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Future Directions Diagnostic ADHD Criteria 1
Attention-Deficit Hyperactivity Disorder Significance Attention-Deficit Hyperactivity Disorder (ADHD) refers to developmentally inappropriate levels of attention most frequently diagnosed in childhood. Its primary symptomatic manifestation consists of inattention, impulsivity, and hyperactivity. ADHD is one of the most commonly diagnosed mental disorders in children; prevalence rates in childhood are 4% - 8.7% (Planczyk, Delima, Horta, Biederman, & Rohde 2007; Faraone, Sergeant, Gillberg & Biederman 2003; Froehlich TE, Lanphear BP, Epstein JN, Barbaresi WJ, Katusic SK & Kahn RS 2007). Although much attention has primarily focused on ADHD in childhood, current studies indicate that ADHD symptoms may decline with age however, frequently persists throughout adolescence and into adulthood. In many cases, core symptoms persist in 50-80% of adolescents and in 30-50% of adults, resulting in long term social disorders, lower SES, and higher academic dropout rates (Fischer, Barkley, Edelbrock & Smallish, 1990; Mannuzza & Klien, 1991; Mannuzza, Klien, Bessler & Malloy, 1993). ADHD is considered highly heritable with a mean heritability rate of 22-75% (Barkley, 2008; Faraone et al. 2005) and the remaining variance explained by environmental factors. ADHD frequently cooccurs with other disorders such as anxiety 27-30% (Biederman, Newcorn, & Sprinch 1991) depression 9-32% (Biederman et al., 1991) and oppositional defiant disorder 45-84% (Barkley, DuPaul, & McMurray, 1990; Barkley & Biederman, 1997). Co-morbid disorders are estimated to range between 60-100% (Gillberg et al. 2004) and these disorders frequently continue into adulthood (Biederman 2004; Kessler et al. 2006). Social Implications Individuals with ADHD frequently have significant social impairment in family relationships and peer relationships in academic and employment settings. A meta- analysis revealed that parents of children with ADHD both Hyperactive-Impulsive and Inattentive subtypes have significantly more stress than parents of children without ADHD (Theule, Wiener, Tannock and Jenkins 2010). Increased parenting challenges can result from difficulty managing hyperactive and non-compliance behaviors (Gadow & Nolan 2002) which results in greater family conflict and impaired family relationships (Escobar R., Soutullo C.A., Hervas et al., 2005; Schreyer I., Hampel P., 2009). Additionally, parents of children with ADHD tend to be more negative and directive and less rewarding perhaps, in response to the defiant and demanding requirements that a child with ADHD may place on them (Danforth, Barkely, & Stokes, 1991; DuPaul, McGoey, Eckert, & VanBrakle, 2001; Gomez & Sanson, 1994; Johnston & Mash, 2001). These negative interactions can begin in preschool (Cunningham & Boyle, 2002; DuPaul et al.,2001) and may even increase during adolescents due to an increase in behavior problems (Lifford K.J., Harold G.T., Thapar A., 2007). Significantly greater conflicts are also apparent in sibling relationships although, there is limited research (Mikami A. Y., 2008). Peer relationships in children and adults with ADHD are also negatively affected. A study by Pelham and Bender (1982) reported more than 50% of children diagnosed with ADHD have significant difficulties with peer relationships. Another review suggested that as
Future Directions Diagnostic ADHD Criteria
many as 52% of children with ADHD are rejected by their peers (Hoza 2007 find article). One study found the most popular peer groups were more likely to report ADHD children as none friends (Hoza 2005). Symptoms of ADHD such as, impulsivity and aggression can predict peer rejection (Erhardt & Hinshaw 1994; Whalen & Henker, 1992; Miller-Johnson, Coie, MaumaryGremaud & Bierman, 2001). Symptoms of ADHD can affect several factors that impair relationships such as; poor social skills, aggression, anti-social behaviors as well as an inability to understand social cues which may lead to socially inappropriate responses (Murray-Close, Hoza, Hinshaw, Arnold, Swanson, Jensen, Hectman & Wells, 2010). Scant research exists regarding peer relationships in the ADHD college populations and existing results are mixed. Overall, the research indicates that college students with ADHD have significantly more difficulty with peer relationships compared to their non-diagnosed counterparts (Grenwald, Mayes 2002; Weyandt, DuPaul; Blas, Gilbert, Anastopoulos, Costello, Swartzwelder, RabinerYEAR?). They also have difficulty with social and emotional adjustment (Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005). After college social abilities continue to be impaired and affect various relationships including; dating, marriage, and parenting ability (Barkley, 2008). Previous studies did not indicate that the ADHD group had higher divorce rates than the control groups however; the ADHD group endorsed significantly higher rates of marital dissatisfaction compared to their non-diagnosed peers (Minde et. al., 2003; Murphy et al., 2002; Barkley, 2008). The adult ADHD group also reported higher rates of parenting stress than the control group (Barkley, 2008). Academic Difficulty Students diagnosed with ADHD frequently struggle with academic underachievement (Merrell& Tymmons, 2001; Murphy, Barkley, & Bush, 2002). In fact, it is estimated that as many as 30% of children diagnosed with ADHD underachieve given their predicted ability, based on age or IQ (Frick & Lahey, 1991; Kamphaus & Frick, 1996).This population may contend with a higher incidence of failing grades, higher retention rates (Fergusson & Horwood, 1995; Fergusson, Lynskey, & Horwood, 1997), lower scores on standardized assessments and a higher occurrence of learning disabilities (Abikoff,Courtney, Szeibel, & Koplewicz, 1996; Carlson & Tamm, 2000; Carter, Krener, Chaderjian, Northcutt, & Wolfe, 1995; Frankenberger & Cannon, 1999; Gaub & Carlson, 1997; Halperin et al., 1993; Hoza, Pelham, Dobbs, Owens, & Pillow, 2002: Lahey et al., 1998; Purvis & Tannock, 1997, 2000; Seidman, Biederman, Stephan, et al., 1997; Semrud- Clikeman, Guy, Griffin, & Hynd, 2000; Semrud-Clikeman, Steingard, et al., 2000; Tannock, Martinussen, & Frijters, 2000; Zametkin, Liebenauer, & Fitzgerald,1993). Additionally, students diagnosed with ADHD may have higher absenteeism, retention rates and drop out of school more frequently when compared to their non-diagnosed peers (Barnares, katusic, collegar, weaver, Jacobson 2007). Common academic difficulties include reading, writing, and math underachievement and these difficulties increase incrementally with an increase in symptoms of ADHD (Barry, Lyman, & Klinger 2002). A study of 2,844 children aged 6-12 found academic improvement for children that endorsed subtype symptoms and negative results for 497 children that where classified as NOS (Barnard, Stevens T., To Y.M. Lan W.Y., Mulsow, M., 2011). After graduating High School those with
ADHD are less likely to attend college compared to their non-diagnosed peers (DuPaul, Weyandt 2009). Approximately 2-8% of college students endorse ADHD symptoms (Weyandt, DuPaul, o Dell, & Varejao, 2009; Weyandt & DuPaul, 2006). College students diagnosed with ADHD may have greater compensatory skills, and achieve greater academic success compared with their ADHD peers that have not pursued a secondary education (Gutting, Younstrom & Watkins 2005). However, studies demonstrate that students who endorse symptoms of ADHD continue to have academic difficulty in the University setting (add a source). Possible contributing factors that lead to academic difficulty in college may include lack of structure, less family support, continually changing schedules, and social distractions (Add a source). College students with ADHD typically have issues with inattention, time management, planning, time management, organization and planning for the future (Barkley 2010) A study by Reaser, Prevatt, Petscher, & Proctor (2007) revealed that college students diagnosed with ADHD endorsed significantly more difficulty with time management, concentration, selecting main ideas, and test taking strategies on the Learning and Study Strategies Inventory (LASSI; Weinstein & Palmer, 2002) when compared to other college students diagnosed with LD and a non-diagnosed group. In another study conducted by Norwalk, Norvilitis, & Maclean (2008) also revealed that, study skills, and study habits were negatively correlated with ADHD symptoms. Maybe beef this up a little bit and add some sources. Academic under achievement is still apparent despite the use of stimulant medication and college accomodations (Advokat, Lane, & Luo., 2011). However, significant academic improvement can be made if the ADHD student develops their study and organizational skills.(Advokat et al, 2011). Wilmshurst et al (2011) suggests that a protective factor that may contribute to academic success in college is positive family support. Driving Impairment Adults diagnosed with ADHD have impaired diving abilities. Driving difficulties includes an increased involvement in auto accidents, traffic violations, speeding violations, license suspension and revocations (Horwood, 2000; Barkely, DuPaul, & Bush 2002) all of which seem to occur more frequently in the primarily hyperactive group (Barkely, Murphy, Fischer 2008) and age is a contributing factor. Furthermore, when involved in an automobile accident the accident tends to be more severe and they tend to be at fault (Barkley, Murphy, Fisher, 2008). Additionally the ADHD group experiences a significant increase in road rage and overall aggression, compared to their non-diagnosed counterparts (Richards, Deffenbacher, Rosen, Barkley, & Rodricks, 2006). Despite these alarming driving impairments the ADHD group tends to view themselves as being good drivers (Knouse, Bagwell, Barkley, & Murphy, 2005). Employment Challenges In the workforce those diagnosed with ADHD must overcome several challenges such as; being on-time, meeting deadlines, organizational problems, misplaced items, scheduling and prioritizing challenges, and poor communication (source). Employers frequently describe their work performance more negatively than their non-diagnosed co-workers (Murphy, Barkley 1996). A study by Barkley, Murphy and Fischer (2008) used a sample of 146 adults diagnosed with ADHD and investigated occupational differences between the ADHD group and a group diagnosed with other clinical disorders and a non-diagnosed control group. In this study the authors gained occupational information from two sources; self-report and their employer (who was blind to the diagnosis). The study yielded the following results from the ADHD clients:
