The DSM definition of ADHD | ADHD Information

This is ADHD as told by the DSM. You can see for yourself if your child fits in here. If you read all the disorders I posted, you will see that it is bipolar that has the symptom of raging and violence, not ADHD. ASD (next) is the one with prodominantly social aspects.

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Symptoms of ADHD

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The year 2000 Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) provides criteria for diagnosing ADHD. The criteria are presented here in modified form in order to make them more accessible to the general public. They are listed here for information purposes and should be used only by trained health care providers to diagnose or treat ADHD.

DSM-IV Criteria for ADHD
I. Either A or B:

Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Often has trouble keeping attention on tasks or play activities.

Often does not seem to listen when spoken to directly.

Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

Often has trouble organizing activities.

Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

Is often easily distracted.

Is often forgetful in daily activities.

Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

Often fidgets with hands or feet or squirms in seat.

Often gets up from seat when remaining in seat is expected.

Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

Often has trouble playing or enjoying leisure activities quietly.

Is often "on the go" or often acts as if "driven by a motor".

Often talks excessively.

Impulsivity

Often blurts out answers before questions have been finished.

Often has trouble waiting one's turn.

Often interrupts or intrudes on others (e.g., butts into conversations or games).

Some symptoms that cause impairment were present before age 7 years.

Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

There must be clear evidence of significant impairment in social, school, or work functioning.

The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months

ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

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Date: September 20, 2005
Content source: National Center on Birth Defects and Developmental Disabilities

What is ADHD
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It does not say raging, violence, disrespect towards parents or teachers, and all the other stuff professionals are chalking up to ADHD. Now check on the DSM for ASD.

[The following is from Diagnostic and Statistical Manual of Mental Disorders: DSM IV](I) Qualitative impairment in social interaction, as manifested by at least two of the following: (A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
(B) failure to develop peer relationships appropriate to developmental level
(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people)
(D) lack of social or emotional reciprocity
(II) Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
(A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(B) apparently inflexible adherence to specific, nonfunctional routines or rituals
(C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
(D) persistent preoccupation with parts of objects

(III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.

(IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)

(V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.

(VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia."

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Early Onset Bipolar is not yet in the DSM (it will be). Here are some symptoms. Which disorder does your child fit into?

adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder, but have not yet experienced the manic phase of the illness.

What are the symptoms of bipolar disorder in children?

Bipolar disorder involves marked changes in mood and energy. Persistent states of extreme elation or agitation accompanied by high energy are called mania. Persistent states of extreme sadness or irritability accompanied by low energy are called depression.

However, the illness may look different in children than it does in adults. Children usually have an ongoing, continuous mood disturbance that is a mix of mania and depression. This rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes.

Diagnosis is made using the DSM-IV criteria, for which there is no lower age limit. See section below for DSM-IV criteria. However, it becomes more difficult to apply the DSM-IV criteria to very young children.

Behaviors reported by parents in children diagnosed with bipolar disorder may include: an expansive or irritable mood extreme sadness or lack of interest in play rapidly changing moods lasting a few hours to a few days explosive, lengthy, and often destructive rages separation anxiety defiance of authority hyperactivity, agitation, and distractibility sleeping little or, alternatively, sleeping too much bed wetting and night terrors strong and frequent cravings, often for carbohydrates and sweets excessive involvement in multiple projects and activities impaired judgment, impulsivity, racing thoughts, and pressure to keep talking dare-devil behaviors (such as jumping out of moving cars or off roofs) inappropriate or precocious sexual behavior delusions and hallucinations grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)

Symptoms of bipolar disorder can emerge as early as infancy. Mothers often report that children later diagnosed with the disorder were extremely difficult to settle and slept erratically. They seemed extraordinarily clingy, and from a very young age often had uncontrollable, seizure-like tantrums or rages out of proportion to any event. The word "no" often triggered these rages.

Several ongoing studies are further exploring characteristics of affected children. Researchers are studying, with promising results, the effectiveness and safety of adult treatments in children.

What are the symptoms of bipolar disorder in adolescents?

In adolescents, bipolar disorder may resemble any of the following classical adult presentations of the illness.

Bipolar I. In this form of the disorder, the adolescent experiences alternating episodes of intense and sometimes psychotic mania and depression.

