Validation of DSM-5 age-of-onset criterion of attention deficit/hyperactivity disorder (ADHD) in adults: Comparison of life quality, functional impairment, and family function
Introduction
Attention-deficit/hyperactivity disorder (ADHD), previously thought as a child-limited disorder, have been proved to persist into adulthood for up to half of the affected people in many longitudinal studies (Faraone et al., 2006b, Weiss et al., 1985). Diagnosing adult ADHD requires retrospective, accurate diagnosis of childhood ADHD, which is problematic for clinicians due to recall bias, influences of comorbidities, and non-specific clinical features of ADHD (Shaffer, 1994). Although some studies supported that the DSM ADHD criteria work considerably well for adults by retrospective diagnosis (Biederman et al., 1990, Murphy and Schachar, 2000), many others doubted the arbitrary decisions of the threshold of symptoms (Faraone et al., 2006b) and the age-of-onset criterion (Barkley & Biederman, 1997). With all renewed efforts, the adult ADHD criteria have been specified in recently released DSM-5 (American Psychiatric Association, 2013), in which the major changes are extending the onset age from 7 to 12 years and lowering the symptom threshold from 6 to 5 at each domain while diagnosing individuals who are 17 years and older.
Before the publication of the DSM-5, several studies had tried to evaluate the contentious age-of-onset criterion. In a field trial, Kessler et al. (2005b) found that only half of adults with ADHD symptoms recalled their symptoms before 7 and 90% before 12 years. While dividing the onset age into two groups, i.e., by 7 years and after, studies reported no differences between these two age-of-onset groups in family transmission and psychiatric comorbidities (Faraone et al., 2006c), neuropsychological functions (Faraone et al., 2006a), personality traits (Faraone, Kunwar, Adamson, & Biederman, 2009), substance use and related impairment (Faraone et al., 2007) and treatment response (Biederman et al., 2006a, Reinhardt et al., 2007). To test whether extending the maximum age of onset to 12 years old would greatly inflate the prevalence rate of ADHD, Polanczyk et al. (2010) estimated the prevalence rates of ADHD at different ages in a birth cohort, and found that only 0.1% newly identified ADHD occurred between 7 to12 years. Yet in a recent study published after the launch of DSM-5, the authors found a mild increase of the prevalence rate of ADHD from 7.38% (DSM-IV) to 10.84% (DSM-5) (Vande Voort, He, Jameson, & Merikangas, 2014). Despite different results with regard to the prevalence rate, both studies showed no difference in clinical features and functional impairment profiles between children with onset of ADHD symptoms before versus those after age 7. The results for sub-threshold ADHD were less conclusive (Faraone et al., 2006c). Despite decline of ADHD symptoms with age (Biederman, Mick, & Faraone, 2000), many adults with childhood ADHD who no longer meet the symptom threshold of ADHD still suffer from ADHD related impairments (Faraone et al., 2006b, Faraone et al., 2000), giving rise to the doubts of the developmental insensitivity of the ADHD criteria used for adults. For this reason, DSM-5 lowers the symptom threshold from 6 to 5 at each domain while diagnosing adult ADHD, causing the skepticism whether the criteria are too lax (Batstra & Frances, 2012).
Adults with ADHD usually fail to fulfill their responsibilities, resulting in academic, occupational underachievement (Barkley et al., 2006, Mannuzza et al., 1993), interpersonal problems, social/emotional difficulties, and other psychiatric comorbidities (Able et al., 2007, Barkley et al., 2006). The inability of adults with ADHD to fulfilling their social roles in several life domains brings great distress and the subsequent emotional problems might in turn influence their functions. Beside functional impairment, quality of life which reflects the subjective perception of individuals is an important outcome measure in clinic and research settings and the main goal of healthcare (Spitzer et al., 1995). Children and adolescents with ADHD were reported to have poorer quality of life in several domains than non-ADHD controls (Danckaerts et al., 2010), and the Adult ADHD Quality of Life Scale (AAQoL) has been proven to be valid (Brod, Johnston, Able, & Swindle, 2006), responsive to ADHD symptom changes (Matza, Johnston, Faries, Malley, & Brod, 2007), and used in several studies (Adler et al., 2008, Lensing et al., 2013). It is of interest whether adults identified with ADHD via DSM-5 have similar severity and patterns of functional impairment in various social roles and influences on quality of life as those identified via DSM-IV that warrant medical attention and resources.
