Other Specified Attention-Deficit Hyperactivity Disorder DSM-5 314.01 (314.9) (F90.9)

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DSM-5 Category: Neurodevelopmental Disorder

Introduction

OS AD/HD (Other Specified Attention-Deficit/Hyperactivity Disorder) Is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who have symptoms of AD/HD, which cause distress or impair social, educational/occupational, or other vital areas of functioning, but they do not meet the complete diagnostic criteria for AD/HD or other disorders in the Neurodevelopmental category. This diagnosis can be assigned when the clinician specifies the reason the diagnostic criteria are unmet. The clinician will record the reason as part of the diagnosis (American Psychiatric Association, 2013).

AD/HD is described as a disorder of complex etiology, with a genetically transmitted neurological basis, as well as involvement of environmental factors (CNRS (Délégation Paris Michel-Ange), 2014 ;Curatolo, D'Agati, & Moavero, 2010). Because of this complexity, the clinical presentation may not always be obvious. An atypical presentation can warrant a diagnosis of OS AD/HD, at least provisionally, until the diagnostic picture clarifies. AD/HD behaviors are believed to be the clinical manifestation of underactivity in the right frontal lobe. The right frontal lobe of the cerebral cortex is the areas of the brain responsible of inhibition, judgment, self-control, planning, consideration of long-term consequences, and linking cause and effect. It is established that this area of the brain is not yet fully developed in children. More specifically, children do not yet have a dense network of interconnected synapses- axonal proliferation is still ongoing. In some individuals, frontal lobe axonal proliferation may not reach the level that is typical of most adults, resulting in symptoms of AD/HD as adults. Motor regulation areas of the brain, the cerebellum and basal ganglia, are also involved with the etiology and symptoms of AD/HD, in that 50% of persons with AD/HD also have degrees of motor impairment, including poor hand to eye coordination, delays in developmental milestones for motor activity, and messy handwriting (Curatolo, D'Agati, & Moavero, 2010). Another area of the brain implicated in AD/HD is the superior colliculus, a mid-brain structure associated with attention, and visual-spatial orientation (CNRS (Délégation Paris Michel-Ange), 2014).

Symptoms of Other Specified Attention-Deficit/Hyperactivity Disorder

According to the DSM-5, (American Psychiatric Association, 2013), the symptoms of Attention-Deficit/Hyperactivity Disorder include:

1) Inattention, persisting for at least six months, and not attributed to developmental phase, which is manifested by:

  • Lack of attention to detail, or careless mistakes.
  • Difficulty maintaining attention.
  • Lack of attendance when directly addressed.
  • Not following instructions.
  • Avoidant of tasks that require sustained mental effort.
  • Frequently losing things.
  • Distractedness and forgetfulness.

2) Hyperactivity, persisting for at least six months, not attributable to developmental phase, considered disruptive, and demonstrated by:

  • Fidgeting, hand tapping, squirming.
  • Difficulty remaining seated.
  • Runs or climbs in inappropriate situations.
  • Cannot play quietly (or for adults, cannot engage in quiet recreational activities)
  • Overly energetic, driven behavior.
  • Excessive talking.
  • Blurts out answers before question is finished.
  • Trouble waiting their turn.
  • Interrupts others activities.

Additional criteria are:

  • “Several” of the above criteria were present before age 12.
  • “Several” symptoms are present in two or more settings.
  • Symptoms interfere with or reduce the quality of functioning.
  • The symptoms cannot be better attributed to schizophrenia or another psychotic disorder.

(American Psychiatric Association, 2013). OS AD/HD symptoms can include any of the above symptoms of AD/HD, but not in sufficient quantity to diagnosis AD/HD, and one or more of the observed symptoms may be very prominent. The DSM specifies that the OS AD/HD diagnosis cause impairment and clinically significant distress, as opposed to the symptom impact description for the full AD/HD diagnosis interference with functioning (Rabiner, n.d.).

Risk Factors for Other Specified Attention-Deficit/Hyperactivity Disorder

The DSM-5 does not specify risk factors for OS AD/HD (American Psychiatric Association, 2013). It could be speculated that the risk factors for OS AD/HD are similar to AD/HD. There may also be other neurodevelopmental disorders present, and at time of evaluation, symptoms resembling AD/HD are emerging (see differential diagnosis). The degree of heritability for AD/HD ranges from 60-90%, (Curatolo, D'Agati, & Moavero, 2010), so having a parent with AD/HD is a risk factor to consider in diagnosis.

