Understanding ADHD Subtypes and Diagnosis Criteria in DSM-IV-TR

ADHD, as defined in the DSM-IV-TR, encompasses three subtypes: Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, and Combined Type. To meet diagnostic criteria for each subtype, specific symptoms must be present for a certain duration and at a degree that is maladaptive. Individuals may also receive a diagnosis of Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified if they meet certain criteria but exhibit symptom onset after the age of 7. Proper evaluation and understanding of these criteria are essential for accurate diagnosis and appropriate management of ADHD.

• ADHD
• DSM-IV-TR
• Diagnosis Criteria
• Subtypes
• Attention-Deficit

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1. + Attention- Deficit/Hyperactivity Disorder Presented by Keith Radley University of Utah Department of Educational Psychology School Psychology Program US Office of Education 84.325K H325K080308

2. +ADHD in the DSM-IV TR ADHD has three subtypes: Predominately Inattentive Type, Predominately Hyperactive-Impulsive Type, and Combined Type To meet criteria for Inattentive Type, six or more of the following symptoms must be present for at least six months, and to a degree that is maladaptive: Fails to give close attention to detail Has difficulty sustaining attention in tasks or play Often does not seem to listen when spoken to Often does not follow through on instructions and fails to finish work Has difficulty organizing tasks and activities Often avoids tasks that require sustained mental effort Often loses things necessary for tasks or activities Is easily distracted by extraneous stimuli Is often forgetful in daily activities

3. +ADHD in the DSM-IV TR To meet criteria for Hyperactive-Impulsive Type, six or more of the following symptoms must be present for at least six months, and to a degree that is maladaptive: Hyperactivity Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or other situation in which remaining seated is expected Often runs or climbs excessively Often has difficulty playing quietly Is often on the go or often acts as if driven by a motor Often talks excessively Impulsivity Often blurts out answers before questions have been finished Often has difficulty awaiting their turn Often interrupts or intrudes on others

4. +ADHD in the DSM-IV TR To meet criteria for Combined Type, criteria for both Inattentive and Hyperactive-Impulsive types must be met for the past six months Some hyperactive-impulsive symptoms or inattentive symptoms must have been present before age 7 Some impairment must be present in two or more settings (e.g., at school and at home)

5. +ADHD in the DSM-IV TR A diagnosis of Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified is available for individuals who: meet the criteria for Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Type, but whose onset of symptoms is 7 years or after Have clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria for the disorder, but have a behavioral pattern of sluggishness, daydreaming, and hypoactivity

6. +Other common characteristics About half of individuals with ADHD also have Oppositional Defiant Disorder or Conduct Disorder Most common in individuals with Hyperactive-Impulsive and combined subtypes Other associated disorders include mood disorders, anxiety disorders, learning disorders, and communication disorders Approximately 50% of individuals with Tourette s Disorder meet criteria for ADHD

7. +History of ADHD First clinical description presented by George Still in 1902, who observed children with aggressive, deviant, highly emotional, and poorly inhibited behavior Still hypothesized that these children had a deficiency in moral control, which resulted from the surrounding environment and internal factors Also hypothesized about possible hereditary factors Strauss and Lehtien (1942) argued that restless and inattentive behavior were evidence of brain damage Term minimal brain damage used to describe such children, and special educational guidelines were proposed Focus began to shift to deficit in filtering of stimuli in CNS (Laufer, Denhoff, & Solomons, 1957)

8. +History of ADHD Terms associated with brain damage or dysfunction were eventually dropped Associations between hyperactivity and decreased attention and impulse control (Douglas, 1972) Impairments in investment, organization, maintenance of attention, inhibition, control of arousal levels, and desire for immediate reinforcement Labeled ADD in 1980 by American Psychiatric Association, ADHD in 1987 Focus returned to poor executive functioning and self-regulation (1981-present) Continuing questions of whether inattentive individuals represent a completely different disorder

9. +Causes and contributory factors Neurology Brain damage to prefrontal cortex associated with ADHD-like symptoms Low birth weight linked to risk for ADHD through relationship to abnormal brain development Neurotransmitter dysfunctions have also been proposed, but little evidence exists Reduced regions of prefrontal cortex as measured by MRI (Baumgardner et al., 1996) Diet and nutrition Proposed to cause ADHD, but little evidence supports this claim

10. +Causes and contributory factors Genetics 10-35% of immediate family members of children with ADHD likely have the disorder, with 32% of siblings having ADHD (Biederman et al., 1992) If parent has ADHD, risk of child having ADHD increases to 57% (Biederman, Faraone, et al., 1995) Twin studies provide strongest evidence for genetic basis: if one MZ twin is diagnosed, risk is 81%; DZ twin, 29% Social Theories propose increased cultural tempo is a cause of ADHD Twin studies have shown that the shared environment minimally contributes to individual differences essentially disproving social basis theories

