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

Hey there, everybody, and welcome to this video on diagnosing adhd with the dsm5tr. I'm your host, Dr. Donnellice 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 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, stuff to remember 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 and 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 Ls, but it was either Scaffold L or L Scaffold or just throw that extra L in there. So the mnemonic is Scaffolding. 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 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 inattentive. He just honestly forgets, and he truly feels bad when we bring it to his attention. And heaven forbid something. 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 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 it can be anything from cleaning the house to learning a hobby, but. 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. 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 gating 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, timeout. And everybody stopped. And she said, that's what life is like for me on a daily basis. People with sensory gating difficulties have difficulty figuring out 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 which is why some people with adhd, especially inattentive type, may need to be in an environment in, 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 mudroom 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 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 meets 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 in 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 affordable 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 gets out of their chair when they are supposed to be sitting still. They're 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 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 they may 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 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 five or six criteria of each, depending on age. Inattentive. The person meets the criteria for the inattentive type or hyperactive. They meet criteria for hyperactive type. If the person is still experiencing impairment in functioning but does not meet all the criteria for adhd, they can be coded as impartial 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 in functioning. Moderate produces moderate impairment in functioning, and severe produces marked impairment in 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 canoe, er. 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 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 a surge of dopamine and norepinephrine, both of which are known to be low in people with adhd. Norepinephrine is our attention neurochemical. 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 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 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 situations other than what we talked about. And remember, 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 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 neurocognitive deficits in working memory. Set shifting or switching gears. Reaction time variability 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%. That's a big stinking difference and that's for children. For adolescents and adults it seems to be pretty stable at about 2.5%. 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 impairment. For lack of a better word. If the symptoms are being caused by the trauma, the hypervigilance, difficulty symptoms, 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 ferret 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 that 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 diffuse 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 normal behavior. It's important to pay attention to how culturally appropriate 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 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 carnotaurus 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. The 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 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 adolescents. Think about why that might be. One of the core features of antisocial behavior is a lack of empathy, a persistent manipulation of others for their own gain. How do you get from one to the other? I would posit, 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 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, and 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, then 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 inspect inspire resentment and irritability and aggression and feeling completely out of control. In a child with adhd, it's important to recognize and 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 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 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. 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 hypervigilant. 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 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 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 than 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 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 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, et cetera. 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 DSM5TR. However, I think it's important to recognize that the child that grows up in an environment with family discord, 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 tics from fidgetiness and the DSM identifies that this can be really difficult and may require sustained 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 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 may be 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 neurotransmitter 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 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 5 TR 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 psych 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, of 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.