- Email: [email protected]
Agreement between Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the proposed DSM-V attention deficit hyperactivity disorder diagnostic criteria: an exploratory study
Available online at www.sciencedirect.com
Comprehensive Psychiatry 54 (2013) 7 – 10 www.elsevier.com/locate/comppsych
Agreement between Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the proposed DSM-V attention deficit hyperactivity disorder diagnostic criteria: an exploratory study Ahmad Ghanizadeh⁎ Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, School of Medicine, Shiraz, Iran Department of Psychiatry, Shiraz University of Medical Sciences, School of Medicine, Shiraz, Iran
Abstract Background: There is no empirical literature about the American Psychiatry Association proposed new diagnostic criteria for attention deficit hyperactivity disorder (ADHD). This study examined the agreement between ADHD diagnosis derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and DSM-V diagnostic criteria. It also reports sensitivity, specificity, and agreement for ADHD diagnosis. Methods: A clinical sample of 246 children and adolescents were interviewed face to face using both ADHD diagnostic criteria for DSM-V and DSM-IV by interviewing clinician. Comorbid psychiatric disorders were screened using DSM-IV criteria. Results: The rate of ADHD diagnosis using DSM-V was significantly higher than the rate detected by using DSM-IV diagnostic criteria. The sensitivity of DSM-V diagnostic criteria was 100%, while its specificity was 71.1%. The kappa agreement between DSM-IV and DSM-V was 0.75. In addition, positive predictive value was 85.1%. All the four newly added symptoms to ADHD diagnostic criteria are statistically more common in the children with ADHD than those in the comparison group. However, these symptoms are also very common in the children without ADHD. Conclusion: It is expected that the rate of ADHD would increase using the proposed ADHD DSM-V criteria. Moreover, the newly added symptoms have a low specificity for ADHD diagnosis. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Attention deficit hyperactivity disorder (ADHD) is a cluster of symptoms which are very common in the community samples of children [1]. There is a debate about the validity of ADHD diagnostic criteria [2]. Some authors reported that ADHD is not an identifiable disease [3]. The key symptoms of inattention, hyperactivity, and impulsivity are detectable in many other conditions such as medical and psychosocial conditions [3]. Making any reliable and valid psychiatric diagnosis such as ADHD is highly dependent on assessing its symptoms. Otherwise, the effect of medication and drug response to medication cannot be evaluated reliably. ⁎ Research Center for Psychiatry and Behavioral Sciences, Department of Psychiatry, Hafez Hospital, Shiraz, Iran. Tel.: +98 711 627 93 19; fax: +98 711 627 93 19. E-mail address: [email protected]. 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2012.06.001
It is suggested that ADHD diagnostic criteria should be revised [4–7] and a proposed draft of ADHD diagnostic criteria is also suggested by American Psychiatric Association [8]. If this new criteria is to be implemented, its changes should be assessed by studies. The empirical literature supporting these proposed changes is necessary. There is a speculation that the increased rate of ADHD due to the changes in ADHD diagnostic criteria leads to an increment in the prescription of medications and mental health care services usage. On the other hand, if the diagnostic criteria reduce the likelihood that patients with ADHD are diagnosed, it inappropriately reduces the opportunity for the treating many patients. Therefore, accurate diagnosis is very important to ensure that the medications are appropriately administered. Moreover, adopting premature changes, which are not based on field researches in different settings, increases the risk of being unreplicable. Another important implication of accurate diagnosis is its use for making mental healthcare policy, including treatment and prevention programs.
