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Old 07-09-09, 04:10 AM
KDLMaj KDLMaj is offline
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April 09 Report of the DSM-V ADHD Working Group

Thought folks might be interested in this. I'll comment on it in the second post, but here's the official report from the working group assigned to the ADHD diagnostic criteria for the upcoming DSM-V (US).

Report of the DSM-V ADHD and Disruptive Behavior Disorders Work Group

April 2009
F. Xavier Castellanos, M.D.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Over the past six months, discussions and deliberations have been held by the ADHD workgroup subcommittee:

1. Secondary data analyses are being performed to inform the decision as to whether to retain all 18 A criteria as is or whether redundant items can be deleted without altering the fundamental structure of the remaining items and their psychometric properties.

2. Decisions regarding cutpoints for meeting diagnostic criteria in childhood will be based on secondary data analyses of extensive data sets that are ongoing. Similarly, the option of applying differential weights to some criteria remains open, pending secondary analyses and deliberations.

3. DSM-IV subtypes of predominantly hyperactive-impulsive and predominantly inattentive ADHD have not been supported by the empirical data; instead the evidence suggests that the classification of subtypes in ADHD is strongly influenced by method variance (e.g., by differences in informants, instruments, or in the algorithms used for combining information across informants). The consensus is that the existing subtypology is not useful.

a. One question being examined is whether to differentiate ADD from ADHD. ADD would only apply in the near or complete absence of lifetime expression of hyperactive/impulsive symptoms; individuals with appreciable hyperactivity symptoms in childhood would retain the diagnosis of ADHD even if the hyperactivity/impulsivity symptoms were to be in partial or full remission. This is not a simple reversion to DSM-III ADD, since that construct permitted/required symptoms of impulsivity.

b. Alternatively, there could be a single disorder of ADHD comprising the popular conceptions of ADD and ADHD.

c. The decision regarding these two options will turn on our judgement regarding the sufficiency of evidence of clinically meaningful distinctions between non-hyperactive/impulsive ADD and ADHD; also relevant will be estimates of the prevalence of the putative ADD construct.

d. Data being compiled by Work Group members bearing on these issues will shortly be available to provide a stronger basis for these decisions.

4. Regardless of the decision with respect to options #3a and 3b, the three cardinal dimensions of the disorder (hyperactivity, inattention, impulsivity) should be considered as domains that could be assessed dimensionally.

a. These three dimensions could also be applicable across other diagnostic categories that are commonly comorbid with DSM-IV-TR ADHD (e.g., Oppositional Defiant Disorder, Conduct Disorder, Learning Disorders; Tourette’s Disorder; Autism Spectrum Disorders). It is not clear whether it would be advantageous to have these three dimensions apply to all axis I disorders. An alternative would be to encourage such use in diagnoses that exhibit appreciable comorbidity as currently defined.

b. There is overwhelming evidence that the DSM-IV-TR A criteria yield two dimensions (inattention and hyperactivity/impulsivity) for children. One problem is that DSM-IV-TR A criteria give short shrift to impulsivity. Arguably, children are also provided fewer opportunities to make impulsive decisions with serious consequences (e.g., motor vehicle accidents, high risk sexual behaviors, substance abuse, etc.).

c. More recent data provide support for a three-dimension factor structure for adults with ADHD that includes impulsivity/impulsive decision-making.

5. There is compelling evidence for the lifespan continuity of ADHD as a disorder that begins and manifests initially in childhood and that can continue to be associated with enduring impairment. However there is also consensus that the DSM-IV-TR A criteria are inadequate for adults and older adolescents. Thus, the A criteria for adults with ADHD, and probably for adolescents with ADHD, will need to be changed, and those changes will need to be tested in field trials. The Childhood and Adolescent Disorders Work Group has suggested, among several alternatives, that DSM-V should contain sections that demonstrate how a particular criterion may manifest at different ages while still reflecting the same underlying construct. These would be called “age-related manifestations.” The ADHD workgroup will consider this as a means of maximizing the continuity of symptom descriptions across the lifespan.

a. Despite the importance of contextualizing existing criteria for age/developmental factors, impulsive decision-making is inadequately covered in DSM-IV-TR. Such impulsive decision-making appears to be associated with much of the disability associated with the diagnosis beyond childhood. [Impulsive symptoms are also inadequately assessed for children – the loss of the earlier item of ‘engages in dangerous activities’ or items such as ‘acts without thinking’ is of concern.] Additionally, since the wording of the DSM-IV-TR criteria were designed with children in mind, several of the criteria apply poorly or not at all to adults and older adolescents. An alternative set of criteria is under consideration by the workgroup.

