All That Wiggles Is Not ADHD History, Classification, and Diagnosis
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All That Wiggles Is Not ADHD History, Assessment, and Diagnosis of ADHD
Jodi A. Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC Director, Hastings Behavioral Health Clinic
Attention-Deficit Hyperactivity Disorder
History: Where did ADHD come from?
“Defects in Moral Control” George Still, M.D. (1902)
A “cluster” of behaviors which: were more common in males seemed to run in families were associated with certain congenital anomalies were not accounted for by any known neurological deficit
Other Names/Classifications Post-encephalic Brain Disorder Brain Injured Child Syndrome Minimal Brain Dysfunction Hyperkinetic Reaction of Childhood (DSM-II) Attention-Deficit Disorder (DSM-III, 1980)
Current Conceptualization Attention-Deficit Hyperactivity Disorder (ADHD) DSM-IV, 1994 Three subtypes: Predominantly Inattentive Predominantly Hyperactive/Impulsive Combined
Adolescent and Adult Outcomes Some symptoms into adolescence: 70% Some symptoms into adulthood: 50% At increased risk for:
Substance abuse Traffic citations Automobile accidents
Cause of ADHD No one cause identified.
Not caused by Diet (i.e. food additives, sugar) Poor parenting
Other Myths/Misconceptions
ADHD is outgrown in adolescence.
Other Myths/Misconceptions ADHD is outgrown in adolescence. Girls are not hyperactive.
Other Myths/Misconceptions ADHD is outgrown in adolescence. Girls are not hyperactive. There is a single test for ADHD.
Other Myths/Misconceptions ADHD is outgrown in adolescence. Girls are not hyperactive. There is a single test for ADHD. Stimulant medication can “diagnose” ADHD.
Other Myths/Misconceptions ADHD is outgrown in adolescence. Girls are not hyperactive. There is a single test for ADHD. Stimulant medication can “diagnose” ADHD. There is a “cure” for ADHD.
Prevalence of ADHD
Best current estimate: 3%-5% school age population are affected.
Attention-Deficit Hyperactivity Disorder
Diagnosis: Who has ADHD?
Formal Diagnostic Criteria DSM-IV, 1994
Criterion A: Six or more symptoms from one or both of these lists: Inattentive Type Hyperactive/Impulsive Type …have been present for at least 6 months.
Symptom Lists Inattentive Type
fails to attend to details, makes careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful
Hyper/Impulsive Type
often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure activities quietly often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others
Formal Diagnostic Criteria DSM-IV, 1994
Criterion B: Some of the symptoms were present before the age of seven years.
Formal Diagnostic Criteria DSM-IV, 1994
Criterion C: Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).
Formal Diagnostic Criteria DSM-IV, 1994
Criterion D: There is evidence of clinically significant impairment in social, academic, or occupational functioning.
Formal Diagnostic Criteria DSM-IV, 1994
Criterion E: The identified symptoms are not better accounted for by another mental disorder.
Attention-Deficit Hyperactivity Disorder
Assessment: All that wiggles is not ADHD
Comprehensive Diagnosis for ADHD There is no single test or laboratory measure which can reliably detect ADHD.
Comprehensive Diagnosis for ADHD Information gained by qualified clinician: From family standardized, norm-referenced ratings detailed history
Comprehensive Diagnosis for ADHD Information gained by qualified clinician: From family standardized, norm-referenced ratings detailed history
From school standardized, norm-refernced ratings academic history in-class observations
Comprehensive Diagnosis for ADHD Information gained by qualified clinician: From family standardized, norm-referenced ratings detailed history
From school standardized, norm-referenced ratings academic history in-class observations
From clinician observations
Other Common Causes of Concentration Problems
Depression/anxiety
Other Common Causes of Concentration Problems Depression/anxiety Drug/alcohol use
Other Common Causes of Concentration Problems Depression/anxiety Drug/alcohol use Poor fit between academic demands and individual’s capabilities
Other Common Causes of Concentration Problems Depression/anxiety Drug/alcohol use Poor fit between academic demands and individual’s capabilities Physical illness
Other Common Causes of Concentration Problems Depression/anxiety Drug/alcohol use Poor fit between academic demands and individual’s capabilities Physical illness Adjustment
Associated Problems
Learning Disability: 25 - 30%
Associated Problems Learning Disability: 25 - 30% Oppositional Defiant Disorder: 35 - 65%
Oppositional Defiant Disorder Pattern of negative, hostile, and defiant behavior:
Often loses temper Often argues with adults Often actively defies or refuses to comply with adults’ requests or rules Often deliberately annoys people Often blames others for his/her mistakes or behavior Often touchy or easily annoyed by others Often angry or resentful Often spiteful or vindictive
Associated Problems Learning Disability: 25 - 30% Oppositional Defiant Disorder: 35 - 65% Variable academic quality
Associated Problems Learning Disability: 25 - 30% Oppositional Defiant Disorder: 35 - 65% Variable academic quality Poor social skills, peer relationships
Who Has ADHD?
Percent
100 90 80 70 60 50 40 30 20 10 0 Extremely Attentive
3-5%
Average
Attentiveness
Extremely Inattentive
Who Has ADHD?
Percent
100 90 80 70 60 50 40 30 20 10 0 Extremely Attentive
3-15%?
3-5%
Average
Attentiveness
Extremely Inattentive
ADHD as Heterogeneous Disorder Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful
often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others
Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships
ADHD as Heterogeneous Disorder Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful
often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others
Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships
ADHD as Heterogeneous Disorder Inattentive Type
Hyper/Impulsive Type
fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful
often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others
Child with ADHD
Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships
Child with ADHD
Importance of Diagnosis
Can help schools document need for additional services. Research purposes. Professional communication. But it doesn’t help individualize a treatment strategy!
Importance of Diagnosis More important than a diagnosis: is a comprehensive, functional assessment of the child’s impairment in daily life • • • •
with peers. with teachers. with siblings. with parents.
New Conceptualization of ADHD Dr. Russell Barkley: “ADHD is a delay in the development of behavioral inhibition.”
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