Symptoms of mania include: elevated, expansive or irritable mood decreased need for sleep racing speech and pressure to keep talking grandiose delusions excessive involvement in pleasurable but risky activities increased physical and mental activity poor judgment in severe cases, hallucinations

Symptoms of depression include: pervasive sadness and crying spells sleeping too much or inability to sleep agitation and irritability withdrawal from activities formerly enjoyed drop in grades and inability to concentrate thoughts of death and suicide low energy significant change in appetite

Periods of relative or complete wellness occur between the episodes.

Bipolar II. In this form of the disorder, the adolescent experiences episodes of hypomania between recurrent periods of depression. Hypomania is a markedly elevated or irritable mood accompanied by increased physical and mental energy. Hypomania can be a time of great creativity. Cyclothymia. Adolescents with this form of the disorder experience periods of less severe, but definite, mood swings. Bipolar Disorder NOS (Not Otherwise Specified). Doctors make this diagnosis when it is not clear which type of bipolar disorder is emerging.

For some adolescents, a loss or other traumatic event may trigger a first episode of depression or mania. Later episodes may occur independently of any obvious stresses, or may worsen with stress. Puberty is a time of risk. In girls, the onset of menses may trigger the illness, and symptoms often vary in severity with the monthly cycle.

Once the illness starts, episodes tend to recur and worsen without treatment. Studies show that after symptoms first appear, typically there is a 10-year lag until treatment begins. CABF encourages parents to take their adolescent for an evaluation if four or more of the above symptoms persist for more than two weeks. Early intervention and treatment can make all the difference in the world during this critical time of development.

Is substance abuse and addiction related to bipolar disorder?

A majority of teens with untreated bipolar disorder abuse alcohol and drugs. Any child or adolescent who abuses substances should be evaluated for a mood disorder.

Adolescents who seemed normal until puberty and experience a comparatively sudden onset of symptoms are thought to be especially vulnerable to developing addiction to drugs or alcohol. Substances may be readily available among their peers and teens may use them to attempt to control their mood swings and insomnia. If addiction develops, it is essential to treat both the bipolar disorder and the substance abuse at the same time.

What role does genetics or family history play in bipolar disorder?

The illness tends to be highly genetic, but there are clearly environmental factors that influence whether the illness will occur in a particular child. Bipolar disorder can skip generations and take different forms in different individuals.

The small group of studies that have been done vary in the estimate of risk to a given individual:

For the general population, a conservative estimate of an individual's risk of having full-blown bipolar disorder is 1 percent. Disorders in the bipolar spectrum may affect 4-6%. When one parent has bipolar disorder, the risk to each child is l5-30%. When both parents have bipolar disorder, the risk increases to 50-75%. The risk in siblings and fraternal twins is 15-25%. The risk in identical twins is approximately 70%.

In every generation since World War II, there is a higher incidence and an earlier age of onset of bipolar disorder and depression. On average, children with bipolar disorder experience their first episode of illness 10 years earlier than their parents' generation did. The reason for this is unknown.

The family trees of many children who develop early-onset bipolar disorder include individuals who suffered from substance abuse and/or mood disorders (often undiagnosed). Also among their relatives are found highly-accomplished, creative, and extremely successful individuals in business, politics, and the arts.

Historical Perspective

Bipolar disorder has left its mark on history. Many famous and accomplished people had symptoms of the illness, including: Abraham Lincoln Winston Churchill Theodore Roosevelt Goethe Balzac Handel Schumann Berlioz Tolstoy Virginia Woolf Hemingway Robert Lowell Anne Sexton

The biographies of Beethoven, Newton, and Dickens, in particular, reveal severe and debilitating recurrent mood swings beginning in childhood.

Timeline

Diagnosing Bipolar Disorder in Children

Healthy children often have moments when they have difficulty staying still, controlling their impulses, or dealing with frustration. The Diagnostic and Statistical Manual IV (DSM-IV) still requires that, for a diagnosis of bipolar disorder, adult criteria must be met. There are as yet no separate criteria for diagnosing children.

Some behaviors by a child, however, should raise a red flag: destructive rages that continue past the age of four talk of wanting to die or kill themselves trying to jump out of a moving car

To illustrate how difficult it is to use the DSM-IV to diagnose children, the manual says that a hypomanic episode requires a "distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." Yet upwards of 70 percent of children with the illness have mood and energy shifts several times a day.

Since the DSM-IV is not scheduled for revision in the immediate future, experts often use some DSM-IV criteria as well as other measures. For example, a Washington University team of researchers uses a structured diagnostic interview called Wash U KIDDE-SADS, which is more sensitive to the rapid-cycling periods commonly observed in children with bipolar disorder.