8
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
A new draft developed by American Psychiatric Association added four symptoms to Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder [8]. All of these symptoms are added to the Hyperactivity and Impulsivity domain of ADHD diagnosis. These symptoms are as follows: “Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions”, “Is often impatient, as shown by feeling restless when waiting for others…’, “Is uncomfortable doing things slowly and systematically…,” and “Finds it difficult to resist temptations or opportunities…” [8]. Therefore, the number of the symptoms in the domain of Hyperactivity and Impulsivity increased from 9 to 13. Nevertheless, similar to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria, six (or more) symptoms are sufficient in order to fulfill the Hyperactivity and Impulsivity domain of ADHD diagnosis. Meanwhile, there is a concern about the psychometric properties of DSM-V ADHD diagnostic criteria. It is reported that the factor analysis of the ADHD DSM-V derived symptoms consists a three-factor model rather than the 2-factor model of inattentiveness and hyperactivity/impulsivity [9]. Of course, there is no gold standard for diagnoses in psychiatry. Therefore, it is not clear whether DSM-V leads to overdiagnosis [10]. However, the prevalence of DSM-V ADHD diagnosis can be compared with DSM-IV ADHD diagnosis. To the best of the authors’ knowledge, this study is the first one that investigating the agreement between DSM-IV and DSM-V diagnostic criteria in a clinical sample of children and adolescents. The present study aims to examine the sensitivity, specificity, and positive as well as negative predictive values of the new proposed DSM-V diagnostic criteria for ADHD. It also aims to assess the agreement between DSM-IV and DSM-V diagnostic criteria for ADHD. Furthermore, another aim is to explore the prevalence of the 4 newly added ADHD symptoms in the children diagnosed with ADHD according to DSM-IV diagnostic criteria.
All the diagnoses were made by one interviewing child and adolescent psychiatrist. All the interviews were conducted by one psychiatrist. The children and adolescents were a convenient sample of children and adolescents from a child and adolescent psychiatry clinic affiliated to Shiraz University of Medical sciences. Children with different symptoms or psychiatric disorders are brought to this clinic, most of whom finally receive psychiatry diagnosis. In the present study, children and at least one of their parents were interviewed face to face. Moreover, the children younger than 12 and parents were interviewed together. The interviews were conducted by a board certified child and adolescent psychiatrist. The interviewer knew the child's diagnosis and only one psychiatrist conducted all the interviews. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for ADHD was used to diagnose the patients with ADHD [10]. All of the children in both groups were interviewed according to the proposed DSM-V ADHD diagnostic criteria, as well [8]. Since both DSM-IV and DSM-V share many criteria, the psychiatrist first go through the DSM-IV criteria one by one and then again go through the newly added criteria one by one. The children and adolescents with head injury with subsequent loss of consciousness, autism spectrum disorders, substance use disorder, symptoms of psychosis, and severe medical condition, such as thyroid dysfunction were not included in the study. In addition, mental retardation according to the medical records or clinically estimated mental retardation was another exclusion criterion. Moreover, taking medication was not considered as an exclusion criterion. Lifetime ADHD diagnosis and current (last one year) other psychiatric disorders were also screened. The study was approved by the Ethics committee of Shiraz University of Medical Sciences. Besides, assent and/or written informed consent were obtained from the parents and/or children. Children and adolescents from different socioeconomic status were included in the study. This study is part of a broader ongoing study about ADHD. 2.2. Statistical analysis
2. Methods 2.1. Subjects The participants of this study include a clinical sample of 246 children and adolescents. According to DSM-IV, 195 of the patients were diagnosed with ADHD, while 51 were not.
All the statistical analyses were performed through the SPSS statistical software. McNemar test was used in order to determine whether the prevalence of ADHD diagnoses is associated with the type of diagnostic criteria. Two separate binary logistic regression analyses were also performed to
Table 1 The characteristics of participants in both groups Variable
ADHD group
Comparison group
Significance
Mean age years (SD) Rate of boys Oppositional defiant disorder Major depressive disorder separation anxiety disorder enuresis tic
9.8 (2.9) 73.8% 53.3% 7.8% 31.4% 9.7% 2%
11.5 (3.7) 49.0% 13.7% 40.4% 11.3% 11.8% 4.6%
t = 3.4, df = 240, P b .001 χ 2 = 1.5, df = 1, P b .001 χ 2 = 25.6, df = 1, P b .001 χ 2 = 36.2, df = 1, P b .001 χ 2 = 12.4, df = 1, P b .001 χ 2 = 0.18, df = 1, P = .6 χ 2 = 0.7, df = 1, P = .3
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
9
Table 2 The distribution of the number of the patients diagnosed according to DSM-IV and DSM-V diagnostic criteria
Patients with DSM-V hyperactivity/impulsivity Patients without DSM-V hyperactivity/impulsivity Total number
Patients with DSM-IV hyperactivity/impulsivity
Patients without DSM-IV hyperactivity/impulsivity
Total number
154
27
181
0
65
65
154
92
246
examine whether age and sex are associated with DSM-IV and DSM-V ADHD diagnosis.
