Transcript Blue Vortex - University of Florida

ADHD: Core Features,
Symptoms & Diagnostic
Criteria
James H. Johnson, Ph.D.
University of Florida
ADHD: Nature of the
Problem
• ADHD is a neurodevelopmental
disorder of childhood that is
characterized by developmentally
inappropriate levels of
Hyperactivity, Impulsivity, and
Inattention.
ADHD: How Common is it?
• It is one of the most common
disorders of childhood.
• It accounts for a large number of
referrals to pediatricians, family
physicians and child mental health
professionals.
• Prevalence is estimated at 3 to 7
per cent of the elementary school
population.
• The disorder occurs more often in
males than females, with the sex
ratio being about 3.4 to 1.
ADHD: Issues in Diagnosis
• As noted earlier, criteria used in
the diagnosis of ADHD have
variedly markedly.
• They have ranged from the very
sparse & subjective Hyperkinetic
Reaction of Childhood criteria
seen in DSM II
• To more objective and more well
delineated criteria for ADD and
ADHD seen in DSM III, DSM III – R
and DSM IV.
ADHD: Issues in Diagnosis
• Despite the changing nature of DSM
criteria over time, the field has
moved in the direction of more
objective criteria, clearer decision
rules, and toward criteria that are
more conservative and less likely to
lead to misdiagnosis of the disorder.
• These developments are highlighted
in DSM IV, which is the presently
accepted diagnostic system.
Focus on DSM IV in
Clinical Decision Making
• As a familiarity with DSM IV diagnostic
criteria is essential in clinical decision
making, we will consider these criteria
in some detail.
• Here we will focus separately on the
diagnostic criteria for hyperactivity,
impulsivity and inattention and how
these characteristics are manifested by
children with this disorder.
• We will then consider other criteria
essential to making an ADHD diagnosis.
Clinical Presentation of
Hyperactivity
• In viewing a child who is hyperactive,
much of the behavior seems purposeless.
• Clinically, the child is seen as restless,
fidgety, and tends to display high levels
of gross body movement and/or
excessive verbalizations.
• Parents often describe such children as
being “squirmy”, as “not being able to sit
still”, as “ talking excessively” and as
“always on the go.”
Clinical Presentation of
Hyperactivity
• Observation of these children at school
or while working independently on
tasks finds them out of their seat,
moving about the classroom without
permission, restlessly moving their
arms and legs while working, playing
with objects not related to the task
and talking out of turn and making
funny noises.
DSM IV Symptoms of
Hyperactivity
• Often fidgets with hands or feet, squirms in
seat.
• Often leaves seat in classroom or in other
situations in which remaining seated is
expected
• Often runs about or climbs excessively in
situations in which it is inappropriate.
• Often has difficulty playing or engaging in
leisure activities quietly.
Hyperactive Symptoms
• Is often "on the go" or often acts as
if "driven by a motor“.
• Often talks excessively when
inappropriate to the situation
• A combined total of 6 or more of
hyperactivity/impulsivity criteria
are required for diagnosis.
What do we Know about
Hyperactivity?
• Children with ADHD are more active,
restless, and fidgety than normal children
during the day and during sleep.
• There are different types of hyperactivity.
– Gross Motor Activity
– Restless/Squirmy
• Hyperactivity often varies according to
situation.
• Degree of hyperactivity may vary with age.
Impulsivity/Disinhibition
• The second group of symptoms assessed
in making a diagnosis is Impulsivity.
• Here the problem is in inhibiting
behavior in the presence of situational
demands
• As Barkley (2006) has noted, impulsivity
is typically reflected in the “undercontrol
of behavior, the inability to delay a
response, to defer gratification, or to
inhibit dominant or prepotent responses
in specific situations.
Impulsivity: Clinical
Presentation
  Impulsive children often respond
quickly to situations without waiting
for instructions or without actually
hearing the questions being asked.
• They often fail to consider potentially
negative or even dangerous
consequences that may result from
their behavior and often take
unnecessary risks.
• They may show careless behaviors
and damage other peoples property.