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overall lower occupational functioning, difficulties in more jobs, more challenges getting along with others in the work place, behavior issues, fired more frequently, quite more frequently due to boredom. The ADHD work supervisors stated they have more symptoms of inattention, more impairment performing assigned work, more difficulty pursing educational opportunities, difficulty being on-time, use poor time management, difficulty managing daily tasks compared to the clinically referred group and the control group. Another study by Painter, Prevatt and Welles (2008) investigated occupational beliefs using a Career Thoughts Inventory (CTI; Sampson, Peterson, Lenz, Reardon & Saunders 1996) and the Minnesota Satisfaction Questionnaire MSQ; Weiss, Dawis, England & Lofquist, 1967). These self ratings indicated that ADHD symptoms significantly predicted dysfunctional career beliefs, career decision making confusion, commitment to career anxiety, and external career decision making conflict. Another investigation of 165 college students diagnosed with ADHD revealed that they had significant occupational impairment compared to their non-diagnosed peers (Shifrin, Proctor, Prevatt, 2010). Gender (Malley, 2000) reported it appears that girls are less susceptible to developing ADHD-C when compared to boys they typically will experience a greater familial psychopathology. This may explain the variance in girls vs. boys diagnosed with ADHD. Etiological factors may differ for girls and boys with ADHD (Guab & Carlson, 1997; Gershon, 2002) In girls the two subtypes may share neuropsychological risk, and family context may determine which ADHD subtype develops for at risks girls (Counts et al., 2005). Etiology of ADHD The clinical heterogeneity of ADHD leads to complex etiology with multiple pathways including genetic, biological, neurological and environmental factors. It has been difficult for research to establish precise causes for ADHD in part due to the natural heterogeneity of the disorder however, due to the growing amount of research that has been conducted broad commonalities have been suggested. Most research is in agreement that the leading cause of ADHD is genetic and neurological in nature (Barkley, 2008). Beef this section up look at other articles and add my section on executive functioning Heritability Heritability is estimated to be approximately 70- 80% (Gjone, Stevenson, Sundet 1996, Hudziak, Rudiger, Neale, Heath, Todd 2000; Rietveld, Hudziak, Bartels, Beijsterveldt, Boomsma; 2003; Biederman, & Faraone, 2002). A UCLA examination of parents whose children were diagnosed with ADHD revealed that 55% had at least one parent that also was affected by the disorder (). As many as 20 twin studies have been conducted to investigate the genetic components, estimates range from 60-100% with a mean range of 76% (Faraone et al. 2005; Harberstick et al. 2008; Heiser et al. 2006; McLoughlin et al. 2007; Schultz et al. 2006). Genes that regulate the neurotransmitter system are implicated in ADHD. Genome studies have indicated alleles that are linked on specific chromosomes (Curatolo, D Agati, Moavero 2010) however, in a recent meta-analysis of genome- wide study they were unable to obtain significant associations of common ADHD genetic variants (Neale et al. 2010). These results indicate that further research is needed in this area. Neuropsychological Findings
The neurological regions most commonly impaired in those with ADHD include areas that are associated with; processing speed, response variability, and executive functioning including working memory, response inhibition, and future planning (Barkley, 1997, Nigg, 2001, Nigg, 2006, Pennington , 2002, Penningtion Ozonoff, 1996, Willcutt et al, 2005, Willcutt et al., 2008). Imaging studies indicate that these impairments may be due to neurological dysfunctions and also neurochemical abnormalities (Nigg, 2006; Curtatolo, 2005; Suskauer et al, 2008). Neuroimaging studies have revealed a decrease in cortical volume by approximately 3 % () and atrophy of the prefrontal cortex, striatum () and cerebellar vermis (). The prefrontal cortex requires a significant amount of dopamine and it is the region identified with executive functioning (Antshel, Hargrave, Siminescu, Kaul, Hendricks & Faraone, 2011). Current biological research is investigating the dopaminergic and norepinephrine system. A recent study by Volkow et al (2010) demonstrates an impaired dopamine reward pathway (Volkow et al. 2010). Volkow et al. (2010) suggests that this hypofunctional reward pathway could explain why motivation and delayed gratification (inhibition) are difficult for this population. Environmental While there is no evidence to support social factors as a cause of ADHD poor social support may influence severity as well as possible co-morbid diagnosis ( ). Twin studies suggest that environment does play a role in the development of ADHD. Non-shared environments are a small but significant contributor while shared environments have proven to provide a negligible contribution to the development of ADHD (Levy et al. 2006; Nikolas, Burt 2010). Some environmental factors that may contribute to ADHD symptomology include: maternal smoking, alcohol consumption, and drug use (Bierderman, Faraone, Sayer, & Kleinman, 2002). Additional environmental contributing factors include: low birth weight, minor brain hemorrhaging, some anticonvulsant medication, elevated amounts of lead during ages 2-3 (Hartsough & Lanbert, 1985; Nichold & Chin, 1981; Sharp et. al., 2003). Environmental influences related to illness such as encephalitis and influenza have been suggested in much earlier accounts of ADHD symptoms. Origins of ADHD Sir Alexander Crichton 1763-1856. Frequently historical investigations of ADHD begin in the 18th century with the work of George Still. However, a more intricate survey of ADHD history reveals an earlier description in the work of Sir Alexander Crichton. Born in 1763 he earned his degree in medicine from the University of Leyden located in the Netherlands in 1785 (Tansey, 1984; Palmer, & Finger, 2001). Crichton studied mental issues by using a physiological and biological perspective which was uncommon in his time (Palmer, & Finger, 2001). He wrote a book on Mental Derangement entitled: An Inquiry into the nature and origin of Mental Derangement Comprehending a Concise System of the Physiology and Pathology of the Human Mind and the History of the Passions and Their Effects . The Inquiry of 1798 is divided into three sections. The book contains many of his clinical cases from which he studied attention, memory, language among other functions which brought him much notoriety (Palmer & Finger, 2001). In book two the chapter entitled On Attention and Disease Crichton describes his view of attention:
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The incapacity of attending with a necessary degree of constancy to any one object, it almost only arises from an unnatural or morbid sensibility of the nerves, by which means this faculty is incessantly withdrawn from one impression to another. It may be either born with a person, or it may be the effect of accidental diseases. When born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate it is generally diminished with age. (Crichton, 1798, reprint p. 271) Later in this same chapter he continues to describe this disorder as easily distracted, mental restlessness and having the fidgets . Crichton claims this disorder of attention may be caused from physical conditions, including diseases, brain tumors, head injury, poor diet, and epilepsy (Palmer & Finger, 2001). While his work is not commonly recognized, it is apparent that there are similarities between his description and current symptoms of ADHD. Heinrich Hoffman 1809-1894. Heinrich Hoffman a physician from Germany born in Frankfurt/Main in 1809. He became a general practitioner and obstetrician in 1835 and in 1851 he founded the first mental hospital in Frankfurt (Bilgin, Remi, & Noachtar, 2008). During his time psychiatric patients were commonly viewed as criminal or possessed. However, Hoffman viewed patients with mental disorders as suffering from medical disorders (Thome & Jacobs, 2004) and he became known for improving the conditions for psychiatric patients (Thome & Jacobs, 2004). Hoffman gained a much notoriety for writing a children s storybook entitled, Strewwelpeter that was based on his clinical experience with patients (Hobrecker, 1933). Two stories in particular have frequently been thought to depict aspects of ADHD, Struwwelpeter which features a character called Fidgety Phil and another called, Johnny Look in the Air (Hoffman, 1846). An illustration of Fidgety Phil shows a boy sitting at a dinner table that later due to his inability to sit still and listen to his father is show sprawled across the floor with all of the table s contents colorfully strewn along side of him (Hoffman, 1846). Additionally, Johnny Look in the Air is a character described as being distracted so much by external stimuli that he fails to watch where he is going and the trouble ensues (Hoffman, 1846). The story of Fidgety Phil has frequently been considered an allegory for ADHD (Klaus et al., 2010). George Still 1902. George Still s defective moral control has typically marked the beginning of the history of ADHD. Still s historic lectures where published in The Lancet entitled: Some Abnormal Psychical Conditions in Children . George Still was born in London in 1868. He was the first professor of pediatrics at King s College Hospital in London (Farrow, 2006) and has been known as The father of British pediatrics (Dunn, 2006).
