Friday, May 3, 2013

A Child Psychiatrist's Thoughts on DSM-5: ADHD

This is part 3 of my series on the DSM-5. Previous posts covered general impressions and PTSD.

If you've been reading the nation's leading mental health blog, you will have been inundated with news and opinion about the rising rates of Attention-Deficit/Hyperactivity Disorder (yes, the hyphen and the slash are both there in the DSM-IV) and abuse of prescription stimulants by college kids. And you may even have come across DSM-5 Taskforce Chair David Kupfer's letter to the editor, in which he defended the DSM-5 by saying "revisions were aimed at helping clinicians more precisely recognize the symptoms of individuals with A.D.H.D. to facilitate the right care for the right person."

Less clear from those articles is what exactly is changing in the DSM-5 when it comes to ADHD, and I hope this post would shed some light on that. But first, some background on the challenges of diagnosing ADHD. Something as broad as an "attention deficit," as dependent on many different parts of the brain working together, and as prone to abuse is inherently going to be a mess when it comes to "accurate" diagnosis. Who can really say at what point "laziness" or "prefers hands-on learning" becomes "ADHD, predominately inattentive?" Thus, misdiagnosis is rampant, and there is a problem of both over- and under-diagnosis of ADHD.

This is nicely illustrated in this study from 2005, which asked parents if their children have been diagnosed with ADHD, and also had the parents complete a standardized questionnaire (the SDQ) about past ADHD symptoms. From the abstract:
Prevalence of clinically significant SDQ ADHD symptoms is 4.19% (males) and 1.77% (females). Male prevalence by race is 3.06% for Hispanics, 4.33% for Whites, and 5.65% for Blacks. Significant differences in prevalence occur across gender (p < .01) and among males across race (p < .01), age (p < .01), and income (p < .02). In the full sample, 6.80% of males and 2.50% of females have a parent-reported lifetime ADHD diagnosis but are negative for SDQ ADHD. Likewise, 1.59% of males and 0.81% of females are positive for SDQ ADHD but negative for parent report of ADHD diagnosis.
Thus, the results support the rough rule of thumb that only about half of kids with ADHD have actually been diagnosed, but about half of those who have the ADHD diagnosis don't really have ADHD. Yes, it's a mess. ADHD is almost certainly over-diagnosed not just among well-off suburban strivers needing "study pills," but also among poor urban youth who may be presenting with behavioral problems under conditions of chronic stress in the family. However, many kids who do have the syndrome are not being diagnosed, for a complex multitude of reasons. Those kids often end up marginalized in school, fall in with the wrong crowd, turn to drugs and alcohol, and have poor outcomes reaching far into adulthood.

The DSM-5 version of ADHD does not change much, but is clearly geared towards decreasing under-diagnosis. The biggest change is that instead of requiring some impairing symptoms before age 7, that age limit is now raised to 12. This is because many children with attention problems, especially if they are intelligent and not especially disruptive in class, can breeze through elementary school without adults noticing that they are not really paying attention. However, once those children reach middle school, they often become overwhelmed by the more challenging material, the demands of going to a different teacher for each subject, and having to keep track of multiple assignments with different due dates.

The 18 diagnostic criteria remain essentially the same. Instead of calling the different forms of ADHD (like combined or predominately inattentive) "subtypes," the term "presentation" is used, since they are not really distinct entities (i.e. most hyperactive children will become less hyperactive over time while continuing to have issues with attention). Also, kids with both autism and ADHD symptoms can now be officially diagnosed with ADHD, since the exclusion for Pervasive Developmental Disorder has been removed. The inattention symptoms have a much needed clarification that they are not due to oppositional behavior or difficulty understanding.

For diagnosis of ADHD in adults, the DSM-5 criteria have been loosened so that patients only need to meet 5 of 9 criteria for inattention, instead of 6 of 9. The manual also provides more examples of symptoms that are relevant to adults.

Ultimately, the question for me is, will the DSM-5 actually solve any problems associated with the ADHD diagnosis in the real world? Sure, it might make the lives of researchers easier since more people would qualify for the full ADHD diagnosis rather than ADHD, NOS. However, I don't think the change in criteria will do anything to improve under-diagnosis, since parents who didn't want to take their hyperactive or inattentive kids to see a doctor before probably still would not do so. Obviously, the DSM-5 won't do anything to stem the tide of over-diagnosis, but I'm also not sure that it'll make the problem any worse. In adults, the problem with diagnosing ADHD is that it is harder to get the third party data like parent or teacher reports that clinicians rely on when making the diagnosis in kids. Anyone can look up the diagnostic criteria and tell their doctor they have those things.

Perhaps it would have helped if the DSM-5 could specify that the symptoms cannot be purely subjective and that objective reports are needed from other sources, but for better or worse, that's not what the book is about. It won't change how I approach those in their late teens or adulthood who come to me saying they have previously undiagnosed ADHD, since I ask those patients to undergo neuropsychological testing so I would have some objective data.

Of course, even with proper diagnosis of ADHD, treatment doesn't necessarily address all the issues or lead to normalized functioning. But that's a topic for another time.