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Welcome to Class # 1 [Monday July 5 th , 2010]. The Psychology & Education of Students with ADHD [HDP3238H] Instructor: Rosemary Tannock , PhD. Goals for today. Introductions Review of Syllabus, Assignments, & case study Housekeeping Objectives (review of readings & didactic)

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the psychology education of students with adhd hdp3238h instructor rosemary tannock phd
Welcome to Class # 1

[Monday July 5th, 2010]

The Psychology & Education of Students with ADHD [HDP3238H]Instructor: Rosemary Tannock, PhD
goals for today
Goals for today
  • Introductions
  • Review of Syllabus, Assignments, & case study
  • Housekeeping
  • Objectives (review of readings & didactic)
    • Be aware of historical changes in conceptualization of ADHD
    • Know core characteristics of ADHD
    • Be able to differentiate ADHD from other disabilities
first some housekeeping

Introductions

  • Review of syllabus, readings, assignments
  • Scoring Rubrics
    • Review the rubrics
    • Attach relevant rubric to your assignment
    • Peer evaluation rubric – circle your rating of each component. I will provide interpretive summary for sum score (score to letter-grade conversion)
    • Rubric for final assignment is pending today’s discussion of the assignment
  • Introduction to i-clickers
  • Closing Routine
    • Ticket-out-the-door face down on my desk
    • Return i-clickers & name card to container
First, some Housekeeping
how do we use the i clickers
How do we use the i-clickers?
  • I ask questions on the screen during the class.
  • You answer using your i>clicker remote.
  • Audience responses are tallied.
  • I display a graph with the audience results on the screen.
  • We discuss the questions and answers.
how do you vote

How do you vote?

Turn on the clicker by pressing the bottom “On/Off” button.

A blue “Power” light will appear at the top of the remote.

how do you vote1

How do you vote?

When I ask a question (and start the timer), select A, B, C, D, or E as your vote.

I may also ask you to talk about your possible choice/answer with your neighbor or in groups, prior to voting.

how do you know your vote was received
How do you know your vote was received?

Check your “Vote Status” Light:

Green light = your vote was sent AND received.

Red flashing light = you need to vote again.

**Not sure you saw the light? Just

vote again.

**Want to change your vote? You can vote again as long as the timer is still going.

slide8

Q0- Audience SurveyLet’s try the i-clickers!

[NB: WHEN I start the timer, THEN press the button corresponding to your choice]

Q. Do you work primarily with students in

A. Elementary school

B. Secondary school

C. Other contexts

D. I don’t work with students

what is adhd
What is ADHD?
  • Your perspectives (small group work)
  • Historical perspectives (didactic)
  • Current perspectives
    • Medical (didactic, group activity & group discussion)
    • Individual (Kids Behind the Label)(small group work)
what is adhd small group activity
WHAT IS ADHD? (small group activity)
  • Gather at your specified flip-chart
  • Designate one person to be recorder/reporter
  • Brain storm and record your responses to ‘What is ADHD” from your perspective
  • Identify emerging themes
  • Report your emergent themes to the large group
adhd historical perspectives
ADHD: Historical perspectives

Tempting to infer that ADHD existed even prior to the 17th century!

La purification de la Vierge

Guido Reni (circa 1636)

The Louvre, Paris

what is adhd1
What is ADHD?

18th century perspective

“On attention & its diseases”

“…incapable of attending with constancy to any one object of education.” (p.271)

1798

early dual conceptualizations of adhd
Early dual conceptualizations of ADHD

Poorly regulated attention

(learning problems)

Poorly regulated behavior

(noncompliance)

“Fidgety Phil”

Dr. Heinrich Hoffman 1845

“Johnny-Head-In-The-Air”

Dr. George Still 1902

“Morbid defect

of moral control”

Impulsive, aggressive, defiant, prone to accidents, unable to control their behavior

adhd in the 1950 s 1960 s minimal brain dysfunction

ADHD in the 1950’s-1960’s ‘minimal brain dysfunction’

Speech, Language

Social interaction

Emotion

Mood

Motor function

Intellectual function

Behavior

slide15

A mental health disorder:

Childhood-onset

Disruptive behavior disorder:

Inattention, impulsiveness, hyperactivity

World-wide recognition of ADHD

Current Medical Perspective of ADHD 1994-2008

attention deficit hyperactivity disorder criteria

Criterion A: Either (1) or (2)