Still (1902) gave three lectures to the Royal College of Physicians. These lectures where published in that same year in The Lancet under the title: Some Abnormal Psychical Conditions in Children . Still (1902 cited by Lange et al. 2010) lectures describe 43 clinical cases of children that had attention difficulties. Palmer and Finger (2001) suggest that George Still strongly linked attention with moral control. Still (1902) explained that moral control was the control of action in conformity with the idea of the good for all (p. 1008, cited by Lange et al. 2010). Still stated, The children show an insufficiency of inhibitory volition and seem to be driven by intense self-gratification . Still suggests that the reason for this may be due to some type injury or disease (Palmer & Finger 2001) therefore, suggesting a biological cause. Still explains that there is either morbid failure in development of moral control or morbid loss of already acquired moral control (Still, 1902, p. 1164, cited by Lange et al. 2010). Still stated; The keynote of these qualities is self-gratification, the immediate gratification of self without regard either to the good of others or to the larger and more remote good of the self (Still, 1902, p. 1009, cited by Lange et al. 2010). Inability to delay gratification in ADHD has been supported in more recent literature (Campbell, 1987; Rapport, Tucker, DuPaul, Merlo, & Stoner, 1986). Still described 20 of his cases; defect of moral control as a morbid manifestation without general impairment of intellect and without physical disease (Still, 1902, cited by Lange et al. 2010). Still s clinical cases also revealed gender differences in children afflicted 15 boys and 5 girls (Palmer & Finger, 2001). This ratio is consistent with current ADHD literature (Barkley, 2006). Still s clinical cases also demonstrated symptoms before the age of 8 years-old which also lines up with the current literature (Barkley & Biederman, 1997). In sum, many symptoms that Still describes are similar to the current ADHD criteria. Encephalitis Epidemic 1917 Starting in the year 1917-1928 approximately 20 million people were affected by encephalitis lethargica (Conners, 2000; Rafalovich, 2001; cited by Lange et al 2010). A number of children survived however, had mental damage (Raflovich, 2001; Cantwell, 1981; Kessler, 1980). Tredgold (1908) and others link the brain damage with behavioral and learning abnormalities. The children were described as described as hyperactive, distractible, irritable, antisocial, destructive, unruly and unmanageable in school Ross and Ross (1976) (p.15). Many of these symptoms labeled as, postencephalitic behavior disorder (Barkley, 2006) were similar to the current symptoms of ADHD. While these symptoms would not lead to a diagnosis of ADHD by current standards the link between these specific behavior and cognitive difficulties with brain damage was significant. Franz Kramer (1878-1967) and Hans Pollnow (1902-43) Two lectures given in the 1930 s entitled Hyperkinetic conditions of children and Symptoms and course of a hyperkinetic disease in children by Kramer and Pollnow was an inquisition as to whether the hyperkinetic syndrome they found in children was due to exposure to encephalitis (Neumarker, 2005). After investigating 45 cases Kramer and Pollnow
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revealed that there was not a connection between Hyperkinetic syndrome and encephalitis. The children studied were between the ages of 2-6 years (Neumarker, 2005). The symptoms they described were: Lack of concentration, insufficient goal orientation, increased distractibility, walking around aimlessly, inability to persistence, affected by external stimuli, occasional irritability, mood liability, and inclination of aggression and extreme educational difficulties (Neumarker, 2005). Charles Bradley 1902-1979 The first known treatment using stimulant medication for children was performed in 1937 by Charles Bradley. Bradley was a medical director of Emma Pendleton Bradley Home a facility that treated neurologically impaired children (Conners, 2000). Bradley s findings were by chance. Bradley was investigating brain abnormalities by using a pneumoencephalogram and found that his patients frequently suffered from severe headaches, caused from loss of spinal fluid during the procedure (Mayes & Rafalovich, 2007; Conners, 2000). In an attempt to alleviate his patient s pain he used bezedrine, a potent stimulant for the time (Mayes & Rafalovich, 2007; Conners, 2000). Unfortunately, this did not diminish the patients headaches however, behavior and school performance improved in half (30) of the children that he treated (Conners, 2000). Teachers labeled the medication arithmetic pills due to the improvement in academic performance (Conners, 2000). After ten more years of research, Bradley concluded that those most likely to respond to the medication had short attention span, dyscalcilia, mood liability, hyperactivity, impulsiveness, and poor memory (Bradley, 1950 cited by Conner, 2000). Minimal Brain Damage and Minimal Brain Dysfunction (MBD) The term brain injured child or minimum brain damage (MBD) began to be used to describe children with behavior problems regardless as to whether or not there were indications of brain injury (Struass & Lehtinen, 1947). Laufer, Denhoff & Solomons (1957) suggests that there are children whose behavioral problems are due to head injury, encephalitis, and measles however, there are others that have none of aforementioned issues. He suggests a more accurate name is, Hyperkinetic Impulse Disorder . The key feature is hyperactivity and the age of onset is five or six (Laufer et al 1957). Other characteristics Laufer et al (1957) describe are: short attention span, lack of ability to concentrate, irritability, impulsiveness, variability and poor school work. They also suggest the use of amphetamines to treat the disorder (Laufer, 1957). DSM-II (Published in 1968) Theoretical Framework The Second Addition of the Diagnostic Statistical Manual of Mental Disorders (DSM-II) was significantly more substantial than the first manual. However both emphasized psychoanalysis and lacked specific diagnosis criteria and empirical support for reliability and validity (Widiger, 2005). The DSM-II distinguished Organic Brain Syndromes from Psychoses that was not related to physical conditions and included psychotic and affective disorders (Pierre, 2010) A section entitled, Behavioral Disorders of childhood and adolescence only included 6 disorders including: Withdrawing Reaction, Overanxious Reaction, Runaway
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Reaction, Unsocialized Aggressive Reaction, Group Delinquent Reaction and Hyperkinetic Reaction of Childhood (Scotti & Morris, 2000). The category related to present day ADHD first appeared in the DSM II as is Hyperkinetic Reaction of Childhood. DSM-II Diagnositic Criteria for Hyperkinetic Reaction of childhood 308.0 Hyperkinetic reaction of childhood (or adolescence) This disorder is characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behavior usually diminishes in adolescence. If this behavior is caused by organic brain damage, it should be diagnosed under the appropriate nonpsychotic organic brain syndrome (DSM-II; American Psychiatric Association, 1968; p. 50). Critics of the DSM-II accused psychiatrists of being moral policemen (Blashfield, 1998) and expressed that it is reliant on societal norms (Jewell, Hupp, & Pomerantz, 2007).
An average interrater agreement was calculated for each classification system. For DSM-II, it was 57%, with a range of 20% to 95%. For axis I of DSM-III, it was 54%, with a range of 20% to 100%. Used 24 cases.
DSM-III (Published in 1980). Empirically Framework The third revised version of the diagnostic manual was developed during a time when the legitimacy of psychiatry was being challenged for failure to delineate between mentally well
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and mentally ill (Wilson, 1993). The DSM-III was a significantly enhanced from the previous DSM-II in both size and scope and was considered a reframing of the biopsychosocial model (Wilson, 1993). The DSM-III followed a research-based medical model (Wilson, 1993) and therefore, empirically based research was used to develop thresholds and criteria for diagnosis. Empirical information was ascertained from 800 clinicians that conducted various field trials and also a two-year NIMH project that cumulated information gathered from 400 clinicians from 120 clinics. The DSM-III used more detailed descriptions for the criteria of diagnosing and categorizing. ). It contained the first multi-axis system which included: Axis I clinical disorders, Axis II developmental and personality disorders, Axis III relevant medical conditions, Axis IV relative psychosocial and environmental factors, Axis V Global Assessment Functioning (GAF) on a scale of 0-100. The use of a multi-axis system and data gained from research lead to a more comprehensive criterion for diagnosing all disorders including ADD, compared to the DSM-II. The criterion for ADD was also more comprehensive in the DSM-III. It included: clearly defined symptoms, specific number of symptoms, age of onset, as well as exclusion criteria. In the DSM-III Hyperkinetic reaction of childhood was changed to Attention Deficit Disorder (ADD) with and without hyperactivity, emphasizing the attention component of ADHD (Rothenberger & Neumarker, 2005; Barkely, 2006). Douglas (1972) concurred that the focus should be attention and also impulse control (Douglas, 1984; Barkley, 2006). The emphasis on attention and impulse control was a clear departure from the World Health Organization which continued to emphasize the hyperactivity on the ICD-9. The creation of subtypes was considered premature since there was not adequate research to support their existence (Barkley, book). However, a great deal of research was underway but not completed in time for the revised DSM-III, the DSM-III-R. The DSM-III guidelines also helped to ensure more consistency in diagnoses. Table 1.1 DSM-III Diagnostic Criteria for Attention Deficit Disorder with and without Hyperactivity The child displays, for his or her mental and chronological age, signs of developmentally inappropriate inattention, impulsivity, and hyperactivity. The signs must be reported by adults in the child s environment, such as parents and teachers. Because the symptoms are typically variable, they may not be observed by the clinician. When the reports of teachers and parents conflict, primary consideration should be given to the teacher reports because of greater familiarity with age-appropriate norms. Symptoms typically worsen in situations that require self-application such as in the classroom. Signs of the disorder may be absent when the child is in a new or one-on-one situation.