3. Results The demographic characteristics and prevalence of psychiatric co-morbidities are depicted in Table 1. The prevalence of the patients diagnosed with ADHDhyperactive impulsive type using the DSM-IV and DSM-V diagnostic criteria was 62.6% and 73.6%, respectively. In addition, a statistically significant difference was found between the two diagnostic criteria (P b .001). The sensitivity of DSM-V diagnostic criteria was 100%; however, its specificity was 71.1%. The proportion of agreement was 0.89. Besides, Kappa, the corrected proportion of the agreement due to chance, was 0.75, which was in the range of substantial. The positive predictive value of the DSM-V criteria was 85.1% while the negative predictive value was 100.0% (Table 2). The results of regression analysis showed that only age was associated with ADHD diagnosis using the DSM-V diagnostic criteria. However, no statistically significant association was found between sex and ADHD diagnosis (Table 3). Meanwhile, both sex and age were significantly associated with ADHD diagnosis using DSM-IV diagnostic criteria (Table 3). Table 4 shows that all the newly added symptoms to ADHD diagnostic criteria are statistically more common in the children with ADHD than those in the comparison group. Moreover, the rate of the symptoms in the children with ADHD was more than 79.0%. The prevalence of the 4 new symptoms in ADHD diagnosed subjects ranged from 79.1% to 94.8% and in the non-ADHD comparison group from 26.1% to 63.0%.
4. Discussion This study is the first one investigating the agreement between DSM-IV and DSM-V diagnostic criteria in a clinical sample of children and adolescents. The most striking finding of this study is the higher prevalence of ADHD diagnosed according to DSM-V compared to the prevalence diagnosed according to DSM-IV. The prevalence of ADHD using the DSM-V protocol was 11.0% higher than the prevalence of ADHD using DSM-IV diagnostic criteria. The sensitivity of the diagnosis was 100.0%. It was expected to be 100.0% because all the symptoms of hyperactivity/impulsivity in DSM-IV are used in DSM-V, too. Therefore, it is expected that all the individuals diagnosed with ADHD using DSM-IV criteria will meet the DSM-VADHD diagnosis. However, the specificity of DSMIV in comparison to DSM-IV was 71.1%. Moreover, the agreement between the two diagnostic criteria is 0.75. It can be interpreted that there is a considerable high rate of disagreement between these 2 diagnostic criteria. The present study also aimed to assess the rate of the newly added symptoms in the children diagnosed with ADHD according to DSM-IV diagnostic criteria. The current results indicated that the rates of all the new symptoms in the children with DSM-IV ADHD were more than the rates in the comparison group. However, the rates of these symptoms in the comparison group were very high except for the symptom of “Act without thinking”. The rate for the three symptoms of “impatient,” “uncomfortable doing things slowly and systematically,” and “difficult to resist temptations or opportunities” was 50.0%, 46.7%, and 63.0%, respectively. These findings suggest that the newly added 4 symptoms are very common in the patients with other psychiatric disorders. In other words, these symptoms are not specific to ADHD. Moreover, the rates of the 4 symptoms in
Table 3 The association of age and sex with ADHD diagnosis using DSM-V diagnostic criteria and DSM-IV diagnostic criteria Diagnostic criteria
Variable
Significance
Odds ratio
DSM-V
Age Sex Age Sex
.001 .060 .001 .018
.811 .546 .790 .489
DSM-IV
95% Confidence Interval for odds ratio Lower
Upper
.738 .291 .719 .270
.892 1.026 .868 .887
10
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
Table 4 The prevalence of the four newly added symptoms to DSM-IV ADHD diagnostic criteria Symptoms
Act without thinking Impatient uncomfortable doing things slowly and systematically difficult to resist temptations or opportunities
With ADHD according to DSM-IV diagnostic criteria
Without ADHD according to DSM-IV diagnostic criteria
Number
%
Number
%
121 145 136
