ADDA Comments on Proposed Changes to the Diagnostic Manual
The members of the Professional Advisory Board of the Attention Deficit Disorder Association (ADDA) want to commend the work of the ADHD and Disruptive Behavior Disorders Work Group in the development of the DSM-5. ADDA is the largest organization devoted specifically to the needs of adults with Attention-Deficit/Hyperactivity Disorder (ADHD).
Though primarily comprised of mental health professionals, the ADDA Professional Advisory Board is represented by members with diverse professional backgrounds who share a focus on helping adults with ADHD. Consequently, we reviewed with great interest the proposed revisions to the ADHD diagnostic category for DSM-5, specifically with regard to issues related to adults with ADHD.
We appreciate that the Work Group is charged with the difficult task of developing scientifically valid and clinically sound diagnostic criteria in order to provide guidance to clinicians trained in diagnostic assessment and treatment. Work Group members are not compensated for their participation, must meet strict criteria regarding potential financial conflicts of interest, and agree to abstain from industry supported symposia at the American Psychiatric Association annual meetings during their tenure. The ADHD Work Group also has an impressive diversity of professional backgrounds, striking a balance of members with M.D.’s and those with Ph.D.’s.
The ADDA Professional Advisory Board offers the following suggestions regarding the proposed revisions to the ADHD diagnosis for DSM-5:
1) First and foremost, there is sufficient scientific data to indicate that a separate list of symptoms be provided to guide the diagnosis of ADHD in adult patients. We commend the Work Group’s consideration of the option of lowering the number of symptoms defining the diagnostic thresholds for adults, as this approach has scientific support; however, having a distinct list of symptoms that are developmentally appropriate for use with adult patients will improve diagnostic accuracy and there are empirically-derived symptoms that are relevant for use with adults. Moreover, adult specific criteria descriptions will also reduce the risk of elevated false positives, which is a stated concern with the option of reducing the existing diagnostic thresholds. (Research rationale: Barkley, Murphy, & Fischer, 2008; Fedele, Hartung, Canu, & Wilkowski, 2009)
2) Following from suggestion #1, considering the developmental changes in the expression of symptoms of ADHD in young adult and adult patients, namely that existing studies have not documented the usefulness of hyperactive symptoms in adulthood, we endorse the establishment of a separate diagnostic category "Adult Attention Deficit Disorder,” comprised of empirically-derived items from recent research on adults with ADHD that have identified factors such as cognitive inflexibility, disinhibition, and executive dysfunction.
We also recommend that this single diagnostic list include sufficient numbers of symptoms consistent with features of inattention and distractibility and other features of executive dysfunction (i.e., the current "predominantly inattentive” subtype) to allow for adequate identification of individuals impaired primarily by the cognitive manifestations of ADHD. There was also support voiced by many members of the Professional Advisory Board for the option of creating altogether separate diagnostic categories reflecting the different clinical presentations of individuals with the "predominantly inattentive type” (e.g., executive functioning difficulties) and those with the "combined type” (e.g., behavioral disinhibition difficulties). Finally, we recommend that the issue of sluggish cognitive tempo be further examined as a unique presentation within the inattentive type of ADHD. (Research rationale: Barkley et al., 2008; Fedele et al., 2009; Solanto et al., 2007)
3) Considering the range of symptom severity and impairment experienced by adults with ADHD, we suggest that the diagnosis of ADHD be augmented and clarified with a specification of severity, such as "Mild,” "Moderate,” "Severe,” and "Profound;” or "Minimal,” "Mild,” "Moderate,” and "Severe.”
4) We agree with the option of increasing the age of onset of symptoms from 7 years-old to an older age. The current symptoms can be difficult to discern in many children who are later diagnosed with ADHD, such as when their symptoms create prominent impairments when they go to college or enter the workplace. However, we suggest that a higher age threshold of 15 or 16 years-old would be appropriate (and many Professional Advisory Board members suggested an age threshold of 18 years-old) and would not raise the incidence of false positives. The text of the diagnostic criteria could be modified to clarify that "symptoms” of ADHD may emerge in childhood or adolescence but may not necessarily create functional impairments necessitating treatment until adulthood. (Research rationale: Barkley et al., 2008; Faraone et al., 2006).
5) The requirements to document issues of impairment and cross-situationality of symptoms as well as to gather corroborative clinical data regarding onset of symptoms and impairment should continue to be emphasized in the diagnosis of ADHD in adults in order to increase diagnostic accuracy. However, considering the significant negative effects of ADHD in adult functioning, we propose that significant impairment in even a single adult role (e.g., occupational, academic, parental, social) is sufficient for the diagnosis, presuming that all other diagnostic criteria are fulfilled (e.g., onset of symptoms, symptom thresholds, etc.).
6) We commend the Work Group’s efforts to develop increased numbers of adult-relevant criteria descriptions and hope that many more appear in the final version of the DSM-5. Considering the effects of ADHD on social functioning, we suggest that criteria descriptions reflecting difficulties in social functioning as well as reports of internal states of mental and/or physical restlessness (that reflects the internalization of hyperactive symptoms in adulthood) also be included in the final text of DSM-5.
In conclusion, the ADDA Professional Advisory Board expresses our profound appreciation of the time and efforts of the members of the ADHD Work Group and hope that it will strongly consider and integrate our suggestions in the final draft of the DSM-5 diagnostic criteria for ADHD. The members of the ADDA Professional Advisory Board have also been encouraged to submit additional recommendations individually directly to the ADHD Work Group, as there was additional feedback that was beyond the purview of this submission.
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford.
Faraone, S. V., Biederman, J., Spender, T., Mick, E., Murray, K., Petty, C., et al. (2006). Diagnosing adult attention deficit hyperactivity disorder: Are late onset and subthreshold diagnoses valid? American Journal of Psychiatry, 163, 1720-1729. doi: 10.1176/appi.ajp.163.10.1720
Fedele, D. A., Hartung, C. M., Canu, W. H., & Wilkowski, B. M. (2009). Potential symptoms of ADHD for emerging adults. Journal of Psychopathology and Behavioral Assessment. Advance online publication. doi 10.1007/s10862-009-9173-x
Solanto, M. V., Gilbert, S. N., Raj, A., Zhu, J., Pope-Boyd, S., Stepak, B., et al. (2007). Neurocognitive functioning in AD/HD, predominantly inattentive and combined subtypes. Journal of Abnormal Child Psychology, 35, 729-744. doi 10.1007/s10802-007-9123-6
Submitted on behalf of and in coordination with the ADDA Professional Advisory Board
ADDA Professional Advisory Board
J. Russell Ramsay, Ph.D.
Assistant Professor of Psychology in Psychiatry
University of Pennsylvania School of Medicine
Roberta L. Waite, Ed.D., APRN, CNS-BC