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The number of symptoms specified is for children between the ages eight and ten the peak age for referral. In younger children, more severe forms of the symptoms and a greater number of symptoms are usually present. The opposite is true of older children. A. Inattention. At least three of the following: (1) Often fails to finish things he or she starts (2) Often doesn t seem to listen (3) Easily distracted (4) Has difficulty concentrating on schoolwork or other tasks requiring sustained attention (5) Has difficulty sticking to a play activity B. Impulsivity. At least three of the following: (1) Often acts before thinking (2) Shifts excessively from one activity to another (3) Has difficulty organizing work (this not being due to cognitive impairment) (4) Needs a lot of supervision (5) Frequently calls out in class (6) Has difficulty waiting turn in games or group situations C. Hyperactivity. At least two of the following (1) Runs about or climbs on things excessively (2) Has difficulty sitting still or fidgets excessively (3) Has difficulty staying seated (4) Moves about excessively during sleep (5) Is always on the go or acts if driven by a motor D. Onset before age seven E. Duration at least six months F. Not due to Schizophrenia, affective disorder, or Severe or Profound Mental Retardation Note. The criteria above are for Attention Deficit Disorder with Hyperactivity. All of the features of Attention Deficit Disorder without Hyperactivity are the same except for the absence of hyperactivity (criterion C). From American Psychiatric Association (1980). The DSM-III-R The DSM-III was revised in 1987 (DSM-III-R). A committee meeting decided that more research was needed in order to understand the utility and validity of subtyping (American Psychiatric Association, 1987). Therefore, the previous three dimensional categories were changed to a single, uni-dimensional category, attention-deficit/hyperactivity disorder (ADHD). The requirement for diagnosis is endorsement of 8 of the total 14 symptoms listed. The list of symptoms had a single cut off score instead of the three separate lists in the DSM-III.
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Additionally, a new category named: undifferentiated ADD was included (American Psychiatric Association 1987, p. 95). No diagnostic criteria was included for undifferentiated ADD, which lead to confusion and potential inconsistencies regarding how to classify children that lacked symptoms of hyperactivity (lahey et al., 1990). Research done by Schachar, Rutter, & Smith (1981) investigated pervasiveness of symptoms and found that pervasive hyperactivity was strongly related to behavioral disturbances and situational hyperactivity was not as strongly related. The results of this study influenced an addition in the DSM-III-R criteria for ADHD to include measures of severity (Barkely, 2006). In 1985 a field trial was conducted to investigate the internal consistency of using the following three items for diagnosis: inattention, impulsivity, and hyperactivity. The field trial also investigated the number of symptoms needed for diagnosis. The symptoms and criteria used for the DSM-III-R were considered to have internal consistency, specificity and high sensitivity (Spitzer, Davies, Barkley, 1990). Critiques of the DSM-III-R suggested that there was no empirical support: to justify using same cut-off scores for all ages or the age of onset, and duration. There was also little research that supported sufficient interrater reliability (Pendergrast et al., 1988). Existing research suggested the parent teacher ratings were significantly different (Edelbrock & Costello, 1988) which lead to variations in diagnosis. Another area of concern regarding diagnosis was the possibility of overdiagnosis due to >>>..a solution was to increase the threshold and/or require symptoms to be apparent in multiple settings( Table 1.2 DSM-III-R Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder A. disturbance of at least six months during which at least eight of the following are present (1) Often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness) (2) Has difficulty remaining seated when required to do so (3) Is easily distracted by extraneous stimuli (4) Has difficulty awaiting turn in games or group situations (5) Often blurts out answers to questions before they have been completed (6) Has difficulty following through on instructions from others (not due to oppositional behavior or failure to comprehend), E.G., fails to finish chores (7) Has difficulty sustaining attention in tasks or play activities (8) Often shifts from one uncompleted activity to another (9) Has difficulty playing quietly (10) Often talks excessively (11) Often interrupts or intrudes on others, e.g. butts into other children s games
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(12) Often does not seem to listen to what is being said to him or her (13) Often loses things necessary for tasks or activities at school or home (e.g., toys, pencils, books, assignments) (14) Often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill seeking, e.g., runs into the street without looking) Note: the above items are listed in descending order of discriminating power based on the data from a national field trial of the DSM-III-R criteria for Disruptive Behavior Disorders. B. Onset before age seven. C. Does not meet the criteria for Pervasive Developmental Disorder. Criteria for severity of Attention-Deficit Hyperactivity Disorder: Mild: Few if any symptoms in excess of those required to make the diagnosis and only minimal or no impairment in school or social functioning. Moderate: symptoms or functional impairment intermediate between mild and severe. Severe: Many symptoms in excess of those required to make the diagnosis and pervasive impairment in functioning at home and school and with peers. Note: From American Psychiatric Association (1987). Copied the DSM III-R DSM-IV (Published in 1994) Diagnostic and Statistical Manual The DSM-IV had some minor text revisions and was renamed the DSM-IV-TR. Since they are basically identical in this paper they will be referred to as the DSM-IV. This version of the DSM took 5 years and over 1,000 people to create (APA, 1994). The amount of disorders listed in the first DSM was 106. The DSM-IV contains descriptions of 357 disorders. Multiple tasks forces were created to focus on specific psychopathologies (Jewell, Hupp, Pomerantz, 2009). Three processes were used to ensure the quality of the DSM-IV which included: conducting literature reviews and field trials and analyzing data sets. The DSM-IV criteria for ADHD utilized a committee of experts in the field of ADHD to conduct literature reviews, field trials and analyze data sets. The criterion developed to diagnose ADHD was considered empirically superior to the criteria in previous diagnostic manuals. While the DSM-III was three dimensional the DSM-III-R was changed to onedimensional which sparked an increase in research. Research used to (one article stated that the dsm expaned to included adults in the 1990 s (Conrad, Potter 2000) (from the DSM-IV source book) Volume 1 Thomas widifer, APa task force on DSM-IV Six issues that were investigated when designing the DSM-IV
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+ when the symptoms in the DSM-III-R were collapsed major criticisms arose which included: 1. It decreased the emphases on impairment in multiple areas 2. It does not correspond with empirical support for two-three clusters of ADHD that seem to exist 3. The term undifferentiated diagnosis is non specific in its criteria and therefore it is possible to have a diagnosis in the category and have more symptoms of hyperactivity than another a child that did receive a dx of ADHD. 4. Identifying 8 symptoms from one list could result in a great deal of heterogeneity among cases. (it would be possible for 2 children with the same dx to only have 2 symptoms in common) 5. Environmental specification 6. Exclusion criteria Symptoms cutoff by age: Research demonstrated that using a cutoff of 6 symptoms still resulted in a severity that was 2 std above the norm in adolescents (Pelham et al., 1992). Another question that was considered in the ---when designing the DSM-Iv was regarding the environmental setting (should they require both school and home symptoms) One study that was used to help decide the answer to this question was a study that showed a 90% predictive power of parent reports for teacher based dx(Biederman et al 1990). (however, this was only one study that had a high number of dx)B (Low concordance rates between parent and teacher reports (Achenbach et al., 1987) Several studies indicated that children also meet the DSM-III criteria for ADD/WO (Berry et al, 1985;Carson C.L., Alverez C. T., Needelman 1989; Conte et al. 1986;Edelbrock et al.,1984; Famularo & Fenton 19887; Frank and Ben-Nun 1988; Frick et al.1991; Hynd et al, 1989; Lahey 1987; Maurer & Stewart 1980) In addition factor analytic and cluster-analytic studies of ADD ?
Lahey et al., conducted a study to determine the optimal threshold for diagnosing ADHD. The sample consisted of 380 children ages 4-17
DSM-IV Field Trials for the Disruptive Behavior Disorders: Symptom Utility Estimates 14
PAUL J. FRICK Ph.D.