  • (1) six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level
Attention-Deficit/Hyperactivity Disorder Criteria
a 1 inattention 6 of more of these 9 symptoms

Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities

  • Often has difficulty sustaining attention in tasks or play activities
  • Often does not listen when spoken to directly
  • Often does not follow through on instructions and fails to finish schoolwork , chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • Often has difficulty organizing tasks and activities
  • Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (eg, schoolwork, homework)
  • Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, tools)
  • Is often easily distracted by extraneous stimuli
  • Is often forgetful in daily activities
A.1. Inattention (6 of more of these 9 symptoms
attention deficit hyperactivity disorder criteria1

Criterion A: Either (1) or (2)

  • (1) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level
Attention-Deficit/Hyperactivity Disorder Criteria
a 2 hyperactivity impulsivity
Hyperactivity

Impulsivity

  • Often fidgets with hands or feet or squirms in seat
  • Often leaves seat in classroom or in other situations in which remaining seated is expected
  • Often runs about or climbs excessively in situations in which it is inappropriate
  • Often has difficulty playing or engaging in leisure activities quietly
  • Is often “on the go” or often acts as if “driven like a motor”
  • Often talks excessively
  • Often blurts out answers before questions have been completed
  • Often has difficulty awaiting turn
  • Often interrupts or intrudes on others (eg butts into conversations or games)
A.2. Hyperactivity-impulsivity
additional dsm iv criteria for adhd

Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years

  • Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home)
  • There must be clear evidence of clinically significant impairment in social, academic or occupational functioning
  • The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (eg, Mood, Anxiety Dissociative or Personality Disorder)
Additional DSM-IV criteria for ADHD
dsm iv tr subtypes of adhd

ADHD-Combined Type

    • If both Criteria A1 and A2 are met for the past 6 months
  • ADHD-Predominantly Inattentive Type
    • If Criterion A1 is met but Criterion A2 is not met for the past 6 months
  • ADHD-Predominantly Hyperactive-Impulsive Type
    • If Criterion A2 is met but Criterion A1 is not met for the past 6 months
DSM-IV-TR Subtypes of ADHD
medical perspectives of adhd

Group Discussion (5 min)

What do you notice about the symptoms of ADHD?

  • Reflect normal behavior not atypical behavior
  • All symptoms are preceded by the qualifier “Often…” how often is often?
  • Some symptoms are ‘double-barelled’ and component parts have different meanings
  • Some seem similar to other symptoms
    • How would you differentiate between the 3 impulsivity symptoms?
  • Most appear to be geared towards children
    • Can symptoms be adapted for adolescents/adults?
Medical perspectives of ADHD
what do adhd symptoms look like at school

What do ADHD symptoms look like at school?

DVD Program 2: Video Clip

A multi-media Professional Development Program for Teachers, developed by researchers at the Hospital for Sick Children1 in collaboration with TV-Ontario & University of Saskatchewan (video footage)

with funds from NIMH, CIHR, TV-Ontario, Hospital for Sick Children & an unrestricted educational grant from Shire Biochem Inc.

1R. Tannock, B. Ferguson, P. Chaban, R. Martinussen, A. McInnes

what the videoclips show
What the videoclips show…
  • A special class for children with “behavior problems”
    • class designed for research
  • 9 children with ADHD: seated at 2 tables
    • None are receiving medication
  • 1 special education teacher & 1 educational assistant
    • Both trained in behavior management
video clip 1
Video-clip #1
  • Teacher-directed activity
    • Card matching game: which card on the wall chart matches the card in teacher’s hand: tell teacher the coordinates on the wall chart (e.g., B3)
  • Video shows 4 boys seated at a table taking part in the activity

Write down what you see your specified student doing (or not doing)

classroom observations

Classroom observations

In the videoclip (card game):

Q.1 which boy was the most restless?

