What exactly does "impairment" mean in ADHD ??

[JOHNCG]

I read that a person cannot be diagnosed with ADHD unless they are
impaired by the disorder, but I am totally confused as to precisely what "impairment" actually means??!!

I would be VERY grateful indeed, if someone could explain it to me.

Regards,

John

[Abi]

Originally Posted by wiki

Before diagnosing a psychological disorder, Clinicians must study the themes, also known as abnormalities, within psychological disorders. The most prominent themes consist of: deviance, distress, dysfunction and danger. These themes are known as the 4 D's, which define abnormality.
Description of the 4 D's when defining abnormality: Deviance: this term describes the idea that specific thoughts, behaviours and emotions are considered deviate when they are unacceptable or not common in society. Clinicians must, however, remember that minority groups are not always deemed deviate just because they may not have anything in common with other groups. Therefore, we define an individual's actions as deviate or abnormal when his or her behaviour is deemed unacceptable by the culture he or she belongs to. Distress: this term accounts for negative feelings by the individual with the disorder. He or she may feel deeply troubled and affected by their illness. Dysfunction: this term involves maladaptive behaviour that impairs the individuals ability to perform normal daily functions such as getting ready for work in the morning, or driving a car. Such maladaptive behaviours prevent the individual from living a normal, healthy lifestyle. However, we must remember that a person's behaviour, who is acting dysfunctional, is not always caused by a disorder. Dysfunctional behaviour may be voluntary, such as engaging in a hunger strike. Danger: this term involves dangerous or violent behaviour directed at the individual, or others in the environment. An example of dangerous behaviour that may suggest a psychological disorder is engaging in suicidal activity.

The degree of deviation or dysfunction required for a psych diagnosis is done on a case by case basis by a psychiatrist or psychologist who has 5+ years of formal education, practical training, and professional experience and use clinical discretion when making a diagnosis.

Of course, many psychiatrists and psychologists get it wrong sometimes, but we don't live in a perfect world.

MEMBERS: Tell us about some of the ways ADHD IMPAIRS you

[Dizfriz]

Originally Posted by JOHNCG

I read that a person cannot be diagnosed with ADHD unless they are
impaired by the disorder, but I am totally confused as to precisely what "impairment" actually means??!!

I would be VERY grateful indeed, if someone could explain it to me.

Regards,

John

Degree of impairment is usually considered to be more an issue of clinical judgement than one of definition. This is often the case when a single definition will not work well with all situations. In research for the various editions of the DSM, as I understand it, clinical judgement is seen to be equal or superior to attempts to define with issues like this. Below is the proposed criteria for Mental Disorder which addresses impairment also. I hope this helps a little.

The proposed definition for the DSM 5 is for Mental Disorder is about as close as one can get on this with the DSM. http://www.dsm5.org/ProposedRevision...n.aspx?rid=465

A Mental Disorder is a health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance.

A mental disorder is not merely an expectable or culturally sanctioned response to a specific event such as the death of a loved one. Neither culturally deviant behavior (e.g., political, religious, or sexual) nor a conflict that is primarily between the individual and society is a mental disorder unless the deviance or conflict results from a dysfunction in the individual, as described above.

Associated Text

The diagnosis of a mental disorder should have clinical utility: it should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients. However, the diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a complex clinical decision that takes into consideration such factors as symptom severity, symptom salience (e.g., the presence of suicidal ideation), the patient’s distress (mental pain) associated with the symptom(s), disability related to the patient’s symptoms, and other factors (e.g., psychiatric symptoms complicating other illness). Clinicians may thus encounter individuals who do not meet full criteria for a mental disorder, but who demonstrate a clear need for treatment or care. The fact that some individuals do not show all symptoms indicative of a diagnosis in these individuals should not be used to justify limiting their access to appropriate care.

This definition of mental disorder was developed for clinical, public health, and research purposes. The inclusion of diagnostic categories such as Gambling Disorder and Pedophilic Disorder does not imply that such conditions meet legal or other nonmedical definitions of mental disease, mental disorder, mental defect, or mental disability. Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria in order to make legal judgments on such issues as criminal responsibility, eligibility for disability compensation, and competency.