79.1 94.8 88.9
24 46 43
26.1 50.0 46.7
χ 2 = 66.8, df = 1, P b .001 χ 2 = 67.0, df = 1, P b .001 χ 2 = 51.8, df = 1, P b .001
143
93.5
58
63.0
χ 2 = 36.0, df = 1, P b .001
the children with DSM-IV ADHD were very high. Considering the very high rate of “difficult to resist temptations or opportunities” in both the ADHD group and the comparison group, it needs to be investigated whether adding this symptom improves our diagnosis. It is expected that these symptoms especially “difficult to resist temptations or opportunities” lead to over diagnosis of ADHD. The frequency of “impatient” in the ADHD and the comparison group was 79.1% and 26.1%, respectively. Therefore, it is suggested that this symptom is more specific for ADHD compared to other psychiatric disorders. The new criteria are somewhat lengthy, and it can be difficult for the clinicians to remember all the symptoms. It seems that at least some symptoms are not specific for the children with ADHD and comorbid disorders. Although sex was associated with DSM-IV ADHD diagnosis, sex was not associated with DSM-V ADHD diagnosis. If these findings are confirmed in future studies, it can be suggested that the impact of changes in ADHD diagnostic criteria is not limited to over diagnosis of ADHD. on the other hand, some other ADHD related factors, such as demographic factors, can be affected, as well. Further studies should be replicated in the community as well as other large clinical sample of children and adolescents. Moreover, inter-rater reliability should be examined. In the current study, the sample was a clinical one. It is possible that the clinical sample have more motivation to report the symptoms and lead to bias. In addition, considering the exclusion criteria, generalization of the results should be with caution. Moreover, the same clinician made the children's ADHD diagnosis as interviewed them for the study. Further studies should use another diagnostic method to make or confirm the diagnosis. In spite of these limitations, to date, no published study has investigated the concordance between DSM-IV and DSM-V ADHD diagnosis in the community or clinical
Significance
sample of children and adolescents. All the interviews were conducted by a board certified child and adolescent psychiatrist. In this cross-sectional study, both interviews were conducted in one session. If the interviews were conducted in 2 separate sessions, the recall bias could have affected the results. In conclusion, we should expect a higher prevalence of ADHD using the proposed DSM-V ADHD diagnostic criteria, because, based on the results of this study, the specificity of most added symptoms appears to be low. References [1] Ghanizadeh A. Distribution of symptoms of attention deficithyperactivity disorder in schoolchildren of Shiraz, south of Iran. Arch Iran Med 2008;11(6):618-24. [2] Woo BS, Rey JM. The validity of the DSM-IV subtypes of attentiondeficit/hyperactivity disorder. Aust N Z J Psychiatry 2005;39(5): 344-53. [3] Furman LM. Attention-deficit hyperactivity disorder (ADHD): does new research support old concepts? J Child Neurol 2008;23(7):775-84. [4] Ghanizadeh A. Should ADHD broaden diagnostic classification to include oppositional defiant disorder? J Paediatr Child Health 2011; 47(6):396-7. [5] Poulton AS. Time to redefine the diagnosis of oppositional defiant disorder. J Paediatr Child Health 2011;47(6):332-4. [6] Ghanizadeh A. Is it time to revise the definition of attention deficit hyperactivity disorder? Ann Acad Med Singapore 2010;39(2):155 [author reply 156]. [7] Solanto MV, Marks DJ, Wasserstein J, Mitchell KJ. Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity? J Atten Disord 2011. [8] Association AP. DSM-5 development American Psychiatry Association 2010 [October 1] Available from: http://www.dsm5.org/ ProposedRevisions/Pages/proposedrevision.aspx?rid=383. [9] Ghanizadeh A. Psychometric analysis of the new ADHD DSM-V derived symptoms. BMC Psychiatry Under press. [10] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Ed. Washington, DC: American Psychiatric Association; 1994.
