The video below is the section for ADHD from Part 4 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 4, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: ADHD
NARRATIVE DEFINITION: Attention-Deficit/Hyperactivity Disorder (ADHD) is a substantially heritable and a lifelong condition which is first evident in childhood. It is characterized by developmentally inappropriate and impairing symptoms of inattention and/or hyperactivity and impulsivity.
This diagnosis was placed in the chapter of neurodevelopmental disorders of the DSM-5, reflecting underlying brain development problems, although these neurological problems are not yet well understood.
Symptoms of inattention associated with ADHD include difficulty paying close attention to detail, making careless mistakes in schoolwork, difficulty with organization, forgetfulness, difficulty following through on instructions and in completing tasks, avoidance of activities that require sustained attention or mental effort, and being easily distracted.
Symptoms of hyperactivity and impulsivity include fidgeting or squirming in one’s seat, difficulty engaging in quiet activities, running around and climbing in inappropriate places, constantly being “on the go,” difficulty waiting one’s turn, blurting out answers before questions are completed, interrupting or intruding upon others, and/or excessive talking.
In order to meet DSM-5 diagnostic criteria, several symptoms of inattention or symptoms of hyperactivity/impulsivity must have been present before age 12 years, for a duration of at least 6 months. Because many symptoms of this condition are normative in young children, it requires extreme levels of demonstrated behaviors and impairments to make a valid diagnosis of ADHD in a child before age 5. Additionally, the symptoms must be present in at least two settings such as home and school or work. Assessment must include information from parents and teachers, who experience the child in everyday settings that place a premium on attention and self-regulation.
There are three specifiers to distinguish clinical presentation: Combined presentation, if six or more symptoms of inattention (criterion A.1) and six or more symptoms of hyperactivity-impulsivity (criterion A.2) have been met in the last six months. It is said to be a Predominantly Inattentive presentation if only criterion A.1 has been met in the last six months (but there are less than six of the listed symptoms for criterion A.2). It is specified as a Predominantly Hyperactive-Impulsive presentation, if only criterion A.2 has been met in the last six months (but there are less than six of the listed symptoms for criterion A.1). Note that for older adolescents and adults (ages 17 or older), only 5 symptoms (instead of 6) of inattention and/or hyperactivity-impulsivity are required to meet diagnostic criteria.
When diagnosing ADHD the clinician is also to assess and specify the severity of the presenting symptoms (mild, moderate, or severe). A specifier of in partial remission is added when full criteria were previously met, but less than full criteria have been met for the past 6 months, yet the individual still experiences symptoms that impair functioning in an important area of life.
Individuals with ADHD, when compared to their non-diagnosed counterparts, face more peer rejection or neglect, more interpersonal conflicts, lower self-esteem, and poorer educational/occupational achievement. Additionally, those with a diagnosis of ADHD may be more accident prone, and are more likely to develop conduct disorder (in adolescence) or antisocial personality disorder (in adulthood), and may also develop a substance use disorder. Symptoms may manifest differently in adults as compared to children. For example, adults may report subjective feelings of restlessness or irritability, may become bored quickly, and may engage in reckless behavior (e.g., impulsive sexual encounters, poor money management). Adults diagnosed with ADHD are likely to have difficulty concentrating; may find it challenging to establish and maintain routines; and may struggle with prioritizing, organizing, and completing tasks. Furthermore, they may change jobs frequently and switch their intimate partners more often than adults without ADHD.
In view of frequent overlap in symptoms, careful differential diagnosis may be required for an accurate diagnosis and an effective treatment plan. Individuals with oppositional defiant disorder may resist school or work tasks, but they exhibit non-confirming behaviors in other areas of their lives, and this resistance to conformity is associated with negativity, hostility, and defiance. This is different from the aversion to sustained mental effort, the forgetfulness, and impulsivity seen in many individuals diagnosed with ADHD.
Children with a learning disorder may appear inattentive due to lack of interest or limited ability, however their inattention will not be impaired in areas other than academic work.
Individuals with autism spectrum disorder exhibit inattention, isolation and social disengagement, which differ from the peer rejection, inability to focus, and the impulsivity of persons with ADHD. Tantrums can be seen in both diagnoses, but the inability to tolerate change in the expected course of events of autism is unlike the reaction to change seen with ADHD because of impulsivity and poor self-control.
