Should ADHD be Divided Into Three New Disorders ?
Is ADHD Conceptualized and Described Well?
Is it possible that in the near future we will throw away the way that we presently categorize ADHD, and replace it with something altogether new? Will we say "good-bye" to "inattentive type", "impulsive-hyperactive type", and "combined type" of ADHD as listed in the DSM-IV today? What will happen to Winnie the Pooh, Tigger, Rabbit, Piglet, and Eeyore as illustrations of the different types of ADHD? After recently hearing a lecture from Russell Barkley on the latest research into ADHD, I was convinced that changes need to be made in how we conceptualize, describe, and treat ADHD. But I am just not sure what changes need to be made. Based on the newest evidence it would seem though that:
- Winnie the Pooh, Piglet, and Eeyore suffer from one common type of ADHD disorder;
- And that Tigger and Rabbit suffer from a separate and distinct and different type of ADHD disorder;
- And that there is a third distinct and separate disorder reserved for those with a co-morbid and combined ADHD and Oppositional Defiant Disorder.
What they have in common are:
- Some degree of Inattention;
- Some degree of frontal lobe involvement;
- Some degree of working memory deficits and executive function impairment;
- Problems at school;
- Some degree of delayed brain development.
ADHD Types : Similarities and Differences
But there are so many more differences that the case will be strongly made that they are not both ADHD with slight differences, but rather that they are completely different neuro-biological disorders. Look at the table below:
| Winnie the Pooh Piglet and Eeyore Inattentive ADHD |
Tigger and Rabbit
Combined Type ADHD |
|---|---|
| Have a characteristically "sluggish cognitive tempo" |
Are characteristically impulsive and hyperactive, moving too fast |
| Daydreaming, spacey, staring, not paying attention to what's going on |
Paying attention to everything around them, and reacting to them all |
| A cognitive processing disorder | An impulsive control disorder |
| Hypo-active | Hyper-active |
| Slow moving lethargic passive |
Fast moving lacks inhibition over active |
| Sluggish in behavior, cognition, and with motor activity | Hyper in behavior, impulsive in cognition, fast motorically |
| Easily confused, brain fog, head in the clouds | Aware of surroundings, knows what's happening |
| Slow information processing | Normal speed information processing, but distracted |
| Prone to errors in school work due to accuracy problems and memory retrieval | Prone to errors due to working too fast, distractions, lack of production or lose the work |
| Poor focus, and poor selective attention | Attentive to everything, lacks ability to inhibit and focus on one thing until done |
| Not impulsive, so by definition not ADHD ? | Impulsive Hyperactive |
| Not disruptive to those around them | Everyone knows who he is |
| Trouble quickly identifying what things are important or not. Impaired selective attention. | Poor inhibition or perseverance to complete a task. Distracted as everything is important |
| Problems with retrieval of memory | Problems with working memory |
| Like people, want friends, can make friends, but tend to be shy | Lack social skills, impulsive, trouble making friends, not at all shy |
| They have NO inhibitory deficits, which is the core feature of ADHD | They define inhibitory deficits, which is the core feature of ADHD |
| Little risk of co-morbid Oppositional Defiant Disorder | Medium to high risk of Oppositional Defiant Disorder |
| Medium to High risk for Anxiety or Depression | Medium risk for Anxiety or Depression |
| Come from families with high rates of Anxiety Disorders and Learning Disabilities | Come from families with high rates of ADHD, drug and alcohol abuse and addiction, oppositional and conduct problems |
| Treatment Response to Ritalin is Moderate to Poor. 20% good, 65% moderate, 15% poor. |
Treatment Response to Ritalin is Excellent. 92% positive |
| Good responders to social skills training. Makes them less shy. | Poor responders to social skills training. Makes them more aggressive. |
| Good responders to cognitive behavioral therapies | Poor responders to cognitive behavioral therapies |
| May respond well to Strattera, which may treat the anxiety as well as inattention. | Stimulants make anxiety worse. |
| Good responders to "internal" therapies, or psychosocial interventions | "Internal" therapies and psychosocial interventions are a waste of time and money |
| Tend more to be girls | Tend more to be boys |
So we will wait to see what the DSM-5 brings in terms of labels. Until then we will have to place Pooh Bear, Piglet, and Eeyore in one corner, with Tigger and Rabbit in another.
What about the co-morbid and combined duo of ADHD and Oppositional Defiant Disorder ? Why are they seen differently ?
Research shows that ADHD by itself is difficult, and ODD by itself is difficult. But when they appear together as one raging disorder, they are probably a distinct disorder - not a co-morbid combination of two disorders. And this single distinct disorder is potentially really bad. Take a closer look:
- ADHD is persistent. ODD is persistent. But when they appear together in a child they are much more severe than when the child has just one or the other;
- The families of children with BOTH ADHD and ODD tend to have more psychiatric problems themselves, such as alcoholism, drug abuse, antisocial personality disorder, or major depression;
- Of those children diagnosed with BOTH ADHD and ODD : 20% will develop traits associated with being "a psychopath" as an adult. These are people who are calloused, unemotional, lack empathy for others, lack guilt or shame or remorse for crimes they have committed, have no conscience. They prey on other people. This starts early in life and persists into adulthood.
- In every physiological measure of stress, this sub-group of children with BOTH ADHD and ODD have a lower response to stress than others do.
- This sub-group of children with BOTH ADHD and ODD are a unique group to themselves. They are unique biologically, psychologically, and developmentally.
Therefore a strong case can be made that this sub-group should be seen and treated as a distinct diagnosis, not a combination of two diagnoses existing co-morbidly.
This book section: The Different Types of ADHD
Douglas Cowan, Psy.D., MFT is a licensed Marriage and Family Therapist in Tehachapi, CA who has been a counselor to children, teens, and adults helping them to overcome ADHD, find relief for depression or anxiety, and solve other problems in life since 1989. He served on the medical advisory board to the company that makes Attend and Extress from 1997 through 2011, and he is the Editor of the ADHD Information Library online resource at http://newideas.net/. His weekly ADHD Newsletter goes out to 9,500 families. Visit his website at http://DouglasCowan.me for more information on achieving greater health, personal growth, Christ-centered spirituality, stress management, parenting skills, ADHD, working out the stresses of being a care-giver to elderly parents and also being a parent to teenagers, or finding greater meaning in retirement years, Dr. Cowan can be a valuable resource to you.
Counselor counseling Tehachapi for ADHD, depression, anxiety, and more.
Douglas Cowan, Psy.D., MFT
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