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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

According to DSM-5, ADHD is characterized by inattention, such as having difficulty focusing; hyperactivity, such as excessive movement; and impulsivity, such as making hasty actions without taking into consideration their consequences [4]. DSM-5 focuses on symptoms instead of impairment [1]. It also bases its definition of functional impairment on any effects on the quality of life [1]. This is unlike DSM-4 that focuses on “both” symptoms and impairment and defines functional impairment as any significant impairment in different areas of life [1]. DSM-5 also allows for a comorbid diagnosis of ADHD with autism, which is important given the high percentage of ADHD patients who have been found to have autism [1]. To diagnose ADHD, the physician should assess the presence of risk factors, such as a family history of ADHD, and other problems, such as sleep disorders, anxiety, or depression [1]. For the diagnosis, symptoms of inattention and/or hyperactivity-impulsivity have to be present [4]. These symptoms of ADHD should also persist for at least 6 months as a diagnostic criterion [4].

Treatment of ADHD

To manage ADHD in the ages of 4 to 5 years old, the American Academy of Pediatrics (AAP) recommends Parent Training in Behavior Management (PTBM), with or without classroom interventions [1]. PTBM teaches parents the appropriate approaches to their children’s problematic behaviors and expected developmental milestones, and it aims to strengthen parent-child relationships [1]. Managing children with both PTBM and classroom interventions is more effective [1]. During this age, children may be prescribed methylphenidate if ADHD is moderate to severe and behavioral therapy did not result in improvements [1]. 

In children of the ages 6 to 11 years old, the recommendations are to prescribe medications approved by the U.S. Food and Drug Administration (FDA), in addition to PTBM with or without classroom interventions [1]. First-line medical therapy, in these ages, is methylphenidate or amphetamine, which are stimulants [1]. Non-stimulants may be used as well [1]. These include atomoxetine, guanfacine, or clonidine [1]. However, non-stimulants are less effective [1].

For pediatric patients of ages 12 to 18 years, it is recommended to prescribe FDA-approved medications and provide behavioral and educational interventions [1]. In these patients, care must be taken to prescribe a long-acting formulation and short-acting formulations as needed [1].

Recently, more medications have been approved for the treatment of ADHD in patients of the ages of 6 years old and beyond [5]. These include pro-drug, extended-release, and delayed-release formulations of methylphenidate [5].

Conclusion

ADHD is one of the most common neurodevelopmental disorders in pediatric patients [1]. Its prevalence is expected to increase in the future [1]. It is diagnosed in accordance with DSM-5 criteria [1]. ADHD’s treatment in pediatric patients varies with age but consists of behavioral therapy with or without pharmacological therapy [1]. 

References

1. Eom TH, Kim YH. Clinical practice guidelines for attention-deficit/hyperactivity disorder: recent updates. Clin Exp Pediatr. 2024 Jan;67(1):26-34. doi: 10.3345/cep.2021.01466. Epub 2023 Jun 14. PMID: 37321571; PMCID: PMC10764666.

2. Kessi M, Duan H, Xiong J, Chen B, He F, Yang L, Ma Y, Bamgbade OA, Peng J, Yin F. Attention-deficit/hyperactive disorder updates. Front Mol Neurosci. 2022 Sep 21;15:925049. doi: 10.3389/fnmol.2022.925049. PMID: 36211978; PMCID: PMC9532551.

3. Salari N, Ghasemi H, Abdoli N, Rahmani A, Shiri MH, Hashemian AH, Akbari H, Mohammadi M. The global prevalence of ADHD in children and adolescents: a systematic review and meta-analysis. Ital J Pediatr. 2023 Apr 20;49(1):48. doi: 10.1186/s13052-023-01456-1. PMID: 37081447; PMCID: PMC10120242.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington (VA): The Association; 2013.

5. O’Connor L, Carbone S, Gobbo A, Gamble H, Faraone SV. Pediatric attention deficit hyperactivity disorder (ADHD): 2022 updates on pharmacological management. Expert Rev Clin Pharmacol. 2023 Jul-Dec;16(9):799-812. doi: 10.1080/17512433.2023.2249414. Epub 2023 Aug 22. PMID: 37587841.

