Diagnosis of ADHD with the DSM 5 TR | Symptoms and Diagnosis

hey there everybody and welcome to this  video on diagnosing adhd with the dsm   5tr i'm your host dr donnelly snipes in this presentation we are very  simply going to review the diagnostic   criteria for adhd in the new dsm  which is now called the dsm-5tr so let's start out with at the very beginning in  order to diagnose add adhd and in the dsm it's   simply referred to as adhd we need the 1266 and  i try to give you little mnemonics and things to   help you remember so if you're taking the ncmhce  or if you're new to diagnosis it's a little bit   easier to remember all of the criteria because  there's a lot of stuff to remember it from the   dsm which is over a thousand pages in order to  be diagnosed with adhd the person has to be 12   years or younger when the symptoms start  according to the dsm-5tr when symptoms first   occur after the age of 13 they're more likely  due to another mental health condition or the   cognitive effects of a substance so that's your  12 symptoms have to start before the age of 12.   you have to have six symptoms of either  hyperactivity or inattentiveness or six symptoms   of both if you want the combined type but you have  to have a minimum of six symptoms for children   if the person is 17 or older when they're being  diagnosed the number of symptoms decreases to five   so it's six symptoms for six months or more and  the person has to be 12 years old or younger   when the symptoms start now you can diagnose  adhd in an adult however you have to do a   retrospective analysis and make sure that the  symptoms began before the age of 12. according   to the text self-report is highly unreliable  so it's good to use ancillary resources but you have these six symptoms or more that are  lasting for six months or more they're present   in multiple situations they interfere with  functioning or development and they are not   exclusive to a psychotic episode or  explained by another mental disorder and   there are a lot of them in the differential  diagnosis category but we'll get there scaffold is the mnemonic i use  for inattention and yes i know   scaffold doesn't typically have two  elves but it was either scaffold l   or l scaffold or just throw that extra l  in there so um the mnemonic is scaffold   sustained mental effort is avoided the person  with adhd is going to have a lot of resistance   to things like standardized testing to things like  reading a a lot of material if they have to read   two or three chapters or a really long chapter  even sustained mental effort sometimes in   activities can be overwhelming for the person  careless mistakes or poor attention to details   this is another sign of attention deficit disorder  it's not that the person is being intentionally   careless it's not that they are disregarding  or not listening to instructions they just   make careless mistakes my son is now 21 and  he still struggles with inattention we have   chickens at our house and most of the chickens are  down at the barn but i had one chicken that was   getting bullied by the rest of them and she was  you know really not doing well so we separated her   and brought a friend so we have two chickens up  closer to the house and the rest of the chickens   at the barn and he habitually forgets to put the  chickens up at the house away he remembers to do   the ones at the barn but he forgets to put them  away even with putting reminders in his phone   and other things it's not that he doesn't care  about the chickens it's not that he's trying to be   um inattentive he just honestly forgets and he  truly feels bad when we bring it to his attention   and heaven forbid something should hurt or  kill one of the chickens overnight he would   be devastated so i know it's not that he's  intending to do it but that's one of those   symptoms that is persisting for him into  adulthood attention is not sustained in   tasks or play activities the child may  bounce around from one thing to another   in different tasks they may have difficulty in  the classroom staying focused on one particular   task at work if they have to do something  especially if it's something monotonous like um assembly line work they may have difficulty  sustaining tasks if they have to do something like   balancing a spreadsheet or something in finance  where not only does it require sustained attention   for a long period of time but it requires  sustained mental effort and attention to detail   there's probably going to be a lot of difficulty  for that person they may seem forgetful in daily   activities they are kind of again it's not that  they're trying to be forgetful it's not that   they're trying to be rude or insensitive but  they simply have difficulty remembering things   which is why a lot of times we  talk about writing things down   and i will well let me get to the end of this  first follow-through is lacking which kind of   goes along with forgetful and careless mistakes  they will start something and people with add   inattention are very often characterized as people  who will start something but never finish it   and and it can be anything from cleaning the house  to learning a hobby or maybe building a model   airplane they start doing it and then they get  sidetracked and never come back to it so they have   multiple projects that they  started and haven't completed organization is difficult and that's for both  time and tasks time management is a very difficult   skill for people with attention deficit  disorder as well as with their tasks even   keeping their books straight keeping their  notes straight for school keeping their   bills and everything