Q 2.which boy participatedthe most?

video clip 2
Video-clip #2
  • Independent seat-work activity
    • Math fluency
    • Timed math task: do as many as you can in 10 minutes (we will watch 1.5 min)
    • work quietly, quickly, and accurately
  • Video shows 4 boys & 1 girl

Write down what you see your specified student doing (or not doing)

classroom observations1
Classroom observations
  • Q.1 Which student attracts the most attention from the teacher?
  • Q.2 Which student appears to be least productive?
  • Q.3 Which students is/are most productive?
slide29

Symptoms vary across contexts

  • Symptoms vary within a child minute-to-minute, day-to-day, & from one situation to another
  • Symptoms increase during activities with:
    • high cognitive demand
    • little active engagement
how might adhd symptoms manifest in school
Often loses things necessary for tasks & activities

Often ‘on the go’ or acts as if ‘driven by a motor’

Often has to hunt for needed items (pencil, book etc)

Often complains that s/he can’t find the necessary items

Often does not know where the needed item is (“um.. It may be in my locker, or perhaps in my knapsack, or maybe at home”)

Frequently rocks chair, stands up or leans over desk, swings legs, shifts in seat, in almost constant motion

How might ADHD symptoms manifest in school?
how might adhd symptoms manifest in school small group activity
How might ADHD symptoms manifest in school? (small group activity)
  • For your designated symptoms of inattention and hyperactivity/impulsivity, describe how they might manifest at school.
  • Consider different situations & different classes at school
  • Consider how they might manifest in elementary , middle, & high school students
  • Report back to large group
what would you observe
What would you observe……?
  • Group 1
    • A1.a. Fails to give close attention to details or …
    • A1.b. Difficulty sustaining attention..
    • A2 a. Fidget or squirms
    • A2. b. Often leaves seat
  • Group 2
    • A1.c. Does not listen..
    • A1.d. Does not follow through on instructions….
    • A2.c. Runs about or climbs
    • A2.d. difficulty playing quietly
  • Group 3
    • A1.e. Difficulty organizing…
    • A1.f. Avoids effortful tasks..
    • A2.f.talks excessively
    • A2.g. Blurts out answers..
  • Group 4
    • A1.h. Easily distracted
    • A1.i. forgetful daily activities
    • A2.h. Difficulty waiting turn
    • A2.i. interrupts, intrudes..
classroom observation ages 13 17 western australia carroll et al ed psychol 2006
Classroom observation: ages 13-17 Western Australia (Carroll et al., Ed Psychol: 2006)

25% of solitary off-task behavior attributed to teacher behavior (multiple/changing instructions)40% to environmental distractions

  • Common Triggers:
  • Failure to begin assigned task
  • Peer-initiated
adhd in the classroom 7 to 11 yr olds
ADHD in the classroom (7- to 11-yr-olds

ADHD-good attn

On-task 68%

Optimal ability 5 min

ADHD-poor attn

On-task 40%

Optimal ability 2 min

TD

On-task 80%,

optimal ability 7 min

Increases with time on task

TD

On-task 80%

Increases with time on task

ADHD-good attn

On-task 68%

ADHD –poor attn

On-task-40% & highly variable

L

H

TD

L

H

TD

Rapport et al (in press ) J Attention Disorders [epub March 2 2009]

kids behind the label

GROUP DISCUSSION

  • What is ADHD according to the youngsters interviewed for this book?
    • What themes emerged?
    • How do they map onto the DSM-IV-TR criteria for ADHD ?
“Kids Behind the Label”
slide36

A mental health disorder:

Childhood-onset

Disruptive behavior disorder:

Inattention, impulsiveness, hyperactivity

Meta-analyses indicate a

world-wide prevalence of ADHD:

~ 5 % in children & adolescents

~ 3 - 4% in adults

More common in males than females (3: 1)

ADHD 1994-2008

diagnosis versus symptoms

Studies suggest that the symptoms of ADHD are normally distributed

    • Few symptoms
    • Some symptoms
    • Many symptoms
  • Several additional students will manifest impairing symptoms but subthreshold for a diagnosis of ADHD
    • Findings also indicate that even moderate levels of ADHD symptoms increase the risk for poor academic outcomes (Currie & Stabile, 2006; Rodriguez et al., 2007).
Diagnosis versus Symptoms
slide40

CD

ADHD
  • poor attention
  • excessive activity
  • impulsivity

extreme

antisocial behaviour:

bullying, lying, stealing, cruelty

Persistent negativistic behavior:

argumentative, defiant,

provocative, hostile

Differs from:

ODD

slide41
ADHD
  • poor attention
  • excessive activity
  • impulsivity

Difficulty learning to read, write, process numbers, or do math, accurately and fluently, despite at least average intellectual ability and opportunity to learn.