Comprehensive Psychiatry 54 (2013) 7 – 10 www.elsevier.com/locate/comppsych
Agreement between Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the proposed DSM-V attention deficit hyperactivity disorder diagnostic criteria: an exploratory study Ahmad Ghanizadeh⁎ Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, School of Medicine, Shiraz, Iran Department of Psychiatry, Shiraz University of Medical Sciences, School of Medicine, Shiraz, Iran
Abstract Background: There is no empirical literature about the American Psychiatry Association proposed new diagnostic criteria for attention deficit hyperactivity disorder (ADHD). This study examined the agreement between ADHD diagnosis derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and DSM-V diagnostic criteria. It also reports sensitivity, specificity, and agreement for ADHD diagnosis. Methods: A clinical sample of 246 children and adolescents were interviewed face to face using both ADHD diagnostic criteria for DSM-V and DSM-IV by interviewing clinician. Comorbid psychiatric disorders were screened using DSM-IV criteria. Results: The rate of ADHD diagnosis using DSM-V was significantly higher than the rate detected by using DSM-IV diagnostic criteria. The sensitivity of DSM-V diagnostic criteria was 100%, while its specificity was 71.1%. The kappa agreement between DSM-IV and DSM-V was 0.75. In addition, positive predictive value was 85.1%. All the four newly added symptoms to ADHD diagnostic criteria are statistically more common in the children with ADHD than those in the comparison group. However, these symptoms are also very common in the children without ADHD. Conclusion: It is expected that the rate of ADHD would increase using the proposed ADHD DSM-V criteria. Moreover, the newly added symptoms have a low specificity for ADHD diagnosis. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Attention deficit hyperactivity disorder (ADHD) is a cluster of symptoms which are very common in the community samples of children [1]. There is a debate about the validity of ADHD diagnostic criteria [2]. Some authors reported that ADHD is not an identifiable disease [3]. The key symptoms of inattention, hyperactivity, and impulsivity are detectable in many other conditions such as medical and psychosocial conditions [3]. Making any reliable and valid psychiatric diagnosis such as ADHD is highly dependent on assessing its symptoms. Otherwise, the effect of medication and drug response to medication cannot be evaluated reliably. ⁎ Research Center for Psychiatry and Behavioral Sciences, Department of Psychiatry, Hafez Hospital, Shiraz, Iran. Tel.: +98 711 627 93 19; fax: +98 711 627 93 19. E-mail address: [email protected]. 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2012.06.001
It is suggested that ADHD diagnostic criteria should be revised [4–7] and a proposed draft of ADHD diagnostic criteria is also suggested by American Psychiatric Association [8]. If this new criteria is to be implemented, its changes should be assessed by studies. The empirical literature supporting these proposed changes is necessary. There is a speculation that the increased rate of ADHD due to the changes in ADHD diagnostic criteria leads to an increment in the prescription of medications and mental health care services usage. On the other hand, if the diagnostic criteria reduce the likelihood that patients with ADHD are diagnosed, it inappropriately reduces the opportunity for the treating many patients. Therefore, accurate diagnosis is very important to ensure that the medications are appropriately administered. Moreover, adopting premature changes, which are not based on field researches in different settings, increases the risk of being unreplicable. Another important implication of accurate diagnosis is its use for making mental healthcare policy, including treatment and prevention programs.