6. The age-of-onset (B) criterion that some symptoms causing impairment be present before age 7 years is being examined. It is important that the age-of-onset criterion be set to an age prior to the ages of greatest risk of drug abuse, mood disorders, and psychotic disorders.

7. There is strong support to eliminate the hierarchical exclusion that “the symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder.” We anticipate that having dimensional measures of hyperactivity, impulsivity and inattention will facilitate assessing and communicating the extent to which such difficulties represent an additional burden in comorbid conditions (in which full criteria are met for both disorders) as well as subthreshold types of comorbidity.

8. The work group will also be discussing the requirement that symptoms be present for at least 6 months, as opposed to 12 months.

9. Although the possibility of adopting Hyperkinetic Conduct Disorder as a way of ‘carving’ off ADD from ADHD+CD was examined, the current thinking is to maintain the disorders as independent but associated diagnoses.

10. The Work Group has conducted or commissioned a number of literature reviews and secondary analyses. These will be compiled to be made readily available to all Work Group members and liaisons.
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  #2  
Old 07-09-09, 04:28 AM
KDLMaj KDLMaj is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

Thoughts:

It's no surprise that the largest item of the report focuses on the subtyping of ADHD (Item 3). The subtypes have been a HUGE problem with the diagnosis for years now- giving many false positives and many false negatives in various groups. Many folks expected to see an elimination of the ADHD-I diagnosis entirely, which it appears as though the committee is considering. But, 3b and 3c make it clear that the possibility still exists for two separate diagnostic subcategories (oddly, this is despite the previous claim that ADHD-I isn't supported by evidence). At the end of the day, it really will depend on the research data (as they say). But I expect we're going to see an end to both ADHD-H/ADHD-I as well as the ADD/ADHD distinction with the new DSM.

Probably the most interesting (and heartening) part of the entire report is the committee's obvious concern with the underemphasis of impulsivity. Now, instead of it being lumped together with hyperactivity, we're going to be seeing a 3 axis set of diagnostic criteria- reflecting that inattention, impulsivity, and hyperactivity are all completely distinct fields. And their emphasis on age-appropriate manifestations really reflects the fact that ADHD is a consistent disorder with changing presentation. Adults should no longer be regarded with skepticism for lacking overt hyperactivity, and their impulsive behavior will get more recognition as potentially indicative of the disorder. Good news.

Sadly, it looks as though sleep criteria aren't likely to make this round of changes either. They were discussed in the pre-DSMIV plans, but ultimately they were dropped. Maybe we'll see it in the age-appropriate manifestations info (assuming that goes through- which it likely will) since it becomes more common as we get older- up to 70% in the 30s and 40s.
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  #3  
Old 07-09-09, 11:30 AM
Dizfriz Dizfriz is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

KDLMaj

Thanks for reporting this. It is coming along pretty much along the general guidelines I expected. Not really a surprise since Russell Barkley a member of the group.

Thanks for noting the sleep disorder issue. Since I mostly dealt with kids, I was only vaguely aware of the impact on adults. I did some research this morning- Good information.

Dizfriz
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Old 07-09-09, 12:18 PM
KDLMaj KDLMaj is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

Quote:
Originally Posted by Dizfriz View Post
KDLMaj

Thanks for reporting this. It is coming along pretty much along the general guidelines I expected. Not really a surprise since Russell Barkley a member of the group.

Thanks for noting the sleep disorder issue. Since I mostly dealt with kids, I was only vaguely aware of the impact on adults. I did some research this morning- Good information.

Dizfriz
Yeah, I think Barkley being on the committee has made a big difference in the conception of ADHD. I'm guessing that the impulsivity list is going to be based on his EF list. There's a really interesting paper he wrote in 2006ish outlining the symptoms he and his colleagues found to be the most indicative of ADHD (and which best distinguished ADHD from controls), it was after that massive study of adults with ADHD (I forget which University it was at). I wish I had the link, the criteria were all the things we know adults deal with but that don't show up on the DSM.

I'm sort of a Barkley groupie, I have to admit. Dude knows his stuff.
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Old 07-09-09, 12:44 PM
Dizfriz Dizfriz is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

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Originally Posted by KDLMaj View Post
Yeah, I think Barkley being on the committee has made a big difference in the conception of ADHD. I'm guessing that the impulsivity list is going to be based on his EF list. There's a really interesting paper he wrote in 2006ish outlining the symptoms he and his colleagues found to be the most indicative of ADHD (and which best distinguished ADHD from controls), it was after that massive study of adults with ADHD (I forget which University it was at). I wish I had the link, the criteria were all the things we know adults deal with but that don't show up on the DSM.

I'm sort of a Barkley groupie, I have to admit. Dude knows his stuff.
Somewhere I have a PowerPoint slide (2006) on the adult criteria he was proposing. It disappeared on a move and I wish I could find it. If it do, I will post it.

