Attention-deficit/hyperactivity disorder: seeking the right balance between over- and undertreatment

Excerpt

This issue of European Child and Adolescent Psychiatry contains an article that addresses functional impairments associated with subthreshold attention-deficit/hyperactivity disorder (ADHD) [2]. In a Korean nationwide community sample of 921 children, aged 8–11 years, the authors report that children with subthreshold ADHD were found to experience significant functional impairments, i.e., poorer behavioral and emotional control and worse academic performance compared to control children. Subthreshold ADHD was defined by the presence of at least three but no more than five inattentive or hyperactive/impulsive symptoms. However, whereas the diagnostic threshold (≥6/9) for the DSM-IV symptoms represents a clear-cut operationalization for a diagnosis of ADHD, this disregards the fact that for the affected individuals and their parents the relevance of each symptom is likely to be different; for the diagnostic assessment as defined by the DSM-IV the symptoms are merely being counted, without taking the severity of each symptom into account. Furthermore, the subjective and objective impairment due to ADHD symptoms can in theory be greater in a child who fulfills only five symptoms in comparison to a child with six or more symptoms. These considerations illustrate how difficult it is to meaningfully operationalize thresholds for a spectrum disorder such as ADHD. …