ADHD Atten Def Hyp Disord DOI 10.1007/s12402-014-0159-5
SHORT COMMUNICATION
Revising the diagnostic criteria for Attention-Deficit Hyperactivity Disorder (ADHD): an adulthood perspective Fred W. Reimherr • Barrie K. Marchant Thomas E. Gift • Tammy A. Steans • Paul H. Wender
•
Received: 17 November 2014 / Accepted: 20 November 2014 Ó Springer-Verlag Wien 2014
Over the several decades since the publication of the DSMIII (American Psychiatric Association 1980), the diagnosis of ADHD in adults has been imbued with uncertainty. At that time, it was thought to be a disorder confined to childhood and consequently the criteria focused on children between the ages of 6–12. These criteria, involving both observable behaviors and reported symptoms, fit this age group quite well, but are not easily applied to either older adolescents or adults. Most other adult DSM diagnoses are based on symptom areas, not specific behaviors, making the application of the DSM ADHD criteria to adults an oddity. In the late 1970s and 1980s at the University of Utah in the United States (Wender et al. 1981; Wood et al. 1976), we started to publish studies of adults with ADHD and noted that many of these patients had problems beyond the accepted inattention, hyperactivity and impulsivity symptoms seen in children. With the publication of the Utah Criteria for the diagnosis of ADHD in 1985 (Wender et al. F. W. Reimherr Department of Psychiatry, University of Utah School of Medicine and Psychiatric and Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT 84105, USA F. W. Reimherr B. K. Marchant (&) T. A. Steans Psychiatric and Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT 84105, USA e-mail: [email protected] T. E. Gift Department of Psychiatry, University of Rochester, 1522 South 1100 East, Salt Lake City, UT 84105, USA P. H. Wender Department of Psychiatry, University of Utah School of Medicine, 1522 South 1100 East, Salt Lake City, UT 84105, USA
1985), we tried to clarify and specify the kinds of problems with emotionality encountered in adults. We then began to develop the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) to help define more precisely the mood lability, temper control and emotional over-reactivity that we found in our adults with ADHD. Both the criteria and the corresponding scale included a variety of emotional symptoms. In addition, both presented ADHD criteria as problem areas, not narrowly defined behaviors. In the 1990s, we published the widely accepted Wender Utah Rating Scale (Ward et al. 1993), which was devised to retrospectively identify childhood characteristics associated with ADHD. It encompasses symptoms, including emotionality, which have been associated with the persistence of ADHD into adulthood. In the early 2000s, publications from the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study, which dealt with children exclusively, helped define more severe ADHD, which frequently included emotional and oppositional symptoms (Jensen et al. 2001). In fact, 70 % of these patients, all with Combined Type ADHD, had emotional and/or oppositional symptoms. Analyzing data in 2005 from a large multicenter study, we used the WRAADDS to define a subset of adult ADHD patients with high levels of emotional symptoms, which we labeled as ‘‘ADHD related emotional dysregulation’’ (Reimherr et al. 2005). These patients were more impaired than others in the sample and were highly responsive to treatment. Since then multiple well-respected researchers from Europe, the United States and more globally have documented the ongoing emotional symptoms in both pediatric and adult ADHD, and numerous reports support the position that emotional symptoms are integral to ADHD.
123
F. W. Reimherr et al.
In our research report in this issue, we suggest an alternative approach to categorizing adults with ADHD based on a factor analysis of the WRAADDS (Marchant et al. 2013). Psychometric analysis of this scale yields a 2-factor solution, and in turn, these two factors lead to two types of adult ADHD, which we have labeled ‘‘ADHD inattentive presentation’’ and ‘‘ADHD emotional dysregulation presentation.’’ A cluster analysis confirmed the validity of these two diagnostic types. There are several benefits to these categories compared to the ICD-10 and DSM-5 (American Psychiatric Association 2013) ADHD formulations. First, this categorization encompasses the emotional symptoms of ADHD. The importance of these symptoms in adults as well as children is supported by a rapidly expanding literature. Second, it identifies a group of adult ADHD patients whose burden of emotional symptoms leaves them with greater severity of illness than is experienced by many patients spared many of these symptoms. Our research report in this issue shows that patients with higher levels of emotional dysregulation tend to have higher levels of other sorts of problems, and therein, we cite references to other investigations that have yielded similar conclusions. Third, it presents the disorder in a manner that allows psychiatrists to more effectively assess and treat their adult patients. Many researchers seeking to better understand emotional symptoms in ADHD have focused almost exclusively on temper control and oppositional symptoms. In contrast, we note in our report that emotionality in ADHD has additional facets, including tension, restlessness, mild cyclothymia, dysphoria, boredom, affective lability and emotional over-reactivity. None of this is adequately reflected in current DSM criteria. Although the DSM-5 surpasses its predecessors in the applicability of ADHD criteria to adults, it continues to exclude the emotional symptoms of ADHD. Use of these two categories, ADHD inattentive presentation and ADHD emotional dysregulation presentation, can increase the likelihood that clinicians will be alert to the differences in symptoms characteristic of each, while at the same time being less likely to erroneously assume a comorbid mood disorder when encountering emotional symptoms. From an interpersonal perspective, these emotional symptoms commonly lead to conflicts, which may be
123
the reason that many adults seek out mental health professionals. This gives rise to the concern that frequently adult ADHD patients may receive sub-optimal interventions because of the unwarranted assumption that they spring from a different psychiatric diagnosis, such as a personality or mood disorder. The perspective sketched above with regard to diagnosing adult ADHD can be understood in the context of medicine generally—improvements in diagnosis interact reciprocally with theory and treatment such that advances in all three areas ensue.