straight and remembering  when they've got to pay what they've got to pay   which is why auto pay can be really helpful  and obviously good budgeting and financial   planning assistance listening is poor when  spoken to directly the person with add adhd   may have difficulty sustaining attention for  a long period of time especially if they're in   an environment where there's distractions  one of the characteristics that we know   exists for a lot of people with adhd is  something called sensory gaiting difficulties and   i had a colleague in graduate school  demonstrate what life is like for her   living as an adult with adhd and it really  attended to this aspect we were in class   and she was doing a presentation on adhd  and she had enlisted some of our peers   to do things one of them started playing the  music on their on their iphone another one started   flicking the lights on and off another one started  tapping their desk while she was presenting and   the rest of us were like oh my gosh you know that  is so rude what's going on here we can't focus and   so finally she was like okay time out and  everybody stopped and she said that's what   life is like for me on a daily basis people with  sensory gaiting difficulties have difficulty   figuring out which scent which sensory  stimulus is important to pay attention to   and which sensory stimulus is unimportant so  that fire truck that goes by outside most of us   may hear it and ignore it or may not even really  note it when it goes by a person with adhd   is going to notice that as much as the  teacher speaking so we do want to be   sensitive to that situation and recognize  what can we do to minimize distracting stimuli   for this person when we're trying to help  them focus even during standardized testing   and testing period at school it can be difficult  for students that have other people in the room   because every time somebody moves or starts  tapping or sneezes or does something else   it will draw their attention and which is why  some people with adhd especially inattentive type   may need to be in an environment in which external  stimulus is limited while they're taking that test   in order to help prevent their  attention from being distracted it can also be helpful for people who are having  difficulty listening to encourage eye contact if   they are focusing on you then at least the visual  stimulus is you know focused on you it's not going   to do everything but it can be helpful especially  with young children they may lose things necessary   for tasks a lot of us when we get caught up in  the hubbub of the day-to-day we may lose things   i know sometimes i'll walk in and the dogs will  be going nuts and my kids will want something   and i'll forget by the time the next morning  comes around where i put down my purse and my keys   normally i have a place where i keep them right in  the foyer but if i get distracted when i walk in   i may forget now i don't have add or adhd so  imagine what that must be like every time you   walk in somewhere having your attention pulled  in a million different directions and then trying   to remember where did i put that thing where  did i put my glasses where did i leave my keys   so that can be difficult creating environments  that are conducive for a person that has these   types of challenges for example having  a foyer area that a person walks into   that is separated from the rest of the house maybe  they come in through a mud room where they have   a basket to put them their things in that can  be helpful so the next morning they don't get   frustrated running around going where did i put my  book bag where did i put this where did i put that lists can also be helpful for anybody but making  a list of what is needed for particular things   and even laminating it or putting it if you don't  have a laminating machine you know no biggie   put it in a ziploc bag that way it  can be kept and it doesn't get all   mucked up or at least not as easily  but you can go through that checklist   i have one in my gym bag so i don't forget  because i got tired of getting to the gym   and you know being in the shower and  realizing that i forgot something crucial   so it isn't helpful for a lot of people but for  people with add this can be huge and distracted   easily by extraneous stimuli in adults and people  17 years old and older this also may include   unrelated thoughts your mind goes in six different  directions or monkey mind so we do want to look at   these different things we also want to consider  how all of these symptoms impact the individual   even if they don't meet the full criteria for  add adhd it's important to address the symptoms   because these symptoms are going to have  a significant deleterious effect on their   relationships on their self-esteem on their sense  of self-efficacy so interventions are important the next criteria is for hyperactivity now you  can have inattentive type where the person has   six crate meet six criteria for inattentiveness  or hyperactive type where they meet six criteria   for hyperactivity or combined type in  which they meet six criteria for each   or if the person is 17 years old or  older they meet five criteria for each this one again i know the  mnemonic is not spelled correctly   there should be a second o and two  however in order to make it make sense   i put it's just run too fast and two is spelled  simply with one o and so that makes sense with   hyperactivity with inattentiveness scaffold  remember scaffolding is what you set up to   help build something to help sustain something  scaffolding in behaviorism is when we   help people we allow people to do