From the Rationale section:

Rationale for proposed revisions are reflected in Stein DJ et al: What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V; Psychological Medicine (Stein et al., 2010)

A. The phrase “clinically significant” is moved to the next criterion, to emphasize that disorders are characterized by clinically significant distress or impairment.

B. The phrase on risk is omitted in order to differentiate more clearly between disorders and risk factors.

C. The phrase on responses to common stressors and losses is added to differentiate more clearly between such responses and psychopathology.

D. The term psychobiological is used to emphasize the inextricable links between the biological and the behavioral/psychological.

E. There is no substantive change here; the proposed version is more succinct.

Other Considerations:

F. Diagnostic validity and clinical utility are key constructs in the delineation of disorder.

It may be timely to reconsider the term “mental disorder”, given our growing knowledge of the psychobiology of these disorders. In considering new disorders for DSM-V, we need to consider their relationship with diagnostic “near-neighbors”, and the overall benefits vs harms of an addition.

In referance to the DSM-IV

Definition of a Mental Disorder

Features

A. A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual

B. Is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

C. Must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one

D. A manifestation of a behavioral, psychological, or biological dysfunction in the individual

E. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual


Other Considerations

F. No definition adequately specifies precise boundaries for the concept of "mental disorder”

G. The concept of mental disorder (like many other concepts in medicine and science) lacks a consistent operational definition that covers all situations

Hope this helps a little.



Dizfriz

[keliza]

Yep, Abi and Dizfriz nailed it. In short, "impairment" basically means that it prevents you from going about one or more of your day to day tasks normally. Whether it's work, school, recreation, etc., an impairment means that ADHD is in some way interfering with your ability to live your life. It's easier to conceptualize impairment in terms of physical impairments, because those are obvious to any observer--someone in a wheelchair is impaired because they cannot walk, climb stairs, etc. It's sometimes harder to conceptualize what it means to be impaired by a mental health issue such as ADHD.

For example, for me ADHD caused impairments in school. I could not focus for a long period of time (or any period of time, really) on my studies. I might read a textbook for 5 or 10 minutes, and maybe take some notes, but my brain starts to "burn out" after that and I begin fidgeting, needing to get up and walk around, etc. If I'm at home, I usually end up on the computer (which I may have been on already to take notes, since I type astronomically faster than I hand write) and tell myself, "I'll just check Facebook real quick." An hour later, I'm still on tumblr, and not a single page further in my reading.

Even when I go to the library, totally free of distractions, I still can't force myself to focus on my studying. And get this, even if the subject is really interesting I may not be able to focus on it for an extended period of time. I generally have more luck, but even in something I am very much interested in learning about, I still max out after 20-30 minutes. When people tell me they spent 8+ hours cramming for a final, my jaw just drops to the floor, I have no idea how anyone could focus on one thing for 8 hours like that.

So in that way, ADHD has been very impairing during all my years of education. I can't study effectively because I can't focus. When you don't study, you don't perform as well on tests as you could/should have. I have a hard time sitting through lectures and taking notes, because again, my attention fizzles out after 15 minutes, and I spend the remaining 35 minutes counting ceiling tiles, playing around on my phone, or just nodding off in the back of class. Sometimes, if it was a large lecture hall and I could slip out relatively unnoticed, I would just get up and leave after 20 minutes because I could not stand to sit still one minute longer.

It's not a matter of will power or applying yourself or being a "good" student, it's truly something beyond my control and I have tried a lot of different behavioral "interventions" to improve it, but the only thing that results in any demonstrable improvement is stimulant medication, or to a lesser extent, a lot of caffeine. I "self-medicated" with coffee my entire freshman year of college without understanding why. After my diagnosis, it made a lot more sense.

[425runner]

@keliza I have the same problem!! Even when medicated I can't study for more then 40-45 minutes, and comprehension is always an issue. I don't get it when people say they took Adderall and studied for 6-8 hrs...

