Use of Psychiatric Diagnoses in Children with ADHD
Introduction
Attention deficit hyperactivity disorder (ADHD) is a cluster of behavioural symptoms consisting of impulsiveness, inattentiveness and hyperactivity. Symptoms of ADHD often become evident at an early age after a change in the circumstances of the sufferer, especially when starting school. According to the National Health Society [NHS] (2016), the majority of the cases are diagnosed between ages 6 and 12. The symptoms of the disorder reduce with an increase in age, although most adults who were diagnosed in their childhood continue to manifest the symptoms. Notably, symptoms of ADHD may overlap with other disorders, especially anxiety and sleep disorders (NHS, 2016).
Statistics
The prevalence of ADHD varies from one community to another, with some communities having a higher prevalence than others. The prevalence of ADHD in children was reported as between 1.70 and 17.8%, with the condition persisting into adolescence in 78-85% of the cases in children and into adulthood in 50-70% of the cases (Karakas, Bakar, Dincer, Ulsever, Ceylan & Taner, 2015).
Concerns have emerged about the heredity of ADHD. According to Sprich et al (2000), the rate of diagnosis of children with ADHD is higher in biological parents with the disorder than in foster parents, indicating the heritability of the disease. Consistent with this assumption, studies by Tuglu and Sahin (2010, cited in Karakas et al., 2015) showed heritability of the disease as ranging between 60 and 94%, with the heritability index of 0.80 (Sprich et al. 2000). These findings suggest the influence of genetics factors in the aetiology of the disease. In fact, Sprich et al. (2000) indicated that 20 – 54% of parents of children with a diagnosis of ADHD are themselves sufferers of the disorder. I ?mren, Rodopman Arman and Ulusan (2013) found that ADHD is the most frequent disorder for parents and relatives of children diagnosed with the disorder.
In children, ADHD is one of the most common childhood developmental and behavioural disorders (Thongseiratch & Worachotekamjorn, 2016). The worldwide-pooled prevalence of ADHD is 5.29% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). According to Visser, Danielson, Bitsko, Holbrook, Kogan, Ghandour and Blumberg (2014), the prevalence of the condition has increased drastically over the previous decade. Physicians, healthcare professionals, and clinicians use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) to help diagnose this childhood developmental disorder. The American Psychiatric Association (APA) published the latest version of the DSM (DSM-V) in 2013. The diagnostic criteria for a range of mental conditions include revisions to the diagnostic criteria for ADHD in the previous version, DSM-IV. The revisions did not change the definition of ADHD, as the exact DSM-IV wording for all 18 symptoms was maintained. However, two significant changes were made to the criteria. First, the diagnostic age of the disorder onset was amended. In particular, the statement “symptoms that caused impairment was presented before age 7” was replaced by “several inattentive or hyperactive-impulsive symptoms were presented prior to age 12.” Second, DSM-V did not list pervasive developmental disorders (PDD) or autism spectrum disorder as exclusion criteria, as was the case in DSM-IV; therefore, a comorbid diagnosis with autism spectrum disorder is now possible. Thus, the new criterion for ADHD diagnosis includes children, adolescents, or adults with PDD (Thongseiratch & Worachotekamjorn 2016).
DSM-IV Criteria for Diagnosing ADHD
According to Rosales and colleagues (2014), the APA has retained the eighteen diagnostic items for ADHD in the 2013 revision of DSM-IV. The subsequent, DSM-V has elaborated on some items citing examples and included a revised age of the start of the disorder below 12 years old. This is intended to enhance the diagnosis of adolescents and adults. Initially, the APA selected the items based on the results of published literature and studies performed specially for revising the DSM (APA, 1994, cited in Rosales et al. 2014). The items have produced prevalence estimates that are consistent and reliable across cultures and different nations, showing a strong relationship with neurobiological markers (Taylor, 2009). Nevertheless, clinicians have suggested the possibility of improving the DSM-IV criteria for clinical applications (Taylor, 2011). Parallel to such a proposal, Rosales and colleagues (2014) stated that several issues with the item remained under investigated, whose answers had the potential to enhance the diagnostic efficiency of DSM criteria.
