Mary V. Solanto, Ph.D. Director, ADHD Center Mt. Sinai School of Medicine

Transcription

1 Mary V. Solanto, Ph.D. Director, ADHD Center Mt. Sinai School of Medicine Disclaimer: The information provided here is supported by Cooperative Agreement Number CDC-RFA-DD from the Centers for Disease Control and Prevention (CDC). The Ask the Expert webinars contents are solely the responsibility of the invited guest Expert and do not necessarily represent the official views of CDC. Neither CHADD, the National Resource Center on ADHD, nor the CDC endorses, supports, represents or guarantees the accuracy of any material or content presented in the Ask the Expert webinars, nor endorses any opinions expressed in any material or content of the webinars. CHADD and the National Resource Center on ADHD offer webinars for educational purposes only; the information presented should not be regarded as medical advice or treatment information.

2 CHADD improves the Lives of people Affected by ADHD. - After my son was diagnosed with ADHD, CHADD s information provided understanding and direction during very difficult times. - Ginger Ballinger, TX

3 Why Join CHADD? Attention National Network of Support Groups CHADD Exchange online Community Professional Directory Advocacy Annual Conference & Regional Conferences Parent to Parent Training Teacher to Teacher Training National Resource Center on ADHD

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6 DSM-5 and ADHD: New Diagnostic Guidelines Mary V. Solanto, Ph.D. Ask the Expert Webinar Sponsored by CHADD July 10, 2013

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8 DSM-IV Symptoms of Inattention Fails to give close attention to details/careless errors Difficulty sustaining attention Often does not seem to listen Fails to follow through/complete tasks Difficulty organizing tasks and activities Avoids/dislikes tasks requiring sustained attention Loses things necessary for tasks/activities Easily distracted by extraneous stimuli Often forgetful in daily activities

9 DSM-IV Symptoms of Hyperactivity- Impulsivity Fidgety, squirms in seat Often leaves seat Often runs or climbs excessively Has difficulty playing quietly Often "on the go"/ "driven by a motor Often talks excessively Blurts out answers before question is completed Often has difficulty awaiting turn Often interrupts or intrudes on others

10 Three Types of Attention Deficit/Hyperactivity Disorder (DSM-IV) Predominantly Inattentive Predominantly Hyperactive-Impulsive Combined (both)

11 Symptom Criteria for Diagnosis Predominantly Inattentive Subtype (IN) 6 of 9 of Inattention symptoms Fewer than 6 Hyperactive-Impulsive symptoms Predominantly Hyperactive-Impulsive type (PI) 6 of 9 of Hyperactive-Impulsive symptoms Fewer than 6 Inattentive symptoms Combined Subtype (CB) 6 of 9 of Inattention symptoms 6 of 9 of Hyperactive-Impulsive symptoms

12 DSM-IV Criteria (continued) Symptoms must be excessive compared to others of the same age and gender Onset by age 7 Duration of at least 6 months Clinically significant impairment at home and at school/work Not due to PDD, or other mental health problem (eg anxiety, depression)

13 Changes in DSM-5 ADHD now classified as a Neurodevelopmental Disorder Changes in wording of symptoms to accommodate adolescents/adults. For example: Often has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, conversations or lengthy reading) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (eg. schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers). Often runs or climbs excessively (In adolescents or adults, may be limited to feeling restlessnes) For adults, criterion number of symptoms reduced from 6 to 5 for each dimension Elevate age of onset to 12 Subtypes changes to Presentations Removal of exclusion for PDD

14 Why Lower the Symptom Threshold for Adults? Thresholds were originally based on studies with children Murphy & Barkley (2006) gave a DSM-IV checklist of ADHD symptoms to a sample of the general population (n=720) The highest-scoring adults (top 7%) have about 4 symptoms in each dimension. Solanto, Marks, Wasserstein et al (2012) showed that only half of adults with ADHD who are high on hyperactivity-impulsivity have at least 6 symptoms. Others have between 4 and 6.

15 Elevate Age of Onset (to 12 yr): The Case In Favor Inattentive subtype has documented higher age of onset (9 yr) (Applegate et al, 1997) Retrospectively reported age of onset for adults is unreliable and >7 yr (Barkley, 2008) No clinically meaningful differences between adults with retrospectively reported onset before vs. after age 7 Faraone, 2006; Barkley, 2008

16 Subtypes: Arguments for Deletion Data thus far show few or no differences between PI and CB in: Neurocognition (except processing speed) Response to methylphenidate or atomoxetine Stein, 2003; Solanto, 2007 Familial or molecular genetics Don t breed true Neuroimaging (very few studies exist) Unstable across development (Lahey, 2005)

17 Subtypes: Arguments for Retention Pronounced differences in presenting symptoms, gender ratio, age of onset, comorbidity, social function Insufficient data re possible neurobiological differences (genetics, neuroimaging) Yet if subtypes are deleted now, research would cease Value to the clinician/teacher/parent: Enhanced recognition (to delete may generate confusion) Indicate need for different psychosocial treatments

18 Compromise: Current Presentation Recognizes that the subtype designation may not be stable

19 Rationale for Deletion of Exclusion Criterion for Autism High rate of comorbidity with ADHD symptoms 30-40% would meet criteria Responds to stimulants But some argue that inattention and hyperactivity are different in etiology in autism vs. ADHD.

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21 Mary V. Solanto, Ph.D. Director, ADHD Center Mt. Sinai School of Medicine

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