LD

Differs from LD:

slide42
ADHD
  • poor attention
  • excessive activity
  • impulsivity

Differs from: Autism, Asperger’s

Social Communication Deficits

Fixated interestsRepetitive behaviors

but adhd rarely occurs by itself
BUT…ADHD rarely occurs by itself!

Carroll et al (2005) J Child Psychol Psychiat 46:524-532; Jensen et al (2001) JAACAP 40:147-158; Kessler et al (2005) Am J Psychiatry 163:716-723; Reich et al (2005) Twin Res Hum Genet 8:459-466

16

case 1 daniel is a 7 year old boy
Case # 1: Daniel is a 7 year old boy
  • Since the start of the school-year, the teacher noticed that he has:
  • problems concentrating & rarely does his homework
  • disrupts the class by calling out
  • frequently leaves his seat to go over to another student and grabs things or pokes him
  • often loses his temper and gets angry
  • often refuses to do what the teacher asks him to do
  • tries to pass the blame onto others, when the teacher reprimands him
  • His mother reports that he is just the same at home and the problems seemed to start about 5 months ago when his father left the family
how likely is it that this boy s behavior is attributable to adhd by show of hands
How likely is it that this boy’s behavior is attributable to ADHD? (by show of hands)
  • 1. Very likely
  • 2. Somewhat likely
  • 3. Somewhat unlikely
  • 4. Very unlikely

Optimum response is #4, because most of the symptoms are diagnostic criteria for Oppositional Defiant Disorder (not ADHD), their onset is recent, have not persisted for at least 6 months, and coincided with a major family stressor

case 2 danielle is a 9 year old student
Case # 2:Danielle is a 9-year-old student…
  • Since the start of the school-year, the teacher noticed that Danielle …
  • Easily distracted by what is going on around her,
  • Has problems concentrating,
  • Makes careless mistakes in her work,
  • Often loses her workbooks, pencil, her library book
  • Generally does her homework but forgets to hand it in
  • Rarely puts loose worksheets into her binder and typically crams them into desk or backpack
  • Typically needs instructions to be repeated
  • Tends to annoy other girls by saying ‘ mean things” to them
  • Her mother says she is like this at home too,and was like it even in preschool
how likely is it that this girl s behavior is attributable to adhd
How likely is it that this girl’s behavior is attributable to ADHD?
  • 1. Very likely
  • 2. Somewhat likely
  • 3. Somewhat unlikely
  • 4. Very unlikely

Optimum response is #2, because she exhibits many symptoms of Inattention, that have persisted for more than 6 months, started in preschool years, and occur in at least 2 contexts (home and school). Need diagnostic assessment to rule out other explanations & confirm ADHD

weaknesses in dsm iv diagnostic criteria for adhd
Weaknesses in DSM-IV diagnostic criteria for ADHD
  • Questionable validity of subtypes
  • Developmental insensitivity of symptoms & thresholds
  • Lack of scientific basis for age-of-onset criterion
  • Reliance on single informant (parent, self)
  • Presence of autism/PDD as diagnostic exclusion
historical changes in adhd subtypin g
Historical changes in ADHD subtyping

DSM-IV subtypes of ADHD

1968 (DSM-II) No subtyping

1980 (DSM-III) Subtyping

ADD (inatt + imp)

ADDH (inatt, imp, hyp)

1987 (DSM-III-R) No subtyping

1994 (DSM-IV) Subtyping

ADHD-PI

ADHD-HI

ADHD-CT

INATTENTION

HYPERACTIVITY-

IMPULSIVITY

INATTENTIVE

SUBTYPE

“ADD”

HYPERACTIVE-

IMPULSIVE SUBTYPE

COMBINED TYPE

“Classic ADHD”

dsm iv subtypes do they show developmental stability
DSM-IV subtypes Do they show developmental stability?
  • Lahey et al., 2005
  • In an 8-year follow-up study of children with confirmed DSM-IV diagnosis of ADHD…
    • 37% of Combined –Type and…
    • 50% of Inattentive –Type
    • Changed subtype classification at least 2 times over an 8-year period
slide52
DSM-IV subtypes Do they differ in stimulant response?Solanto et al., in press J Child Adolesc Psychopharm

Bedard AC, Tannock R.

