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ADHD work group weighing options.

HONOLULU--The publication of DSM-V will likely include substantial changes in the diagnostic criteria of attention-deficit /hyperactivity disorder.

However, the nature of many of those changes has not yet been finalized, according to three members of the work group who delivered a progress report to a packed--and very lively--audience at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dr. F. Xavier Castellanos of New York University pointed out that many aspects of the diagnosis work well now. "There's a lot about ADHD that's not broken," he said. "It turns out that the 18 criteria that we have as a whole work rather well. They are clinically useful; they've been validated innumerable times across multiple cultural settings."

One likely change is the current requirement that the patient's symptoms cause significant impairment before the age of 7 years, though the work group believes that eliminating the age requirement entirely would not be a good idea.

"We want to differentiate this from something that occurs at age 55 following a stroke or age 25 following a psychotic break," said Dr. Castellanos, Brooke and Daniel Neidich professor of child and adolescent psychiatry at the university. "There's some need to assert the importance of childhood origin. ... The greatest sentiment is toward moving the age criteria ... to age 12. And most recently, we discussed not simply requiring that some impairment be present by age 12, but in one way, shape, or form the diagnosis should be in place by age 12. Again, this is very tentative, but that was the most recent discussion on the topic."

Another likely change will be the ability to diagnose ADHD in a child who also has a pervasive developmental disorder (PDD). "It turns out that between 40% and 70% of individuals who meet criteria for the autism spectrum also have very substantial problems with hyperactivity and attention," Dr. Castellanos said. "There's a very strong desire, especially on the part of individuals who are engaged in the autism community, to do away with this exclusion."

Dr. Castellanos observed that some children with mild PDD can have a primary ADHD. Standard ADHD treatments tend to work well in these children. On the other hand, in more severe PDD cases, the treatment response tends to be idiosyncratic.

But the most significant unanswered question is whether the ADHD diagnosis will continue to have subtypes. Currently, there are three: ADHD that's predominantly hyperactive/compulsive, ADHD that's predominantly inattentive, and ADHD combined type.

Certain changes are all but definite, said Dr. David Shaffer of Columbia University, New York. For example, in the DSM-V, a strong effort will be made to differentiate between "impairment" and severity of a disorder.

"We really separated ourselves from the rest of medicine by saying you couldn't have a disorder unless you were impaired," said Dr. Shaffer, Irving Philips professor of child psychiatry at the university. "We all know that there are some people who persist with a very active and unimpaired life even though they have very severe illness."

Reviews of the literature and a metaanalysis of 490 studies involving more than 25,000 patients call into question the validity of the various subtypes that are currently used, said Joel Nigg, Ph.D., director of the division of psychology at Oregon Health and Science University, Portland. "A major concern for our work group is: Are these subtypes valid, and what do we do about the inattentive but not hyperactive children?" he said. "We have to decide if we don't have subtypes at all whether we're going to go back to a three-, two-, or one-dimensional symptom list."

In studies published since the release of DSM-IV, "The two-factor structure of inattention and hyperactivity/impulsivity had fairly good support," Dr. Nigg said, "with the caveat that the three-factor model, with impulsivity as a separate factor, does have some improvement in fit over the two-factor model. But the correlation between hyperactivity and impulsivity is so high that that's probably of academic interest more than clinical utility." Arguing against distinct subtypes are nine studies that show no difference in response to medication in children diagnosed ADHD-combined versus ADHD-inattentive. Furthermore, longitudinal studies have demonstrated that the subtypes are not stable over time. A child's subtype might change many times over the years, and less than 40% of children maintain the same diagnosis at two time points.

"The subtypes are more like state type than trait type," Dr. Nigg said.

Moreover, studies have shown that most differences in symptoms between subtypes lie on a continuum, with arbitrary cut points separating one diagnosis from the other. There is one exception to a purely dimensional model, however, Social dysfunction appears to be worse in patients with ADHD combined. A purely dimensional model would predict the opposite.

According to Dr. Nigg, the work group is considering three options. The first is to eliminate subtypes entirely, but to define two dimensions of the disorder.

"[This] would clearly require aggressive revision of the text to remind clinicians of the importance of heterogeneity in presentation and the differential predictive power of inattention versus hyperactivity in terms of the predominant presentation of the child," Dr. Nigg said.

The second option is to keep the subtypes but to make other aggressive text revisions reminding clinicians that the subtypes are not stable.

"Option 3 is to do something creative with the research appendix that will allow us to stimulate research on subtypes," Dr. Nigg said.

In discussing the work group's report, Dr. Gabrielle A. Carlson, director of child and adolescent psychiatry at Stony Brook State University of New York, said that some of these distinctions are more important to academic researchers than to clinicians.

Turning to the audience, Dr. Carlson asked how many of those present would fail to give a child an ADHD diagnosis if he or she had only 10 symptoms. Among several hundred clinicians, only one raised her hand.

Then, turning to the three work group members, Dr. Carlson said: "We don't really give a crap about 10 symptoms versus 12 symptoms. Because part of the reason is people are coming in, and they want help for problems. And if you're a decent clinician, you're used to kind of hearing what the symptom constellation sounds like."

She asked Dr. Castellanos why the work group had not included members who had a primarily clinical practice. "I don't think that anyone ever thought, 'well, we'll get rid of the clinicians,'" he replied. "But that's effectively what happened."

He cited the fact that service on the work group was voluntary and carried no monetary stipend, a condition that favors salaried academics. Another barrier to clinicians might have been the extensive conflict-of-interest verifications required of all potential members.

On the issue of subtypes, Dr. Carlson said it is important to be able to tell parents something that makes sense. And then you have to assist him or her in getting an individualized education plan that will be helpful and develop a sensible treatment plan. In her view, maintaining subtypes would be important for that.

"I also promise you that nobody gives a crap what you're going to put in the text. Nobody reads the text," she said to laughter and applause.

"I realize the amount of time and effort and energy that goes into doing what you're doing. ... But I also think you need to understand that you're making clothes for people who have to wear them. And if you don't have a place for us to put the kids that we see, there are unintended consequences of where those kids get put."
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Author:Finn, Robert
Publication:Clinical Psychiatry News
Date:Dec 1, 2009
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