References American Psychiatric Association (1980) DSM-III diagnostic and statistical manual of mental disorders, 3rd edn. APA, Washington DC American Psychiatric Association (2013) DSM-5 diagnostic and statistical manual of mental disorders, 5th edn. APA New York, London Jensen PS, Hinshaw SP, Kraemer HC, Lenora N, Newcorn JH, Abikoff HB, March JS, Arnold LE, Cantwell DP, Conners CK, Elliott GR, Greenhill LL, Hechtman L, Hoza B, Pelham WE, Severe JB, Swanson JM, Wells KC, Wigal T, Vitiello B (2001) ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry 40:147–158 Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH (2013) Psychometric properties of the Wender–Reimherr adult attention deficit disorder scale. Psychol Assess 25:942–950 Reimherr FW, Marchant BK, Strong RE, Hedges DW, Adler L, Spencer TJ, West SA, Soni P (2005) Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry 58:125–131 Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah rating scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 150:885–890 Wender PH, Reimherr FW, Wood DR (1981) Attention deficit disorder (‘minimal brain dysfunction’) in adults. A replication study of diagnosis and drug treatment. Arch Gen Psychiatry 38:449–456 Wender PH, Reimherr FW, Wood D, Ward M (1985) A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults. Am J Psychiatry 142:547–552 Wood DR, Reimherr FW, Wender PH, Johnson GE (1976) Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report. Arch Gen Psychiatry 33:1453–1460
SHORT COMMUNICATION
Revising the diagnostic criteria for Attention-Deficit Hyperactivity Disorder (ADHD): an adulthood perspective Fred W. Reimherr • Barrie K. Marchant Thomas E. Gift • Tammy A. Steans • Paul H. Wender
•
Received: 17 November 2014 / Accepted: 20 November 2014 Ó Springer-Verlag Wien 2014
Over the several decades since the publication of the DSMIII (American Psychiatric Association 1980), the diagnosis of ADHD in adults has been imbued with uncertainty. At that time, it was thought to be a disorder confined to childhood and consequently the criteria focused on children between the ages of 6–12. These criteria, involving both observable behaviors and reported symptoms, fit this age group quite well, but are not easily applied to either older adolescents or adults. Most other adult DSM diagnoses are based on symptom areas, not specific behaviors, making the application of the DSM ADHD criteria to adults an oddity. In the late 1970s and 1980s at the University of Utah in the United States (Wender et al. 1981; Wood et al. 1976), we started to publish studies of adults with ADHD and noted that many of these patients had problems beyond the accepted inattention, hyperactivity and impulsivity symptoms seen in children. With the publication of the Utah Criteria for the diagnosis of ADHD in 1985 (Wender et al. F. W. Reimherr Department of Psychiatry, University of Utah School of Medicine and Psychiatric and Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT 84105, USA F. W. Reimherr B. K. Marchant (&) T. A. Steans Psychiatric and Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT 84105, USA e-mail: [email protected] T. E. Gift Department of Psychiatry, University of Rochester, 1522 South 1100 East, Salt Lake City, UT 84105, USA P. H. Wender Department of Psychiatry, University of Utah School of Medicine, 1522 South 1100 East, Salt Lake City, UT 84105, USA
1985), we tried to clarify and specify the kinds of problems with emotionality encountered in adults. We then began to develop the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) to help define more precisely the mood lability, temper control and emotional over-reactivity that we found in our adults with ADHD. Both the criteria and the corresponding scale included a variety of emotional symptoms. In addition, both presented ADHD criteria as problem areas, not narrowly defined behaviors. In the 1990s, we published the widely accepted Wender Utah Rating Scale (Ward et al. 1993), which was devised to retrospectively identify childhood characteristics associated with ADHD. It encompasses symptoms, including emotionality, which have been associated with the persistence of ADHD into adulthood. In the early 2000s, publications from the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study, which dealt with children exclusively, helped define more severe ADHD, which frequently included emotional and oppositional symptoms (Jensen et al. 2001). In fact, 70 % of these patients, all with Combined Type ADHD, had emotional and/or oppositional symptoms. Analyzing data in 2005 from a large multicenter study, we used the WRAADDS to define a subset of adult ADHD patients with high levels of emotional symptoms, which we labeled as ‘‘ADHD related emotional dysregulation’’ (Reimherr et al. 2005). These patients were more impaired than others in the sample and were highly responsive to treatment. Since then multiple well-respected researchers from Europe, the United States and more globally have documented the ongoing emotional symptoms in both pediatric and adult ADHD, and numerous reports support the position that emotional symptoms are integral to ADHD.
