Contextual variability of ADHD symptoms: embracement not erasement of a key moderating factor

Excerpt

‘Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).’ (p. 60, DSM-5). It is remarkable that the DSM-5 stresses symptoms rather than impairment in relation to different contexts in the diagnostic criteria for Attention-Deficit/Hyperactivity Disorder (ADHD). One would expect that pervasiveness (criterion C) means the presence of impairment of functioning, due to ADHD symptoms, in two or more settings. According to the DSM-5, a diagnosis of ADHD is warranted—when all other criteria are met—if only two out of the minimal six symptoms occur at school, even though this is clearly below the clinical cut-off. Is a child with such a clinical profile not meaningfully different from a child exhibiting six or more symptoms in all settings? It has long been recognized that this is the case [22]. We argue that this vaguely defined criterion reflects a broader neglected issue of variability in number and contextual (in)stability of symptoms that is so typical in ADHD affected populations. We believe that variation in number and contextual expression of symptoms is a key factor to improve diagnostic and treatment procedures. Below we provide a new perspective on this issue and how to embrace and not erase it in clinical practice and research [9]. We further believe that observational assessment that allows for standardized assessment of cross-contextual variation in child behavior of the child may aid in a more precise measurement of contextual variability of ADHD symptoms in a manner that is clinically feasible and ecologically valid [7]. Observational assessment should be part of the assessment of ADHD for clinical and research purposes in a similar manner as is currently the gold standard for autism spectrum disorder (ASD). …