J Atten Disord. 2008 Mar;11(5):546-57

No differential effects of stimulants on subtypes

revisiting the factor structure of adhd symptoms
Revisiting the factor structure of ADHD symptoms

bifactor model with general & specific factors

correlated two-factor model

evidence for a general adhd factor with specific factors
Evidence for a ‘General” ADHD factor with specific factors
  • Martel, von Eye, Nigg (2010)
  • Dumenici, McConaughy, Achenbach(2004)
inattentive subtype
Inattentive subtype
  • Clinical experience argues for the need to recognize an Inattentive Subtype of ADHD
  • Predominantly Inattentive ADHD is one of the most frequently used diagnoses in very large samples of treated inattentive children.
  • Clinical consultants have informed us that many such children show few if any manifestations of hyperactivity however the current subtype structure does not accurately describe purely inattentive children.
what is your vote
What is your vote?
  • Keep as is: keep current DSM-IV ADHD subtypes
  • Code for ADHD only; eliminate subtypes and rate severity of inattention, hyperactivity/impulsivity dimensionally
  • Eliminate Predominantly Inattentive subtype as a subtype of ADHD & code among Neurodevelopmental disorders
  • Create new Inattentive Subtype (only 2 hyperactive/ impulsive symptoms allowed)
what is the validity of criterion b age of onset of adhd symptoms
What is the validity of Criterion B ?“Age-of-Onset of ADHD symptoms”
  • Criterion B: Some hyperactive/impulsive or inattentive symptoms that caused impairment were present before age 7 years. (Introduced in DSM-III)
  • Data base: systematic literature search
    • 31 studies reporting original data on age of onset

(Kieling, Kieling, Rohde, Frick, Moffitt, Nigg, Tannock, Castellanos (2010). Am J Psychiatry 167: 1 )

evidence against criterion b
Evidence against Criterion B
  • Analysis of DSM-IV field trials revealed later onset for inattentive group
  • Adult population study revealed that only 50% individuals with ADHD retrospectively recalled an onset before 7 years
  • Prospective studies reveal poor stability of recall of age of onset
  • Series of studies reveal that later-onset ADHD does not differ from before-age-7-onset in comorbidity, neuropsychological profile, impairment, treatment response
provisional recommendations by dsm v work group on adhd
Provisional recommendations by DSM-V Work Group on ADHD
  • In the absence of a scientific basis for the existing age of onset criterion, modify the current age-of-onset (age 7) to a later time (age 12)
  • What are the implications of changing Criterion B?
    • Polanczyk (2010) concluded that raising the age of onset to age 12 would not increase prevalence rates of the disorder (J Am Acad Child Adolesc Psychiatry 49: 210)
what is your vote for age of onset
What is your vote for age-of-onset?
  • Keep as is (onset before age 7 years)
  • Modify to “onset before age 12”
  • Modify as “onset before age 18” (broadly interpreted as the developmental period)
developmental insensitivity of symptoms and threshold
Developmental insensitivity of symptoms and threshold

Suggestions for improving assessment of ADHD in adults include:

  • Adding 4 impulsivity items
  • Elaborating examples of current criteria
  • Changing diagnostic threshold from 6 to 3 symptoms (of inattention, hyperactivity/impulsivity)
proposed new impulsivity symptoms
Proposed new impulsivity symptoms
  • The following new criteria would be applied to all ages:
  • a. Often acts without thinking
    • (e.g. often starts tasks without adequate preparation, such as reading or listening to instructions, jumps into activities, speaks out without considering consequences; makes important decisions on the spur of the moment, such as buying items, quitting a job suddenly, breaking up with friend).
  • b. Is often impatient
    • ( e.g. grabs things instead of asking, wants others to move faster, wants people to get to the point, often speeds while driving, cuts into traffic to go faster than others).
  • c. Often rushes through activities or tasks, is fast paced
    • (e.g averse to doing things carefully and systematically).
  • d. Often has difficulty resisting immediate temptations or appealing opportunities, while disregarding negative consequences
    • (in childhood, grabs toys off store shelf, or fascinating dangerous objects or plays with dangerous objects; in adulthood, commits to a relationship after brief acquaintance, takes job or enters into business arrangement without doing due diligence).
elaboration of existing criteria
Elaboration of existing criteria
  • Existing: Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • Elaboration:(work has to be checked for accuracy, details are often missed or skipped, materials are not reviewed systematically)
  • Existing:Often does not seem to listen when spoken to directly
  • Elaboration: (mind often seems to be elsewhere, others often complain that he/she does not listen)
elaboration of criteria
Elaboration of criteria

FOR

  • 1. Encourages clinicians to obtain real-life vignettes & examples, rather than to accept broad, poorly defined descriptors.
  • 2. More specific descriptions of behavior could result in greater reliability and consistency.
  • 3. Examples written to a cover a broad age range.