, BENJAMIN B. LAHEY Ph.D., BROOKS APPLEGATE Ph.D., LYNN
KERDYCK Ph.D., THOMAS OLLENDICK Ph.D., GEORGE W. HYND Ed.D., BARRY GARFINKEL M.D., LAURENCE GREENHILL M.D., JOSEPH BIEDERMAN M.D., RUSSELL A. BARKLEY Ph.D., KEITH McBURNETT Ph.D., JEFFREY NEWCORN M.D., IRWIN WALDMAN Ph.D. From the University of Alabama (Dr. Frick), the University of Miami (Drs. Lahey, Applegate, and Kerdyck), Virginia Polytechnic Institute and State University (Dr. Ollendick), the University of Georgia (Dr. Hynd), the University of Minnesota School of Medicine (Dr. Garfinkel), Columbia University College of Physicians and Surgeons (Dr. Greenhill), Harvard University School of Medicine (Dr. Biederman), the University of Massachusetts Medical Center, Worcester (Dr. Barkley), the University of California at Irvine School of Medicine (Dr. McBurnett), Mt. Sinai School of Medicine (Dr. Newcorn), and Emory University (Dr. Waldman) Accepted 8 September 1993. Available online 19 November 2009. ABSTRACT Objective We tested the predictive utility of symptoms for proposed DSM-IV definitions of the disruptive behavior disorders using indices corrected for symptom and diagnosis base rates. Method
The field trials sample consisted of 440 clinic-referred youths who were consecutive referrals to a heterogeneous group of mental health clinics. Multiple informants were interviewed to determine the presence of symptoms and diagnoses. Results Some symptoms which were either not in DSM-III or DSM-III-R, or were modifications of DSM-III-R symptoms, had greater diagnostic efficiency than did several existing symptoms. Symptom utility estimates were generally similar for different ages and genders, although some interesting age and sex trends emerged for a few symptoms. Conclusions The results supported the inclusion of more restricted definitions of lying and truancy to increase their association with a conduct disorder diagnosis and they supported the elimination of swearing in the oppositional defiant disorder criteria. In addition to their relevance for developing optimal criteria for DSM-IV, these results can aid DSM-IV users by
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providing a useful guide to the relative efficiency of individual symptoms based on data from a large heterogeneous clinic population. Key Words: DSM-IV field trials; disruptive behavior disorders; symptom utility; diagnostic criteria
3&4 consisted of a factor analysis3. Lahey B.B., Carlson C.L., Frick P. J., Attention deficit disorder without hyperactivity: a review of research relevant to the DSM-IV, in DSM-IV sourcebook, vol 1. Edited by Widiger T.A., Frances A. J., Davis W. First M., Washington, D.C., American Psychiatric press (year?) 4. McBurnett K, Attention-deficit hyperactivity disorder: review of diagnositic issues for the DSM-IV committee (IBID)
Write the DSM-IV stuff and Edit the DSM-III-R

Maybe add key people in my descriptions (DSM-II, III,IV) and also maybe add controversies after each or critics?? The DSM-III was three dimensional The DSM-III-R was single dimensional In order to address the number of dimensions that were appropriate for ADHD a review of factor analysis in the existing literature was conducted 3,4, 5 3. Lahey Carlson Frick Attention Deficit Disorder without hyperactivity: a review of research relevant to DSM-IV DMS-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Lahey, Benjamin B.;Applegate, Brooks;McBurnett, Keith;Biederman, Joseph;et al The American Journal of Psychiatry, Vol 151(11), Nov 1994, 1673-1685.
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A field trial conducted by Lahey et al (1994) determined that a cut off score of six The cut of scores of six were decided after a field trial (Lahey et al. 1994). Finally there was a return to subtyping back which included: Predominantly-Inattentive, Hyperactive-Impulsive, and Combined-Type.
A study by (Lahey et al., (1994) and Sptizer et al., (1990) used a factor analysis to investigate items in parent and teacher rating scale. These items were found to have high intercorrelations, and were able to differentiate ADHD from other disorders. Additionally, after performing a factor analysis two main constructs were significant: inattention and hyperactive-impulsive Lahey et al (1994). DSM-IV A. (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities (2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is
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expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" (f) often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) A. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. B. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). C. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. D. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder). Code based on type: 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months 314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.
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Multi-Method Assessment Child/Adult Assessment of ADHD in both children and adults requires an integration of information obtained from: questionnaires, structured interviews or semi structured interviews, behavior rating scales, standardized; norm referenced assessments as well as differential diagnosis data. The questions to be answered through assessments are is a diagnosis of ADHD warranted, is there a differential diagnosis that better accounts for the client s symptoms and is there a comorbid diagnosis that should be considered? Assessment for ADHD in children will investigate multiple environments, typically including school and home. Frequently intelligence and achievement tests are administered. Intelligence tests have frequently been used in part to rule out other possible disorders in mental functioning. (Barkley, book) Additionally, some of the assessments have been considered significant measures of attention (Klee & Garfinkel, 1983). However, there is contraversey regarding t
Questionnaires 1. Behavior rating scales 2. Rating Scales that are suggested for adults include: The ADHD rating scale SelfReport (ASRS Symptoms Checklist: the Brown Attention Deficit Disorder scale for adults; Connors Adult ADHD rating Scale (CAARS) and the Wender Utah Rating Scale (WURS) Structured and Semi-structured interviews Standardized and Norm references assessments Differential diagnosis Examples of structured interviews: Parent Interview for Child Symptoms (PICS;Ickowicz et al., 2006) Behavior rating interviews: Strengths and Weaknesses of ADHD Symptoms and Normal Behavior (SWAM) (Swanson et al 2006) Impairment Scale:
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Subtypes In the DSM-IV developed in (1994) Primarily inattentive type denotes a deficit in attention while the combined type includes a deficit in the area of attention and hyperactivity-impulsivity this is referred to as the combined type (C ) (add information that can delineate the three subtypes of ADHD) Subtype differences Check this section Currently ADHD is has been divided into two dimensions; Hyperactivity and Inattentive. Based on these two dimensions three subtypes have been formed which include; Primarily Inattentive (PI), Primarily Hyperactive/Impulsive (HI) and Combined type (C). One advantage hope to be gained from forming subtypes was to create more homogeneous groups that could be researched more effectively. Research that investigates unique differences between ADHD-C and ADHD-I has shown mixed results. Recent findings have revealed there are specific genetic findings as well as shared genetic influences in ADHD-C and ADHD-I subtypes (Larsson, Lichtenstein Larsson, 2004; Nadder, Rutter, Silberg, Maers, Eaves, 2002; Nadder, Silberg, Rutter, Maes, Eaves, 2001; Willcutt, Pennington, Chhabildas, Friedman, Alexander 1999).These findings were further supported in a study by Stawicki, Nigg & Von Eye (2006). They conducted a meta-analysis investigating 335 parents divided by ADHD subtype and co-morbid disorders. Although the effects were small one process was found to be distinct for the two syndromes and the other is shared. The combined type demonstrates great difficulty with inhibitory control compared to the inattentive type (Nigg et al.2002; Hinshaw et al. 2002; Huang-Pollock et al. 2006). The inattentive type have a greater impaired ability in processing speed (Chhabildas et al. 2001;Nigg et al.2002). A study by Solanto et al (2007) suggested that primarily inattentive and combined subtypes have not revealed differences in neurological substrates and also points
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out that several studies that found differences between subtypes failed to control for IQ and/or comorbid disorders. by Stawicki, Nigg & Von Eye (2006Overall, we found partial support for a distinct subtype model of the relation between ADHD-C and ADHD-PI, but the effect was modest in magnitude, suggesting these are probably partially overlapping conditions with some notable etiological distinction between them.
Current Controversy Despite the empirical progress of the current DSM a plethora of ADHD research has unearthed a multitude flaws. The controversy surrounds the current diagnostic criteria and methodology. Since ADHD was considered a childhood disorder that abated with age the diagnostic criteria was designed for use with children not adults. Therefore, the DSM-IV field trial only included male children. The lack of developmental considerations led to temporal instability in the current diagnostic criteria. Additionally, the current literature shows that male children have more frequency of symptoms compared to female children and adults therefore, the required threshold for diagnosis may not be sensitive to these two groups. Other current ADHD diagnostic controversy includes inconsistent informant data, and the validity of subtype criteria. Current guidelines state that there must be impairment in multiple settings and information must be obtained from parents and teachers (American Academy of child and Adolescent Psychiatry, 2007; American Academy of Pediatrics, 2000: NICE, 2009). However, there is no specificity regarding how to combine the information obtained from multiple sources. This is a concern since research has frequently revealed variance between informants (Barkley et al., 2002; Brewin, Andrews & Gotlib, 1993; Kooij et al., 2008; Zucker et al., 2002 Need sources). Some suggest that these differences are a result of differences of opinion while others suggest the variance reflect true differences in home and school settings (Gomez, 2008; Severa et al., 2010). Possibly in an effort to resolve the issue of informant variance some researchers have opted to rely on only one source (Need sources). However, deciding on a primary informant has led to controversy regarding credence. Some suggest that the parent has the most credence since the teacher is only with the child a few months while others and perhaps most suggest the teachers ratings trumps the parents since they are experts on normal behavior for a given age group (Barkley, 2006; American Academy of child and Adolescent Psychiatry, 2007;
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American Academy of Pediatrics, 2000: NICE, 2009). Research demonstrates that parent reports used to measure symptoms in a school setting are not predictive of teacher s behavioral report of school functioning and information provided by the parent should be limited to the home setting. Therefore, it is prudent to utilize both sources for subtype differentiation and diagnosis. A study by Valo and Tannock (2010) found a significant influence on overall diagnosis and subtype classification based on how informant information was combined. An earlier study by Rowland et al (2008) investigated a sample of children in grades 1-5 (N=7847) to see if subtype diagnosis was influenced by variations in how the informant data was combined. The results indicated significant differences in subtype classification based on how parent and teacher data were combined (Rowland et al., 2008). Maybe add specific information about the AND OR suggestions. Given that ADHD diagnosis and classification is significantly affected by how informant data is combined it has been suggested that a standard procedure be implemented (Rowland et al. 2008; Valo & Tannock 2010). Controversy regarding informants is also evident in adult diagnosis. Diagnosing ADHD in adults requires a retrospective account of childhood behavior as well as obtaining data from a second informant such as a parent. Ability for both informant and client to accurately recall childhood information has been concerning (Barkley, Fischer, Smallish, & Fletcher, 2002; Mannuzza, Klein, Klein, Bessler, & Shrout, 2002; Murphy & Adler, 2004). When diagnosing an adult client that does not live at home using a parent as the only other informant can also lead to inaccurate diagnostic information (Barkley, 2008). Some suggests informants used in adult evaluations can include: parents, siblings, spouse, or a cohabiting partner (Murphy et al., 2001; Barkley, 2001). The rate of agreement between adult self-report and the informant has been mixed. An investigation by Barkley (2008) suggested that self-report and parent report correlations were at .21 with the parent endorsing more symptoms than the client. Barkley then revealed that the correlation increased to .50 and .53 for other informants. At times studies suggest that adults underreport (Barkley et al., 2002) and other studies suggest the adult client reports more symptoms than the informant (Glutting, Youngstron, & Watkins, 2005; Murphy & Schacar, 2000). There are several possible explanations for these discrepancies such as; differences in perception, parent attitude, informants lack of current information about the client, failure of an accurate retrospective account of behavior or possibly malingering (Barkley, 2006; Zucker et al., 2002add). Since there is no standard method for dealing with informant discrepancies there is a concern regarding the consistency of diagnosis. This is apparent when comparing ADHD subtypes. Rowland et al (2008)Pull and check this investigated a sample of children in grades 1-5 (N=7847) to see if subtype diagnosis was influenced by variations in how the informant data was combined. The results indicated significant differences in subtype classification based on how parent and teacher data were combined. The validity of ADHD subtypes has come in to question for other reasons as well.