Onset of Other Specified Attention-Deficit/Hyperactivity Disorder

According to the DSM-5, the onset of Other Specified Attention-Deficit/Hyperactivity Disorder occurs in childhood, although it may not be first recognized until young adulthood (American Psychiatric Association, 2013).

Differential Diagnosis in Other Specified Attention-Deficit/Hyperactivity Disorder

The DSM-5 lists a number of diagnostic rule-outs for the clinician to consider (American Psychiatric Association, 2013). One important point the clinician must be aware of is over-pathologizing. During the early developmental phase, there are many behaviors that are WNL (Within Normal Limits) given the child’s developmental capacity, these behaviors may be transient, and resolve without intervention. A host of factors, including environmental stressors and reactive acting-out behaviors must also be considered. The clinician must inquire about the child’s’ home life, and peer interaction. The direction of causality of a suspected disorder is important: The child may be rejected by peers due to acting out, or peers may bully and abuse the child precipitating and triggering the acting out. The patience of parents and siblings may be exhausted, and they are maltreating the child. Or the child may be acting out because they have been abused or neglected by the parents, older siblings, or other caregivers. Specific differential diagnoses are:

CD (Conduct Disorder): Comorbidity with CD is well established (De Sanctis, Nomura, Newcorn, and Halperinb, 2012). A possible pathway between AD/HD is the distractibility and disruptive behaviors can lead to social rejection by peers, parents and teachers. This can lead to isolation, retreat into a fantasy world, resentment, anger, abandonment of goals and prosocial behavior, and association with delinquent peers.

ODD (Oppositional Defiant Disorder): It can be speculated that this is the same disorder as AD/HD, but with a resistant behavioral component. The distinction is that the AD/HD child may be genuinely contrite and frustrated with their behaviors, while the ODD child will appear to enjoy resisting and annoying adults and peers. There is a more deliberate, volitional component in ODD.

IED (Intermittent Explosive Disorder): The DSM-5 notes that this disorder is typically only diagnosed in adults, making it an automatic rule-out for children.

Other NDD (Neurodevelopmental Disorders): NDD’s are part of a broad spectrum of disorders that affect multiple domains, and are first diagnosed in children, typically before school age. There is diagnostic overlap in symptoms, and co-morbidity between the NDD’s. The commonality is disruption in behavioral, cognitive, intellectual, and emotional development.

Specific LD (Learning Disability): A child’s inability to grasp a specific academic area can lead to loss of interest, lack of motivation, and distractibility. The symptomatology with AD/HD may appear similar, but the root etiology is very different.

Intellectual disability: A global deficit in age expected intellectual development could lead to the problems listed above in specific LD- loss of interest, motivation, and distractibility that can be misinterpreted as AD/HD symptoms

Autism Spectrum Disorder: AD/HD may be co-morbid as a discrete disorder, or AD/HD symptoms may have a similar presentation. Children with AD/HD are actively rejected by their peers due to their history of acting out, while children w/ Autism Spectrum Disorder choose to avoid social interaction with peers. They also tend to focus their attention and perseverate on irrelevancies, rather than being inattentive and distracted as the AD/HD child.

RAD (Reactive Attachment Disorder): Behaviors may be similar, but the etiology is different- Lack of attachment to the primary caregiver at a critical stage of development.

Anxiety Disorder: Anxiety manifested as inability to concentrate and focus and restlessness can look like AD/HD, but there is a different underlying etiology, and a very different focus of treatment.

Depressive Disorder: can result in agitation, restlessness, and inability to concentrate, which on the surface may look like AD/HD, but again, the etiology and treatment are different.

Bipolar Disorder: Some of the impulsive, reckless, and mis- or undirected behavior of a manic state can be confused with symptoms of AD/AD in an adult.

Disruptive Mood Dysregulation Disorder: A new diagnosis in the DSM-5, which may better account for what was formerly diagnosed as bipolar disorder in children.

Substance abuse: Use of CNS stimulants or withdrawal from CNS depressants can produce agitation, and restlessness.

Personality disorder: Adults only- Personality disorders, which already have a low inter-rater reliability, cannot be reliably diagnosed until at least young adulthood. Histrionic, borderline, or narcissistic personalities, with a dramatic presentation, can look like adult AD/HD.

Psychotic Disorder: If the symptoms of hyperactivity and inattention occur during a psychotic episode, the default diagnosis is a psychotic disorder.