whatever they  can up to the point they can't do it anymore   and then we provide assistance we  provide scaffolding or a framework   to help them better accomplish that goal  so scaffold makes sense for inattention   run too fast makes sense for hyperactivity to  me and i like to have my mnemonics kind of make   sense to what i'm looking at just because there  are so many it's easier to remember criteria   the person runs around a lot or is restless  and it gets out of their chair when they are   supposed to be sitting still they are unable  to wait their turn they tend to interrupt they   tend to jump in line they're noisy not able to  play quietly they may tend to interrupt people   they may be like they're on the go  kind of like a the energizer bunny   that just kind of never stops going they  may fidget or squirm a lot in their seat   they may blurt out answers to  questions or finish people's sentences   sitting still is very very difficult for the  person with the hyperactive type sitting in   class sitting in the car sitting at dinner sitting  in church any of those things that require sustain   sustained sitting especially sustained sitting  where the person is expected to remain calm and   quiet can be exceptionally challenging and they  may talk excessively the person with adhd tends to talk a lot and and they may uh well they talk  excessively what i was getting to earlier   there is a lot of overlap and  comorbidity between adhd and giftedness   children who are gifted often talk a lot they  often get bored very easily and fidget or squirm   they often their mind goes really  really fast so they may make mistakes   in what they're writing down because their  brain is going faster than their hand   there are there is a doctor from the university of  wisconsin medical school that i will put a link to   his video in the notes to this into this video  that talks about differential diagnosis between   adhd autism asperger's it was filmed a while ago  and giftedness and he talks about how they can be   differentially diagnosed or may co-occur it is  important as with all disorders to examine what   exactly is causing this symptom and what is the  best way to mitigate it for this person you can   be gifted and have adhd okay that's fine what  are your presenting symptoms in what situation   and what strategies will help you in that  situation minimize the impact of this problem   specifiers for adhd you can have the combined  type that i've talked about you have six or   five or six criteria of each depending on age  inattentive the person hat meets the criteria   for the inattentive type or hyperactive  they meet criteria for hyperactive type   if the person is still experiencing impairment and  functioning but does not meet all the criteria for   adhd they can be coded as in partial remission  obviously this means at some point they needed   to meet all of the criteria and then there's  the severity specifier mild it produces mild   impairment and functioning moderate produces  moderate impairment and functioning and severe   produces marked impairment and functioning  it was this one is pretty straightforward diagnostic features the symptoms vary depending  on the context and they may be minimal at times   and this is another one of those mnemonics  when i was growing up if you were out of   luck if you're having difficulty or in this  case if the person's extremely symptomatic   you may say they're kind of up the creek without  a paddle because they're having difficulty functioning or surviving a particular  situation in this case the mnemonic is canoer   because the person is up the creek with the paddle  they're actually able to manage their symptoms   canoer stands for close supervision if someone has  add or adhd and is under close supervision they   may be able to manage their symptoms especially  if that person providing close supervision   gives them cues and provides early intervention  tips so if they notice that johnny is starting   to get distracted they help johnny redirect  attention to the task at hand that can help   quite a bit and activities that are especially  interesting we often think of people with adhd   as not being able to focus their attention at  all in fact people with adhd have difficulty   focus focusing their attention on things that  are not very interesting now let's think about   neurotransmitters for a minute what happens  when we engage in something really interesting   we have an a surge of dopamine and norepinephrine  both of which are known to be low in people with   adhd norepinephrine is our attention neurochemical  you know this is very very simplified but   norepinephrine helps us pay attention and dopamine  is our motivation or let's keep doing this   neurochemical therefore it makes sense if the  activities are not very interesting and the   person is already deficient in dopamine and  norepinephrine then they may have difficulty   sustaining attention and managing symptoms but if  something is especially interesting their brain is   just pumping out dopamine and norepinephrine  that can help them focus and stay on task   if it's a novel setting that also can reduce  symptoms for some for other people it seems to   increase symptoms because they are so distracted  by all of the things that are going around going   on around them and the newness of the situation  however for others being in a novel setting   prompts the release of possibly glutamate we  don't know this hypothesis which the increase in   glutamate may also help them sustain focus because  glutamate is a stimulatory neurotransmitter   what do we know about the medications that people  take for adhd a lot of