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As previously noted in order to meet a diagnosis of ADHD six of the nine symptoms of Inattention and or six of the nine symptoms of Hyperactivity/Impulsivity must be apparent often over 6 months resulting in significant impairment in social, academic, or occupational functioning. However, previous research has indicated that subtype diagnosis lacks temporal stability. A longitudinal study by Lahey et al (2005) investigated 118 children aged 4-6 years-old and found that those diagnosed with hyperactivity-impulsivity showed diminishing symptoms later resulting in a non-diagnosis or a shift to a diagnosis of combined type. Additionally, those that were diagnosed with inattentiveness were diagnosed with a different subtype twice on six later assessments Lahey et al (2005). Some research has revealed a lack of distinction between subtypes (Solanto, 2007) as well as a lack of heritability differences (Stawicki, Nigg, 2006). While other research has suggested subtypes are distinct (Huang-Pollock, 2007). In adulthood, temporal instability is very apparent among those previously diagnosed as hyperactive ( ). Since the current symptoms are developmentally inappropriate temporal inconsistency is not surprising. Some of the symptoms clearly lack face validity such as; leaves seat in classroom, and runs about or climbs excessively (Barkley 2008). Additionally, impairments in work settings, social, marital relationships are not represented in the current ADHD criteria. A study by Prevatt et al (2010) investigated 299 college students diagnosed with primarily inattentive and combined ADHD and differences in their current symptoms compared to their retrospective account of childhood symptoms. The results indicated that the most commonly endorsed symptoms were related to inattention and the least endorsed symptoms were related to impulsivity (Prevatt, 2010). Additionally, there was one symptom of hyperactivity fidgets was also commonly endorsed (Prevatt, 2010). Research has revealed that the current core features are impulsivity and inhibition and the symptoms of impulsivity in the current DSM-IV only represent verbal impulsivity and there are no symptoms that represent impulsive behavior or lack of inhibition; such as acts before thinking or has difficulty waiting for things (Barkley, 2008). Also, lack of adult normative data makes it difficult to know what would be considered symptomatically above average for adults. It is hypothesized that the threshold to meet diagnosis for an adult would be considerable less. In a study performed by Murphy & Barkley, (1996) that studied ADHD symptoms in adults revealed that 6 symptoms was 2-4 standard deviations above the mean for non-diagnosed adults. Another study by Barkley et al., (2002) found the current threshold was 3.5 standard deviations above the mean for the non-diagnosed adults. Others suggest that a separate normative sample for college students is warranted (Kooij et al. 2004). Another consideration regarding adult diagnosis is that the cut off age of 6 for symptoms first noticed was not based on empirical studies and several studies have refuted this age restriction as not valid (Barkley, 2008; Polanczyk, Caspi, Houts, Kollins, Rohde & Moffitt, 2010).
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While some question whether it is the methodology or if it is the subtype itself that is fundamentally flawed, perhaps it is both.
The DSM-5 As described previously the current diagnostic manual is not without flaws. Although its design was based on information gleaned from empirical studies since its initial launch in 1994 a great deal of new research has evidenced a need to make several changes in the DSM-5. The current method to ensue change to diagnostic criteria involves a formalized procedure to develop committees and experts to investigate each diagnostic criterion. The reveals that there are more than 500 clinicians and researchers involved in scrutinizing data gleaned from various scientific studies. These experts were gathered in 2007 to begin the process of designing the new diagnostic manual. Summaries from the meetings are accessible to anyone and other researchers are welcome to submit prosed changes at scientific conference. The development of the DSM-5 has proclaimed to be the most open forum since the development of the DSM. This is in part attributed to the technical advances and also because through transparity the manual will have the best opportunity to be clinically useful for global professionals. There are several specific guidelines that must be met in order to provoke change in the manual. Two of the guidelines that must be met are that it must increase the clinical utility and that the revisions are based on research evidence. Given the plethora of ADHD research that has been completed since the DSM-IV was published in 1994 it seems logical that revisions are in order. A committee consisting of experts in the field of ADHD has put together a list of proposed changes. These proposed changes were based on evidence gleaned from research. The changes that have been proposed would address the following; the general ADHD diagnostic structure, subtypes, number content and distribution of criteria, age of onset, adult diagnostic differences, informant guidelines, inclusion and exclusion criteria and detailed descriptions of criterion for inattention, and hyperactivity-impulsivity. See below for a list of the proposed changes
Shaffer, David M.D. FRCP (Chair) Castellanos, F. Xavier, M.D. (co-chair) Frick, Paul J. Ph.D. Moffitt, Terrie, Ph.D. Nigg, Joel T., Ph.D. Rohde, Luis Augusto, M.D., Sc.D Tannock, Rosemary, Ph.D.
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Todd, Richard, Ph.D., M.D.
Future Directions A. Diagnostic Consistency As mentioned in the section entitled current controversies there is a lack of diagnostic consistency. The proposed changes does address the informant inconsistencies and since the criterion is more detailed there will also be more consistency when B. Normed Comparison groups Address the issue of needing a separate norm criteria based on: children, college students and adults This should include co-morbid frequencies as well C. Importance of understanding Differences between subtypes Once there is consistency with diagnosing according to subtypes it will be important to research these groups separately and not lump them together. 1. Treatment Treatment should include information about subtype as well as any comorbid disorders 2. Prognosis- Once subtype/comorbidity and treatments are separated research will make prognosis clear and further develop treatments
D. Future Research 1. Considerations for Diagnosis using current criteria As mentioned the diagnosis for ADHD has frequently been lumped together and comorbid diagnosis has been largely ignored..researchers have justified this by claiming since many people with ADHD have co morbid dx we can put them all together however, combining anxiety, depression and bipolar disorder with ADHD can significantly skew research. Future research should delineate the population that they are studying so as not to contaminate the results and therefore, digress the field of ADHD research. 2. Samples should be grouped according to subtype-
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3. 4.
Should control for IQ and comorbid diagnosis Considerations regarding self-referral and age of diagnosis
DSM-V In the future diagnostic manual Rohde lists eight questions about categorical diagnosis 1. Differences, dimensional adjunct, developmental sensitivity, gender-specific thresholds, biological markers, validity of different criteria, subtypes, and age of onset criteria Dimensional adjunct to categorical diagnosis
Current Diagnostic Controversy (DSM-IV-TR) There are questions concerning the validity and utility of the current classification system. Some suggest that the subtype conceptualization is inaccurate and others feel that the subtype concept is correct and instead it is the implementation that is lacking (Nigg, Tannock & Rohde 2010). Most agree that there is research to support the distinction between ADHD-PI and ADHD-H (Willcutt et al., 2010). However, there is little heritability support (Stawicki, Nigg, & von Eye, 2006) and there is temporal instability (Lahey, Pelham, Loney, Lee, &Willcutt, 2005). Some suggest that ADHD-PI and ADHD-C are distinct (Barkley, 2001; Diamond, 2005; Hinshaw, 2001;Milich et al.,2001) and there is evidence that supports two distinct dimensions (Martel, Nigg, & Von Eye,2008; Thorell, 2007;Wahlstedt, Thorell, & Bohlin, 2008). However, when investigating the evidence to support differences between three subtypes the results are mixed (Huang-Pollock, Kikami, Pfiffner, & McBurnett, 2007; Solanto et al.,2007;Tucha et al.,2008). Some suggests that these differences are a result of Heterogeneity within the ADHD-PI and only those with sluggish cognitive tempo are significantly different from ADHD-C (McBurnett, Pfiffner, & Frick, 2001).
