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Attention-deficit/hyperactivity disorder: are we helping or harming?

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6172 (Published 05 November 2013) Cite this as: BMJ 2013;347:f6172

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Re: Attention-deficit/hyperactivity disorder: are we helping or harming?

Thomas et al.[1] are concerned that the recent change in the maximum age of symptoms onset in the ADHD diagnostic criteria (from 7 years in the DSM-IV [2] to 12 years in the DSM-5 [3]) may increase “the risk of confusing ADHD with normal developmental processes, such as pubertal restlessness and distractibility”. Whilst it is legitimate to be concerned about medicalising normal processes, I am not aware of any empirical evidence supporting such concern.

Indeed, a prospective study by Polanczyk et al. [4] conducted in a cohort of 2,232 British children showed that extending the age-of-onset criterion from 7 to 12 years resulted in an increase of ADHD prevalence of only 0.1%. If raising the maximum age of onset led to diagnose non-pathological behaviors as ADHD, one would expect a significant increase in the prevalence of this disorder. Additional results of this study are consistent with other research reports showing that individuals with retrospectively reported ADHD symptoms onset before or after 7 years do not significantly differ in terms of ADHD severity, comorbid disorders [5, 6], and outcome [7].

Such evidence supported the DSM-5 change in the age of onset criterion, aimed at reducing false negative diagnoses in adults. It has been shown that only 50% of adults referred for ADHD assessment retrospectively recall an onset of symptoms before age 7; on the other hand, 95% report ADHD an onset be¬fore age 12 [8]. However, the study by Polanczyk et al. [4] showed that adults who retrospectively report onset of ADHD between 7 and 12 years very likely had symptoms before 7 years. Therefore, keeping the maximum age of onset at 7 years would contribute to underdiagnose ADHD in a substantial number of adults.

The practitioner should also keep in mind that, to avoid labelling transitory processes as “ADHD”, DSM-5 criteria include a note specifying that “…symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level…”. Thus, DSM-5 criteria are unlikely to increase the risk of misdiagnosing pubertal restlessness and distractibility as ADHD.

In sum, the concern that the DSM-5 age of onset criterion contributes to confuse ADHD with normal developmental processes, leading to an inappropriate increase in the diagnosis of this disorder, is currently not supported by empirical evidence. However, as Thomas et al. [1] thoughtfully remind us, transitory restlessness and distractibility during puberty should be considered in the differential diagnosis of ADHD.

References
1.Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. American Psychiatric Publishing ed., Washington DC, 2000.
3.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. American Psychiatric Publishing ed., Washington DC, 2013.
4.Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE. Implications of extending the ADHD age-of-onset criterion to age 12: results from a prospectively studied birth cohort. J Am Acad Child Adolesc Psychiatry 2010;49(3):210-216.
5.Faraone SV, Biederman J, Spencer T, Mick E, Murray K, Petty C et al. Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry 2006;163(10):1720-1729.
6.Rohde LA, Biederman J, Zimmermann H, Schmitz M, Martins S, Tramontina S. Exploring ADHD age-of-onset criterion in Brazilian adolescents. Eur Child Adolesc Psychiatry 2000;9(3):212-218.
7.American Psychiatric Association, 2013. http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf. Accessed: 09/11/13
8.Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):593-602.

Competing interests: Dr Cortese has served as scientific consultant for Shire Pharmaceuticals from June 2009 to December 2010. He has received support to attend meetings from Eli Lilly and co in 2008 and from Shire in 2009-2010. There are no further conflicts of interest.

09 November 2013
Samuele Cortese
Child Neuropsychiatrist
Cambridge University Hospitals NHS Foundation Trust
Hills Road, Cambridge, CB2 0QQ