them not all of them but   a lot of them are stimulant in nature so it would  make sense that something that is somewhat stress   provoking may actually improve symptoms not  that we're advocating for increasing kids stress   one-on-one situations especially if distractions  are minimized may be a lot easier to sustain focus   if that person is getting regular feedback  from the other person then it may be   sufficient to prompt the release of that   norepinephrine and dopamine and help them focus  on what's going on this is especially true in clinical experience when people are in a  one-on-one situation and they are re really   engaged with the other person or they're  getting to talk a lot they're they're sort   of dominating the conversation but a lot  of times one-on-one people do a lot better   group therapy for people with adhd is  not really usually extremely effective   adhd co-occurs with substance use quite a bit  and i bring this up because a lot of substance   use treatment your partial hospitalization  intensive outpatient residential treatment   the majority of treatment even your support  group meetings are group oriented and this can be   just intensely difficult for a person with adhd  especially a person with adhd in early recovery   where their neurotransmitters and their brain is  still recovering from the effects of the substance   if the external stimulation is consistent   then the person may do something that we  we call habituating to that stimulation and   if they're in an environment say they're  in the middle of new york city or something   and they have the windows open and the hum of  the traffic is consistent it's not punctuated by   sirens or anything it's just a constant hum of the  traffic then they may not be as easily distracted   and if they receive frequent rewards for  appropriate behavior this can number one shape   the behavior but those rewards prompt the release  of guess what dopamine and norepinephrine so   that can contribute to improving or regulating the  neurotransmitter balance in the person with adhd i encourage you to think about why symptoms may  be reduced in these situ situations other than   what we talked about and remember it a lot of it  has to do with their ability or inability to gate   or ignore certain stimuli in the environment and  to their low levels of norepinephrine and dopamine associated features these are things that  commonly co-occur they don't cause but   they commonly co-occur with adhd delays  in language motor or social development   well think about the symptoms and think  about how that would make sense children   who have difficulty focusing difficulty with  sustained attention may have developmental delays   emotional dysregulation is also  very common and it may not be the   a sign of a bigger personality disorder or  something it may be simply or pseudo simply   that the person is under a lot of stress and  they have difficulty with impulse control   children are known to be more likely to  emotionally dysregulate because they have   less impulse control they have fewer coping skills  they have fewer experiences to guide their coping   therefore emotional dysregulation typically  is can easily become a problem and a lot   of times children have a lower frustration  tolerance because they don't have the skills   in order to develop the skills they have to have  attention and focus and guidance in some of the   identifying some of the triggers identifying  the emotion and regulating their own emotions   those are skills that people learn and if they're  having difficulty with learning because of their   hyperactivity or their inattention then they're  going to have difficulty mastering those skills   they may also have neural cognitive deficits in  working memory set shifting or switching gears   reaction time variability and vigilance  this is slightly reworded from the dsm-5   however it's important to note these things if  the person has difficulty with working memory   what interventions can you employ to help them  with that to help them remember for example with   children instead of giving them multi-part  instructions give them one instruction at   a time or write things down so they have a  checklist of things that they've got to do   set shifting or switching gears like going between  classes or switching between history and math   having some sort of transition  ritual has been shown to be helpful reaction time variability it's important to  identify what triggers the variability in that   particular person those with neurodevelopmental  disorders with a known cause like fragile x   may also receive a concurrent diagnosis  of adhd if they meet the full criteria   so some neurodevelopmental disorders  have a lot of the same symptoms   however if they do meet the full criteria  for adhd they can also have that diagnosis how prevalent is it well across national  prevalence which means we're looking   at multiple different nations  the rate of adhd ranges from 0.1   to 10.2 percent that's a big stinking  difference uh and that's for children   for adolescents and adults it seems to  be pretty stable at about 2.5 percent   why is there such a big difference part  of it is cultural expectations part of it   may be shame and diagnosis certain cultures are  still not embracing of mental health issues or   mental disorders the parents may perceive these  behaviors as a parental failing and keep it   in the house instead of recognizing that there  may be a neurochemical disruption in the child   there are a lot of reasons however the take home  is that adhd may affect a significant portion of   people prevalence is higher in special populations  