Family is a main source of social support and the parenting style, which is undoubtedly important for an individual's development, is quite different between Chinese and western culture (see review by Lim & Lim, 2003). The traditional Chinese family interactions are influenced by the Confucius, which empathizes filial piety and hierarchical relationships. Higher parental control, greater encouragement of independence and more emphasis on the achievement are more often seen in Chinese parents than western parents (Lin & Fu, 1990). These values make ADHD-related disturbing and aggressive behaviors and underachievement even more unacceptable in the Chinese than the western society (Chan & Leong, 1994). Our previous studies found significant correlations between parenting style/family difficulties and youths with ADHD (Chang et al., 2013, Gau, 2007, Gau and Chang, 2013). Negative parent–child interactions create a vicious cycle in the development of the affected children's welfare, which had been found, for example, in school and social adjustment (Kawabata, Tseng, & Gau, 2012). We want to expand our knowledge to adults with ADHD. Also, in order to validate DSM-5 age-of-onset criterion, we want to know whether adults recalling ADHD symptoms at different stage (i.e., preschool age and school age) have different perception in family support in the context of Chinese culture.
Although ADHD symptoms have been reported to have a negative impact on the quality of life, the explicit mechanism in between has not been well described. Identifying the modifiable factors is clinically important to improve the well-being of individuals with ADHD (Agarwal, Goldenberg, Perry, & IsHak, 2012). One study suggested that anxiety and depression symptoms serve as mediators between childhood ADHD symptoms and decreased quality of life (Yang, Tai, Yang, & Gau, 2013), and another reported the origin of family dynamics predicted the quality of life in college students with ADHD (Grenwald-Mayes, 2002). Because there is strong correlation between family functions and ANX/DEP, we wonder whether the family support and ANX/DEP independently mediate the relationship between ADHD and functional impairment/quality of life or one is more determining than the other, and whether there is difference between those who recalled their symptoms by 7 and between 7 and 12 years.
In sum, despite several lines of studies supported that extending the age-of-onset criterion will not inflate the prevalence of ADHD (Polanczyk et al., 2010) and over-diagnose adults with ADHD (Applegate et al., 1997, Faraone et al., 2006c, Reinhardt et al., 2007), there are still concerns about the harmful effect brought by the lax DSM-5 criteria, such as increasing health care costs, misuse of ADHD medication, misallocation of resources, etc (Batstra & Frances, 2012). Besides, previous studies did not study the impacts of the age-of-onset criterion in combination with the new symptom threshold criterion in participants aged 17 years and older (needing 5 symptoms at each domain instead of 6). In this study, we diagnosed the adults as ADHD while they had 5 or more symptoms at each domain and had symptom onset prior to their ages of 12. The primary aim of this study is to compare the perceived family support, functional impairment and quality of life between the ADHD groups with the control group to validate the DSM-5 symptom threshold criterion and between two ADHD subgroups to validate the age-of-onset criterion. Clinically, the individuals might perceive and recall their symptoms when their capacity was challenged. If the time of symptom recalled, either before 7 or between 7 and 12 years, does not change the influence of ADHD on various life domain of affected adults, then we could justify the DSM-5 criteria to diagnose adults with ADHD. As far as we know, no previous study ever compared the quality of life and perceived family function between ADHD with onset before 7 years and between 7 and 12 years using DSM-5 diagnostic criteria for adults.
The secondary aim of this study is to verify whether family functions and ANX/DEP also mediate the DSM-5 diagnosis of ADHD with recalled onset between 7 and 12 years to quality of life and functions as the DSM-IV did. If family and ANX/DEP have similar mediation effects between late-onset ADHD and functional impairment, then late-onset ADHD might impact affected individuals through similar mechanisms as previous reports in DSM-IV ADHD.
Section snippets
Participants and procedures
Adults aged 17–40 years who suspected themselves of ADHD were recruited by advertisement, which provided the six questions of the screener of the Chinese Adult ADHD Self-Report Scale-v1.1 (Kessler et al., 2005a, Yeh et al., 2008) and a synopsis of the objectives and procedure of this study. Adults who either found that they might have ADHD based on the screener or reading material about adult ADHD would identify themselves as susceptible case of ADHD, and then either directly called Adult ADHD
Group comparisons of demographic data and ADHD symptoms
The demographics showed no difference with respect to sex, intelligence, highest education level, and types of occupation between any two of the three groups (Table 1). The non-ADHD adults tended to be single in comparison with those with ADHD, which could possibly be due to the younger age of this group. Significantly more parents of adults with ADHD were divorced or separated than controls. Fewer fathers of late-onset ADHD adults had technical jobs than fathers of early-onset ADHD adults and
Major findings
As the first study measuring quality of life based on the DSM-5 ADHD criteria in Asia, our study demonstrated that regardless of recalled age of symptom onset, adults with DSM-5 diagnosed ADHD suffer from lower quality of life assessed by the Chinese version of the AAQoL and exhibited greater functional impairments assessed by the Chinese version of the WFIRS-S than the controls after controlling for age, sex, educational level and any psychiatric comorbidity. The domains of functional
Acknowledgements
This work was supported by National Health Research Institute (NHRI-EX100-10008PI, NHRI-EX101-10008PI, NHRI-EX102-10008PI, NHRI-EX102-10008PI). We would like to express our thanks to Ms. Yu-Lun Lin for interviewing the participants and managing the data. We are grateful for all participants for taking part of the study.
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