11. +Assessment of ADHD Broadband Scales BASC correctly identified 97.7% of ADHD cases in Parent Report (Boyle et al., 1993) CBCL Attention subscale highly effective in identifying ADHD (Chen, Faraone, Beiderman, & Tsuang, 1994) Conners Rating Scale also well validated (Shaffer et al., 2000) Overall, empirically-derived scales are accurate and reliable in identifying individuals with ADHD Also sensitive to pharmacological effects

12. +Assessment of ADHD Structured Interviews Reliability of parent versions of Diagnostic Interview for Children and Adolescents-Revised are high (Boyle et al., 1993) Parent agreement is low (.01-.34) Measures of Impairment Highly effective in dividing clinical and nonclinical cases (Pelham, Fabiano, & Massetti, 2005) Substantial evidence for validity of Vanderbilt, Impairment Rating Scale, Columbia Impairment Rating, and Child and Adolescent Functional Assessment Rating Scale (Wolraich et al., 2003; Fabiano et al., 2005; Bird et al.,1993,1996)

13. +Assessment of ADHD Observation Able to discriminate between ADHD and comparison children, and sensitive to treatment effects (Fabiano et al., 2004; Klein & Abikoff,1997; Chronis et al., 2004) Example of observation system: Individualized Target Behavior Evaluation (ITBE) Functional Behavior Assessment Should be used to operational presenting problems, gather information about the problems, and determine treatment options Other than pharmacological interventions, no evidence-based treatment for ADHD can be developed without a FBA (Pelham, Fabiano, & Massetti, 2005)

14. +Evidence-based reviews Mash and Barkley-Treatment of childhood disorders, (pp. 55- 110) Barkley-Adolescents with Attention-Deficit/Hyperactivity Disorder: An Overview of Empirically Based Treatments

15. +Treatment approaches Pharmacological therapies Stimulant medication-improvements in attention, impulsivity, and irrelevant behavior Increase in academic productivity, but not long-term achievement Antidepressants May be useful for individuals unable to use stimulants however, they have more serious side effects Behavior management First treatment option Self-monitoring beep tapes, MotivAtor Repetition of instructions Reminder cards

16. +Treatment approaches Parent and teacher training Contingency management Positive reinforcement Response-cost Superior effect to methylphenidate (Rapport et al., 1993) Reducing task length Combined treatment Optimally, treatment plans consist of a combination of evidence- based treatments

17. +Fads and non-EBP Biofeedback Relaxation training Vitamins, minerals, and other health foods Running Vestibular stimulation Social skills training Especially for children with high levels of aggression

18. +Recent ADHD research IMPROVING HOMEWORK IN ADOLESCENTS WITH ADHD: COMPARING TRAINING IN SELF-VS. PARENT-MONITORING OF HOMEWORK AND STUDY SKILLS COMPLETION (Meyer, 2005) Objective: Comparison of self-monitoring and parent- monitoring effects on homework completion and test preparation Participants: 42 6-8thgrade students, all of whom were previously diagnosed with ADHD Assessment: Diagnoses of ADHD were confirmed through the Conners Rating Scale for parents and teachers. Mean scores were 73.62 and 73.52. The ADHD Rating Scale-IV and a semi- structured interview werealso conducted.

19. +Recent ADHD research Design: A between groups designed was utilized. Three groups were compared: 1)No treatment; 2) Parent- monitoring; and 3) Self-monitoring. Participants were randomly assigned to a treatment group. Steps to intervention: Parent-Monitoring: Checklists were constructed using the SQ4R study method. Participants and their parents were trained on how to use the checklist to monitor homework completion. Parents were instructed to review the accuracy of the checklist each night, and to reward participants based on checklist completion (80%).

20. +Recent ADHD research Steps to intervention Self-monitoring: The same checklist was utilized for this group. Participants were instructed on how to develop a proper homework routine. Parents were encouraged to reward their student for checklist completion (80%), but told not to complete the checklist themselves or review the checklist for accuracy. Data analysis: Measured by the Homework Problem Checklist (HPC) and Classroom Performance Survey (CPS) A split-plot ANOVA was used to determine treatment differences in HPC and CPS scores Results No-treatment participants were statistically different than treatment participants, but no statistically significant differences were found between self- and parent-monitoring. Received high parental and student satisfaction

21. +Conclusions ADHD is one of the most common disorders seen by school psychologists school psychologists can be especially helpful in helping teachers develop classroom interventions Pharmaceutical interventions have been proven to be highly effective, but some behavioral interventions (response-cost) have been shown to have stronger effects Behavioral interventions should be the first interventions implemented Combined treatments (those incorporating elements of parent training, classroom modification, behavioral interventions, and pharmaceutical interventions) show the greatest promise