These authors pointed out various problems with the criteria. The first problem they stated was that 18 items used for diagnosis of ADHD were rather many for use by clinicians because they are often busy. Typically, individual items in the criteria need a single assessment and the limited time clinicians have usually forces them to overlook other aspects of the case, leading in turn to a rush of often inaccurate diagnoses. Thus, a review of the item lists for inter-item redundancy and reduction of the list could reduce the diagnosis time considerably. Based on Rosale et al. (2014), the wording of an item was a possible source of redundancy with two or more items showing the same underlying phenomenon. Secondly, function impairment consistent with different settings was a necessary requirement for improved criteria, DSM-V.
Usually, ADHD symptoms beyond some severity threshold cause significant impairment of the sufferer. In this regard, findings of a study by (Bussing, Mason, Bell, Porter & Garvan, 2010) showed that children with ADHD whose parents have ADHD presented more functional impairment in conjunction with reduced quality of life compared to those children diagnosed with the disorder whose parents were healthy. Similarly, (4) showed that patients who satisfied the diagnostic threshold were more functionally impaired by the disorder throughout their lifespan. Nonetheless, it was not obvious whether all symptoms contributed to impairment or whether they had any special significance for general adjustment of the criteria (Rosales et al., 2014).
Further, the DSM-IV tests offered symptom application estimates for formulating ADHD diagnostic criteria (Rosales et al., 2014). The items selected for inclusion varied in positive and negative predictive powers, although they indicated moderate to high values, which were acceptable. Whereas the item “often does not seem to listen when spoken directly” had the least predictive positive diagnostic powers with “listen” as an exception (Rosales et al., 2014). The item “is often easily distracted” was also identified as weak with “distracted” implying the “listen” item (Willcut et al., 2012). On the contrary, Wolraich, Bard, Neas, Doffng and Beck (2013) indicated that “distracted” had a high item-total relationship compared to “often blurts out an answer before a question has been completed” and “often talks excessively” as indicating low item-total relationship. Therefore, symptom application of ADHD diagnostic criteria required further assessment to inform the publication of DSM-5 (Rosales et al, 2014).
Apart from that, DSM-5 and DSM-IV have an equal weightage of 18 items along with the diagnostic threshold set at the additive sum of items present. Alternatively, some of the items could be more discriminating or have a greater severity in latent ADHD symptoms. Thus, it is expedient to assess the DSM criteria for differential discriminating properties of the 18 items, and the possibility of striking out some items from the list to shorten it (Rosale et al., 2014). The relationship between impairment and differential weighting of symptom severity as estimated by Item Response Theory (IRT) and impairment is understudied.
ADHD comorbidity with oppositional and conduct problems has been diagnosed (Sung, Erkanli, Angold & Costello, 2004). Moreover, it may be helpful to the clinician to be aware of symptoms of ADHD that are least confounded with conduct disorder (CD) when assessing for co-morbidity. One possible reason for the co-existence of these conditions is that the wording of criteria for each fails to differentiate their core expression properly, creating an overlap due to the linguistic blurring diction (Caron & Ritter, 1991). Hence, clinicians must pay special attention to any item that shares features with CD and indicates contamination in case the item concerned cross-loads onto ADHD and CD. However, in a study by Newcorn et al. (2001), patients with ADHD and comorbid oppositional defiant disorder (ODD) or CD scored higher on impulsivity than their ADHD patients without comorbidity (Newcorn et al., 2001). Nevertheless, there is evidence to dismiss the assumption that ADHD is the forerunner of CD, as proven by the study by Lahey, Van Hulle, Rathouz, Rodgers, D’Onofrio and Waldman (2009) which showed that the genetic and environmental effects on CD in early childhood were controlled, the predictive power of early ADHD symptoms on later conduct problems was weakened considerably.
Critique of the DSM-IV Criteria
The study conducted by Rosales and colleagues revealed four important points. First, the evidence of item redundancy amongst the 18 DSM-IV items, concerning KR-20 and item–total correlations was vague. Nevertheless, the IRT models suggested that items Listen, corresponding to inattentiveness (IA), and Blurts hyperactivity (HI) with ?at slopes did not provide convincing information. Rosales et al. (2014) noted that the items had the lowest discrimination limits in their scales and identical severity with other items.