AGAINST

  • 1. Risk that a single example will be taken as the sole reference for the broader criterion.
  • 2. Examples tend to be more age specific than the underlying construct.
  • 3. Not all additions convey an elaboration (e.g., Inattention d, Hyperactivity b).
  • 5. Not empirically based or tested.

.

alter symptom threshold for adult adhd
Alter symptom threshold for adult ADHD

For: Takes account of research findings that symptoms decline in number with age despite persistent impairment.

Against

  • Increases likelihood of false positives.
  • Impulsive behaviors found in many disorders, and increased representation of impulsivity will increase likelihood of co-morbidity.
  • No good explanation yet available for previous studies showing a high level of correlation between impulsivity and hyperactivity in DSM-IV that led to the inclusions of impulsivity items in the HA list.
developmental insensitivity of symptoms and threshold1
Developmental insensitivity of symptoms and threshold

Suggestions for improving assessment of ADHD in adults include:

  • Adding 4 impulsivity items
  • Elaborating examples of current criteria
  • Changing diagnostic threshold from 6 to 3 symptoms (of inattention, hyperactivity/impulsivity)

What are your thoughts?

inclusion and exclusion criteria autism pdd
Inclusion and Exclusion Criteria: Autism/PDD

Option 1. No change.

Option 2. Remove autism-spectrum disorder (ASD) and PDD from the excluders.

FOR

  • a. No sound evidence that ADHD is inconsistent with these disorders.
  • b. Association between ADHD and these disorders (i.e., ADHD and ASD; ADHD and PDD) is not universal, and, when it exists, it is beneficial to treat both.
  • c. Treatment of ADHD with or without ASD/PDD is broadly similar.

AGAINST

  • Unsure whether the neuropathology of inattention and hyperactivity are similar in children with and without ASD and PDD .
requirement for multi informants to confirm cross situationality
Requirement for multi-informants to confirm cross-situationality
  • Children: ascertain information directly from teachers
  • Adults (& college/university students): ascertain information from a significant other (collateral report)
proposed introductory text for dsm v adhd
Proposed Introductory Text for DSM-V ADHD
  • In children and young adolescents, the diagnosis should be based on information obtained from parents andteachers.
  • When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school.
  • Examination of the patient in the clinician’s office may or may not be informative.  For older adolescents and adults, confirmatory observations by third parties should be obtained whenever possible.
  • Proposed changes to DSM-IV Criterion C
  • [Some impairment from]The symptoms are apparentin two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities)
are adhd dsm iv subtypes valid constructs diagnoses
Are ADHD DSM-IV subtypes valid constructs/diagnoses?
  • “Taken together (field trials DSM-III-R), these findings suggest that the DSM-IV types of attention deficit hyperactivity disorder are distinct in a number of ways, but tests are needed in future studies of possible differences in etiology, clinical course, and response to treatment among the three types” (Lahey et al. 1994).
  • 14 years later this picture has not changed: little robust evidence that subtypes are valid or stable
  • Classification/diagnosis of subtypes varies as a function of informant and how information from different informants are combined (Rowland et al, 2008; Valo & Tannock, under review)
proposed dsm 5 presentations castellanos 163 rd annual meeting apa new orleans la 5 25 2010
Proposed DSM-5 PresentationsCastellanos:163rd Annual Meeting – APA - New Orleans, LA 5/25/2010
  • Specify Based on Current Presentation
  • Combined Presentation:If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months.
  • Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months.
  • Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months.
  • Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months.

Inattentive Presentation (Restrictive) is not well supported empirically – double bind of confounds inherent in DSM-IV – justification based on clinical experience

class 1 summary

ADHD is not a ‘new’ disorder: its symptoms & impairments were described in medical literature as early as 18th century

  • The essential construct of ADHD remains equivocal: currently conceptualized as a mental health disorder that manifests as disruptive behavior
  • It often co-occurs with other disorders (ODD, CD, Anxiety, Autism, LD) but can be distinguished from those disorders
  • The diagnostic criteria specified in the DSM-IV are problematic and are under revision
Class #1: Summary