Attention-Deficit/Hyperactivity Disorder


I attended a lecture today about addiction where the lecturer claimed that the American Medical Association requires that a phenomenon meet the following criteria to be considered a disease:

1) It must be progressive

2) It must manifest identifiable symptoms

3) It must occur chronically in affected individuals

4) It must be fatal if left untreated

That makes some things obvious diseases. Cancers, for example. There are many things that we consider diseases that do not fit these criteria, though. I believe that obesity, for example, is not officially considered a disease because it is not fatal. It’s correlated with many fatal conditions but isn’t fatal on its own. Most mental disorders fail to meet this criteria too. Anorexia is fatal if untreated, but anxiety disorders, dissociative disorders, ADHD, learning disorders, conduct disorders, psychotic disorders, and dissociative disorders and many others are not. There is a pretty good case to make for  alcoholism and some other addictions meeting these criteria. Disorders that are associated with suicidality, too, might qualify, like severe depression, and possibly “gender identity disorder,” though GID may not be progressive and so fail the first criteria.

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According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

My mom sent me this in response to my posting the diagnostic criteria for AD/HD yesterday. She’s not a health care professional, but she did raise five boys. Since I’m the oldest I got to see her do it. I also got to benefit from her love of nature (and sending us out into it), reading to her kids, being affectionate with her kids, making nutritious food, and her skepticism of TV and traditional schooling. And many, many other things, like her faith in her kids. The first thing they told us in my class on psychopathology was that we were not to diagnose ourselves, our friends, or family, so I won’t, but I suspect that all of us (except perhaps Ben) fit the diagnostic criteria for AD/HD for periods of our young lives. She wouldn’t even feed us sugar, much less amphetamines, so it’s not like it was a close call, but thanks, Mom, for not feeding us stimulants!

Here it is:
“Be forewarned, this takes effort on the parent’s part!

“Here is my humble prescription for hyperactivity in children (who, by the way, are usually boys): First, TAKE HIM OUT OF SCHOOL!! Live in, or move to, a rural area. (Or at least make sure there is a wild area, like woods or a meadow, nearby). Each day, after he has slept as late as he wants to, feed him a highly nutritious breakfast that contains no sugar, no additives, no colorings. Just whole foods. Then, send him outside to play in nature. Make sure he gets plenty of sun exposure. Make sure he has some of these things: trees to climb, grass to lie in, rocks to scramble on, water to swim or wade in, wildlife to watch, dirt to dig in, and bushes to hide in. (Create a beautiful outdoor environment for him if your outdoor area is naturally very stark.) Make sure he has plenty of water to drink. Let him roam freely. At lunchtime have him come in for another nutritious meal of whole foods. No sugar. Only water to drink. After a cuddle and as much attention as he wants from you, send him back outside to play in nature. Let him play as long as he wants. When he wants to come back inside, he can be read to or told stories, he can play or read quietly, or he can just rest while listening to soft classical music, or take a nap. No TV. No computers. No gameboys… no screens of any kind. Nothing with headphones. Then, back outside to play until the sun goes down. Back in for another nutritious meal, and then he is put in the bathtub. He plays in the bathtub for as long as he wants (an hour or more in very warm water is good). Then, he has a bedtime routine (thorough teeth brushing and flossing- you do it if necessary- and then jammies). After that he gets read to for a LONG TIME in bed…an hour or more is good… until he is sleepy. Make sure he has plenty of hugs and cuddles and kisses and loving words as he drifts off. Follow this prescription every day until his hyperactivity is cured. By the way, this routine could be of benefit to “normal” children, as well. It works for calming and soothing and centering and bringing color to their cheeks, and a more cheerful attitude in general. And, I’d go so far as to say, adults should try it, too… to cure whatever ails them.”

The DSM-IV-TR reports a prevalence of 3-7% for the famous AD/HD, depending, somewhat cryptically, on “the population sampled and the method of ascertainment” (p. 90). AD/HD is a shoe-in for medication in the minds of most mental health professionals. Children have been treated for this Disorder with stimulants since 1937. We still do not know for certain, however, what the effects are on adults who took stimulants as children. We do know that AD/HD tends to go away during adolescence.

Here are the diagnostic criteria, straight from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Note that criterion C is an attempt to make sure that the troublesome behavior is not just a reaction to one situation, like school–you shouldn’t be diagnosed AD/HD based on behavior that only happens at school, or just at home. That would be something else going on. Note also that, according to the “coding note” at the bottom that once you have this diagnosis, unless you have none of these symptoms, you will always be considered AD/HD “in partial remission.” One last note: I notice in reading literature referring to this Disorder that it is usually referred to as ADD/ADHD. I don’t know why this is, as there is no “Attention Deficit Disorder” in the DSM-IV-TR. Perhaps there was in earlier editions.

Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) often has difficulty sustaining attention in tasks or play activities

(c) often does not seem to listen when spoken to directly

(d) often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) often has difficulty organizing tasks and activities

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with development level:

Hyperactivity

(a) often fidgets with hands or feet or squirms in seat

(b) often leaves seat in classroom or in other situations in which remaining seated is expected

(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) often has difficulty playing or engaging in leisure activities quietly

(e) is often “on the go” or often acts as if “driven by a motor”

(f) often talks excessively

Impulsivity

(g) often blurts out answers before questions have been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

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

C. Some impairment from the symptoms is present in two or more settings (e.g., at shool [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. 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 (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified.