Friday, May 24th, 2013
The new diagnostic criteria for ADHD in DSM-5 flag issues that deserve attention if you are a parent. These include:
1) Age doesn’t matter as much. In prior versions of the DSM, ADHD was represented as a disorder which starts in childhood – an onset prior to age 7 had to be established to make a diagnosis. This has changed – the age of onset has been extended to before 12 years of age. So parents should be aware that ADHD symptoms may now be detected later in childhood. And parents too may be more likely to be diagnosed themselves, as the new criteria make it easier to recognize ADHD in adults.
2) Age does matter though. While it is legitimate to say that children, teens, and adults all can show symptoms of ADHD, applying the criteria to the different age groups requires much clinical skill. Keep in mind that the proper use of DSM-5 requires this. For example, a clinician must apply the same criteria to a 5-year-old, a 10-year-old, and a 15-year old. The symptoms of ADHD reflect behaviors that can be shown by any child – it’s typically the frequency of these behaviors (they occur much more often as compared to what’s expected developmentally), the pervasiveness of the behaviors (you see them at home and in school), and the consequences of the behaviors (e.g., a kid is having difficulties keeping up with school work, is getting in trouble in school). A clinician needs to have a reference point for each age in their head in order to properly apply the DSM-5 criteria. This means that they should have very solid training in developmental science as part of their overall expertise. This is particularly true given the controversies about diagnosing and treating ADHD in preschoolers.
3) Be careful who applies the criteria. The DSM series (we are now on the 5th edition) is a guidebook for clinicians. It represents current thinking on the most telling signs of a disorder. It does not say anything about how the information should be collected to come to a clinical decision. So, you need to beware of anyone who doesn’t do a full, comprehensive evaluation that includes observations of the child, interviews with the child, much discussion with parents, acquiring lots of information from parents via questionnaires, collecting information from teachers and school personnel, and ideally a range of tests (including neuropsychological exams) that can consider alternative issues (like underlying learning disorders). This kind of evaluation is required to prevent overdiagnosis of ADHD, which may be rampant these days.
4) DSM-5 does not dictate what treatment will work best. DSM-5 is designed to facilitate the diagnostic process. It does not dictate the treatment strategy. A diagnosis of ADHD does not mean that a child necessarily needs Ritalin or other similar medications to control the symptoms. That’s a whole different discussion with a clinician who is trained to consider a range of treatment strategies. It is always wise to consider first behavioral treatments for ADHD and determine, after a sufficient amount of time, how much improvement can be gained by them before thinking about medication. Do not believe a practitioner who only endorses medication after a diagnosis is made.
The bottom line is the the DSM-5 is not intended to be used in a simplistic way to quickly diagnose ADHD and immediately promote medication. It is a tool that helps clinicians come to a determination of where a child is at developmentally with respect to ADHD. This is a complex process that requires lots of clinical insight. Having DSM-5 in hand doesn’t change that.
ADHD via Shutterstock.com
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Sunday, January 29th, 2012
A provocative essay published in the New York Times suggests that Ritalin (and other stimulant drugs) is essentially ineffective for treating ADHD when one looks at kids’ behavior over time – and that what’s missing (and what’s needed) is a much stronger focus on the psychosocial environment and not pharmaceuticals.
There are two parts to this argument that I agree with and wish to expand on.
First, even though ADHD is believed to be highly heritable (based primarily on twin studies), this does not mean that kids with ADHD will not respond to changes in their environment – or that genetic or biological treatment is the only form of effective treatment. In fact, much of the most salient research on kids’ behavior problems conducted over the last decade has shown that “risk genes” are in fact highly responsive to the environment. Some studies have shown that psychosocial interventions work especially well for kids who have a “risk gene” (or more technically in these studies an allelic combination that confers the highest risk for a given disorder – such as two copies of the short arm of the serotonin transporter gene when examining depression). While this work has not been applied yet to ADHD it is becoming clear that genes and environment come together in specific and sometimes counterintuitive ways – and that kids who are at high risk genetically may also be highly likely to benefit from positive changes in their environment.
Second, perhaps the most important contribution of the essay is to point out that drug treatments for kids need to be evaluated over time and sometimes over years in order to understand how effective they really are. Through this lens I think it would be irresponsible to say that drug treatments alone produce the most beneficial developmental outcomes for kids with ADHD – modifying and structuring their environment is critically important.
While I appreciate the strong sentiment expressed in the essay, I do take a more balanced view in that I understand that some kids respond well to drugs such as Ritalin. But I see drug treatments for kids as a last step in a complex process that should start with, and focus heavily on, discovering what changes can be made in the psychosocial environment. This process ideally involves a partnership between clinicians, parents, and teachers. Once that is in place and executed over time, rational decisions can be made about the added value of considering drug treatment. In some cases introducing a drug into the mix may in fact make all the environmental changes that much more effective.
The bottom line is that it’s become necessary to champion the environment in an era of science and treatment that is infatuated with DNA and biology. Virtually all behavioral traits and disorders not only reflect genetic and environmental influences – much of the cutting edge research shows how the expression of genes are often dependent on the quality of the environment. And in the case of ADHD, it’s very important to reorient thinking about treatment to be sure that the essential and powerful role of environmental change is not forgotten.
Image of molecular ball and stick model via Shutterstock.com
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