The DSM IV Criteria for ADD: A
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)
An Extravert-Intuitive-Thinking-Perceiving person is
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.
The DSM IV Diagnostic Criteria Vs. Normal
If a person meets six of the following they are considered to be ADHD with
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."
"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
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.
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
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
|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.
"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.
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
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
||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
||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."
Additional Requirements for the Diagnosis of ADD/ADHD:
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
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"
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.