When the diagnosis of bipolar disorder is given, the increase in activity, poor concentration, and impulsivity are associated with clearly bipolar features, such as grandiosity and elevated mood, which are episodic, occurring for several days at a time. In contrast, fluctuations in mood throughout the day, the excessive activity and impulsivity in ADHD are relatively continuous in comparison.
Individuals whose symptoms meet criteria for ADHD often have comorbid conditions. Oppositional defiant disorder co-occurs with ADHD in about half of the children with combined presentation, and in about one quarter of children with predominantly inattentive presentation. Conduct disorder and disruptive mood dysregulation disorder can also be diagnosed in individuals with ADHD. Less frequently seen associated with ADHD are anxiety disorders, intermittent explosive disorder, obsessive-compulsive disorder, tic disorder, and autism spectrum disorder.
In addition to genetic factors, other risk factors include very low-birth weight, smoking during pregnancy, and a range of prenatal and perinatal complications. Although ineffective parenting is not likely a cause of ADHD, maladaptive parenting styles may fuel persistence of the condition, as well as potential comorbidities. The prevalence of ADHD in most cultures is about 5% of children and about 2.5% of adults, according to population surveys. Boys (13.2%) are more likely than girls (5.6%) to be diagnosed with ADHD (Center for Disease Control, 2012).
Evidence-based treatments for ADHD include (a) medications (stimulants or selective norepinephrine reuptake inhibitors), and (b) behavioral treatments (parent management, school consultation).
Key Term: Attention-Deficit/Hyperactivity Disorder
- Childhood onset: must be exhibited before age 7 (except inattentive type)
- Apan at least six months duration
- Result in impairment of overall functioning levels
- Be exhibited in at least two settings
- Condition marked by developmentally extreme symptoms of inattention/disorganization and/or hyperactivity/impulsivity
- Predominantly Hyperactive-Impulsive
- Predominantly Inattentive
- Hyperactivity could include motor agitation, fidgeting, difficulty engaging in quiet activities, constantly being “on the go,” intruding upon others, and/or excessive talking
- Difficult to diagnose in preschoolers, because constituent behaviors relatively normative in that age group; assessment must include informants with knowledge of everyday behaviors
- Impairments span low achievement, peer rejection, problematic family interactions, accidental injuries
- ADHD lasts through adulthood in a majority of cases
- Characteristics of ADHD in adulthood include experiencing sujective feelings of restlessness or irritability, becoming bored quickly, engaging in reckless behavior (impulsive sexual encounters, poor money management), and having difficulty concentrating, establishing and maintaining routines, prioritizing, and organizing and completing tasks. Furthermore, adults diagnosed with ADHD may change jobs frequently and switch their intimate partners more often than do adults without ADHD.
- 9.5% of children and adolescents; somewhat lower in adults
- Sex ratio is 3:1 male-to-female
- Comorbidity with Oppositional Defiant Disorder/Conduct Disorder (40%), Anxiety Disorders, (25-40%), Mood Disorders (10-30% in children; 47% in adults), Learning Disorders (50%), Bipolar Disorder (20%)
- Strongly heritable (approaching 80%)
- Frontal-lobe functioning and frontal-striatal pathways are implicated in ADHD symptomatology
- Maladaptive parenting styles may fuel persistence of the condition as well as potential comorbidities
- Medications (stimulants; SNRIs)
- Behavioral strategies
The DSM-5 includes three subtypes of ADHD. They are:
A. Predominantly Inattentive Presentation, Predominantly Hyperactive Presentation, Predominantly Impulsive Presentation.
B. Predominantly Inattentive-Oppositional Presentation, Predominantly Hyperactive-Impulsive Presentation, Combined Presentation.
C. Predominantly Inattentive Presentation, Predominantly Hyperactive-Impulsive Presentation, Combined Presentation.
D. Predominantly Impulsive Presentation, Primarily Oppositional Presentation, Predominantly Hyperactive-Inattentive Presentation.
Rationale: C is correct, as these are the DSM-5 types of ADHD. The other responses include types that do not exist in the nomenclature.