How does bipolar disorder differ from other conditions?

Even when a child's behavior is unquestionably not normal, correct diagnosis remains challenging. Bipolar disorder is often accompanied by symptoms of other psychiatric disorders. In some children, proper treatment for the bipolar disorder clears up the troublesome symptoms thought to indicate another diagnosis. In other children, bipolar disorder may explain only part of a more complicated case that includes neurological, developmental, and other components.

Diagnoses that mask or sometimes occur along with bipolar disorder include: depression conduct disorder (CD) oppositional-defiant disorder (ODD) attention-deficit disorder with hyperactivity (ADHD) panic disorder generalized anxiety disorder (GAD) obsessive-compulsive disorder (OCD) Tourette's syndrome (TS) intermittent explosive disorder reactive attachment disorder (RAD)

In adolescents, bipolar disorder is often misdiagnosed as: borderline personality disorder post-traumatic stress disorder (PTSD) schizophrenia

The need for prompt and proper diagnosis

Tragically, after symptoms first appear in children, years often pass before treatment begins, if ever. Meanwhile, the disorder worsens and the child's functioning at home, school, and in the community is progressively more impaired.

The importance of proper diagnosis cannot be overstated. The results of untreated or improperly treated bipolar disorder can include:

an unnecessary increase in symptomatic behaviors leading to removal from school, placement in a residential treatment center, hospitalization in a psychiatric hospital, or incarceration in the juvenile justice system the development of personality disorders such as narcissistic, antisocial, and borderline personality a worsening of the disorder due to incorrect medications drug abuse, accidents, and suicide.

It is important to remember that a diagnosis is not a scientific fact. It is a considered opinion based upon the behavior of the child over time, what is known of the child's family history, the child's response to medications, his or her developmental stage, the current state of scientific knowledge and the training and experience of the doctor making the diagnosis. These factors (and the diagnosis) can change as more information becomes available. Competent professionals can disagree on which diagnosis fits an individual best. Diagnosis is important, however, because it guides treatment decisions and allows the family to put a name to the condition that affects their child. Diagnosis can provide answers to some questions but raises others that are unanswerable given the current state of scientific knowledge.

How can I help my child?

Parents concerned about their child's behavior, especially suicidal talk and gestures, should have the child immediately evaluated by a professional familiar with the symptoms and treatment of early-onset bipolar disorder.

There is no a blood test or brain scan, as yet, that can establish a diagnosis of bipolar disorder.

Parents who suspect that their child has bipolar disorder (or any psychiatric illness) should take daily notes of their child's mood, behavior, sleep patterns, unusual events, and statements by the child of concern to the parents. Share these notes with the doctor making the evaluation and with the doctor who eventually treats your child. Some parents fax or e-mail a copy of their notes to the doctor before each appointment.

Because children with bipolar disorder can be charming and charismatic during an appointment, they initially may appear to a professional to be functioning well. Therefore, a good evaluation takes at least two appointments and includes a detailed family history.

Finding the right doctor

If possible, have a board-certified child psychiatrist diagnose and treat your child. A child psychiatrist is a medical doctor who has completed two to three years of an adult psychiatric residency and two additional years of a child psychiatry fellowship program. Unfortunately, there is a severe shortage of child psychiatrists, and few have extensive experience treating early-onset bipolar disorder.

Teaching hospitals affiliated with reputable medical schools are often a good place to start looking for an experienced child psychiatrist. You can also ask your child's pediatrician for a referral. Check the CABF Directory of Professional Members to see the names of doctors who practice in your area.

If your community does not have a child psychiatrist with expertise in mood disorders, then look for an adult psychiatrist who has 1) a broad background in mood disorders, and 2) experience in treating children and adolescents.

Other specialists who may be able to help, at least with an initial evaluation, include pediatric neurologists. Neurologists have experience with the anti-convulsant medications often used for treating juvenile bipolar disorders. Pediatricians who consult with a psychopharmacologist can also provide competent care if a child psychiatrist is not available.

Some families take their child to nationally-known doctors at teaching hospitals for diagnosis and stabilization. They then turn to local professionals for medical management of their child's treatment and psychotherapy. The local professionals consult with the expert as needed.

