ADD and ADHD: Symptoms, Neurobiology, and Over-Diagnosis

Symptoms and Diagnosis

Attention-deficit disorder (ADD) and attention-deficit hyperactivity disorder (ADHD) are both classified as neurodevelopmental disorders of childhood, although the definitions of both have been broadened to encompass adults, given the acknowledgement that appropriate diagnosis may not have been given in childhood ("Facts," 2015). According to the most recent revised criteria for the DSM-5, "individuals younger than 17 must display at least 6 of 9 inattentive and/or hyperactive impulsive symptoms" to warrant a diagnosis of ADD or ADHD (Rabiner 2013).

Symptoms of inattentiveness according to the DSM-5 include careless mistakes, difficulty sustaining attention to either work or play, an apparent refusal to listen, a failure to follow through on tasks, difficulties organizing activities, difficulties sustaining effort, losing things, distractedness, and forgetfulness (Rabiner 2013). Impulsivity may be evident in fidgeting, leaving one's seat when expected to remain still, inappropriate activity — or desire to engage in it — such as running or climbing, difficulty engaging in sustained leisure activities, constantly needing to be on the go, excessive talking, blurting out answers before questions have been asked, interrupting others, or an inability to wait one's turn (Rabiner 2013).

In recognition of the fact that even many neurologically typical children may have moments of excessive activity, but that older children are expected to exercise more self-control, "for individuals 17 and above … only 5 or more symptoms are needed. This change from DSM-IV was made because of the reduction in symptoms that tends to occur with increasing age" (Rabiner 2013).

Given the neurological basis for ADHD, these symptoms must have been evident before the age of seven. They must also not have been caused by drugs (such as caffeine) or other psychiatric or physical illnesses. Symptoms must be evident in at least two contexts, such as work and school — that is, there must not be a very specific environmental trigger for the behavior. There must be "clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning" (Rabiner 2013). Inattentive behaviors must be evident for a diagnosis, and once a diagnosis is made the child can then be screened for the hyperactivity criteria. Severity is gauged as mild, moderate, or severe. An ADHD Not Otherwise Specified (NOS) diagnosis can be given to individuals whose symptoms do not meet the specified criteria (Rabiner 2013).

The DSM-5 criteria have a notably more flexible threshold for diagnosing the disorder, reflecting the fact that adults may not have been appropriately diagnosed as children, even though the condition is considered biological and hard-wired into an individual's neurological circuitry at birth (Rabiner 2013). The threshold of impairment has also been considerably lowered: the requirement for "clinically significant impairment" has been changed to evidence that "symptoms interfere with or reduce the quality of performance in important life domains," which has given rise to criticisms that this change has increased the rate of over-diagnosis (Rabiner 2013). As Rabiner (2013) notes, "individuals who will be diagnosed with the 'mild' specifier, and even some with the 'moderate' specifier" would not have been diagnosed under the previous criteria of the DSM-IV, and "an increase in diagnoses may also result in more individuals being treated with medication when this is not really necessary," or given more accommodations in a school or work setting than are truly needed.

References

Facts about ADHD. (2015). CDC. Retrieved from: http://www.cdc.gov/ncbddd/adhd/facts.html

Knouse, L. & Safren, S. (2010). Current status of cognitive behavioral therapy for adult attention deficit hyperactivity disorder. Psychiatric Clinics of North America, 33(3): 497–509. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909688/

Purper-Ouakil, D., Ramoz, N., Lepagnol-Bestel, A., Gorwood, P., & Simonneau, N. (2011). Neurobiology of attention deficit hyperactivity disorder. Pediatric Research, 69, 69R–76R.

Rabiner, D. (2013). New diagnostic criteria for ADHD: Subtle but important changes. Help for ADD. Retrieved from: http://www.helpforadd.com/2013/june.htm

Schwarz, A. (2013). The selling of ADHD. The New York Times.

Wedge, M. (2012). Why French kids don't have ADHD. Psychology Today. Retrieved from: https://www.psychologytoday.com/blog/suffer-the-children/201203/why-french-kids-dont-have-adhd