such as foster children and correctional settings   this is another one of those  things i want you to think about what is unique or common among foster children and  correctional settings i'll give you a hint trauma   when we get to differential diagnosis you will  see that the dsm highlights the fact that a person   with ptsd can present with all of the symptoms  to meet the criteria for adhd we need to rule out   whether the symptoms were present before  the trauma or not and whether the symptoms   are being caused as a result of traumatic um  impairment for lack of a better word if the   symptoms are being caused by the trauma the hyper  vigilance difficulty sleeping impulsivity then   that would be a ptsd diagnosis foster children  experience trauma they wouldn't be being taken   out of their house if there wasn't trauma going on  and being taken out of the house can be traumatic foster children have a higher rate  of fetal alcohol spectrum disorders   foster children have a higher rate  of ptsd attachment issues anxiety   and potentially oppositional defiant disorder  these are all things that we are going to explore   and try to differentially diagnose as  well we need to recognize the impact that   prenatal exposure to alcohol for example has  on the development of adhd we want to rule out   are these symptoms again are these symptoms  being caused by the trauma that led to the   foster care or are they being caused in a child  with fasd are they being caused by prenatal   exposure to alcohol so there is a lot of stuff  to kind of fare it out here why am i bringing   this up if they meet the criteria for adhd  we need to treat the symptoms this is true   however we also don't want to miss underlying  diagnoses that will complicate the picture and   potentially prevent full treatment or full symptom  remission correctional settings have repeatedly   been shown to have people in them that  have a much higher rate of ptsd or   cptsd borderline personality disorder and fetal  alcohol spectrum disorders we see a higher   proportion of these diagnoses in correctional  settings than in the non-correctional settings   likewise we see a higher prevalence  of adhd in both of these settings   start getting curious why why is what are the  common threads here and in what ways might   trauma and developmental issues be  related to later life challenges development and course according to the dsm 5tr  preschool primary manifestation is hyperactivity   now if you've been around preschool kids you  know they they can be pretty hyperactive anyway   we also need to ask what else might  cause hyperactivity in preschool there's culturally typical i try to  avoid using the n-word normal   culturally typical activity of preschool  children but then there are the children who are almost literally bouncing off the walls we want  to say what is that behavior communicating is   the child unable to contain that is that  behavior communicating anxiety when children   are exposed to trauma some children will resort  to hyperactivity in order to defuse the situation   if i can draw the attention over here they'll  quit fighting we do see some of these behaviors   in children who've been exposed to trauma exposed  to domestic violence obviously we also see them   in children who haven't been exposed to those  things who have adhd it's always important to   ask what is this behavior saying and what might be  the potential biopsychosocial environmental causes adhd is often not diagnosed  until elementary school   preschool and kindergarten is much less  structured so it is easier for them to   fly under the radar so to speak or easier  for the symptoms to be minimized as just   quote normal behavior it's important to  pay attention to how culturally appropriate   uh or culturally normative i don't like saying  normal but i'm struggling to find an alternative   that the child's behavior is at any point in time  the earlier the child can experience interventions   the more better the outcomes in later life so  earlier intervention can be very very helpful   once they get to first grade  it becomes much more structured   and children may have more behavioral problems  or may exhibit more issues with going to school   because of their symptoms my son again using  him as an example no hipaa issues there   when he was in first grade told me that he  couldn't go to school because he had carnotaurs   in his tummy and at his particular school he  was told that when he finished his assignment   he had to put his head down on his desk and  wait until everybody else was done there   were no options for doing anything else for  a child with adhd that is torturous therefore   he struggled he knew that he wasn't supposed to  quote act out and he was trying to resist that   however he also had all this stuff going on inside  him that was kind of making him feel like he   wanted to crawl out of his skin and it would make  him feel literally physically ill in the morning i bring this up because a lot of times children  who are not behavior problems get missed if   they're not the ones acting out they're not the  ones getting the red light on the behavior chart   then they're considered okay and that is not  necessarily the case we need to attend to   all children regardless of how their  symptoms manifest typically adhd is   stable through adolescence but inner feelings  of restlessness and impatience may persist in my opinion now this isn't in the dsm  but in my opinion if the child is able to   reduce some of their symptoms in  adolescence and instead of getting   out of their seat and fidgeting or fidgeting at  the at the table or something all of the time   and restrain