123
F. W. Reimherr et al.
In our research report in this issue, we suggest an alternative approach to categorizing adults with ADHD based on a factor analysis of the WRAADDS (Marchant et al. 2013). Psychometric analysis of this scale yields a 2-factor solution, and in turn, these two factors lead to two types of adult ADHD, which we have labeled ‘‘ADHD inattentive presentation’’ and ‘‘ADHD emotional dysregulation presentation.’’ A cluster analysis confirmed the validity of these two diagnostic types. There are several benefits to these categories compared to the ICD-10 and DSM-5 (American Psychiatric Association 2013) ADHD formulations. First, this categorization encompasses the emotional symptoms of ADHD. The importance of these symptoms in adults as well as children is supported by a rapidly expanding literature. Second, it identifies a group of adult ADHD patients whose burden of emotional symptoms leaves them with greater severity of illness than is experienced by many patients spared many of these symptoms. Our research report in this issue shows that patients with higher levels of emotional dysregulation tend to have higher levels of other sorts of problems, and therein, we cite references to other investigations that have yielded similar conclusions. Third, it presents the disorder in a manner that allows psychiatrists to more effectively assess and treat their adult patients. Many researchers seeking to better understand emotional symptoms in ADHD have focused almost exclusively on temper control and oppositional symptoms. In contrast, we note in our report that emotionality in ADHD has additional facets, including tension, restlessness, mild cyclothymia, dysphoria, boredom, affective lability and emotional over-reactivity. None of this is adequately reflected in current DSM criteria. Although the DSM-5 surpasses its predecessors in the applicability of ADHD criteria to adults, it continues to exclude the emotional symptoms of ADHD. Use of these two categories, ADHD inattentive presentation and ADHD emotional dysregulation presentation, can increase the likelihood that clinicians will be alert to the differences in symptoms characteristic of each, while at the same time being less likely to erroneously assume a comorbid mood disorder when encountering emotional symptoms. From an interpersonal perspective, these emotional symptoms commonly lead to conflicts, which may be
123
the reason that many adults seek out mental health professionals. This gives rise to the concern that frequently adult ADHD patients may receive sub-optimal interventions because of the unwarranted assumption that they spring from a different psychiatric diagnosis, such as a personality or mood disorder. The perspective sketched above with regard to diagnosing adult ADHD can be understood in the context of medicine generally—improvements in diagnosis interact reciprocally with theory and treatment such that advances in all three areas ensue.
References American Psychiatric Association (1980) DSM-III diagnostic and statistical manual of mental disorders, 3rd edn. APA, Washington DC American Psychiatric Association (2013) DSM-5 diagnostic and statistical manual of mental disorders, 5th edn. APA New York, London Jensen PS, Hinshaw SP, Kraemer HC, Lenora N, Newcorn JH, Abikoff HB, March JS, Arnold LE, Cantwell DP, Conners CK, Elliott GR, Greenhill LL, Hechtman L, Hoza B, Pelham WE, Severe JB, Swanson JM, Wells KC, Wigal T, Vitiello B (2001) ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry 40:147–158 Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH (2013) Psychometric properties of the Wender–Reimherr adult attention deficit disorder scale. Psychol Assess 25:942–950 Reimherr FW, Marchant BK, Strong RE, Hedges DW, Adler L, Spencer TJ, West SA, Soni P (2005) Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry 58:125–131 Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah rating scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 150:885–890 Wender PH, Reimherr FW, Wood DR (1981) Attention deficit disorder (‘minimal brain dysfunction’) in adults. A replication study of diagnosis and drug treatment. Arch Gen Psychiatry 38:449–456 Wender PH, Reimherr FW, Wood D, Ward M (1985) A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults. Am J Psychiatry 142:547–552 Wood DR, Reimherr FW, Wender PH, Johnson GE (1976) Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report. Arch Gen Psychiatry 33:1453–1460