8
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
A new draft developed by American Psychiatric Association added four symptoms to Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder [8]. All of these symptoms are added to the Hyperactivity and Impulsivity domain of ADHD diagnosis. These symptoms are as follows: “Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions”, “Is often impatient, as shown by feeling restless when waiting for others…’, “Is uncomfortable doing things slowly and systematically…,” and “Finds it difficult to resist temptations or opportunities…” [8]. Therefore, the number of the symptoms in the domain of Hyperactivity and Impulsivity increased from 9 to 13. Nevertheless, similar to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria, six (or more) symptoms are sufficient in order to fulfill the Hyperactivity and Impulsivity domain of ADHD diagnosis. Meanwhile, there is a concern about the psychometric properties of DSM-V ADHD diagnostic criteria. It is reported that the factor analysis of the ADHD DSM-V derived symptoms consists a three-factor model rather than the 2-factor model of inattentiveness and hyperactivity/impulsivity [9]. Of course, there is no gold standard for diagnoses in psychiatry. Therefore, it is not clear whether DSM-V leads to overdiagnosis [10]. However, the prevalence of DSM-V ADHD diagnosis can be compared with DSM-IV ADHD diagnosis. To the best of the authors’ knowledge, this study is the first one that investigating the agreement between DSM-IV and DSM-V diagnostic criteria in a clinical sample of children and adolescents. The present study aims to examine the sensitivity, specificity, and positive as well as negative predictive values of the new proposed DSM-V diagnostic criteria for ADHD. It also aims to assess the agreement between DSM-IV and DSM-V diagnostic criteria for ADHD. Furthermore, another aim is to explore the prevalence of the 4 newly added ADHD symptoms in the children diagnosed with ADHD according to DSM-IV diagnostic criteria.
All the diagnoses were made by one interviewing child and adolescent psychiatrist. All the interviews were conducted by one psychiatrist. The children and adolescents were a convenient sample of children and adolescents from a child and adolescent psychiatry clinic affiliated to Shiraz University of Medical sciences. Children with different symptoms or psychiatric disorders are brought to this clinic, most of whom finally receive psychiatry diagnosis. In the present study, children and at least one of their parents were interviewed face to face. Moreover, the children younger than 12 and parents were interviewed together. The interviews were conducted by a board certified child and adolescent psychiatrist. The interviewer knew the child's diagnosis and only one psychiatrist conducted all the interviews. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for ADHD was used to diagnose the patients with ADHD [10]. All of the children in both groups were interviewed according to the proposed DSM-V ADHD diagnostic criteria, as well [8]. Since both DSM-IV and DSM-V share many criteria, the psychiatrist first go through the DSM-IV criteria one by one and then again go through the newly added criteria one by one. The children and adolescents with head injury with subsequent loss of consciousness, autism spectrum disorders, substance use disorder, symptoms of psychosis, and severe medical condition, such as thyroid dysfunction were not included in the study. In addition, mental retardation according to the medical records or clinically estimated mental retardation was another exclusion criterion. Moreover, taking medication was not considered as an exclusion criterion. Lifetime ADHD diagnosis and current (last one year) other psychiatric disorders were also screened. The study was approved by the Ethics committee of Shiraz University of Medical Sciences. Besides, assent and/or written informed consent were obtained from the parents and/or children. Children and adolescents from different socioeconomic status were included in the study. This study is part of a broader ongoing study about ADHD. 2.2. Statistical analysis
2. Methods 2.1. Subjects The participants of this study include a clinical sample of 246 children and adolescents. According to DSM-IV, 195 of the patients were diagnosed with ADHD, while 51 were not.
All the statistical analyses were performed through the SPSS statistical software. McNemar test was used in order to determine whether the prevalence of ADHD diagnoses is associated with the type of diagnostic criteria. Two separate binary logistic regression analyses were also performed to
Table 1 The characteristics of participants in both groups Variable
ADHD group
Comparison group
Significance
Mean age years (SD) Rate of boys Oppositional defiant disorder Major depressive disorder separation anxiety disorder enuresis tic
9.8 (2.9) 73.8% 53.3% 7.8% 31.4% 9.7% 2%
11.5 (3.7) 49.0% 13.7% 40.4% 11.3% 11.8% 4.6%
t = 3.4, df = 240, P b .001 χ 2 = 1.5, df = 1, P b .001 χ 2 = 25.6, df = 1, P b .001 χ 2 = 36.2, df = 1, P b .001 χ 2 = 12.4, df = 1, P b .001 χ 2 = 0.18, df = 1, P = .6 χ 2 = 0.7, df = 1, P = .3
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
9
Table 2 The distribution of the number of the patients diagnosed according to DSM-IV and DSM-V diagnostic criteria
Patients with DSM-V hyperactivity/impulsivity Patients without DSM-V hyperactivity/impulsivity Total number
Patients with DSM-IV hyperactivity/impulsivity
Patients without DSM-IV hyperactivity/impulsivity
Total number
154
27
181
0
65
65
154
92
246
examine whether age and sex are associated with DSM-IV and DSM-V ADHD diagnosis.
