I thought it would be important to point this out to people about the DSM, because for too long I've seen people either misuse DSM criteria for their diagnoses (or self-diagnoses) or not understand what that list really is.

The DSM is not an arbitrary list of things that if you meet, you have ADHD. Those criteria are not made up, and the disorder based on the criteria. The criteria are generated by what symptoms an individual with a disorder are statistically likely to have. An individual who has the symptoms doesn't have ADHD. An individual who has ADHD, however, does have the symptoms.

The diagnostic tool is that it allows trained professionals to determine whether or not an individual is likely to have a disorder based on the symptoms. The symptoms don't make the disorder, however; the disorder makes the symptoms.

The DSM was written by evaluating individuals with ADHD, and determining the symptoms those individuals were most likely to demonstrate; not vice versa. This is important to know for individuals who say "if you meet the criteria, you have the disorder." In fact, the exact opposite is true: if you have the disorder, you meet the criteria.

That makes it difficult for people to read a list and determine if they have something, and in fact it should. The DSM is not to be used alone to make diagnoses based on checklists. If that were the case, I guarantee I could make any individual meet virtually any disorder.

Instead, the criteria are used by clinicians to help them determine, through vasts amounts of training and experience, what the most likely and best diagnosis is. This is one of the reasons I get very upset when non-psychiatric professionals (general practitioners, pediatricians, etc.) without formal psychiatric/psychological schooling, make ADHD diagnoses: the fact is, with some exceptions (those who have taken training on diagnosis of psychiatric disorders), they don't have the training or experience necessary to make a reliable judgment.

Please always bear in mind: symptoms don't make disorders. Disorders make symptoms.

A little information is a bad thing. The criteria from the DSM people so often look at online is not complete. Another important part of the DSM that is not included in online criteria is the indepth information and the "differential diagnosis" section. This section is specifically designed to ensure that it is the diagnosis being made, and not a similar disorder. This is important because in many cases, the comorbid disorders talked about a lot here and other places are actually either aspects of the ADHD diagnosis (and not another disorder) or the actual problem (and ADHD is not present.) For example, individuals with Asperger's Disorder who demonstrate ADHD like symptoms do not have ADHD. They have Asperger's Disorder. That the symptoms are similar does not mean both conditions exist.

I am debating whether I should type up the entire entry on ADHD in the DSM (it's 3 or 4 pages long) and post it here. Part of me wants to, to allow people a more accurate look of what symptoms are often attributed to ADHD. The other part, however, tells me not to, because it will just let people misdiagnose further, or cause other problems. I'd like to know what you guys want from that, or if you want to flay me because I'm railing against self-diagnosis, etc...

K.Miller,

First of all, welcome back.

Secondly, thank you for that post. Excellent points.

I've posted on this before, and I know I've read some of Barkley's comments on the subject that scuro has posted.

I can not agree more. Without the diagnostic criteria being met, the symptoms are meaningless.

As I've said many times before, "The clinical threshold is impairment.No impairment,no disorder."

Impairment, as well as clinical diagnostic criteria which, most importantly, cannot be assessed based on the criteria list alone. Most of the important details concerning the definitions of the terms are not on the short list of diagnostic criteria seen most often online. Though that list is part of the criteria, and lists the major parts, meeting 9 of 14 criteria alone does not make a viable diagnosis.

I agree.

When I get the chance, I'll be glad to post some of the information presented by Russ Barkley in a March teleconference on ADHD in Adults.

He points out how , for adults, the symptoms need to be "age referenced," meaning they need to apply to adult activities.

He has some lists of the different comparison's between the symptoms and how they'd be manifested by an adult with ADHD.

Thanks again.

I think another important thing to go with is that things in the DSM are what they are. One of the things I've noticed a lot of, especially since Strattera came along, are the use of the term "ADD" and especially "Adult ADD." Clinically, neither of those things exist. They both fall under "ADHD" and the terms aren't even used. ADD is an older term for ADHD without Hyperactivity. "Adult ADD" was invented entirely by Lilly to push Strattera. If they invent Adult ADD, then they can market their drug as the "only drug approved" to treat it.

In this circle, the use of the term ADD and Adult ADD is not detrimental...but it does cause loss of clarity. It also establishes a lot of differences where there should be none, and mostly hurts diagnosis. Calling ADHD "ADD" is not a problem. Believing one has "ADD" and not "ADHD" is. ADD works as a shorthand for Attention Deficit/Hyperactivity Disorder Predominantly Inattentive Type (AD/HD-PI) but it isn't it's own real diagnosis.

ADD works as a shorthand for Attention Deficit/Hyperactivity Disorder Predominantly Inattentive Type (AD/HD-PI) but it isn't it's own real diagnosis.
I know it's the accepted term, but I don't like it. Attention Deficit/Hyperactivity Disoder without hyperactivity? What the heck is that? Is it something like a steak sandwich without the steak?

At any rate, looking at some of the posts on this list (by scuro in particular) and mainstream stuff by Barkely et al, there seems to be a move toward giving this type its own diagnosis anyway (SCT; cf Is Inattentive AD/HD Really Another Type of Disorder? (http://www.addforums.com/forums/showthread.php?t=19889)).

Another thing: about self diagnosis. When the main center for adult diagnosis in my country of residence stopped accepting new patients after its waiting list reached 10 years, I realized that I was going to have to muddle through a lot of this on my own. I will probably sit myself in front of a head shrinker at some point, but in the meantime I'll do what I can to find out what is wrong with me, and what I can do to improve it.

Your case is somewhat unique, Uminchu, with no access to a pdoc. But self-diagnosis has a place. Provided you understand that a self-diagnosis is not 100% certain, and that it's more an approximation, then it's well placed. But don't generalize things onto yourself based on that diagnosis.

ADHD without Hyperactivity isn't a diagnosis anymore. Now there's a "Predominantly" scale. But I do believe Inattentive ADHD is likely another disorder. It appears to be very different in that it demonstrates a difference in the way the dopamine receptors are affected, at the least.

If you go back and look at the history of what we now call ADHD, you'll see a progession of different name changes ,as well as changes in the direction of theories,etc.

A perfect example is the DSM. With each subsequent revision, there were evidenced based changes made. In other words, the new symptoms came about as a result of the research and not vice versa.

ADHD and the Nature of Self-Control (1997) is a very complicated but equally interesting book. It's geared more for professionals and you have to reeeaally like to read this stuff.

The history part in the beginning is excellent. It's not diifcult in the least and is actually quite fascinating in terms of how we've gotten where we are now.

What is currently being found more and more often is a new appreciation of George Still's original (1902) research study on ADHD

He's really very close in his theory to what is being said now about "self-regulation."

Good luck and please keep us posted.

take care

mctavish23 (Robert)

But self-diagnosis has a place. Provided you understand that a self-diagnosis is not 100% certain, and that it's more an approximation, then it's well placed. But don't generalize things onto yourself based on that diagnosis.
Yes, I think that's an important point. Reading the various books on ADD, and reading these forums, I see lots of things that don't describe me at all -- but I can see how easy it would be for someone to assume they had those problems because "I'm ADD too."

ADHD without Hyperactivity isn't a diagnosis anymore. Now there's a "Predominantly" scale.
But it still doesn't explain how someone who is not hyperactive could have a hyperactivity disorder.

Apparently, not even the professional community is all that happy with the term "AD/HD." For instance, Delivered from Distraction uses "ADD." So I feel like I'm in good company continuing to use it. :)

I also think that "adult ADD" is a useful term, not as a diagnosis but when looking for psychiatrists/psychologists willing to treat you.

But I do believe Inattentive ADHD is likely another disorder. It appears to be very different in that it demonstrates a difference in the way the dopamine receptors are affected, at the least.
It will be interesting to see how it turns out.

Okay,

The DSM -IV uses different nomenclature based on research results.

ADHD-Predominantly Inattentive type 314.00

ADHD-Combined and ADHD-Predominantly Hyperactive -Impulsive type 314.01 (for both)

ADHD Not Otherwise Specified (NOS) 314.9

ADHD NOS is for those "in between" or "borderline" cases where you believe ADHD to be present, but don't have the required number of symptoms ( 6 out of 9 for either ADHD-I,ADHD-C or ADHD-H-I types).

Lots of people still interchangably use "ADD" and "ADHD." I do it all the time when I'm talking to parents.However, I do make a point of telling them that "Today,everything is called ADHD, so when I' say ADHD -Predominantly Inattentive type, I'm referring to the old "ADD."

I even make that distinction in letters and reports.

Hope that helps :)

I'm interested in how you (anyone can answer) define impairment when applied to AD/HD. What qualifies as impairment vs being merely an annoying habit or quirk? This seems very subjective to me.

Hope that helps :)
Sure does!

But I think I'll keep calling it ADD until the name changes to "disinhibition disorder." :)

"Impairments" are the "problems" that result from ADHD that others (without ADHD ) don't experience.

The impairments are considered "developmental delays" in the sense that same age /peers don't have those problems.

The journal article International Consensus 2002 has the most definitive definition of what constitutes a "disorder."

It's available at www.chadd.org or at Russell Barkley's website.

I hope that helps.I'll keep looking for more examples.

Disinhibition is also at the top of my list as the next choice too.

Good insight.

I'm interested in how you (anyone can answer) define impairment when applied to AD/HD. What qualifies as impairment vs being merely an annoying habit or quirk? This seems very subjective to me.

I will quote the DSM itself in this regard:

"Attentional and behavioral manifestations usually appear in multiple contexts, including home, school, work, and social situations. To make the diagnosis, some impairment must be present in at least two settings (Criterion C). It is very unusual for an individual to display the same level of dysfucntion in all settings or within the same setting at all times. Symptoms typically worsen in situations that require sustained attention or mental effort or that lack intrinsic appeal or novelty (e.g., listening to classroom teachers, doing class assignments, listening to or reading lengthy materials, or working on monotonous, repetitive tasks.) Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situations (e.g., in playgroups, classrooms, or work environments)."

That's how it talks about diagnosing impairment for this disorder. As far as the actual definition of what is impairment, we'd have to look someplace else. The generally accepted definition is exactly as it seems; functioning below the level at which a normal functioning peer is likely to function given no situational interference.

Thank you both for your responses. They helped.

It seems that a "well behaved" adult that has hidden their ADHD traits (impairment) from the world makes it very difficult for people to take their diagnosis seriously. Frustrating. Extremely.

"Inadequate self-application to tasks that require sustained effort is often interpreted by others as indicating laziness, a poor sense of responsibility, and oppositional behavior. Family relationships are often characterized by resentment and antagonism, especially because variability in the individual's symptomatic status often leads others to believe that all the troublesome behavior is willful." DSM-IV, pp. 88, Emphasis Added.

"Symptoms of Attention Deficit/Hyperactivity Disorder are typically at their most prominent during the elementary grades. As children mature, symptoms usually become less conspicuous. By late childhood and early adolescence, signs of excessive gross motor activity (e.g., excessive running and climbing, not remaining seated) are less common, and hyperactivity symptoms may be confined to fidgetiness or an inner feeling of jitteriness or restlessness. In adulthood, restlessness may lead to difficulty in participating in sedentary activities and to avoiding pastimes or occupations that provide limited opportunities for spontaneous movement (e.g., desk jobs.) Social dysfunction in adults appears to be especially likely in those who had additional concurrent diagnoses in childhood." DSM-IV, pp. 89, Emphasis Added.