[Dizfriz]

John,

I will refer you to this post of mctavish23. http://www.addforums.com/forums/show...3&postcount=24

As usual, Robert has it accurately stated and in a few precise words.

Dizfriz

[Lunacie]

I'd say impairment varies from person to person, and from situation to situation or time frame.

I was certainly impaired in school but others with ADHD may be able to cope in that situation.

There are some impairments that seem general or across-the-board with most adults with ADHD:

forgetting to pay bills, becoming overloaded with social stimuli and needing quiet time to recover.

Impairment is best discussed with the physician or psychiatrist, and determined on a personal basis.

[Assumption]

Sorry, I skim read. Combining that with what I remember from undergrad though, it's distress OR impairment, right? Does that hold true with ADHD the same as it would with depression? Why do so many professions ignore the distress part (my experience is that if you explain that you're distressed by it, they'll assume you're depressed+anxious).

[Retromancer]

I have the suspicion that this qualification is being fallen back on fairly often, judging by the number of individuals that discover they are ADD upon entering college:

Clinicians may thus encounter individuals who do not meet full criteria for a mental disorder, but who demonstrate a clear need for treatment or care. The fact that some individuals do not show all symptoms indicative of a diagnosis in these individuals should not be used to justify limiting their access to appropriate care.

[Assumption]

That sounds reasonable. Also, the DSM IV lists 9 criteria each for H/Imp and Inn. You only need 6 to meet the diagnostic threshold. So if a medical professional says "if you don't have symptom X, you're not ADHD" then that seems wrong to me...

I haven't been diagnosed yet, but looking back, I definitely feel that my symptoms "ramped up" during school and college - every time I was given more responsibility/freedom, it got harder. I don't remember it being particularly hard before we started being given homework, so although I can see some things going back to age 7 which may have been markers of some kind of issue (emotional regulation, didn't like haircuts or tags on clothes, for instance) , the symptoms have gotten worse over time. I'm not sure how this fits into the diagnostic criteria, though?

[mctavish23]

Sylvie,

To quote a far more learned man than I...

"The DSM was not chisled in stone in Isreal." - Russell Barkley Ph.D. (2000, p.8)

In other words, five of nine symptoms is considered "sub clinical," and therefore

CAN be used diagnostically.

You should also be aware the the 1994 DSM Field Trial for ADHD, was normed

(developed) on a research sample population between the ages of 4 - 16 years old;

84% of whom were BOYS !!

Hope that helps.

tc

mctavish23

(Robert)

[Fortune]

There's a reason the DSM-5 criteria falls back on four symptoms from each category for adult diagnosis. Much of it being how the six-per-category was normed on 4-16 year old boys.

[Assumption]

4 out of those same 9? Wow. That's a whole different ballgame to 6. I imagine a lot of PIs will change subtype...

[Fortune]

Originally Posted by Sylvie

4 out of those same 9? Wow. That's a whole different ballgame to 6. I imagine a lot of PIs will change subtype...

Looking at the current criteria, they were changed again in May and simply state six out of nine for each.

For a time, there were additional hyperactive and impulsive symptoms added and adults only needed four from each category.

They're still considering cutting the number required for adults. I am not sure why they removed the additional H/I symptoms. They did keep the increase from age 7 to age 12 for onset of symptoms, however.

I try to keep up with this stuff, but I missed that change. Ah, well.

It's all here.

[Drewbacca]

Just adding something that I found that hasn't been stated yet, not in exact words at least:

The definition of mental disorder in the introduction to DSM-IV requires that there be clinically significant impairment or distress. To highlight the importance of considering this issue, the criteria sets for most disorders include a clinical significance criterion (usually worded “...causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”). This criterion helps establish the threshold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological and may be encountered in individuals for whom a diagnosis of “mental disorder” would be inappropriate. Assessing whether this criterion is met, especially in terms of role function, is an inherently difficult clinical judgment. Reliance on information from family members and other third parties (in addition to the individual) regarding the individual’s performance is often necessary. (DSM-IV, p. 7)