Impulsivity: Clinical
Presentation
  These children may have problems
waiting for one’s turn in a game or in
lineup at school.
• They may show problems with delay
of gratification.
• They often take shortcuts in tasks,
finding a way to apply the least
amount of effort and in taking the
least amount of time in dealing with
tasks they find boring or aversive.
Impulsivity: Clinical
Presentation
  Situations that involve sharing,
cooperation, and restraint with peers are
especially problematic.
• In interacting with peers and adults, they
often interrupt others
• Frequently blurt out statements that get
them into trouble because what they say
may be inappropriate.
• To the layman, these children come
across as immature for their age and as
rude and irresponsible children with poor
self control.
DSM IV Symptoms of
Impulsivity
• Often blurts out answers before questions
have been completed.
• Often has difficulty awaiting turn.
• Often interrupts or intrudes on others.
Six symptoms of hyperactivity and
impulsivity are required for diagnosis.
Impulsivity vs Hyperactivity
• While DSM IV highlights symptoms of
both impulsivity and hyperactivity it is
often difficult to differentiate the two.
• Factor analyses of ratings of impulsive
behaviors that are mixed in with ratings
of inattention and hyperactivity have
often failed to differentiate a dimension
of impulsivity that can be distinguished
from hyperactivity (Barkley 2006).
• Impulsive children are usually
overactive and overactive children are
usually impulsive.
Impulsivity vs Hyperactivity
• Barkley has suggested that these
findings call into question the existence
of over activity as a separate dimension
of behavioral impairment apart from
disinhibition.
• He goes on to suggest that – it also
strongly implies that the more global
problem of behavioral disinhibition
unites the two symptoms.
• Indeed, in considering the importance
of this core symptom of impulsivity,
Barkely has gone so far as suggesting
that impulsivity/disinhibition is the
primary defining feature of ADHD
(Barkley 2006).
DSM IV Symptoms of
Inattention
• Often fails to give close attention to
details or makes careless mistakes.
• Are these careless mistakes reflective of
inattention or impulsivity?
• Often has difficulties sustaining
attention in tasks or play activities.
• Often does not seem to listen when
spoken to directly.
• Often does not follow through on
instructions and fails to finish
homework, chores, or duties in the
workplace
Symptoms of Inattention
• Often has difficulty organizing tasks and
activities
• Often avoids, dislikes, or is reluctant to
engage in tasks that require sustained
mental effort.
• Might this reflect a motivational deficit rather
than simply inattention?
• Often loses things necessary for tasks or
activities - (Inattention or Memory???)
• Is often easily distracted by extraneous
stimuli.
• Is often forgetful in daily activities
• (6 or more necessary for diagnosis)
What Do We Know About
ADHD Attention Problems?
• ADHD "attentional" problems may be most
obvious on specific types of attentional
tasks.
• Children with ADHD seem to have their
greatest difficulties with sustaining their
attention in responding to tasks - in being
vigilant.
• Attention problems are usually seen most
clearly in situations requiring the child to
attend over time to dull, boring, and
repetitive tasks.
Situational Variations in
ADHD Symptoms
• ADHD symptoms show significant
variation across situations.
• Children with ADHD do not display
symptoms in all situations
• The absence of symptoms in some
situations does not necessarily
mean that the child does not have
ADHD (e.g. Video Games, Exciting
TV program).
Situations That Increase
ADHD Symptoms
• When the demands of the situation are to
be good, to be still, and to be quiet.
• The greater the demands the more
problematic the behavior of the child will
likely become.
• An exception might be in situations
where the child is being continuously
rewarded for complying with demands.
• In familiar situations where novelty and
task stimulation are low.
Other Situations That
Increase Symptoms
• Situations where there are low rates of
intrinsic or external reinforcement.
• When the child is fatigued.
– Studies, monitoring 24 hour activity levels
have suggested that the hours of 1 – 5 seem
to be peak times for increased activity in
children with ADHD.
Overview of Specific
Diagnostic Criteria
• Symptom Criteria - Core Symptoms of
Hyperactivity & Impulsivity and/or Inattention
(Six or More Symptoms of either category).