Nicely done K.Miller.

Here's some of the power point notes from Russ Barkley's March teleconference on ADHD in Adults:

This power point is titled: SYMPTOMS OF HYPERACTIVITY OFTEN MANIFEST DIFFERENTLY IN ADULTS

DSM-IV Symptom Domain ..... Common Adult Manifestation

Squirms & fidgets ..... Workaholic

Can't stay seated ..... Overscheduled/overwhelmed


Runs/ climbs excessively ..... Self-select active job


Can't work/play......Constant activity quitely

Talks excessively.....Talks excessivley

Talks excessively.....Talks excessivley
It is interesting that we don't grow out of this, isn't it?

It seems that a "well behaved" adult that has hidden their ADHD traits (impairment) from the world makes it very difficult for people to take their diagnosis seriously. Frustrating. Extremely.Definately frustrating! I was reading Dr. Barkley's book recently and he was discussing how if a child does well twice in their life we hold it against them forever! I can relate.

Like Keith quoted (BTW, very nice to have your informative posting with us again, Keith!)
especially because variability in the individual's symptomatic status often leads others to believe that all the troublesome behavior is willful." DSM-IV, pp. 88, Emphasis Added.It's an unenviable position to try to convince someone you have a deficit -- "No guys, really!" One of my husband's favorite lines before he saw the difference meds made was "You're a Phi Kappa Phi and you can't even .......... (fill in the blank with many apparently easy tasks).

Mostly I've found you can't convince people if' you've done a good job of covering it for years, so I don't much try anymore. Having a couple of people who do believe you and care about you (and access to a good therapist) is generally enough.

Take care,
Scattered

[QUOTE=KMiller]
<SNIP>
I am debating whether I should type up the entire entry on ADHD in the DSM (it's 3 or 4 pages long) and post it here.
<snip>
/QUOTE]

I would love to see it.

Thanks, Vic

Advertising may be described a the science of arresting the human intelligence long enough to get money from it. --- Stephen Leacock, Humourist

Well, that's one for, zero against...I may type it up later tonight when I get back from working in the lab...late subject appointment tonight, bah.

Well, that's one for, zero against...I may type it up later tonight when I get back from working in the lab...late subject appointment tonight, bah.
Hey, I didn't know this was a vote.

Count me as one in favor.

I have decided I will type up the complete ADHD diagnostic criteria and discussion as is written in the DSM-IV. However, I will also type up the notes in the front of the book regarding using the DSM-IV, as well as the disclaimer. The NOTES are VERY IMPORTANT because they discuss the limitations in the DSM-IV. I may or may not decide to make this a separate thread.

I have decided I will type up the complete ADHD diagnostic criteria and discussion as is written in the DSM-IV. However, I will also type up the notes in the front of the book regarding using the DSM-IV, as well as the disclaimer. The NOTES are VERY IMPORTANT because they discuss the limitations in the DSM-IV. I may or may not decide to make this a separate thread.
That would be a great service to the forums, thanks.

The disclaimers and important notes on using DSM-IV, as transcribed by me from my copy of DSM-IV. All typographical errors are my own, unless otherwise noted (my excuse is that I'm typing this without looking at the screen, just the book, because it's quite long). The paragraphs are denoted by a double space, because you can't tab here apparently.

==ISSUES IN THE USE OF DSM-IV==

LIMITATIONS OF THE CATEGORICAL APPROACH (pg. xxxi, xxxii)

DSM-IV is a categorical classification that divides mental disorders into types based on criteria sets with defining features. This naming of categories is the traditional method of organizing and transmitting information in everyday life and has been the fundamental approach used in all systems of medical diagnosis. A categorical approach to classification works best when all members of a diagnostic class are homogeneous, when there are clear boundaries between classes, and when the different classes are mutuallty exclusive. Nonetheless, the limitations of the categorical classification system must be recognized.

In DSM-IV, there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder. There is also no assumption that all individiauls described as having the same mental disorder are alike in all important ways. The clinician using DSM-IV should therefore consider that individuals sharing a diagnosis are likely to be heteroeneous even in regard to the defining features of the diagnosis and that boundary cases will be difficult to diagnose in any but a probabilistic fashion. This outlook allows greater flexibility in the use of the system, encourages more specific attentnion to boundary cases, and emphasizes the need to capture additional clinical information that goes beyond diagnosis. In recognition of the heterogeneity of clinical presentations, DSM-IV often invludes polythetic criteria sets, in which the individual need only present with a subset of items from a longer list (e.g., the diagnosis of Borderline Personality Disorder requirs only five out of nine items.)

It was suggested that the DSM-IV Classification be organized following a dimensional model rather than the categorical model used in DSM-III-R. A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment to categories and works best in describing phenomena that are attributed continuously and do not have clear boundaries. Although dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be subthreshold in a categorical system), they also have serious limitations and thus far have been less useful than categorical systems in clinical practice and in stimulating research. Numerical dimensional discriptions are much less familiar and vivid than are the categorical names for mental disorders. Moreover, there is as yet no agreement on the choie of the optimal dimentions to be used for classification purposes. Nonetheless, it is possible that the increasing research on, and familiarity with, dimensional systems may eventually result in the greater acceptance both as a method of conveying clinical information and as a research tool.

