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The role of impairment in making the diagnosis of ADHD

Sam Goldstein, PhD

Recently as I watched a popular comedic actor's new movie, I was struck by the fact that many of the actor's behaviors appeared similar to the symptoms of ADHD. I began to count. By the end of the movie, the actor's character had met the diagnostic symptom count for the combined diagnosis of ADHD. Even the chronic, persuasive and early presentation of symptoms criteria were met. Astoundingly, as I considered whether this character or possibly the actor himself might actually suffer from ADHD, I reminded myself to consider one additional but most important criteria - impairment. In the end this character, and in fact this actor, was very successful and, by popular report, doing well in life. This issue reminded me as it should all of us, that diagnostic criteria must not end with a symptom count or a review of history but rather with a discussion and serious consideration of impairment. Keep in mind that epidemiologic or large scale screening studies for symptoms of ADHD find approximately one in five youths to meet the symptom criteria, yet when the impairment criteria is added, 50% of these youths are not found to be struggling, nor for that matter experiencing problems reported by parents or teachers.

Why is impairment important? First and foremost, the impairment criteria in the DSM-IV diagnosis for ADHD (criterion C) reads, "some impairment from the symptoms is present in two or more settings (e.g. at school or at work or at home)." Criterion D follows. It reads, "there must be clear evidence of clinically significant impairment in social, academic or occupational functioning." Why do the authors of these diagnostic criteria choose to create two separate but clearly overlapping criteria? I have inquired about this issue from colleagues as well as individuals affiliated with the DSM-IV field studies and have not found a satisfactory answer. Certainly criteria C and D are a step in the right direction from the criteria listed in the revised third edition of the Diagnostic and Statistical Manual. Recall that these diagnostic criteria required the individual to meet eight of fourteen symptoms and have an onset before age seven as well as not meeting the criteria for Pervasive Developmental Disorder. Once these diagnostic criteria were met, the diagnosis was made in the absence of any review of impairment. The DSM-III-R diagnostic criteria, however, then contained a set of criteria for severity. The diagnostician was offered three options: mild, moderate and severe. Mild criteria read, "few, if any, symptoms in excess of those required to make the diagnosis and only minimal or no impairment in school and social function." Thus, up until 1994 a diagnosis of ADHD based upon symptom presentation crossing a threshold for age and number could be made, even if an individual demonstrated very mild impairment in every day functioning. I believe the authors of these diagnostic criteria could not foretell the popularization of this diagnosis and the potential for over-diagnosis based on the appropriate utilization of the criteria. It may be the authors of the fourth edition of the Diagnostic and Statistical Manual, in an effort to provide continuity, chose to first describe "some impairment" in two or more settings but then once that criteria was met, decided to add a more stringent definition suggesting that the impairment had to be "clinically significant".

In my discussions with colleagues, many though well aware of the evolution of the ADHD diagnostic criteria, are often surprised when the shift between DSM III-R and DSM-IV in regards to defining severity of the condition and impairment is presented. It would appear then, that prior to 1994 a clinician evaluating a late high school or college student with fairly good grades, absent of significant life problems but demonstrating symptoms of ADHD, despite only mild negative impact and impairment as the result of these symptoms, stood on safe clinical ground in making the diagnosis. However, it would also appear that since 1994 a diagnosis of ADHD for such an individual may not fit the diagnostic criteria for the condition and in fact may place the clinician on shaky ground clinically as well as in the legal arena. It would also appear that the DSM-IV diagnostic criteria represent a step closer, either intentionally or unintentionally by its authors, to fit the clinical diagnosis with the qualifications necessary to meet handicapping conditions under the Americans for Disabilities Act. This Act, as well as the courts' interpretation, has very clearly reflected the importance of not only meeting symptom criteria but also demonstrating significant impairment as the result of these symptoms while simultaneously processing all of the skills and abilities necessary to perform a particular job or activity successfully had accommodations been made. It is my opinion that when the fifth edition of the Diagnostic and Statistical Manual appears, the issue of impairment relative to symptoms will be even more stringently defined. Thus, I advise clinicians to carefully consider the question of impairment when making the diagnosis of ADHD. I also advise they keep in mind that since problems with impulsivity and self-control cause the greatest degree of impairment, those with the inattentive type of ADHD are likely to have more subtle but not necessarily less negatively impacting impairments. Suggesting that an impairment is subtle (e.g. difficulty staying focused while studying) is not the equivalent of suggesting that it is not important nor causing a significant handicap in every day life. I also advise parents as well as those with ADHD to become experts in the condition, including the ongoing issue of symptoms versus impairment in making the diagnosis. By understanding this issue, parents are in a better position to advocate for their children and those with ADHD are in a better position to advocate for themselves.

Impairments with ADHD are the consequences that occur from living with disabling symptoms related to limited self-control and self-regulation. A number of researchers are collecting data in an effort to create a questionnaire and statistical formula for evaluating severity of impairment relative to symptoms. The more successful the field is in focusing upon a balanced clinical view of symptoms versus impairment, the more we will be able to truly help affected individuals and their families.

This article has been reproduced with the kind permission of Sam Goldstein PhD, Neurology, Learning and Behavior Center, Salt Lake City, Utah, from his website

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