The American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders (DSM) -- or the rules for diagnosing and treating mental health problems -- is getting updated for the first time since the fourth edition, DSM-IV, was published in 1994. And as the experts go back to the drawing board, either the label ADHD or ADD may even go away, or at the very least, change meaning.
DSM-V -- which is currently in the planning stages and is slated to be published in 2013 -- will bring changes for the attention deficit and hyperactivity disorder (AD/HD) community, perhaps by treating these as two separate disorders, rather than subtypes of the same condition.
Condition-specific proposed changes to DSM -- from eating disorders to autism -- are available for anyone to view, comment on, and contribute to on the APA’s new DSM-V website. There you’ll find criticisms of the current diagnosis of ADHD. Among them: concerns that DSM-IV’s diagnosis guidelines lists more criteria for inattention than hyperactivity, a component of the disorder that should be treated with more equal weight; claims that the DSM-IV age of onset for ADHD (7 years old) is arbitrary; and that the “large number of criteria is difficult to remember.”
1) Doing away with the three ADHD subtypes developed in DSM-IV : predominantly hyperactive/impulsive (HI), predominantly inattentive, and combined, both inattentive and hyperactive.
Over time the three subtypes of ADHD have “proven to be problematic because many children who met criteria for a given subtype at one point, met criteria for a different one a few months later,” explained , professor of child psychiatry, psychiatry, and pediatrics, and chief of Columbia University Medical Center’s Division of Child and Adolescent Psychiatry. One proposed way of eliminating the three subtypes includes grouping all inattentive and hyperactive/impulsive diagnoses together.
Reverting back to a single diagnosis of ADHD is not without problems, explained Dr. Shaffer. “Many children are referred because of poor school progress and although clearly inattentive, they have never been hyperactive. They now receive a diagnosis of ADHD, which includes a behavior that they don’t have. This can become a problem for teachers and parents and ultimately for clinicians.”
Another option is to completely separate the two by creating a new diagnosis of attention deficit disorder (ADD) that has it’s own characteristics and symptoms -- including loses belongings, being easily distracted and forgetfulness -- separate from the current ADHD, which is inclusive of hyperactivity. A proposal on DMM-V’s website claimed this option presents a cons as well, including little empirical or experimental data to “define the pathology” -- or nature and conditions of this diagnosis.
2) Changing the age of onset. On the table for discussion is to alter the age of onset from "on or before age 7" to "on or before age 12." The rationale? “Retrospective studies show that age of onset can occur or be first noticed or recalled between the ages of 7 and 12,” according to a proposal on DSM-V’s website. The complexity of the condition – and its concurrence with other disorders – makes it difficult to recognize in earlier years.
3) Fewer symptoms required for a diagnosis of adult ADHD. Under DSM-IV’s current guidelines, a certain number of symptoms -- six -- must be met to be diagnosed with adult ADHD. The proposed change would account for recent findings that indicate a decline in symptoms as a patient ages. “Follow-up studies of children who had ADHD show that as they grow older they have fewer and fewer symptoms but they remain impaired,” explained Dr. Shaffer. “One can reach a point where an impaired individual no longer meets the criterion requirement of 6 symptoms from each category.”
To see the full list of proposed changes, along with the rationale and the pros and cons of each, and to suggest your own, visit the DSM-V website and register to leave a comment.