USE OF CLINICAL JUDGMENT (pg. xxxii) [READ THIS]

DSM-IV is a classification of mental disorders that was developed for use in clinical, educational, and research settings. The diagnostic categories, criteria, and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in daignosis. It is important that DSM-IV not be applied mechanically by untrained individuals. The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion. For example, the use of clinical judgment may justify giving a certain diagnosis to an individual even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe. On the other hand, lack of familiarity with DSM-IV or excessively flexible and idiosyncratic application of DSM-IV criteria or conventions substantially reduces its utility as a common languages for communication.

In addition to the need for clinical training and judgment, the method of data collection is also important. The valid application of the diagnostic criteria included in this manual necessitates and evaluation that directly accesses the information contained in the criteria sets (e.g., whether a syndrome has persisted for a minimum period of time). Assessments that rely solely on psychological testing not covering the criteria content( e.g., projective testing) cannot be validly used as the primary source of diagnostic information.

==CAUTIONARY STATEMENT== (pg. xxxvii)

The specified diagnostic criteria for each mental disorder are offered as guildines for making diagnoses, because it has been demonstrated that the use of such criteria enhances agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.

These diagnostic criteria and the DSM-IV Classification of mental disorders reflect a consensus of current formulations of evolving knowledge in our field. They do not encompass, however, all the conditions for which people may be treated or that may be appropriate topics for research efforts.

The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that includion here, for clinical and research purposes, of a diatnostic category such as Pathological Gambling or Pedophilia does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency.

[Editorial Notes: In this transcription, ==text== is used to designate header sized text. All capitalization, bold, italization, and so further is as written in the book, unless otherwise noted. In some cases, I have made editorial comments, as noted.]

Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision., Washington, D.C., American Psychiatric Association, 2000 , pg. 85-91

== ATTENTION DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS ==

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

==Diagnostic Features==
The essential feature of Attention-Deficit/Hyperactivity Disorder [Ed. Note: henceforth I will be shortening this to ADHD, in brackets] is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development (Criterion A). Some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years, although many individuals are diagnosed after the symptoms have been present for a number of years, especially in the case of individuals with the Predominantly Inattentive Type (Criterion B). Some impairment from the symptoms must be present in at least two settings (e.g., at home and at school or work) (Criterion C). There must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning (Criterion D). The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and is not better accounted for by another mental disorder (e.g., a Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder). [Ed. Note: this is why I'm always wary of the Autism/ADHD diagnoses: it says they aren't allowed]

Inattention may be manifest in academic, occupational, or social situations. Individuals with this disorder may fail to give close attention to details or may make careless mistakes in schoolwork or other tasks (Criterion A1a). Work is often messy and performed carelessly and without considered thought. Individuals often have difficulty sustaining attention in tasks or play activities and often find it hard to persist with tasks until completion (Criterion A1b). They often appear as if their mind is elsewhere or as if they are not listening or did not hear what has just been said (Criterion A1c). There may be frequent shifts from one uncompleted activity to another. Individuals diagnosed with this disorder may begin a task, move on to another, then turn to yet something else, prior to completing any one task. They often do not follow through on requests or instructions and fail to complete schoolwork, chores, or other duties (Criterion A1d). Failure to complete tasks should be considered in making this diagnosis only if it is due to inattention as opposed to other possible reasons (e.g., failure to understand instructions, defiance). These individuals often have difficulties organizing tasks and activities (Criterion A1e). Tasks that require sustained mental effort are experienced as unpleasant and markedly aversive. As a result, these individuals typically avoid or have a strong dislike for activities that demand sustained self-application and mental effort or that require organizational demands or close concentration (e.g., homework or paperwork) (Criterion A1f). This avoidance must be due to the person's difficulties with attention and not due to a primary oppositional attitude, although secondary oppositionalism may also occur. Work habits are often disorganized and the materials necessary for doing the task are often scattered, lost, or carelessly handled and damaged (Criterian A1g). Individuals with this disorder are easily distracted by irrelevant stimuli and frequently interrupt ongoing tasks to attend to trivial noises or events that are usually and easily ignored by others (e.g., a car honking, a background conversation) (Criterion A1h). They are often forgetful in daily activities (e.h., missing appointments, forgetting to bring lunch) (Criterion A1i). In social situations, inattention may be expressed as frequent shifts in conversation, not listening to others, not keeping one's mind on conversations, and not following details or rules of games or activities.

Hyperactivity may be manifested by fidgitiness or squirming in one's seat (Criterion A2a), by not remaining seated when expected to do so (Criterion A2b), by excessive running or climbing in situations where it is inappropriate (Criterion A2c), by havin difficulty playing or engaging quietly in leisure activities (Criterion A2d), by appearing to be often "on the go" or as if "driven by a motor." (Criterion A2e) or by talking excessively (Criterion A2f). Hyperactivity may vary with the individual's age and developmental level, and the diagnosis should be made cautiously in young children. Toddlers and preschoolers with this disorder differ from normally active young children by being constantly on the go and into everything; they dart back and forth, are "out of the door before their coat is on," jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes (e.g., listening to a story). School-age children display similar behaviors but usually with less frequency or intensity than toddlers and preschoolers. THey have difficulty remaining seated, get up frequently, and squirm in, or hang on to the edge of, their seat. They fidget with objects, tap their hands, and shake their feet or legs excessively. They often get up from the table during meals, while watching television or while doing homework; they talk excessively; and they make excessive noise during quiet activities. In adolescents and adults, symptoms of hyperactivity take the form of feelings of restlessness and difficulty engaging in quiet sedentary activities.

