ADD with Hyperactivity to ADHD Subtypes

DSM-III

In 1980, the DSM-III was released and with it the diagnosis of ADD with Hyperactivity, ADD without Hyperactivity and ADD Residual Type (Lange, Reichl, Lange, Tucha & Tucha, 2010). While all three types are important, this section will focus primarily on ADD with Hyperactivity, as it is the precursor to ADHD. In addition, we will discuss the outside influences which led to the removal of all ADD disorders from the DSM-III-R and the addition of ADHD.

The introduction of ADD with and without Hyperactivity was largely in response to Virginia Douglas’ article, “Stop, look and listen: The problem of sustained attention and impulse control in hyperactive and normal children” (cited in Lange et al., 2010). In it, Douglas suggested that children’s symptoms of difficulty paying attention for long periods of time and impulsive behaviors were far more important characterisitics of hyperkinesis than hyperactivity was (Lange et al., 2010). As a result, the DSM-III was revolutionary because it allowed children to be diagnosed as having ADD without Hyperactivity (Lange et al., 2010).

Virginia Douglas’ article led to the creation of ADD without Hyperactivity / created by Pamela Wilson

In addition, the DSM-III changed in regards to how diagnoses were determined. In the DSM-II, there was one diagnostic criteria that the patient had to meet in order to receive a diagnosis. With the DSM-III, the patient had to have at least eight of the fourteen diagnostic criteria in order to recieve a diagnosis of ADD (McBurnett, Lahey & Pfiffner, 1993). The DSM-III also divided the fourteen criteria into three categories: “inattention (5 symptoms), impulsivity (5 symptoms), and hyperactivity (4 symptoms)” (McBurnett et al., 1993).

DSM-III-R

With the release of the DSM-III-R (1987), (Lange et al., 2010) came new changes to the previous diagnosis of ADD with and without Hyperactivity. The DSM-III diagnoses of ADD with and without Hyperactivity with a new diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)  (McBurnett et all., 1993). The committee developing the DSM-III-R reverted back to a single diagnosis without any subtypes because there was no empirical evidence that suggested there was a difference between ADD with Hyperactivity and ADD without Hyperactivity (Lange et al., 2010).

Additonally, the diagnostic criteria for ADHD changed from the DSM-III to the DSM-III-R. While a patient did need to meet at least eight of the fourteen criteria for a diagnosis of ADHD, the fourteen criteria were no longer broken into three separate categories. The three categories were also removed from the DSM-III-R because of a lack of evidence supporting the existence as well as the necessity for the symptoms to be divided into three groups (McBurnett et all., 1993).

DSM-IV

When the DSM-IV was being developed, researchers looked into the basis for ADHD subtypes. Their findings led to the introduction of two subtypes and a combination of the two. Children diagnosed with the first subtype, “ADHD-predominately inattentive type” (p. 199) are those who display levels of inattention to the degree that they interfere with school and other daily activites. These children have little to no hyperactivity symptoms (Carlson, Shin & Booth, 1999). Children diagnosed with the second subtype, “ADHD-predominately hyperactive-impulsive type” (p. 199) have excess hyperactivity but do not have inattention symptoms. Finally, children are sometimes diagnosed with, “ADHD – Combined Type” (p.199). These children display symptoms from both the hyperactivity and inattenton categories (Carlson et al., 1999).

The studies supporting the existence of the three subtypes found that the age of onset for the combined and inattentive subtypes were different. Those diagnosed with “ADHD-IA” were on average “9.8 years old” when they were first diagnosed; while, those diagnosed with “ADHD-C” were on average “8.53 years old” (p. 200) when they were first diagnosed (Carlson et al., 1999). Additionally, the field trials found that of the three subtypes, ADHD-C was the most often diagnosed (Carlson et al. 1999). However, across studies that looked at the frequency of the three subtypes, ADHD-IA was the most common (Carlson et al., 1999). The discrepancy is a result of the populations studied; that is, ADHD-IA is most commonly diagnosed in the general population, while ADHD-C appears most often in the clinical population (Carlson et al., 1999).

The hyperactive-impulsive subtype (HI) was the least researched during the field trials; however, this does not mean that the inclusion of this subtype into the DSM-IV was without basis. There were a number of children with ADHD who did not meet the criteria for a diagnosis of either of the other two subtypes (Carlson et al., 1999). The field trials also showed that ADHD-HI was diagnosed less often than ADHD-C and ADHD-IA in both the general and the clincial populations (Carlson et al., 1999).

Prevalence of ADHD Subtypes found in one study / Farone SV, Biederman J, Weber W, et al. Psychiatric, neuropsychological and psychosocial features of DSM-IV subtypes of ADHD: results from a clinically referred sample. J Am Acad Child Adolesc Psychiatry 1998; 37: 185-193.

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