3. Results The demographic characteristics and prevalence of psychiatric co-morbidities are depicted in Table 1. The prevalence of the patients diagnosed with ADHDhyperactive impulsive type using the DSM-IV and DSM-V diagnostic criteria was 62.6% and 73.6%, respectively. In addition, a statistically significant difference was found between the two diagnostic criteria (P b .001). The sensitivity of DSM-V diagnostic criteria was 100%; however, its specificity was 71.1%. The proportion of agreement was 0.89. Besides, Kappa, the corrected proportion of the agreement due to chance, was 0.75, which was in the range of substantial. The positive predictive value of the DSM-V criteria was 85.1% while the negative predictive value was 100.0% (Table 2). The results of regression analysis showed that only age was associated with ADHD diagnosis using the DSM-V diagnostic criteria. However, no statistically significant association was found between sex and ADHD diagnosis (Table 3). Meanwhile, both sex and age were significantly associated with ADHD diagnosis using DSM-IV diagnostic criteria (Table 3). Table 4 shows that all the newly added symptoms to ADHD diagnostic criteria are statistically more common in the children with ADHD than those in the comparison group. Moreover, the rate of the symptoms in the children with ADHD was more than 79.0%. The prevalence of the 4 new symptoms in ADHD diagnosed subjects ranged from 79.1% to 94.8% and in the non-ADHD comparison group from 26.1% to 63.0%.
4. Discussion This study is the first one investigating the agreement between DSM-IV and DSM-V diagnostic criteria in a clinical sample of children and adolescents. The most striking finding of this study is the higher prevalence of ADHD diagnosed according to DSM-V compared to the prevalence diagnosed according to DSM-IV. The prevalence of ADHD using the DSM-V protocol was 11.0% higher than the prevalence of ADHD using DSM-IV diagnostic criteria. The sensitivity of the diagnosis was 100.0%. It was expected to be 100.0% because all the symptoms of hyperactivity/impulsivity in DSM-IV are used in DSM-V, too. Therefore, it is expected that all the individuals diagnosed with ADHD using DSM-IV criteria will meet the DSM-VADHD diagnosis. However, the specificity of DSMIV in comparison to DSM-IV was 71.1%. Moreover, the agreement between the two diagnostic criteria is 0.75. It can be interpreted that there is a considerable high rate of disagreement between these 2 diagnostic criteria. The present study also aimed to assess the rate of the newly added symptoms in the children diagnosed with ADHD according to DSM-IV diagnostic criteria. The current results indicated that the rates of all the new symptoms in the children with DSM-IV ADHD were more than the rates in the comparison group. However, the rates of these symptoms in the comparison group were very high except for the symptom of “Act without thinking”. The rate for the three symptoms of “impatient,” “uncomfortable doing things slowly and systematically,” and “difficult to resist temptations or opportunities” was 50.0%, 46.7%, and 63.0%, respectively. These findings suggest that the newly added 4 symptoms are very common in the patients with other psychiatric disorders. In other words, these symptoms are not specific to ADHD. Moreover, the rates of the 4 symptoms in
Table 3 The association of age and sex with ADHD diagnosis using DSM-V diagnostic criteria and DSM-IV diagnostic criteria Diagnostic criteria
Variable
Significance
Odds ratio
DSM-V
Age Sex Age Sex
.001 .060 .001 .018
.811 .546 .790 .489
DSM-IV
95% Confidence Interval for odds ratio Lower
Upper
.738 .291 .719 .270
.892 1.026 .868 .887
10
A. Ghanizadeh / Comprehensive Psychiatry 54 (2013) 7–10
Table 4 The prevalence of the four newly added symptoms to DSM-IV ADHD diagnostic criteria Symptoms
Act without thinking Impatient uncomfortable doing things slowly and systematically difficult to resist temptations or opportunities
With ADHD according to DSM-IV diagnostic criteria
Without ADHD according to DSM-IV diagnostic criteria
Number
%
Number
%
121 145 136