Impulsivity manifests itself as impatience, difficulty in delaying responses, blurting out answers before questions of been completed (Criterion A2g), difficulty awaiting one's turn (Criterion A2h), and frequently interrupting or intruding on others to the point of causing difficulties in social, academic, or occupational settings (Criterion A2i). Others may complain that they cannot get a word in edgewise. Individuals with this disorder typically make comments out of turn, fail to listen to directions, initiate conversations at inappropriate times, interrupt others excessively, intrude on others, grab objects from others, touch things they are not supposed to touch, and clown around. Impulsivity may lead to accidents (e.g., knocking over objects, banging into people, grabbing a hot pan) and to engagement in potentially dangerous activities without consideration of possible consequences (e.g., repeatedly climbing to precarious positions or riding a skateboard over extremely rough terrain).

Attentional and behavioral manifestations usually appear in multiple contexts, including home, school, work, and social situations. To make the diagnosis, some impariment must be present in at least two setings (Criterion C). It is very unusual for an individual to display the same level of dysfunction in all settings or within the same setting at all times. Symptoms typically worsen in situations that require sustained attention or mental effort or that lack intrinsic appeal or novelty )e.g., listening to classroom teachers, doing class assignments, listening to or reading lengthy materials, or working on monotonous, repetitive tasks). [Ed. Note: I am, in fact, having a hard time continuing to write all of this...but I'm waiting to be tired enough to sleep, and keeping myself distracted, so it's ok] Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situation (e.g., the clinician's office). The symptoms are more likely to occur in group situations (e.g., in playgroups, classrooms, or work environments). The clinician should therefore gather information from multiple sources (e.g., parents, teachers) and inquire about the individual's behavior in a variety of situations within each setting (e.g., doing homework, having meals).

==Subtypes==
Although many individuals present with symptoms of both inattention and hyperactivity-impulsivity, there are individuals in whom one or the other pattern is predominant. The appropriate subtype (for a current diagnosis) should be indicated based on the predominant symptom pattern for the past 6 months.

[Ed. Note: the following is centered in the page, that is, tabbed in entirely]
314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type. This subtype should be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months. Most children and adolescents with the disorder have the Combined Type. It is not known whether the same is true of adults with the disorder.
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. This sybtype should be used if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months. Hyperactivity may still be a significant clinical feature in many such cases, wheras other cases are more purely inattentive.
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type. This subtype should be used if six (or more) symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) have persisted for at least 7 months. Inattention may often still be a significant clinical feature in such cases.

==Recording Procedures==
Individuals who at an earlier stage of the disorder had the Predominantly Inattentive Type or the Predominantly Hyperactive-Impulsive Type may go on to develop the Combined Type, and vice versa. The appropriate sybtype (for a current diagnosis) should be indicated on the basis of the predominant symptom pattern for the past 6 months. If clinically significant symptoms remain but criteria are no longer met for any of the subtypes, the appropriate diagnosis is Attention-Deficit/Hyperactivity Disorder, In Partial Remission. When an individual's symptoms do not currently meet full criteria for the disorder and it is unclear whether criteria for the disorer have previously been met, Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified should be diagnosed.

==Associated Features and Disorders== [Ed. Note: these are particularly of interest, as most people here will have never seen these before, as they aren't on the criteria sheet commonly used online
Associated descriptive features and mental disorders. Associated features vary depending on age and developmental stage and may include low frustration tolerance, temper outbursts, bossiness, stubbornness, excessive and frequent insistence that requests be met, mood lability, demoralization, dysphoria, rejection by peers, and poor self-esteem. Academic achivement is often markedly impaired and devalued, typically leading to conflict with the family and with school authorities. Inadequate self-application to tasks that require sustained effort is often interpreted by others as indicating laziness, a poor sense of responsibility, and oppositional behavior. Family relationships are often cahracterized by resentment and antagonism, especially because variability in the individual's symptomatic status often leads others to believe that all the troublesome behavior is willful. Family discored and negative parent-child interactions are often preent. Such negative interactions often diminish with successful treatment. On average, individuals with [ADHD] obtain less schooling than their peers and have poorer vocational achievement. Also, on average, intellectual level,a s assessed by individual IQ tests, is several points lower in children with this disorder compared with peers. At the same time, great variability in IQ is evidenced: individuals with [ADHD] may show intellectual development in the above-average or gifted range. In its severe form, the disorder is markedly impairing, affecting social, familiar, and scholastic adjustment. All three subtypes are associated with significant impairment. Academic deficits and school-related problems tend to be most pronounced in the types marked by inattention (Predominantly Inattentive and Combined Types) , whereas peer rejection and, to a lesser extent, accidental injury are most salient in the types marked by hyperactivity and impulsivity (Predominantly Hyperactive-Impulsive and Combined Types). Individuals with the Predominantly Inattentive Type tend to be socially passive and appear to be neglected, rather than rejected, by peers.

A substantial portion (approximately half) of clinic-referred children with [ADHD] also have Oppositional Defiant Disorder or Conduct Disorder. The rates of co-pccurence of [ADHD] with these other Disruptive Behavior Disorders are higher than with other mental disorers, and this co-occurrence is most likely in the two subtypes marked by hyperactivity-impulsivity (Hyperactive-Impulsive and Combined Types). Other associated disorders include Mood Disorders, Anxiety Disorders, Learning Disorders, and Communication Disorders in children with [ADHD]. Although [ADHD] appears in at least 50% of clinic-regerred individuals with Tourette's Disorder, most individuals with [ADHD] do not have accompanying Tourette's Disoder. When the two disorders coexist, the onset of the [ADHD] often precedes the onset of the Tourette's Disorder.

There may be a history of child abuse or neglect, multiple foster placements, neurotoxin exposure (e.g., lead poisoning), infections (e.g., encephalitis), drug exposure in utero, or Mental Retardation. Although low birth weight may sometimes be associated with [ADHD], anmost children with low birth weight do not develop [ADHD] and most children with [ADHD] do not have a history of low birth weight.