Second, DSM-V items vary in their weighting. “Loses”, “Forget” and “Attention” mark severity for IA items; “Quiet”, “Motor”, “Seat” and “Blurts” marked severity for HI items; whereas “Distracted”, “Careless”, “Interrupts” and “Fidgets” are associated with milder presentations of ADHD (Rosales et al., 2014). Notably, the results depict that within the IA domain, the “distracted” yielded maximum information in the range of low severity of the latent trait, “careless” in the mid-severity range, and “loses” in the high severity range. In the HI domains, “interrupts” produced most information in the low-severity range, while “motor” and “quiet” were in the high-severity range. Therefore, the IA and HI items have distinctive characteristics (Rosales et al. 2014).
Thirdly, whereas all the 18 items predicted impairment, only a few items remained significant after adjusting for the overall symptoms, with “Listen” and “Seat” predicting heightened impairment. Fourthly, specific items including “loses” and “unmotivated” are predictors of ADHD-CD comorbidity (Rosales et al., 2014).
Implication of Change to DSM-V
Thongseiratch and Worachotekamjorn (2016) contend that the changes in the DSM-V criterion have led to an increase in the number of people diagnosed with ADHD. Specifically, changes in the DSM-V diagnostic criterion increased the prevalence of ADHD from 7.38% to 10.84% among children between ages 12 and 15 (Vande Voort, He, Jameson, & Merikangas, 2014).
The resulting increase in diagnosis especially relates to high-IQ children. The characteristic behaviours of gifted children are often closely similar to the symptoms of ADHD (Budding & Chidekel, 2012; Minahim & Rohde, 2015). Importantly, high-IQ traits can mask ADHD in such gifted children, because these children perform generally well in school and/or do not present any challenges for their teachers (Mullet & Rinn, 2015). Pfeiffer (2009) highlighted that this group of children may visit a physician in later development or not. Research evidence shows that an ADHD diagnosis using the DSM-IV criteria can be accurate for the majority of children with high IQ (Antshel et al., 2007). The changes in the DSM-IV criteria of ADHD have affected its diagnosis in gifted children, although the mechanism of such effect is currently unknown.
Thongseiratch et al., (2016) compared the DSM-IV and DSM-V criteria for diagnosing ADHD in gifted children. The findings of this study showed that using DSM-V criteria for diagnosis of ADHD could increase the incidences of ADHD by up to 14%. The increase is attributed mainly to the expansion of the age of onset to include 7 and 12-years-olds. A higher increase in diagnosis of 31% was reported in adolescents aged from 12 and 15 years old (Vande Voort, He, Jameson & Merikangas, 2014). The increase suggested that the prevalence of this developmental disorder was less robust in the high-IQ population of 6 to 12 years of age at presentation. Vande Voort et al. (2014) argued that the reduced age of onset in the DSM-V from 12 to 7 years caused an increase in the number of cases diagnosed with ADHD inattentive subtype. The combined type cases that exhibit serious symptoms generally have a lower full-size intelligence quotient (FSIQ), which excludes them from the first sample (Baum, Olenchak & Owen, 2004).
Thongseiratch et al. (2016) demonstrated the effect of the DSM-V criteria in the diagnosis of ADHD on high-IQ children. The changes in the DSM-V increased the number of patients diagnosed with ADHD. Although the previous DSM criteria excluded about 14% of high-IQ children with ADHD, the new criteria raises concerns about over-inclusion. Consequently, further research should be expedient to explore this possibility fully. All the former DSM-IV diagnostic items appear to be valid and not redundant; however, some items carried more weight than others.
Conclusion
DSM-V diagnostic criteria for ADHD have increased the number of people diagnosed with ADHD. The reduction in the onset age to 7 years has increased the accuracy of the criteria in diagnosing ADHD in high-IQ children that were previously missed due to the previous diagnostic criteria. The new criteria have reduced redundancy in the items for diagnosing this developmental disorder. However, concerns have been raised regarding the inclusion of gifted children in the number of cases identified as ADHD. Also, all items were associated with impairment and ADHD is not a forerunner of CD.
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