79.1 94.8 88.9
24 46 43
26.1 50.0 46.7
χ 2 = 66.8, df = 1, P b .001 χ 2 = 67.0, df = 1, P b .001 χ 2 = 51.8, df = 1, P b .001
143
93.5
58
63.0
χ 2 = 36.0, df = 1, P b .001
the children with DSM-IV ADHD were very high. Considering the very high rate of “difficult to resist temptations or opportunities” in both the ADHD group and the comparison group, it needs to be investigated whether adding this symptom improves our diagnosis. It is expected that these symptoms especially “difficult to resist temptations or opportunities” lead to over diagnosis of ADHD. The frequency of “impatient” in the ADHD and the comparison group was 79.1% and 26.1%, respectively. Therefore, it is suggested that this symptom is more specific for ADHD compared to other psychiatric disorders. The new criteria are somewhat lengthy, and it can be difficult for the clinicians to remember all the symptoms. It seems that at least some symptoms are not specific for the children with ADHD and comorbid disorders. Although sex was associated with DSM-IV ADHD diagnosis, sex was not associated with DSM-V ADHD diagnosis. If these findings are confirmed in future studies, it can be suggested that the impact of changes in ADHD diagnostic criteria is not limited to over diagnosis of ADHD. on the other hand, some other ADHD related factors, such as demographic factors, can be affected, as well. Further studies should be replicated in the community as well as other large clinical sample of children and adolescents. Moreover, inter-rater reliability should be examined. In the current study, the sample was a clinical one. It is possible that the clinical sample have more motivation to report the symptoms and lead to bias. In addition, considering the exclusion criteria, generalization of the results should be with caution. Moreover, the same clinician made the children's ADHD diagnosis as interviewed them for the study. Further studies should use another diagnostic method to make or confirm the diagnosis. In spite of these limitations, to date, no published study has investigated the concordance between DSM-IV and DSM-V ADHD diagnosis in the community or clinical
Significance
sample of children and adolescents. All the interviews were conducted by a board certified child and adolescent psychiatrist. In this cross-sectional study, both interviews were conducted in one session. If the interviews were conducted in 2 separate sessions, the recall bias could have affected the results. In conclusion, we should expect a higher prevalence of ADHD using the proposed DSM-V ADHD diagnostic criteria, because, based on the results of this study, the specificity of most added symptoms appears to be low. References [1] Ghanizadeh A. Distribution of symptoms of attention deficithyperactivity disorder in schoolchildren of Shiraz, south of Iran. Arch Iran Med 2008;11(6):618-24. [2] Woo BS, Rey JM. The validity of the DSM-IV subtypes of attentiondeficit/hyperactivity disorder. Aust N Z J Psychiatry 2005;39(5): 344-53. [3] Furman LM. Attention-deficit hyperactivity disorder (ADHD): does new research support old concepts? J Child Neurol 2008;23(7):775-84. [4] Ghanizadeh A. Should ADHD broaden diagnostic classification to include oppositional defiant disorder? J Paediatr Child Health 2011; 47(6):396-7. [5] Poulton AS. Time to redefine the diagnosis of oppositional defiant disorder. J Paediatr Child Health 2011;47(6):332-4. [6] Ghanizadeh A. Is it time to revise the definition of attention deficit hyperactivity disorder? Ann Acad Med Singapore 2010;39(2):155 [author reply 156]. [7] Solanto MV, Marks DJ, Wasserstein J, Mitchell KJ. Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity? J Atten Disord 2011. [8] Association AP. DSM-5 development American Psychiatry Association 2010 [October 1] Available from: http://www.dsm5.org/ ProposedRevisions/Pages/proposedrevision.aspx?rid=383. [9] Ghanizadeh A. Psychometric analysis of the new ADHD DSM-V derived symptoms. BMC Psychiatry Under press. [10] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Ed. Washington, DC: American Psychiatric Association; 1994.