• Duration Criterion - Symptoms have Persisted
for at Least 6 Months.
• Developmental Criterion - Symptoms are
Inconsistent with Developmental Level.
• Impairment Criterion - Clear Evidence of
Clinically Significant Impairment in Social,
Academic, or Occupational Functioning
Overview of Criteria
(cont.)
  Age Criterion - Some Symptoms that Cause
Impairment Present Before Age 7.
  Situation Criterion - Some Impairment from
Symptoms is Present in Two or More Settings.
• NOTE. The failure to attend to full range of
symptoms is not uncommon
• Presence of hyperactivity, impulsivity, and
inattention is not necessarily to be equated
with ADHD.
Types of ADHD
• Combined Type
– Symptoms of hyperactivity,
impulsivity and inattention.
• Hyperactive/Impulsive
– Symptoms of hyperactivity
and impulsivity.
• Predominately Inattentive
– Symptoms of inattention.
DSM IV and ADHD: A
Critique
• It seems clear that the DSM IV system
represents a major advance over earlier
classification systems for childhood
psychopathology.
• Nevertheless it seems important to
consider the adequacy of this system as
it relates to the diagnosis of ADHD.
• Here, Barkley (2006) has raised several
criticisms regarding the usefulness of
the system in diagnosing this disorder.
DSM IV & ADHD: A Critique
  First, it is suggested that it is not clear
that the predominately inattentive type of
ADHD is really a subtype of ADHD that
shares similar attention problems with
other types.
• Here, Barkley cites research suggesting
– That the inattentive type seems to have more
problems with focused/selective attention and
sluggish information processing
– While the combined type has more problems
with persistence of effort and distractability.
Sensitivity of Diagnostic
Criteria
• There are questions regarding whether
diagnostic thresholds set for the two
symptoms lists apply to older children and
adolescents.
• This relates to the fact that hyperactive
symptoms often decline with age.
• With this decline in hyperactive symptoms
with age, using present cut off criteria
with older children may result in reduced
sensitivity for diagnosis due to failure to
display enough hyperactive symptoms
(although they may have been displayed
earlier).
• Question – What do you do with the pt who once
met criteria for combined type but no longer does due
to age?
Age of Onset Criteria
• Is the age of onset criterion (symptoms
before age 7) useful?
• There is no empirical data to support
this particular cut off age limit (Barkely,
2006), although there are findings that
those who develop the disorder early
may have more severe problems.
• It has been suggested that the age of
onset criterion be broadened to include
symptoms beginning in childhood.
Failure to Set a Lower
Limit for Diagnosis
• It has been suggested that there is a
problem with the failure to set a lower age
cutoff for giving a diagnosis of ADHD.
• Here, research suggests that below age 3 a
separate dimension of hyperactiveimpulsive behavior is often not
distinguishable form aggression or defiant
behavior.
• This would argue against a diagnosis of
ADHD before age 3.
IQ Limit for Diagnosis?
  There is a failure to indicate a lower IQ
below which a diagnosis should not be
given.
• Here, it has been suggested that children
with an IQ below 50 display a qualitatively
different type of mental retardation than
those above 50 - with genetic factors being
more prominent in the lower IQ group
(Barkley 2006).
• Such a cut off might be useful as decreased
numbers of children with IQ’s <50 respond
to stimulants.
Increased Emphasis on
Hyperactivity/Impulsivity
• · Given suggestions that behavioral
disinhibition is the hallmark of ADHD,
Barkley suggests that a greater emphasis
be placed on hyperactive/impulsive
symptoms than on inattentive
symptoms in describing the disorder.
• He suggests that, since these features are
more useful in discriminating ADHD from
other disorders, meeting a cutoff score
for these items should be the first
requirement in making an ADHD
diagnosis.
DSM IV: Overview
• This critique suggests that while
DSM IV may represent a significant
advance over earlier classification
systems, the system is clearly in
the process of evolving.
• Further changes are likely to be
found in subsequent versions of
this classification system.
That’s All Folks!