I am a Barkley fan also mainly because the research backs him up quite well and his theory is very useful in dealing with ADHD.

McTavish23 and myself post a lot trying to give good reliable information on the disorder. He is also a big Barkley fan and is quite knowledgeable.

I feel that good information is the prime key for dealing with ADHD and maybe we (along with others) can keep the information flowing.

I have been quite busy lately and really do not have much time to post but I have read some of your writing. You do good work here and you are having an impact.


Dizfriz
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Old 07-09-09, 01:01 PM
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Lunacie Lunacie is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

Let me see if I have this right... they're talking about making ADHD a spectrum diagnosis (similar to Autistim diagnosis), yes? I've been thinking for about a year that it would make more sense to do that.

I'm glad to hear they are making a distinction between hyperactivity and impulsivity - although there is still a lack of awareness that hyperactivity can manifest in -quieter- ways such as hair twirling and fidgeting as well as getting up and moving around or being loud. Impulsivity is a big marker in my (limited) experience with things like answering a question before it's finished, or interrupting constantly, for instance.

I am disappointed they aren't looking into the sleep part of the disorder though. This has been a big problem for my granddaughter ever since she started school 7 years ago. Melatonin supplements are helpful.
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Old 07-09-09, 01:46 PM
KDLMaj KDLMaj is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

Quote:
Originally Posted by Dizfriz View Post
Somewhere I have a PowerPoint slide (2006) on the adult criteria he was proposing. It disappeared on a move and I wish I could find it. If it do, I will post it.

I am a Barkley fan also mainly because the research backs him up quite well and his theory is very useful in dealing with ADHD.

McTavish23 and myself post a lot trying to give good reliable information on the disorder. He is also a big Barkley fan and is quite knowledgeable.

I feel that good information is the prime key for dealing with ADHD and maybe we (along with others) can keep the information flowing.

I have been quite busy lately and really do not have much time to post but I have read some of your writing. You do good work here and you are having an impact.


Dizfriz
Thank you sir, you as well of course. It's definitely an exciting time for ADHD- thanks for the work of folks like Barkley we're really starting to get a handle on what exactly is making life so hard for the ADHD folk. Maybe one day we'll get medication that gives more than just a 50% (if you're lucky) symptom reduction. *cough*
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Old 07-09-09, 01:52 PM
KDLMaj KDLMaj is offline
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Re: April 09 Report of the DSM-V ADHD Working Group

Quote:
Originally Posted by Lunacie View Post
Let me see if I have this right... they're talking about making ADHD a spectrum diagnosis (similar to Autistim diagnosis), yes? I've been thinking for about a year that it would make more sense to do that.

I'm glad to hear they are making a distinction between hyperactivity and impulsivity - although there is still a lack of awareness that hyperactivity can manifest in -quieter- ways such as hair twirling and fidgeting as well as getting up and moving around or being loud. Impulsivity is a big marker in my (limited) experience with things like answering a question before it's finished, or interrupting constantly, for instance.

I am disappointed they aren't looking into the sleep part of the disorder though. This has been a big problem for my granddaughter ever since she started school 7 years ago. Melatonin supplements are helpful.
I don't think they're so much going for a spectrum diagnosis as they're trying to recognize the importance of impulsivity as a core feature of the disorder and to create a set of diagnostic criteria that reflect the changing presentation of the disorder over a lifespan. Given all of the "concern" (read: panic) over the imprecise nature of the diagnostic criteria, a spectrum style diagnosis isn't likely. There's a move away from that kind of approach these days- DSMV is looking to eliminate schizophrenia subtyping (and schizoaffective disorder), for example.
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Old 07-24-09, 11:41 AM
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Re: April 09 Report of the DSM-V ADHD Working Group

Impulsiveness / thrill seeking has been the number one problem in my life for 50 years. This component of ADHD is the most destructive because it feeds on itself.

The thrills need to be upped or frequency increased just like drugs in order to get "high".

When ADHD people get together, the limits can go off the chart into criminal behavior.

I remember the worst times were when I was around an "enabler". This is the passive person that spots my ADHD and dares or encourages me to take it to the next level for mutual thrill.

The enabler always escapes detection (and arrest), leaving the ADHD person to take the rap because the ADHD person is not paying attention to getting caught.

Thank goodness I finally found a good woman that has the patience to anchor me. If not for my wife, I would probably be dead or in prison or a druggie.

Also, they should look at smoking and fingernail biting as diagnostic criteria. I have done both nearly all my life and can't give them up even with Vyvanse/Dex. But I gave up beer and benzodiazapines right away when starting meds.
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