Associated laboratory findings. There are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of [ADHD]. Tests that require effortful mental processing have been noted to be abnormal in groups of individuals with [ADHD] compared with peers, but these tests are not of demonstrated utility when one is trying to determine whether a particular individual has the disorder. It is not yet known what fundamental cognitive deficits are responsible for such group differences.

Associated physical examination findings and general medical conditions. There are no specific physical features associated with [ADHD], although minor physical anomalies (e.g., hypertelorism, hylery arched palate, low-set ears) may occur at a higher rate than in the general population. There may also be a higher rate of accidental physical injury.

==Specific Culture, Age, and Gender Features==
[ADHD] is known to occur in various cultures, with variations in reported prevalence among Western countries probably arising more from different diagnostic practices than from differences in clinical presenation.

It is difficult to establish this diagnosis in children younger than age 4 or 5 years, because their charactersitic behavior is much more variable than that of older children and may include features that are similar to symptoms of [ADHD]. Furthermore, symptoms of inattention in toddlers or preschool children are often not readily observed because young children typically experiecne few demands for sustained attention. However, even the attention of toddlers can be held in a variety of situations (e.g., the average 2- or 3-year-old child can typically sit with an adult looking through picture books). Young children with [ADHD] move more excessively and typically are difficult to contain. Inquiring about a wide variety of behaviors in a young child may be helpful in ensuring that a full clinical picture has been obtained. Substantial impairment has been demonstrated in preschool-age children with [ADHD]. In school-age children, symptoms of inattention affect classroom work and academic performance. Impulsive symptoms may also lead to the breaking of familiar, interpersonal, and educational rules. Symptoms of [ADHD] are typically at their most prominent during the elementary grades. As children mature, symptoms usually become less conspicuous. By late childhood and early adolescence, signs of excessive gross motor activity (e.g., excessive running and climbing, not remaining seated) are less common, and hyperactivity symptoms may be confied to fidgetiness or an inner feeling of jitteriness or restlessness. In adulthood, restlessness may lead to difficulty in participating in sedentary activities and to avoiding pastimes or occupations that provide limited opportunity for spontaneous movement (e.g., desk jobs). Social dysfunction in adults appears to be especially likely in those who had additional concurrent diagnoses in childhood. Caution should be exercised in making the diagnosis of [ADHD] in adults solely on the basis of the adult's recall of being inattentive or hyperactive as a child, because the validity of such retrospective data is often problematic. Although supporting information may not always be available, corroborating information from other informations (invluding prior school recorsd) is helpful for improving the accuracy of the diagnosis.

The disorder is more frequent in males than in females, with the male-to-female ratio ranging from 2:1 to 9:1, depending on the type (i.e., Predominantly Inattentive Type may have a gener ratio that is less pronounced) and setting (i.e., clinic-referred children are more likely to be male).

==Prevalence==
The prevalence of [ADHD] has been estimated at 3%-7% in school-age children. These reported rates vary depending on the nature of the population sampled and the method of ascertainment. Data on prevalence in adolescence and adulthood are limited. Evidence suggests that the prevalence of [ADHD] as defined in DSM-IV may be somewhat greater than the prevalence of the disorder based on DSM-III-R criteria because of the inclusion of the Predominantly Hyperactive-Impulsive and Predominantly Inattentive Types (which would have been diagnosesd as [ADHD] Not Otherwise Specified in DSM-III-R).

==Course==
Most parents first observe excessive motor activity when the chidlren are toddlers, frequently coincidign with the development of independent locomotion. HOwever, because many overactive toddlers will not go on to develop [ADHD], special attention should be paid to differentiating normal overactivity from the hyperactivity characteristic of [ADHD] before making this diagnosis in early years. Usually, the disorer is first diagnosed during elementary school years, when school adjustment is compromised. Some children with the Predominantly Inattentive Type may not come to clinical attention until late childhood. In the majority of cases seen in clinical settings, the disorder is relatively stable through early adolescence. In most individuals, symptoms (particularly motor hyperactivity) attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of [ADHD] into mid-adulthood. Other adults may retain only some of the symptoms, in which case the diagnosis of [ADHD], in Partial Remission, should be used. The latter diagnosis applies to individuals who no longer have the full disorder but still retain some symptoms that cause functional impairment.

==Familial Pattern==
[ADHD] has been fooound to be more comon in the first-degree biological relatives of children with [ADHD] than in the general population. Considerable evidence attests to the strong influence of genetic factors on levels of hyperactivity, impulsivity, and inattention as measured dimensionally. However, family, school, and peer influences are also curcial in determining the extent of impairments and comorbidity. Studies also suggest that there is a higher prevalence of Mood and Anxiety Disorders, Learnign Disorders, Substance-Related Disorders, and Antisocial Personality Disorder in family members of individuals with [ADHD].

==Differential Diagnosis== [Ed. Note: Important!]
In early childhood, it may be difficult to distinguish symptoms of [ADHD] from age-appropriate behaviors in active children (e.g., running around or being noisy).

Symptoms of inattention are common among children with low IQ who are placed in academic settings that are inapprorpiate to their intellectual ability. These behaviors must be distinguished from similar signs in children with [ADHD]. In children with Mental Retardation, an additional diagnosis of [ADHD] should be made only if the symptoms of inattention or hyperactivity are excessive for the child's mental age. Inattention in the classroom may also occur when children with high intelligence are placed in academically understimulating environments. [ADHD] must also be distinguished from difficulty in goal-directed behavoir in children from inadequate, disorganized, or chaotic environments. Thorough histories of symptoms pattern obtained from multiple informatns (e.g., baby-sitters, grandparents, or parents of playmates) are helpful in providing a confluence of observations concerning the child's inattention, hyperactivity, and capacity for developmentally appropriate self-regulation in various settings.