Experienced parents recommend that you look for a doctor who:

is knowledgeable about mood disorders, has a strong background in psychopharmacology, and stays up-to-date on the latest research in the field knows he or she does not have all the answers and welcomes information discovered by the parents explains medical matters clearly, listens well, and returns phone calls promptly offers to work closely with parents and values their input has a good rapport with the child understands how traumatic a hospitalization is for both child and parents, and keeps in touch with the family during this period advocates for the child with managed care companies when necessary advocates for the child with the school to make sure the child receives services appropriate to the child's educational needs.

Treatment

Although there is no cure for bipolar disorder, in most cases treatment can stabilize mood and allow for management and control of symptoms.

A good treatment plan includes medication, close monitoring of symptoms, education about the illness, counseling or psychotherapy for the individual and family, stress reduction, good nutrition, regular sleep and exercise, and participation in a network of support.

The response to medications and treatment varies. Factors that contribute to a better outcome are: access to competent medical care early diagnosis and treatment adherence to medication and treatment plan a flexible, low-stress home and school environment a supportive network of family and friends

Factors that complicate treatment are: lack of access to competent medical care time lag between onset of illness and treatment not taking prescribed medications stressful and inflexible home and school environment the co-occurrence of other diagnoses use of substances such as illegal drugs and alcohol

The good news is that with appropriate treatment and support at home and at school, many children with bipolar disorder achieve a marked reduction in the severity, frequency and duration of episodes of illness. With education about their illness (as is provided to children with epilepsy, diabetes, and other chronic conditions) they learn how to manage and monitor their symptoms as they grow older.

The parent's role in treatment

As with other chronic medical conditions such as diabetes, epilepsy, and asthma, children and adolescents with bipolar disorder and their families need to work closely with their doctor and other treatment professionals. Having the entire family involved in the child's treatment plan can usually reduce the frequency, duration, and severity of episodes. It can also help improve the child's ability to function successfully at home, in school, and in the community.

Parents: Learn all you can about bipolar disorder. Read, join support groups, and network with other parents. There are many questions still unanswered about early onset bipolar disorder, but early intervention and treatment can often stabilize mood and restore wellness. You can best manage relapses by prompt intervention at the first re-occurrence of symptoms.

Medication

Few controlled studies have been done on the use of psychiatric medications in children. The U.S. Food and Drug Administration (FDA) has approved only a handful for pediatric use. Psychiatrists must adapt what they know about treating adults to children and adolescents.

Medications used to treat adults are often helpful in stabilizing mood in children. Most doctors start medication immediately upon diagnosis if both parents agree. If one parent disagrees, a short period of watchful waiting and charting of symptoms can be helpful. Treatment should not be postponed for long, however, because of the risk of suicide and school failure.

A symptomatic child should never be left unsupervised. If parental disagreement makes treatment impossible, as may happen in families undergoing divorce, a court order regarding treatment may be necessary.

Other treatments, such as psychotherapy, may not be effective until mood stabilization occurs. In fact, stimulants and antidepressants given without a mood stabilizer (often the result of misdiagnosis) can cause havoc in bipolar children, potentially inducing mania, more frequent cycling, and increases in aggressive outbursts.

No one medication works in all children. The family should expect a trial-and-error process lasting weeks, months, or longer as doctors try several medications alone and in combination before they find the best treatment for your child. It is important not to become discouraged during the initial treatment phase. Two or more mood stabilizers, plus additional medications for symptoms that remain, are often necessary to achieve and maintain stability.

Parents often find it hard to accept that their child has a chronic condition that may require treatment with several medications. It is important to remember that bipolar disorder has a high rate of suicide. Estimates vary, but mortality rates of 5-10% from suicide are reported by various studies, rates equal to or greater than the mortality rates for many serious physical illnesses. The untreated disorder carries the risk of drug and alcohol addiction, damaged relationships, school failure, and difficulty finding and holding jobs. The risks of not treating are substantial and must be measured against the unknown risks of using medications whose safety and efficacy have been established in adults, but not yet in children.

A Cautionary Note on Antidepressants and Stimulants from the National Institute of Mental Health

Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.

From:
Child and Adolescent Bipolar Disorder:[NL]An Update from the National Institute of Mental Health

Psychotherapy

In addition to seeing a child psychiatrist, the treatment plan for a child with bipolar disorder usually includes regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist who provides psychotherapy. Cognitive behavioral therapy, interpersonal therapy, and multi-family support groups are an essential part of treatment for children and adolescents with bipolar disorder. A support group for the child or adolescent with the disorder can also be beneficial, although few exist.