Another critique of the current DSM-IV-TR is that it lacks developmental considerations therefore, those diagnosed with ADHD-HI and ADHD-C are likely to be younger than those with ADHD-PI and hyperactivity may be less apparent due to internal manifestations (Weyandt et al., 2003, Barkley, Fischer, Smallish, Fletcher, 2002). The DSM-IV-TR failed to include adults in their field trial. (barkley 2008, suggests that the current dsm has three items for impulsiveness however, these items do not include poor inhibition mental such as makes decisions impulsivily , or has difficulty waiting barkely suggests that the dsm v include more balanced distribution of items and that the current threshold of 9 symptoms that was previously
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established for children be investigated. It will also be important to consider gender differences when creating a threshold for diagnosis. Parent report and teacher report not consistent (source Variance) Clients that seek an ADHD evaluation will typically need to include information from three sources parent/s, teacher and self. Each provides a different perspective of behavior and performance. Barkley (2006) suggests that the information the teacher provides trumps the parent information because the teacher has more information about what is considered normal for a particular age group. However, others suggest that the parent s information is more important because the teachers are only have a few months of observation time with the student compared to a lifetime with their parents (American Academy of Child and Adolescent Psychiatry, 2007; American Academy of Pediatrics, 2000: NICE, 2009). An alternate view to giving more credence in the parent or the teacher s evaluation is to recognize that behavior may actually be different in each setting and each informant provides valuable information. Using both sources of information is also called multisource investigation or systematic multitrait of the construct validity of ADHD rating scales is supported by several researchers (Sims & Lonigan, 2010;Burns, desmul, Walsh, Silpakit, & Ussahawanitchakit, 2009; Gomez, Burns, Wals, & de Moura, 2003; Gomez, Burns, Walsh, & Hafetz, 2005). A utilization of various sources will help to illuminate perception differences. Lee and others (2008) suggest that standardizing the required minimum number of symptoms be met for each informant will help to maintain consistent results. An additional complication arises when evaluating adults since it is very difficult to recall childhood symptoms (Shaffer, 1994). Studies have shown that adults and adolescents with ADHD tend to underreport their symptoms (Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2002). A more current study by Barkley (2010) found more symptom disagreement in a college sample than in previous studies of children. College students reported more symptoms than the parents however, the differences were not significant. Barkley points out that this is interesting since the original purpose of using multiple sources was to prevent underreporting of the client. Assessment of Adult ADHD The diagnosis of adult ADHD is a clinical decisionmaking process (Faraone & Biederman, 1998). A diagnosis is established through the use of a comprehensive examination assessing psychopathology, functional impairments, pervasiveness of the disorder, age of onset, and absence of other disorders that could better explain the symptoms (Rosler et al., 2006). Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a
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diagnosis of ADHD on an individual basis (Rosler et al., 2006). Instead, diagnosticians often rely on a combination of clinical interviews, behavioral rating scales, family history, and neuropsychological evaluation. The use of reports from multiple informants is considered best practice, as evidence from multiple studies suggests that adults with ADHD underreport their ADHD symptoms and the severity of those symptoms (Barkley, Fischer, et al., 2002; Fischer, 1997; Wender, 1995). Barkley et al., 2008, for more discussion of this important issue of clinician judgment in adult ADHD diagnosis). For instance, adults may have reported being significantly distractible or forgetful, yet when asked to provide examples, they gave such trivial instances as to be unconvincing to the clinician. Even so, there is a possible contamination of the clinical group with adults with ADHD. This, however, would have had a conservative bias on our results, serving to make our ADHD and clinical groups closer together in their ratings. Yet differences still emerged here as a function taken from the article entitled; Correspondence and disparity in the self and other ratings of curren and childhoof adhd symptoms and impairment in adults with ADHD. 2011 BARKELY Knouse murphy.
Vola and Tannock (2010) investigated if another possible explanation for lack of differences is method variance in diagnosis. Their results indicated that different methods used to combine information from different informants and/or the use of different instrumentation can influence subtype classification (Vola & Tannock 2010).
Another study supports these results and both indicate that ADHD-C is the subtype that is most influenced by this these differences in diagnosis (Rowland et al., 2008). Vola & Tannock also found that ADHD subtypes were not stable and as many as 50% were reclassified from one subtype to another suggesting poor validity and reliability.
Inhibition, impulsive core features not mentioned (CPT after controlling for IQ only InH remained)Article suggests inhibition difficulty but not EF overall (Our study implies that adult ADHD may be mainly about inhibition, and we therefore endorse the recent suggestion Naglieri & Goldstein, 2006) to define ADHD in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as a disorder of self-regulation rather than as a disorder of attention and hyperactivity (Boonstra Oosterlaan, Sergeant, Kooij, Buiterlaar 2010).
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(Inhibition) Controversy exists as to whether or not the symptoms accurately depict the current conceptualization of ADHD since the symptom lists includes 9 symptoms of inattention, six symptoms of hyperactivity and three symptoms of impulsivity however, it fails to list symptoms of inhibition (Barkley 2008) Barkley 2008 states that the core feature of ADHD is impulsive and poorly inhibited however, these are not symptoms listed in the current DSM. Lack of balance in number of features needed for dx
(Parents tend to over report their child s ADHD symptoms compared to other informants (Re & Cornoldi 2009) Look at hoe this article cited e.g. Teacher-ratings (is a section) Teacher ratings seem to be better at differentiating between subtypes (Owens & Hoza, 2003;Sims & Lonigan 2010) y y Self-underreporting y Many of the symptoms described in the hyperactivity lack face validity if using for adults (Barkley 2008). Controversy about the appropriate criteria for diagnosing adult ADHD. From the article to act or not to act.AS stated in an earlier section many difficulties encountered by those diagnosed with ADHD may be due to impairments in the executive functioning. While EF has been reported to have as many as 33 different definitions (Eslinger, 1996) many have suggested that a core feature of the EF is inhibition (Nigg 2005; Barkley 1997) that may be the source for difficulty in other areas of EF since the self-regulating feature of inhibition interrelates with many other EF. Although far y fewer studies have been conducted in adults with ADHD, y deficits in both EFs in general and EFs in inhibition in specific y have been confirmed in a number of reviews and meta-analytic y articles (Boonstra, Oosterlaan, Sergeant, & Buitelaar, 2005; y Hervey, Epstein, & Curry, 2004; Schoechlin & Engel, 2005; y Seidman et al., 2004; Woods, Lovejoy, & Ball, 2002) and more (this study controlled for things that can effect the functioning of EF however are not components of EF such as; IQ, perception, attention and memory) After controlling for these in a study of stimulant nave adults with ADHD the results revealed that the inhibition component of ef was the only significant factor. However it is unclear id inhibition effects attention or if attention effects inhibition On the contrary: Our study implies that adult ADHD may be mainly about inhibition, and we therefore endorse the recent suggestion (Naglieri & Goldstein, 2006) to define ADHD in the fifth
29
edition of the Diagnostic and Statistical Manual of Mental Disorders as a disorder of selfregulation rather than as a disorder of attention and hyperactivity. References Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2002). The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of the disorder. Journal of Abnormal Psychology, 111, 279-289. Barkley, R. A., & Murphy, A. (1998). Attention-deficit hyperactivity). Abstracts by Russell a. barkley ADHD Report volume 18 number 2 issn 1065-8025 april 2010 Rating scale developed for sluggish cognitive Tempo (SCT) in ADHD SCT (taken from article above: Barkley states that the subtypes of ADHD have not been valuable for research, diagnosis, or treatment due to cross- contamination , instability over development. (In large scale studies he states that there is indications that it is a single disorder varying in severity. Innattentiveness does seem to differ from combined type in comorbidities and symptoms. Innattentive- Low comorbidity with CD/ODD deficits with inhibition more unlikely, Few EF and are more likely to be slow, error prone. Some have labeled inattentive as SCT Symptoms: daydreaming, spaciness, mental confusion, fogginess, sluggishness, hypo activity, lethargy and social passivity and they sometimes have inattentive symptoms such as; forgetfulness, disorganization, difficulty following instructions. The authors conclude THAT THE SYMPTOMS ARE DISTINCT FROM ADHD Barkley suggests that emotional impulsiveness be a central feature consideration for the DSM V: Emotional Impulsiveness and deficit of emotional self- control are not included in the current diagnostic criteria. Barkley includes the following emotions: anger, frustration, impatience, and anger in particular. He suggests that these emotions are not more intensely felt however, they are felt more quickly He defined emotional regulation as ability to; inhibit inappropriate behavior, self soothe, refocus attention, organize and coordinate an action to an external goal.
