk, superfluous chatter, and scattered impressions that he preferred to retreat to a quieter place for contemplation. The things that did tend to penetrate his consciousness were usually what he considered highly interesting or important." Also Intuitives who are daydreaming (see above quotes) or SPs who are focused on something they are doing. If often means the child can actually focus better than other children: They are so focused on what they are doing they do not hear you.
Often has difficulty organizing tasks and activities.	"The Perceiving child...may seem unconcerned about whether he is on time for class or not. He may have a jumble in his closets and make a rat's nest o his dresser drawers -- and has difficulty understanding why this causes his mother discomfort...The Perceiving child may have to be reminded to get dressed, to come to dinner, to take out the trash, to do his homework, and so on." - Keirsey/ "Please Understand Me" Intuitives are famous for losing things while they are daydreaming - see above quotes. ENFP: "Life can be chaotic with an ENFP. They seem to create messes everywhere and are not nearly as interested in finishing projects as they are in starting them. Cleanup is almost always a battle."
Often loses things necessary to tasks or activities (eg. toys, school assignments, pencils, books, or tools).
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).	Note that very few kids like to do schoolwork, so almost all kids would meet this one. Perceivers are especially inclined to challenge authority when required to do so: "Perceiving children tend to live life in resistance to limits. They are constantly pushing the edges of acceptable behavior, incessantly questioning the reason for rules, or simply forgetting the rules altogether, claming they never heard you say they couldn't climb on the dining room table. Rather than being comforted by limits, they see them as barriers to exploring their world." The SP [Sensory-Perceiver] appears to be flighty, jumping from one thing to another, disinterested in completion. He must do something if he is to learn. The more game-like the task, the better. ..And yet, if an SP is so inclined, he can get involved in an activity which captures his attention for hours on end...As the curriculum becomes less active, the SP does not find the activity and excitement he wants. As the demand is for concentration, he becomes restless and turns to activities of his own initiation. These often take the form of a disruption of class routines or increased absenteeism. The extreme SP can easily become restless, jittery, bored, and engaged in random action to such as extent as to be labeled "hyperactive" by foolish school and medical personnel naively applying the current physicalism." - Keirsey Intuitive children are easily bored and may resist school-work that they find boring (see above quotes).
Is often distracted by extraneous stimuli.	Perceiving Children: "For Scott, a Perceiving child, cleaning his room can end up taking three times as long as his mom, a Judger, thinks it ought to. As he picks up his many toys, he usually find all kids of treasures he hasn't seen for a long time and stops to play for a while." Intuitives are often distracted by inner thoughts, see above quotes. Joke Prayer for an Intuitive-Perceiver type: "Please God, help me to concentrate on one - Look, a bird! - thing at a time."

1. The symptoms must be to a degree that is "maladaptive and inconsistent with development level."

This part is highly subjective. Remember: Just because a behavior appears to be maladaptive, it doesn't necessarily mean a child actually has some sort of brain defect, as proved by Thomas Edison's remarkable career after being kicked out of school for his divergent thinking traits. Gifted students may also display behavior that is "maladaptive" but they certainly do not have a disorder or brain defect. Parents and professionals alike should not only judge the child's behavior, but also their own expectations of conformity and convenience. Because children become less impulsive as they get older, a child who is naturally more impulsive than others will appear to be "developmentally behind."

2. "Some impairment from the symptoms is present in two or more settings." If a child is only having problems in school, then the DSM IV criteria have not been met. The wording, however, is so vague that just about anything can be considered impairment by someone who is looking for it. If you report that it is difficult to get your child to clean up his room, or that you have a lot of trouble getting him to do his homework, this may be taken as a sign of "some impairment," when both traits are very normal for divergent thinkers. An astute parent, however, can make a solid argument against an ADD diagnosis if he or she has not had significant problems with the child outside of school.

3. "There must be clear evidence of clinically significant impairment in social, academic or occupational functioning."

There are some children who really do have severe dysfunction. But if a bright but bored student gets only C's, is that "clinically significant impairment"? Many would argue yes. Others would argue no. It is this ambiguity that can lead to high levels of diagnoses. In Greenwich, Connecticut, one of the wealthiest cities in the U.S., 30% of all school kids have been diagnosed with some type of learning disability, qualifying them for additional school resources like one-on-one tutors.

4. "The symptoms are not better accounted for by another mental disorder." Depression and anxiety are often overlooked in kids, but they can mimic many of the traits of ADD. Inability to concentrate can be severe in kids or adults with depression and anxiety. Sometimes kids are being bullied in school and don't want to tell anyone, so they may become depressed or anxious and can appear to have ADD without hyperactivity.

5. The symptoms that cause impairment must have been present before the age of 7. If your sweet child never had a problem until his third grade teacher insisted he be tested for ADD because he won't sit still, then the DSM IV criteria have not been met. However, in "real life" there are people who acquire ADD as a result of brain trauma.

1. David Keirsey, author of "Please Understand Me" and other books is a well-respected expert in Jungian temperament theory and has had significant experience dealing with difficult or "mischievous" kids. He is outspoken about his feeling against labeling kids ADD or hyperactive and using medications, and has instead devised a discipline strategy called "Abuse It - Lose It" which I have found to be highly effective. Keirsey believes that most kids labeled hyperactive (as the label was apply a few decades ago) simply have strong "SP" or "artisan" temperaments.

2. The book "Nurture by Nature" by Tieger & Tieger provides detailed descriptions and explanations of Jungian temperament theory as it applies to children. I found the author's descriptions of strong extraverts, introverts, and divergent thinkers fascinating.

3. In her book "The Edison Trait" author Lucy Jo Pallidino describes divergent thinkers and the many challenges they pose to schools and parents. In her opinion, about 20% of the population is divergent thinking to a significant degree, and ADDers represent a subset of that group.