Therapeutic ParentingTM

Parents of children with bipolar disorder have discovered numerous techniques that the CABF refers to as therapeutic parenting. These techniques help calm their children when they are symptomatic and can help prevent and contain relapses. Such techniques include: practicing and teaching their child relaxation techniques using firm restraint holds to contain rages prioritizing battles and letting go of less important matters reducing stress in the home, including learning and using good listening and communication skills using music and sound, lighting, water, and massage to assist the child with waking, falling asleep, and relaxation becoming an advocate for stress reduction and other accommodations at school helping the child anticipate and avoid, or prepare for stressful situations by developing coping strategies beforehand engaging the child's creativity through activities that express and channel their gifts and strengths providing routine structure and a great deal of freedom within limits removing objects from the home (or locking them in a safe place) that could be used to harm self or others during a rage, especially guns; keeping medications in a locked cabinet or box.

What are the educational needs of a child with bipolar disorder?

A diagnosis of bipolar disorder means the child has a significant health impairment (such as diabetes, epilepsy, or leukemia) that requires ongoing medical management. The child needs and is entitled to accommodations in school to benefit from his or her education. Bipolar disorder and the medications used to treat it can affect a child's school attendance, alertness and concentration, sensitivity to light, noise and stress, motivation, and energy available for learning. The child's functioning can vary greatly at different times throughout the day, season, and school year.

The special education staff, parents and professionals should meet as a team to determine the child's educational needs. An evaluation including psychoeducational testing will be done by the school (some families arrange for more extensive private testing). The educational needs of a particular child with bipolar disorder vary depending on the frequency, severity and duration of episodes of illness. These factors are difficult to predict in an individual case. Transitions to new teachers and new schools, return to school from vacations and absences, and changing to new medications are common times of increased symptoms for children with bipolar disorder. Medication side effects that can be troublesome at school include increased thirst and urination, excessive sleepiness or agitation, and interference with concentration. Weight gain, fatigue, and a tendency to become easily overheated and dehydrated impact a child's participation in gym and regular classes.

These factors and any others that affect the child's education must be identified. A plan (called an IEP) will be written to accommodate the child's needs. The IEP should include accommodations for periods when the child is relatively well (when a less intense level of services may suffice), and accommodations available to the child in the event of relapse. Specific accommodations should be backed up by a letter or phone call from the child's doctor to the director of special education in the school district. Some parents find it necessary to hire a lawyer to obtain the accommodations and services that federal law requires public schools to provide for children with similar health impairments.

Examples of accommodations helpful to children and adolescents with bipolar disorder include:

preschool special education testing and services small class size (with children of similar intelligence) or self-contained classroom with other emotionally fragile (not "behavior disorder") children for part or all of the day one-on-one or shared special education aide to assist child in class back-and-forth notebook between home and school to assist communication homework reduced or excused and deadlines extended when energy is low late start to school day if fatigued in morning recorded books as alternative to self-reading when concentration is low designation of a "safe place" at school where child can retreat when overwhelmed designation of a staff member to whom the child can go as needed unlimited access to bathroom unlimited access to drinking water art therapy and music therapy extended time on tests use of calculator for math extra set of books at home use of keyboard or dictation for writing assignments regular sessions with a social worker or school psychologist social skills groups and peer support groups annual in-service training for teachers by child's treatment professionals (sponsored by school) enriched art, music, or other areas of particular strength curriculum that engages creativity and reduces boredom (for highly creative children) tutoring during extended absences goals set each week with rewards for achievement summer services such as day camps and special education summer school placement in a day hospital treatment program for periods of acute illness that can be managed without inpatient hospitalization placement in a therapeutic day school during extended relapses or to provide a period of extra support after hospitalization and before returning to regular school placement in a residential treatment center during extended periods of illness if a therapeutic day school near the family's home is not available or is unable to meet the child's needs

A Turning Point

Learning that one's child has bipolar disorder can be traumatic. Diagnosis usually follows months or years of the child's mood instability, school difficulties, and damaged relationships with family and friends. However, diagnosis can and should be a turning point for everyone concerned. Once the illness is identified, energies can be directed towards treatment, education, and developing coping strategies.

This article reviewed by CABF Professional Advisory Council members and Martha Hellander, Executive Director.

Last revised: 10/27/02.

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