22. +References Baumgardner, T., Singer, H. S., Denkla, M., Rubin, M., Abrams, M., Colli, M., & Reiss, A. (1996). Corpus callosum morphology in children with Tourette s syndrome and Attention Deficit Hyperactivity Disorder. Neurology, 47, 477-482. Barkley, R. (2004). Adolescents with Attention-Deficit/Hyperactivity Disorder:An Overview of Empirically Based Treatments. Journal of Psychiatric Practice, 10, 39-56. Biederman, J., Faraone, S., & Lapey, K. (1992). Comorbidity of diagnosis in Attention-Deficit Hyperactivity Disorder. Child and Adolescent Psychiatric Clinics of North America, 1(2), 335-360. Biederman, J., Faraone, S., Mick, E., Spencer, T., Wilens, T., Kiely, K., Guite, J., Ablon, J., Reed, E., & Warburton, R. (1995). High risk for Attention Deficit Hyperactivity Disorder among children of parents with childhood onset of the disorder: A pilot study. American Journal of Psychiatry, 152, 431-435. Bird, H.R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J., et al. (1996). Global measures of impairment for epidemiologic and clinical usewith children and adolescents. International Journal of Methods in Psychiatric Research, 6, 295 307. Bird, H. R., Shaffer, D., Fisher, P., Gould, M. S., Staghezza, B., Chen, J. Y., et al. (1993). The Columbia Impairment Scale (CIS): Pilot findings on a measure of global impairment for children and adolescents. International Journal of Methods in Psychiatric Research, 3, 167 176. Boyle, M. H., Offord, D. R., Racine, Y., Sanford, M., Szatmari, P., Fleming, J. E., et al (1993). Evaluation of the Diagnostic Interview for Children and Adolescents for use in general population samples. Journal of Abnormal Child Psychology, 21, 663 681. Chen,W.J.,Faraone,S.V.,Biederman,J.,&Tsuang,M.T.(1994). Diagnostic accuracy of the Child Behavior Checklist scales for attention-deficit hyperactivity disorder: Areceiver-operating characteristic analysis. Journal of Consulting and Clinical Psychology, 62, 1017 1025. Chronis, A.M., Fabiano, G.A., Gnagy, E.M., Onyango, A.N., Pel[ham, W. E., Williams, A., et al. (2004). An evaluation of the Summer Treatment Program for children with attention- deficit/hyperactivity disorder using a treatment withdrawal design. Behavior Therapy, 35, 561 585. Douglas, V. (1972). Stop, look, think, listen: The problem of sustained attention and impulse control in hyperactive and normal children. Canadian Journal of Behavioural Science, 4, 259-282. Fabiano, G. A., Pelham, W. E., Manos, M., Gnagy, E. M., Chronis, A. M., Onyango, A. N., et al. (2004). An evaluation of three timeout procedures for children with attention- deficit/hyperactivity disorder. Behavior Therapy, 35, 449 469.

23. +References Klein, R. G., &Abikoff, H. (1997). Behavior therapy and methylphenidate treatment of children with ADHD. Journal of Attention Disorders, 2, 89 114. Laufer, M., Denhoff, E., & Solomons, G. (1957). Hyperkenetic impulse disorder in children s behavior problems. Psychosomatic Medicine, 19, 38-49. Mash, E. & Barkley, R (1998). Treatment of childhood disorders, (pp. 55-110). New York, NY: Guilford Press. Meyer, K. (2005). Improving homework in adolescents with ADHD: Comparing training in self- vs. parent-monitoring of homework and study skills completion. Unpublished thesis. Pelham, W., Fabiano, G., & Massetti, G. (2005). Evidence-based assessment of Attention-Deficit Hyperactivity Disorder in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 449-476. Pelham, W. E., Lahey, B., Gnagy, E., Kipp, H., &Roy, A. (2005, June). Predictive validity of ADHD symptoms. Impairment on functional outcomes. Poster to be presented at the annual meeting of the International Society for Research on Child and Adolescent Psychopathology, New York. Rapport, M., & Kelly, K. (1993). Psychostimulant effects on learning and cognitive function. In J. L. Matson (Ed.) Handbook of hyperactivity in children, (pp. 97-135). Needham Heights, MA: Allyn & Bacon. Shaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIM HDISC IV): Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 28 38.: Still, G. (1902). Some abnormal psychical conditions in children. Lencet, I, 1008-1012, 1077-1082, 1163-1169. Strauss, A., & Lehtinen, J. (1947) Psychopathology and education of the brain-injured child. New York: Grune & Stratton Wolraich, M. L., Lambert, W., Doffing, M. A., Bickman, L., Simmons,T.,&Worley,K.(2003).Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28, 559 568.