it to feelings  of restlessness and impatience   that's not a quality of life that i would wish on  a child but that does show a strength that shows   that they have done something to develop some  adaptive skills to restrain their outward behavior i'd like to point that out because so often  people who are being diagnosed with adhd have   always been told that they fail at this they fail  at that they can't do this they can't do that   well let's look at what strengths they had  how have they managed to cope until now   what do these behaviors mean how have they  managed to cope until now what can we build on   a certain percentage of youth with adhd may go  on to develop antisocial behaviors in adolescence   think about why that might be one of  the core features of antisocial behavior   is a lack of empathy and a persistent  manipulation of others for their own gain how do you get from one to the other i would  pause it and i would you know encourage you   to think about it and think about your  explanations for why this might happen   i would posit that in a certain percentage of  youth their behaviors feel so out of control   and they've gotten punished so often for their  behaviors instead of getting help they've gotten   punished that they've shut off that empathy  and they have potentially learned to use their skills for their own benefit it is overwhelming  sometimes when every time you turn around you   feel like you're making a mistake so this  can be a an adaptive reactive or reaction to   having untreated unmanaged adhd so i would  encourage you to look at the criteria for   antisocial and ask yourself how might these  behaviors develop as a result of having adhd   what are these behaviors saying in what benefit  are these behaviors giving the person with adhd as adults people often still  continue to struggle with impulsivity risk and prognostic factors the prognosis  is worse for people who have higher levels   of impulsivity higher levels of negative  emotionality higher levels of novelty seeking   an extremely low birth weight they didn't specify  whether it was only someone with a very low birth   weight who was born at term or if it also included  those who were premature i would hypothesize that   it also does include premature infants because  they're born before they're finished developing   exposure to tobacco or alcohol in utero is  also associated strongly associated correlated   with children who end up developing adhd   later on neurotoxin exposure such as lead  and in the research they also talked about   pofas and thiolates and other things we are  not endocrinologists what's important to   recognize is that neurotoxin exposure  can impact neural development and lead to   neurodevelopmental problems including but not  limited to adhd encephalitis which is swelling   of the brain can be caused by a virus it is also  associated with later on development of adhd   family interaction patterns may result  in development of conduct problems family   interaction patterns that are not supportive that  don't help the child learn how to manage their   symptoms that blame the child for their symptoms  you can see how this might inspire resentment   and irritability and aggression and feeling  completely out of control in a child with adhd it's important to recognize and it's a it  can be an upward spiral or a downward spiral   if the family is responsive and provides the  tools and scaffolding necessary for the child   to learn how to manage their symptoms then  they are probably going to do a lot better   if the family either ignores it or worse  yet shames it scolds it criticizes it   then the outlook for the child is a lot worse and  diet sensitivities was also mentioned fleetingly   in the dsm-5tr this can be a risk factor for later  development of adhd and they really didn't talk   a lot about that the research really didn't  show a lot about that in recent meta-analyses   but clinically speaking i've talked to enough  people that have indicated that people with   adhd often have tend to tend to be more  sensitive to certain things in the diet   and it's not uniform for everybody you  can't say that this additive or this food   will cause or worsen adhd symptoms for any  individual but it is important to recognize that a   lot of people with adhd do tend to have some diet  sensitivities now i put rule out this the dsm-5tr   lists it under a risk and prognostic factor  however i also think it's important to rule out   whether the person's symptoms are being  caused by a diet sensitivity now follow   me here it may be an extreme case but for  a child who has gluten intolerance and   crohn's disease that systemic inflammation can  make it harder to sleep it can make it harder   to concentrate it can make it harder to sustain  attention it can make it harder to pay attention   and focus on one thing because you're in pain and  when we're in pain our stress response system is   triggered that hpa axis so we naturally tend to  become more hyper vigilant it is possible that certain underlying health conditions may produce  symptoms that mimic adhd however when that   physiological issue is addressed and effectively  managed then the symptoms would go away if the   physiological issue is addressed and the symptoms  persist then we know that the adhd is still there associated features individuals with adhd may  exhibit neurocognitive deficits in a variety   of areas including working memory set shifting  reaction time variability response inhibition   neurobiological features regarding reduced  brain volume and delays in cortical maturation   are all eliminated from what was in the dsm  5 so i thought that was