Individuals with oppositional behavior may resits work or school tasks that require self-application because of an unwillingness to conform to others' demands. These symptoms must be differentiated from the avoidance of school tasks seen in individuals with [ADHD]. Complicating the differential diagnosis is the fact that some individuals with [ADHD] develop secondary oppositional attitudes toward such tasks and devalue their importance, often as a rationalization for their failure.

The increased motor activity that amy occur in [ADHD] must be distinguished from the repetitive motor behavior that characterizes Stereotypic Movement Disorder. In Stereotypic Movement Disorder, the motor behavior is generally focused and fixed (e.g., body rocking, self-biting), whereas the fidgetiness and restlessness in [ADHD] are more typically generalized. Furthermore, individuals with Stereotypic Movement Disorder are not generally overactive; aside from the stereotypy, they may be underactive.

[ADHD] is not diagnosed if the symptoms are better accounted for by another mental disorder. (e.g., Mood Disorder [especially Bipolar Disorder], Anxiety Disorder, Dissociateive Disoder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Subtance-Related Disorder). In all these disorders, the symptoms of inattention typically have an onset after age 7 years, and the childhood history of school adjustment generally is not characterized by disruptive behavior or teacher complaints concerning inattentive, hyperactive, or impulsive behavior. When a Mood Disorder or Anxiety Disorder co-occurs with [ADHD], each should be diagnosed. [ADHD] is not diagnosed if the symptoms of inattention and hyperactivity occur exclusively during the course of a Pervasive Developmental Disorder or a Psychotic Disorder. Symptoms of inattention, hyperactivity, or impulsivity related to the use of medication (e.g., bronchodilators, isoniazid, akathisia from neuroleptics) in children before age 7 years are not diagnosed as [ADHD] but instead are diagnosed as Other Substance-Related Disorder Not Otherwise Specified.

(this would be easier to read, for me, if each section was in a different color)

LOL I'm just giving you a difficult time, Keith. Thanks for making this information available.

(this would be easier to read, for me, if each section was in a different color)

LOL I'm just giving you a difficult time, Keith. Thanks for making this information available.

I thought about doing something like that, but then it dawned on me that I'd probably better not edit it...it's probably inappropriate for me to have even posted the entire thing.

Thank you for taking the time to type that. It was very helpful.

something about copyrighting laws or such--i promise not to tell anyone, k? it's valuable information.

It doesn't violate copyright laws because I cited it, but the APA may not consider this appropriate use because, as they do mention, it is intended for trained clinicians.

I for one am happy and grateful that you posted it. I think the benefits of more information definitely outweigh the risks in our case.

Thanks!

Thanks Keith for taking the time to type that up. You gave appropriate warnings about use and misuse -- so don't sweat it! It's a good thing!:)

<snip> ... it's probably inappropriate for me to have even posted the entire thing.
Thanks Keith

Don't worry about it. We will send you letters while you are in jail.

Best wishes, Vic

Hey, Keith:

Many thanks for the posting. Your work is very helpful. I thought you would have used a scanner.

I see in your signature that you are very smart.

A spell checker could still help you. ;-) You can have an online one available for all posts if you download the Google tool bar. I have no association with Google.

Best wishes and thanks again,

Vic

I just found at for my daughter at almost age 16 she has a CAPD ( Central Auditory Processing Disability), for her it is she has basically NO short term auditory memory! She was diagnosed add/inattentive. We are now questioning if she even has ADD. Here is a link for CAPD .....worth taking a look at.Learning Disorders and children and facts and strategies for parents | Notmykid.org Child Mental Health Article (http://www.notmykid.org/parentArticles/LearningDisorders/default.asp), and another one is,Auditory processing - auditory processing disorders and auditory processing approaches (http://www.innovative-therapies.com/auditory.htm).

Last month (Nov), I participated in a UBH (United Behavioral Health ) ADHD teleconference on ADHD and Comorbidity.

The presenter was Russ Barkley,whose most recent work,The ADHD Handbook: Third Edition,just came out.

These data (from the teleconference) can be found there as well.

Actually, these data have been around for some time.

The comorbidity range for ADHD and Learning Disabilities is 24-70%. with the mean being around 50%.

In Minnesota, we have the luxury of having an excellent CAPD clinic at the Univ of Mn -Twin Cities.

I've made several referrals there and have been quite pleased.

Psychologists are not necessarily going to catch CAPD.

When you consider that there's no one way to test for ADHD,it becomes even more problematic.

However, the dawn of evidenced based practice is upon us, so I'm optimistic for the future.

As a rule of thumb, a thorough evidenced based ADHD assessment requires a medical checkup, including tests for thyroid conditions, as well as hearing and vision screens.

One of the most helpful referrals though, is for an Occupational Therapy eval. for motor coordination deficits.

I have several OT friends who I know will screen for that (CAPD) as well.

The bottom line is that this is like putting a puzzle together in the dark.

There's also no rule that says you can't have both CAPD and ADHD.

Second opinions though are always a good thing.

Good luck.

Happy Holidays

mctavish23
(Robert)

The comorbidity range for ADHD and Learning Disabilities is 24-70%. with the mean being around 50%.

...

Psychologists are not necessarily going to catch CAPD.

When you consider that there's no one way to test for ADHD,it becomes even more problematic.
Robert,

First, thanks for the update. 50% -- :eek: I feel very lucky. The most my 8yo has is dyscalculia. He seems to have gotten letters under control (a little bit later than average, but done), however numbers are still a real problem.

Second, this is troublesome to me. The school psychologist and nurse ruled out CAPD and, in fact, determined my son's auditory processing is outstanding. But, I was under the impression that ruling out LDs is one of the most effective ways of landing at an AD/HD diagnosis. If LDs are comorbid, and the child is not hyperactive, how does one avoid missing AD/HD?

My experience has been that most school psychologists don't assess for ADHD.

I do have a colleague though who is an exceptional school psych.,so I usually don't worry if he's involved.

I have never had a school nurse involved in the assessment of ADHD.

Their role has historically been to make sure the meds are properly dispensed.

That's not meant as a criticism of their role, it's just a description of what has been done around here for the 22 yrs, I've been here.

I've also never had a school psych test for CAPD, however, that doesn't mean thet can't or don't.

I've just never seen it.

An evidenced based ADHD covers a number of areas;one of which is to rule out LD's.

As far as "missing ADHD" goes, not everyone (psych's) is on the same page.

Someone I respect very much recently took a shot at me for not using a more "formal" assessment tool like the TOVA.

I'm hoping that in the near future, there will be more uniformity in assessment.

One thing that I've always insisted on is a second opinion from a medical specialist;like a pediatric psychiatrist,pediatric neurologist, or Clinical Nurse Specialist.

While I've never had a diagnosis overturned, the point is that this isn't an exact science and I'm not so ego bound to what I do to expect I'm always going to be "right."

I've posted on this before, but sleep disorders are, in my opinion,the most likely problem to be overlooked.

My experience has been that most school psychologists don't assess for ADHD.

Again I feel lucky. The school did a complete battery on my son, even though he wasn't behind academically and we suspected dyslexia and dyscalculia. The nurse got a complete history, checked his hearing and vision, and looked into specific things based on the school psychologist's recommendations. The school psychologist was the most involved, giving him 4 different cognitive tests, an academic achievement test, 2 CAP tests, and observations in the classroom and play yard. I filled out the Conner's and 2 other surveys. The adaptive P.E. coach did a report. The resource specialist did something, too.

The more I hear about the experience of others, the more I appreciate my kids' school. If they hadn't done such a great job identifying his specific problems, we'd still be chasing a non-existent LD.



Someone I respect very much recently took a shot at me for not using a more "formal" assessment tool like the TOVA.

:eek: I hope you set them straight about the reliability of that cr*p.



One thing that I've always insisted on is a second opinion from a medical specialist;like a pediatric psychiatrist,pediatric neurologist, or Clinical Nurse Specialist.
I admire you for that. It's wise.


I've posted on this before, but sleep disorders are, in my opinion,the most likely problem to be overlooked.
I missed that post. What sleep disorders are overlooked and are they secondary, a symptom of AD/HD, or something else?

The reason I ask is my 8yo sometimes has trouble. He used to wake up several times a night, but this hasn't been a problem since he started meds. He does need to get up to use the bathroom a lot, but is able to get right back to sleep.

Since I raised his dose 3 days ago, getting to sleep has been a problem. The first night he read for about an hour, then went right to sleep. The second night, same thing. Last night, however, he was up until 4am. He cried a lot of that time because he was frustrated (and I think a little afraid we'd be mad at him).

Man,

You ask hard questions...lol.

I was referring to sleep disorders in general;specifically as pertains to working with kids.

Historically, they're the last thing that gets looked at;usually by process of elimination.

The types vary. I don't think any one predominated.

I don't have any data on the referrals I've made over the years, but I can say that every kid I've ever referred came back with some type of a sleep disorder.

My point is that it's difficult to notice,so a proper history is important.

Anecdotally, it does seem to run in families though.

As a rule I don't pay a lot of attention to what type(s).

My main concern is trying to cover as many (treatment) bases as possible.

I think that this is where my having ADHD gives me an advantage over a non-ADHD clinician, as I'm going to ask more ( and different types of) questions.

Now, try getting that done in an hour..lol.

I'm impressed with your school. They certainly do an excellent job.

Happy New Year

tc
(Robert)

Thanks for the feedback. I'm sure we'll get his sleep situation figured out!

Happy New Year! Only 2 more hours to go.

There is talk of the DSM-IV definition being changed.

For example (a) to change the childhood onset age, and (b) to include more female-style ADHD behaviours. (e.g. women's impulsivity can be manifested as binge eating, or overshopping; women's hyperactiveity can be manifested as hyper-talking rather than hyper-active physical activity and movements.)

I find the DSM to be very very andro-centric and very inappropriate --- right down to the definitions of women's sexual dysfunctions. The DSM SCID manual's too.

Mental Health and it's definitions are social created and politically entrenched, depending on the dominant hegemony.

As my SO calls it: "Evidence-based Politics."


Emma

Queens,

I respectfully disagree, as the dx's are based on research found to be valid & reliable.

Now, as far as ADHD is concerned, I totally agree .

There will in fact, be a number of (anticipated) changes,which I hope will be for the better.

The age of onset(7) is inaccurate and has been done away with.

They definately need more attention to females,however, the current symptoms DO work for girls.

I'm relatively certain that age referencing the symptoms is going to be addressed;as that is a problem.

The only other comment I'd make about assessing girls is to make sure that whatever checklist is used :

1) Is actually normed on girls and;

2) The clinician uses the correct protocol and/or normative group for scoring purposes.

I've never seen a problem with the Behavior Rating Inventory of Executive Function (BRIEF) Parent (or Teacher) Form, however, it's really easy to screw up the Conners if you aren't paying attention to which side of the form you're using.

I always appreciate your posts.

I'm impressed with how well read you are, as well as for your commitment to learning .

thanks
tc
mctavish23 (Robert)