The Role of Intellectual Processes in the DSM-V Diagnosis of ADHD

In May 1968, the American Psychiatric Association published the second edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-II). Under the category of behavior disorders of childhood and adolescence, a condition referred to as hyperkinetic reaction of childhood (or adolescence) was described as a problem “characterized by over activity, restlessness, distractibility and short attention span, especially in young children; the behavior usually diminishes in adolescence” (American Psychiatric Association, 1968, p. 50). The manual noted that these conditions “are more stable, internalized and resistant to treatment than transient situational disturbances but less so than psychoses, neuroses and personality disorders” (p. 50). Beyond these guidelines, this manual provided little in the way of normative comparisons, statistical analyses, or methods of data collection. It was assumed that the diagnosis was made based on the characteristics described and/or observed by parents, teachers, and the diagnostician. Thirty-two years later, the text revision of the fourth edition (DSM-IV-TR) of the diagnostic and statistical manual of the American Psychiatric Association (2000) was published. In the interim, the diagnostic manual grew from 134 to 943 pages. The diagnosis of hyperkinetic reaction of childhood evolved and is now referred to as ADHD. The original description of eight lines grew to a set of diagnostic criteria and accompanying descriptions filling 8 pages. Yet the diagnostic process remained unchanged—ADHD is evaluated on the basis of the correspondence of behavioral characteristics described by parents and DSM criteria. The essential feature of ADHD is currently described as a “persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development” (American Psychiatric Association, 2000, p. 85). The current diagnostic criteria contain five parts (A through E). Part A contains the often-cited 18 diagnostic symptoms; Part B requires that symptoms must cause impairment before age 7; Part C that impairment must be present in two or more settings; Part D that there is clear evidence “of clinically significant impairment in social, academic or occupational function” (American Psychiatric Association, 2000, p. 93); and finally, Part E requires that symptoms should not occur exclusively during the course of other conditions or be better accounted for by other mental disorders. One of those conditions mentioned, pervasive developmental disorder, has already been found to frequently be comorbid rather than a rule out for ADHD (Frazier et al., 2001; Goldstein & Schwebach, 2004). ADHD grew from a simple description to a set of diagnostic criteria based on an effort to provide empirical, statistically valid and reliable descriptors (McBurnett et al., 1999). Though a citation is made in the DSM-IV-TR that those with ADHD may demonstrate variability in IQ, the diagnostic criteria continue to reflect behavioral rather than cognitive manifestations. The quest to provide a cognitive profile for ADHD using traditional, general ability measures employing verbal and nonverbal tests or a variety of neuropsychological measures has been generally unsuccessful. However, we believe careful consideration should be given to the emerging research relative to cognitive processes. Cognitive processes could be incorporated into the DSM-V diagnostic criteria for ADHD. As the DSM-V will not be published until at least 2012, there is more than sufficient time to begin an organized course of research toward this end.