kind of interesting marked co-occurring clumsiness and  motor delays if you have somebody   with adhd we know they may have some delays  in motor development but marked co-occurring   clumsiness and motor delay should be coded as  developmental coordination disorder that's just   another disorder diagnosis  that you need to be aware of   culture-related issues mislabeling adhd  symptoms as oppositional or disruptive   in socially oppressed ethnic or racialized groups  because of an explicit or implicit clinician bias   may lead to over diagnosis of disruptive disorders  in these populations we want to pay attention to what is really there versus what our expectations  are what is really there versus what our   interpretation is what's causing the symptom  versus what our interpretation is in order to   be sensitive we also need to be sensitive to what  is culturally normative for that particular person   certain cultures are far more reserved  therefore what might be typical in one culture   may not be typical in another culture  additionally it notes there's a higher   prevalence in non-latinx white youth which may  also be influenced by a greater parental demand   for diagnosis of behaviors seen as adhd  related basically they theorize that   non-latinx white families may present and push for  an adhd diagnosis a lot more insistently and a lot   more frequently than those from oppressed  ethnic or racialized groups additionally   non-latinx white youth may have more  access to mental health care they may   be more embracing of mental health  care whereas other cultures may not   may resist mental health care again because  it's seen as shameful and not not acceptable sex and gender related diagnostic issues this was  formerly just gender related it does discuss sex   differences but it uses the binary male female  concept females are more likely to be inattentive   males are more likely to be hyperactive i  really get frustrated when we see these binary   conceptualizations because then people  tend to think that if a female has adhd   she will present as inattentive and if a  male has adhd he will present as hyperactive   and that's not the case it says more likely  additionally are these differences due to a   neurotransmitter hormone interaction people who  are biologically male have more testosterone and   does that interact differently with the dopamine  and norepinephrine neurotransmitter systems   that estrogen does it could be so what happens if  you have somebody who is biologically male who has   low levels of testosterone or who is undergoing  gender transition therapy which category and   should we expect a difference in presentation i  don't know and i could not find any research on it   i also question whether part of this is  due to cultural social indoctrination   in many cultures the children who are born  biologically female are encouraged to be quiet   to be sedentary to not be hyperactive and  being hyperactive often tends to draw more   consternation from parents and caregivers  and not always but often than it does for   children who are born biologically little  boys biologically little boys are often   it's often passed off as oh boys will be boys or  boys always have so much energy well girls do too my question is do do we see this presentation different between  the biological genders because of some behavioral   shaping and you know left to their own devices  we may see more hyperactivity in biological   females i don't know i don't know the answer  but it's certainly interesting to consider the dsm-5tr added that sex differences in adhd  symptom severity may be due to differing genetic   and cognitive liabilities between the sexes  they don't explain what they mean by this and   my gut reaction and i know it's a  personal reaction but my gut reaction   was to take offense at the term  cognitive liabilities between the sexes   but that is my personal issue and again i  don't know what they mean they did not go on to   explain it at all in terms of suicidal  thoughts or behaviors this is a new section   the only notable information in that section  for the purposes of you know regular diagnosis   was that people with adhd have an increased risk  of ideation and attempts even when comorbidity   is controlled for so even if you take out the  depression and control for depression and anxiety   and those other things if a person has adhd they  are at an increased risk of ideation and attempts   well think back what are we talking about with  some symptoms impulsivity social intrusion and   a lot of their symptoms often cause psychosocial  difficulties leading to lower self-esteem reduced   social support etc so it makes sense that we  might see increased risk for suicidal ideation   or attempts being aware of that we can better  mitigate that risk functional consequences   reduced academic or occupational performance  and attainment if you have difficulty focusing   that makes sense lower self-esteem we talked about  greater family discord and i put chicken egg here   obviously that wasn't in the dsm-5 tr however  i think it's important to recognize that the child that grows up in an environment with  family discord me that's considered an adverse   childhood experience that trauma may lead to the  development of adhd like symptoms or ptsd reduced   social support due to peer rejection neglect or  teasing a higher risk for substance use disorders   they may be more likely than peers to be  injured mainly because of their impulsivity   and sometimes because of their social intrusion  or their blurting they may be more likely to get   into situations in which they're at risk higher  risk for suffering trauma