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ADHD Work GroupWeighing Options

B Y R O B E R T F I N N

H O N O L U L U The publica-tion of DSM-V will likely in-clude substantial changes in thediagnostic criteria of attention-

deficit/hyperactivity disorder.However, the nature of many

of those changes has not yet been finalized, according tothree members of the workgroup who delivered a progressreport to a packedand verylivelyaudience at the annualmeeting of the American Acad-emy of Child and AdolescentPsychiatry.

Dr. F. Xavier Castellanos ofNew York University pointedout that many aspects of the di-agnosis work well now. Theresa lot about ADHD thats not

broken, he said. It turns outthat the 18 criteria that we haveas a whole work rather well.They are clinically useful;theyve been validated innu-merable times across multiplecultural settings.

One likely change is the cur-

rent requirement that the pa-tients symptoms cause signifi-cant impairment before the ageof 7 years, though the workgroup believes that eliminatingthe age requirement entirely

would not be a good idea.We want to differentiate this

from something that occurs atage 55 following a stroke or age25 following a psychotic break,said Dr. Castellanos, Brooke andDaniel Neidich professorof childand adolescent psychiatry at theuniversity. Theres some need toassert the importance of child-hood origin. ... The greatest sen-timent is toward moving the agecriteria ... to age 12. And most re-cently, we discussed not simplyrequiring that some impairmentbe present by age 12, but in one

way, shape, or form the diagno-sis should be in place by age 12.Again, this is very tentative, butthat was the most recent discus-sion on the topic.

Another likely change will bethe ability to diagnose ADHD in

B Y E L I Z A B E T H

ME CHCAT IE

The Food and Drug Admin-istrations approval of theatypical antipsychotic aripipra-zole for the treatment of irri-tability associated with autisticdisorder in children and adoles-

cents aged 6-17 years providesphysicians with one more op-tion for this indicationwhichincludes symptoms of aggres-sion toward others, deliberateself-injuriousness, tempertantrums, and quickly chang-ing moods.

Risperidone (Risperdal), alsoan atypical antipsychotic, wasapproved in 2006 for the sameindication for children aged 5-16years.

Aripiprazole, marketed as Abilify by the manufacturers,Bristol-Myers Squibb Co. andOtsuka Pharmaceutical Co.,

was initially approved by theFDA in 2002 for schizophrenia.Aripiprazole has been approvedfor several other adult and pe-diatric indications, includingtreatment of schizophrenia inadolescents aged 13-17 years,

More than 15% of students had PTSD.

New Data Point toExtent of TraumaAt Virginia Tech

Aripiprazole Approved forAutism-Related Irritability

B Y D A M I A N M C N A M A R A

AT L A N T A Research is

starting to demonstrate the ex-tent to which the differentialloss and trauma experienced bystudents and staff at VirginiaTech on the morning of ashooting rampage more than 2years ago relates to risk for post-traumatic stress disorder anddevelopment of mental illnessin general.

Russell Jones, Ph.D., professorof psychology at Virginia Tech,presented findings of two fol-low-up surveys of nearly 5,000students and 1,700 faculty andstaff conducted in the wake ofthe shootings by student Seung

Hui Cho. In two separate inci-dents on April 16, 2007, Mr. Chokilled 32 people and wounded

17 others on the school campusin Blacksburg, Va.Students, faculty, and staff

members were surveyed a fewmonths later, in July and Augustof 2007, to estimate the extentof exposure and psychologicalreactions. In those surveys, re-spondents indicated their initialawareness and proximity to theshooting incidents at Ambler Johnson Hall and/or NorrisHall on that day. A total of 77%of students said they wereaware of the first incident, and98% were aware of the second

Theres someneed to assert

the importanceof childhood

origin of ADHDin the DSM-V,

Dr. F. XavierCastellanossays.

See ADHDpage 28

See Traumapage 4

See Aripiprazolepage 53

PsychiatristsStand Firm

Possible cut in Medicare

payments criticized.

P A G E 4

ReframingStimulant AbuseAmelia M. Arria, Ph.D.,

and Dr. Robert L. DuPont

issue a challenge to doctors.

P A G E 6

PTSD and theDSM-V

Adding negative mood

states to criteria considered.

P A G E 2 2

Helping Patients

At End of LifeDr. Carl C. Bell says

psychiatrists facility must

go beyond prescribing.

P A G E 4 0

I N S I D E

COURTE

SY

CIELO

DIAZ

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ANDMEETING

COVERAGE

TREAT PTSD, SUBSTANCE ABUSE AT SAME TIME, PAGE 18

Clinical Psychiatry NewsVO L . 3 7 , N O . 1 2 The Leading Independent Newspaper for the Psychiatr istSince 1973 D E C E M B E R 2 0 0 9

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28 CHILD/ADOLESCENT PSYCHIATRY D EC EM B ER 2 0 0 9 C L I N I C A L P S Y C H I A TR Y N EW S

a child who also has a pervasive devel-opmental disorder (PDD). It turns outthat between 40% and 70% of individu-als who meet criteria for the autismspectrum also have very substantial prob-lems with hyperactivity and attention,Dr. Castellanos said. Theres a very

strong desire, especially on the part of in-dividuals who are engaged in the autismcommunity, to do away with this exclu-sion.