(Now ADHD is 2 dimensionalBarkley cites articles that HAVE A GOOD HISTORY OF ADHD:
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Accardo & Blondis 2000; barkley 2006; goldstien & Goldstien, 1998; Kessler, 1980; Ross & Ross 1982; Schacher, 1986; werry, 1992). Edlebrock, C., Costello, A., J. (1988). Convergence between statistically derived behavior problem syndromes and child psychistric disagnosis. Journal of Abnormal Child Psychology, 16, 219-231. Pendergrast, M., Tayor, E., Rapoport, J. L., Bartko, J., Donnely, M., Zametkin, A., Ahearn, M.B., Dunn, G., & Wieselberg, H.M., (1988). The diagnosis of childhood hyperactivity: A U.S.-U.K. cross-national study of DSM-III and ICD-9. Journal of Children Psychology and Psychiatry, 29, 289-300 Schachar, R.J., Rutter, M., & Smith, A. (1981). The characteristics of situationally and pervasively hyperactive children: Implications for syndrome definition. Journal of Child Psychology and Psychiatry, 22 375-392. Spitzer, R.L., Davies, M., & Barkley, R.A. (1990). The DSM-III-R field trial for the disruptive behavior disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 690-697. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC:
Journal of Clinical Child & Adolescent Psychology
Volume 39, Issue 6, 2010 Biederman J., Faraone S.V., (2002), Current Concepts on the neurobiology of attention deficit/hyperactivity disorder. J Atten Disord. 6 (suppl 1: s7-s16 Curatolo P., The neurology of attention deficit/hyperactivity disorder. Brain Dev 2005, 27:541-543 Suskauer s.j., Simmonds D.J., Fotedar S., Blankner J.G., Pekar J. J., Denckla M.B., Mostofsky S.h. Functional magnetic resonance imaging evidence for abnormalities in response selection in attention deficit hyperactivity disorder: differences in activation associated with response inhibition but not habitual motor response. J cogn Neurosci 2008, 20 478-493. R.A. Barkley, Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121 (1997), pp. 65 94
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J.T. Nigg, Is ADHD a disinhibitory disorder?. Psychological Bulletin, 127 (2001), pp. 571 598. J.T. Nigg, What Causes ADHD? Understanding What Goes Wrong and Why, Guilford, New York, NY (2006). B.F. Pennington, From single to multiple deficit models of developmental disorders. Cognition, 101 (2006), pp. 385 413 B.F. Pennington and S. Ozonoff, Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37 (1996), pp. 51 87. Willcutt EG. Understanding comorbidity between reading disability and ADHD. Annual Meeting of the International Dyslexia Association, 2008 E.G. Willcutt, A.E. Doyle, J.T. Nigg, S.V. Faraone and B.F. Pennington, Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review. Biological Psychiatry, 57 (2005), pp. 1336 1346. B.F. Pennington, From single to multiple deficit models of developmental disorders. Cognition, 101 (2006), pp. 385 413 Advokat, C., Lane S.M., Chunqiao, L., 2010. College students with and without ADHD: Comparison of Self Report of medication usage, study habits, and academic achievement Journal of Attention Disorders DOI: 10.1177/1087054710371168 Wilmshurst, L., Peele, M. Wilmshurst L., 2011. Resilience and well-being in college students with and without a diagnosis of ADHD Journal of Attention Disorders DOI: 10.1177/1087054709347261 Barkley, R.A. (2010). Attention deficit hyperactivity disorder in adults. Sudbury, MA: Jones and Barlett Publishers. Barnard, L. Stevens, T., To, Y.M Lan, W. Y. Mulsow. M., (2011). The importance of ADHD subtype classification for educational applications of DSM-V Journal of Attentional Disorders 13,6 573-583. DOI: 10.1177/1087054708326433. Volkow, N.D., Wang G.J. Newcorn, J.H., Kollins, S.H., Wigal T.L., Telang, F. Fowler, J.S. Golstien R.Z., Klein N., Logan J., Wong C. Swanson J.M. (2010) Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway Molecular Psychiatry 16, 11471154.
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What Is to Be the Fate of ADHD Subtypes? An Introduction to the Special Section on Research on the ADHD Subtypes and Implications for the DSM V .DOI:10.1080/15374416.2010.517171Joel T. Nigga*, Rosemary Tannockb & Luis A. Rohdec pages 723-725 Available online: 06 Nov 2010 References for current controversy section American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 894-921. American Academy of Pediatrics. (2000). Clinical practice guideline: diagnosis and evaluation of the child with Attention-deficit/hyperactivity disorder. American Academy of Pediatrics, Pediatrics, 105, 1158-1170. NICE. (2009). Attention Deficit Hyperactivity Disorder: The NICE guidelines on diagnosis and management of ADHD in children, young people and adults (Vol. National Clinical Practice Guidelines). London: The British Psychological Society and the Royal College of Psychiatrists. Barkley et al 2002 (I think that I alreasy have this for the intro Brewin, C. R., Andrews, B., & Gotlib, I. H. (1993). Psychopathology and early experience: A reappraisal of retrospective reports. Psychology Bulletin, 113, 82-98. Kooij, J. J. S., Boonstra, A. M., Swinkels, S. H. N., Bekker, E. M., deNoord, I., & Buitelaar, J. K. (2008). Reliability, validity, and utility of instruments for self-report and informant-report concerning symptoms of ADHD in adult patients. Journal of Attention Disorders, 11, 445-458. Gomez, R. (2008). Item response theory analyses of the parent and teacher ratings of the DSMIV ADHD rating scale. Journal of Abnormal Child Psychology, 36, 865-885. Severa, M., Lorenzo-Seva, U., Cardo, E., Rodriguez-Fornells, A., Burns, L. G., (2010). Understanding trait and source effects in attention-deficit/hyperactivity disorder and oppositional defiant disorder rating scales: Mothers , Fathers , and Teachers rating of children from Balearic Islands. Journal of Clinical Child and Adolescent Psychology, 39(1), 1-11. Barkley, R. A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.). New York: Guilford. Valo, S., & Tannock, R. (2010) Diagnostic instability of DSM-IV ADHD subtypes: Effects of informant source, instrumentation, and methods for combining symptoms reports. Journal of Clinical Child and Adolescent Psychology, 39, 749-760. Rowland, A.S., Skipper, B., Rabiner, D.L., Unbach, D.M., Stallone, L., Campbell, R.A., et al. (2008). The shifting of subtypes of ADHD: classification depends on how symptom reports are combined. Journal of Abnormal Child Psychology, 36, 731-743. Mannuzza, Klien Klien Bessler Shrout 2002
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Murphy, K. R., & Adler, L. A. (2004). Assessing attention deficit/hyperactivity disorders in adults: Focus on rating scales. Journal of Clinical Psychiatry, 65(suppl.3), 12-17 Barkley, R.A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York:NY: Guilford. Barkley, R.A. (2001). The inattentive type of ADHD as a distinct disorder: What remains to be done. Clinical Psychology: Science and Practice, 8, 489-501 Murphy et al 2001 Glutting, J. J., Youngstrom, E.A., & Watkins, M.W. (2005). ADHD and college students: Exploratory and confirmatory factor structures with student and parent data. Psychological Assessment, 17, 44-55. Murphy, P., & Schacar, R. (2000) Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults. American Journal of Psychiatry, 157, 11561159. Zucker, M., Morris, M. K., Ingram, S.M., Morris, R.D., & Bakeman, R. (2002). Concordance of self- and informant-ratings of adults current and childhood attentiondeficit/hyperactivity disorder symptoms. Psychological Assessment, 14, 379-389. Lahey, B.B., Pelham, W.E., Loney, J., Lee, S.S., & Willcutt, E. (2005). Instability of the DSM_IV subtypes of ADHD from preschool through elementary school. Archives of General Psychiatry, 62, 896-902 Solanto, M. V., Gilbert, S. N., Raj, A., Zhu, J., Pope-Boyd, S., Stepak, B., et al. (2007). Neurocognitive functioning in AD/HD, predominantly inattentive and combined subtypes. Journal of Abnormal Child Psychology, 35, 729-744. Stawicki, J.A., Nigg, J.T., & von Eye, A. (2006) Family psychiatric history evidence on the nosological relations of DSM-IV ADHD combined and inattentive subtypes: new data and meta analysis. Journal of Child Psychology and Psychiatry, 47, 935-945 Huang-Pollock, C.L., Mikami, A. Y., Pfiffner, L., & McBurnett, K. (2007) ADHD subtype differences in motivational responsivity but not inhibitory control:Evidence from a rewardbased variation of the stop signal paradigm. Journal of Clinical Child and Adolescent Psychology, 36, 127-136. Prevatt Walker Baker Taylor 2010 college student self-perception of changes in ADHD symptoms over time: Implications for DSM-V subtype schema (ADHD report) Polanczyk caspi Houts Koolins Pohde Moffitt 2010 ADD NIGG TANNOCK AND ROHDE SOMEWHERE IN THIS SECTION OF MY PAPER!! WILLCUTT 2010 TOO!! Barkley et all 2011 too!! For summary sections (note to me: it seems very aparant that one of the most significant and persistent controversies surrounding ADHD is the lack of consistency. It seems logical that consistency
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would be impaired given the variation in diagnosis and differences in covaration in the research studies. It seems most prudent to delieneate subtypes based on a consistent diagnosistic method that includes a consistent way of combining informant data. Additionaly, IQ, gender, age, need tp be controlled for in order to rule out that the differences are not mearly caused by IQ. Studies that do not adhere to this standard mare the strides that can be gained in ADHD research. Understandiblly, these standards may be difficult to adhere to given the high comorbidity and difficulty in obtaining a data set. Possible solutions are to match comorbid diagnosis and cooperative or shared data sets between researchers. Research integrity is the only way to make logical progress in the area of ADHD research. ADULT Norms, Gender norms both for children and for adults Also it is important to know if the sample being tested is currently taking or not medication or if the are medication nave. Seperation between children, college and adults as well as gender. Incipient change (like this word) D
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Future Directions Diagnostic ADHD Criteria 1

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

PAUL J. FRICK Ph.D.

, BENJAMIN B. LAHEY Ph.D., BROOKS APPLEGATE Ph.D., LYNN

Future Directions Diagnostic ADHD Criteria

Write the DSM-IV stuff and Edit the DSM-III-R

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Todd, Richard, Ph.D., M.D.

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Journal of Clinical Child & Adolescent Psychology

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

Future Directions Diagnostic ADHD Criteria

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