and developing ptsd   again same thing that puts them  at higher risk for being injured   and there also may be an elevated likelihood  of obesity and hypertension thought that was   interesting differential diagnosis and i know  i'm running short on time here so i'm just   going to go through these really quick ptsd  was added in the dsm-5tr so score for that   symptoms in ptsd are trauma related but can mimic  adhd parents may inadvertently minimize trauma   symptoms they may not understand the symptoms of  trauma so they assume this is adhd or oppositional   defiant disorder when in reality these are trauma  reactions oppositional defiant disorder in this   diagnosis symptoms are due to confirmation  resistance they don't want to follow instructions   not because they have an inability to sustain  attention or control their impulses so an   oppositional defiant is willful resistance  intermittent explosive disorder displays   extreme hostility toward others but no difficulty  sustaining attention now intermittent explosive   and adhd can co-occur but we typically don't see  extreme hostility towards others in adhd alone   autism stereotypic movement versus restlessness  and fidgetiness in autism and autism spectrum   disorders we see the movements as  being very repetitive and stereotyped   not just random fidgeting and restlessness  and tantrums in autism are often due to   difficulty with change again not due to lack of  self-control or difficulty controlling impulses   tourette's it's important to differentiate ticks  from fidgetiness and the dsm identifies that this   can be really difficult and may require sustained  observation in specific learning disorders   inattention is only present during the learning  disorder task so if the symptoms are present in   multiple situations and pervasive then it's not  a learning disorder you can have them co-occur   intellectual disability symptoms are specifically  present during intellectual tasks that are above   that child's developmental level not their  chronological level but their developmental   level however when they're engaging in other  tasks that are not intellectual in nature   they do not exhibit the symptoms reactive  attachment in reactive attachment disorder the   person often fails to meet full adhd criteria and  has and often has a lack of enduring relationships   now you may also see this a little bit in adhd  because of their difficulty with social intrusion   and turn taking and those sorts of things  but it is important to rule that out   anxiety disorders present as inattention  due to rumination and worry in depression   poor concentration only is present during a mood  episode so if poor concentration is persistent   then it's not due to depression you can have  again concurrent adhd and anxiety or adhd   and depression bipolar symptoms are episodic  and accompanied by additional mood features   so if it's episodic not consistent  then we're looking at something else   disruptive mood dysregulation disorder  requires pervasive irritability those   with dmdd often also have adhd though so you're  maybe looking at a concurrent diagnosis here   the dsm notes that differentiation between adhd  and substance use may be difficult after the onset   of abuse because substances disrupt  the systems specifically dopamine   and norepinephrine as the person recovers while  they're in that post-acute withdrawal phase   especially which can last up to two years they  may exhibit adhd like symptoms however if they're   we need to look back because remember  the symptoms had to be present before   age 12. most people did not begin  abusing substances prior to age 12.   personality disorders are not characterized by  fear of abandonment self-injury or personality   disorders are characterized by fear of  abandonment self and injury and lack of empathy   whereas adhd is not and in psychotic disorders  and schizophrenia the symptoms only appear   during the course of a psychotic episode that  goes back to is it persistent or episodic   medication-induced symptoms obviously  remit as soon as the medication is removed   neurocognitive represents a decline from prior  functioning typically this is seen in adulthood   when the person develops dementia but it can  also be seen in childhood disintegrative disorder   the dsm-5tr does not indicate specific tests to be  done and a medical differential diagnosis is still   not really present so you're grasping for what  medical conditions might contribute to these   symptoms they did update the site comorbidity we  want to recognize that autism spectrum disorder   personality disorders and substance use  disorders often co-occur with adhd additionally   we want to rule out or rule in  oppositional defiant and conduct disorder the medical comorbidity they did add included  sleep disorders allergies autoimmune issues   and epilepsy however they did not include obesity  which may be causally related according to current   research and obstructive sleep apnea which may  also be causally related as the person loses   sleep because of breathing difficulties at night  it may contribute to daytime symptoms of adhd basic diagnostic criteria for  adhd remains largely unchanged   with the exception of they added  the differential diagnosis for ptsd   our understanding of the development course  cultural influences and comorbidities however has   changed that might give you a better clinical  picture and a better idea of other questions to   ask if the person is not responding as you  would expect to first-line adhd treatments

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Length: 62min 14sec (3734 seconds)

Published: Wed Apr 20 2022