Dr. Castellanos observed that somechildren with mild PDD can have a pri-mary ADHD. Standard ADHD treat-ments tend to work well in these chil-dren. On the other hand, in more severePDD cases, the treatment response tendsto be idiosyncratic.

But the most significant unansweredquestion is whether the ADHD diagno-sis will continue to have subtypes. Cur-rently, there are three: ADHD thats pre-

dominantly hyperactive/compulsive,ADHD thats predominantly inattentive,and ADHD combined type.

Certain changes are all but definite,said Dr. David Shaffer of Columbia Uni-versity, New York. For example, in theDSM-V, a strong effort will be made todifferentiate between impairment andseverity of a disorder.

We really separated ourselves fromthe rest of medicine by saying you

couldnt have a disorder unless you wereimpaired, said Dr. Shaffer, Irving Philipsprofessor of child psychiatry at the uni-versity. We all know that there are

some people who persist with a very ac-tive and unimpaired life even thoughthey have very severe illness.

Reviews of the literature and a meta-analysis of 490 studies involving morethan 25,000 patients call into questionthe validity of the various subtypes thatare currently used, said Joel Nigg, Ph.D.,director of the division of psychology atOregon Health and Science University,Portland. A major concern for our work

group is: Are these subtypes valid, andwhat do we do about the inattentive butnot hyperactive children? he said. Wehave to decide if we dont have subtypes

Will Diagnosis Keep Subtypes?ADHDfrom page 1

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D EC EM B ER 2 0 0 9 W W W . C L I N I C A L P S Y C H I A TR Y N EW S . C O M CHILD/ADOLESCENT PSYCHIATRY 29

at all whether were going to go back toa three-, two-, or one-dimensional symp-tom list.

In studies published since the releaseof DSM-IV, The two-factor structure ofinattention and hyperactivity/impulsiv-ity had fairly good support, Dr. Niggsaid, with the caveat that the three-fac-tor model, with impulsivity as a separatefactor, does have some improvement infit over the two-factor model. But the

correlation between hyperactivity andimpulsivity is so high that thats proba-bly of academic interest more than clin-ical utility. Arguing against distinct sub-

types are nine studies that show no dif-ference in response to medication inchildren diagnosed ADHD-combinedversus ADHD-inattentive. Furthermore,longitudinal studies have demonstratedthat the subtypes are not stable overtime. A childs subtype might changemany times over the years, and less than40% of children maintain the same di-agnosis at two time points.

The subtypes are more like state type

than trait type, Dr. Nigg said.Moreover, studies have shown that

most differences in symptoms betweensubtypes lie on a continuum, with arbi-

trary cut points separating one diagno-sis from the other. There is one excep-tion to a purely dimensional model,however. Social dysfunction appears tobe worse in patients with ADHD inat-tentive than in patients with ADHDcombined. A purely dimensional modelwould predict the opposite.

According to Dr. Nigg, the work groupis considering three options. The first isto eliminate subtypes entirely, but to de-

fine two dimensions of the disorder.[This] would clearly require aggressive

revision of the text to remind clinicians ofthe importance of heterogeneity in pre-

sentation and the differential predictivepower of inattention versus hyperactivi-ty in terms of the predominant presen-tation of the child, Dr. Nigg said.

The second option is to keep the sub-types but to make other aggressive textrevisions reminding clinicians that thesubtypes are not stable.

Option 3 is to do something creativewith the research appendix that will al-low us to stimulate research on sub-

types, Dr. Nigg said.In discussing the work groups report,

Dr. Gabrielle A. Carlson, director ofchild and adolescent psychiatry at StonyBrook State University of New York,said that some of these distinctions aremore important to academic researchersthan to clinicians.

Turning to the audience, Dr. Carlsonasked how many of those present wouldfail to give a child an ADHD diagnosisif he or she had only 10 symptoms.Among several hundred clinicians, onlyone raised her hand.

Then, turning to the three workgroup members, Dr. Carlson said: We

dont really give a crap about 10 symp-

toms versus 12 symptoms. Because partof the reason is people are coming in,and they want help for problems. And ifyoure a decent clinician, youre used tokind of hearing what the symptom con-

stellation sounds like.She asked Dr. Castellanos why the

work group had not included memberswho had a primarily clinical practice. Idont think that anyone ever thought,well, well get rid of the clinicians, he replied. But thats effectively whathappened.

He cited the fact that service on thework group was voluntary and carriedno monetary stipend, a condition thatfavors salaried academics. Another bar-rier to clinicians might have been theextensive conflict-of-interest verifica-tions required of all potential members.

On the issue of subtypes, Dr. Carlson

said it is important to be able to tell par-ents something that makes sense. Andthen you have to assist him or her in get-ting an individualized education plan thatwill be helpful and develop a sensibletreatment plan. In her view, maintainingsubtypes would be important for that.

I also promise you that nobody givesa crap what youre going to put in thetext. Nobody reads the text, she said tolaughter and applause.

I realize the amount of time and ef-fort and energy that goes into doingwhat youre doing. .. . But I also thinkyou need to understand that youre mak-ing clothes for people who have to wearthem. And if you dont have a place forus to put the kids that we see, there areunintended consequences of wherethose kids get put.

Reviews of the literature and a

meta-analysis of 490 studies

involving more than 25,000

patients call into question the

validity of various subtypes of

ADHD that are currently used.