Medication induced AD/HD symptoms: Medication side effects must be ruled out as a cause of AD/HD symptoms.

Early Major Neurocognitive Disorder: Will have a late age of onset, and include deficits in recall as the disorder progresses. (American Psychiatric Association, 2013).

Treatment of Other Specified Attention-Deficit/Hyperactivity Disorder

The DSM-5 does not specify treatment options for OS AD/HD (American Psychiatric Association, 2013). Before the best treatment for a disorder can be provided, an accurate diagnosis must be assigned. If the diagnostic picture is unclear, the patient should be observed further, or another clinician should be consulted. AD/HD can be treated with CNS (Central Nervous System) stimulants, such as Ritalin or Concerta.

Another option for treatment of AD/HD, in lieu of, or in addition to medication, is a behavioral plan in children, or organizational and time management tools for adults. This requires a great deal of effort on the part of the parents, as well as consistency, follow through, clear communication and cooperation between parents, who may be estranged from each other, or conflicted in their relationship. For adults with AD/HD, modifying behaviors requires a great deal of discipline and motivation. It can be speculated that many adults who had AD/HD as children did not grow out of it as is commonly believed, but rather they developed and implemented coping skills which allow them to minimize the impact of the disorder- or they were mis-diagnosed as children. The environmental influence of their acting out- e.g. - peer abuse- has ceased.

Prognosis of Other Specified Attention-Deficit/Hyperactivity Disorder

The prognosis of OS AD/HD will be more dependent on the clarified diagnosis. It will be difficult to make a prognosis when the exact nature of the disorder is unclear, still unfolding, or questionable. Co-morbid conditions and their impact should be considered in the prognosis. It is noted in the literature that AD/HD is correlated with substance abuse disorders, although causality is unclear. A meta-analysis of n = 27 studies revealed that a diagnosis of AD/HD in childhood was a predictor of adult use of ethanol, nicotine, cannabis, and cocaine (Lee, Humphreys, Flory, Liu, and Glass, 2011). AD/HD when combined with CD/APD is associated with increased risk taking behaviors, including reckless driving and high-risk sexual behaviors resulting in STI (Sexually Transmitted Infection), ER admissions, and head injuries (Olazagasti, Klein, Mannuzza, Belsky, Hutchison, Lashua-Shriftman, and Castellanos,2012).

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.

(5th Edition). Washington, DC.

Curatolo, P., D'Agati, E., and Moavero, R. (2010). Italian Journal of Pediatrics. The neurobiological basis of ADHD. 2010; 36: 79. doi: 10.1186/1824-7288-36-79. PMCID: PMC3016271

CNRS (Délégation Paris Michel-Ange). (2014). Confirmation of neurobiological origin of attention-deficit disorder. Science Daily. Retrieved November 2, 2014 from www.sciencedaily.com/releases/2014/04/140411091727.htm

De Sanctis, V.A. Nomura, Y, Newcorn, J. H., and Halperinb. J.M, (2012). Childhood

maltreatment and conduct disorder: Independent predictors of criminal outcomes in ADHD youth. Child Abuse and Neglect 36(0): 782–789. doi: 10.1016/j.chiabu. 2012.08.003 PMCID: PMC3514569

NIHMSID: NIHMS422057

Lee, S.S., Humphreys, K.L., Flory, K., Liu, R., Glass, C. (2011). Prospective Association of Childhood Attention-deficit/hyperactivity Disorder (ADHD), Substance Use, and Abuse/Dependence: A Meta-Analytic Review. Clinical Psychology Review. 31(3): 328–341. doi: 10.1016/j.cpr.2011.01.006. PMCID: PMC3180912. NIHMSID: NIHMS314363

Olazagasti, M.A.R., Klein, R.G., Mannuzza, S., Belsky, E.R., Hutchison, J.A., Lashua-Shriftman, E.C., and F. Xavier Castellanos, F.X. (2012). The lifetime impact of attention-deficit hyperactivity disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of the American Academy of Child and Adolescent Psychiatry. 52(2): 153–162.e4. doi: 10.1016/j.jaac.2012.11.012. PMCID: PMC3662801. NIHMSID: NIHMS433333

Rabiner, D. (n.d.). New Diagnostic Criteria for ADHD. Attention Deficit Disorder Association. Retrieved November 1, 2014, from http://www.add.org/?page=DiagnosticCriteria


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