The idea of personalized medicine is very prevalent in today’s world. We are currently living in a period characterized by personalized experiences and tailored solutions, and this has extended into medicine. We understand that some treatments do not work for every individual and that we need to create a care plan that is best for the individual. I feel that this needs to expand into wellness practices as well. We need to break from the “one-size-fits-all” mentality. Early intervention and personalized plans could be the key to reducing the burnout rate. At the Medical University of Vienna, a “Coping with Stress” course was added to the undergraduate curriculum, and medical students who participated in the seminar documented a decline in certain burnout indicators, a reduction in stress levels, and an enhancement in awareness regarding accessible support resources (Till, et. al., 2024). Combining this with the option of meeting with a wellness coach to discuss and create a personal plan could benefit many individuals. Incorporating things that you know work for you, while also trying new things to find what may or may not work can help create a list of sources to turn to when any negative feelings invade.

So, what would this look like? The main step in this would first be on the institution. Make sure you create time in the student’s schedules for them to actually have the time to implement wellness practices. This can be hard, especially in the medical field. The packed schedule and feeling of no time to yourself is a huge factor in burnout. But it will prove to be beneficial. Miami Children’s Hospital incorporated a wellness program (with multiple resources and benefits) for employees and their spouses and found that 92% of employees took full advantage (Eskew, CWM). As mentioned previously, do not create mandatory wellness lectures/events/check ins. This can just feel like another chore. Next is to work on your mental health. Personalized mental health services consider not only the symptoms of mental health conditions but also the broader context of an individual’s life, including social, environmental, and cultural factors. This holistic approach helps address underlying causes and contributes to more comprehensive and effective treatment. This can be a preventative initiative as well. A personal wellness plan also needs to consider the cultural background an individual may have. Understanding an individual’s cultural background and beliefs is crucial for providing effective mental health support, as cultural factors can influence the expression of symptoms and attitudes toward mental health treatment. Identify activities in your life that contribute to a sense of grounding. For example, consider participating in a recreational basketball team or forming one with peers who share similar interests. Alternatively, if you find enjoyment in baking, allocate time to experiment with new recipes or to watch episodes of a favored baking program.

Do not forget about the nutritional side of wellness. Meeting with a dietician to discuss your nutritional habits and goals can help build an individualized plan for your needs. Set realistic goals and understand your nutritional needs based on your metrics. You know your body best, so choose foods that will provide you with energy to get you through the day. Do not just follow a pre-set, general diet plan as this could lead to minimal/unanticipated results that could lead to stress. Exercise can be preventative for physical health, as well as mental. Recent studies show that exercise can affect how certain genes are expressed in the suprachiasmatic nucleus, causing an improvement in depressive symptoms (Lei, et al., 2024). Find the exercises that work for your body. I am not a runner or weightlifter, but I like to walk on the treadmill. Walking a couple of miles is something that does not stress my body or put me at elevated risk of injury. It is what works for me. 

The most crucial factor in all of this is that the plan must be sustainable. It needs to be tailored to the unique needs and schedule of the individual. You do not want to add things to your schedule to try to improve well-being that you do not realistically have the time for. By tailoring health and wellness strategies to individual needs, preferences, and circumstances, we can address the unique stressors that contribute to burnout. As we acknowledge and prioritize the diverse experiences of individuals, personalized wellness emerges as a crucial tool in creating resilient, thriving communities where individuals can navigate the challenges of life with greater resilience and balance.

References:

De Hert S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg Anesth. 2020 Oct 28;13:171-183. doi: 10.2147/LRA.S240564. PMID: 33149664; PMCID: PMC7604257.

Eskew, Sandi. “Personalization Is ‘secret Sauce’ for Any Wellness Program.” Corporate Wellness Magazine, www.corporatewellnessmagazine.com/article/personalization-is-secret-sauce-for-any-wellness-program. Accessed 29 Jan. 2024.

Till, B., Hofhansl, A. & Niederkrotenthaler, T. Effects of the mental health promotion seminar ‘Coping with stress’ in the undergraduate medical curriculum of the Medical University of Vienna. BMC Med Educ 24, 41 (2024). https://doi.org/10.1186/s12909-023-05019-0\

Yu, Lei; Xue, Haonan; Li, Zhongtang. Exercise alters molecular rhythms in the central nervous system that negatively correlate with depression-like behavior. NeuroReport ():10.1097/WNR.0000000000001994, January 05, 2024. | DOI: 10.1097/WNR.0000000000001994

Dr. Link and Phelan (2001) develop a widely used conceptualization of stigma. Their conceptualization defines stigma as the convergence of some interrelated components: 

    In the first component, people distinguish and label human differences. In the second, dominant cultural beliefs link labeled persons to undesirable characteristics – to negative stereotypes. In the third, labeled persons are placed in distinct categories so as to accomplish some degree of separation of “us” from “them.” In the fourth, labeled persons experience status loss and discrimination that lead to unequal outcomes. Stigmatization is entirely contingent on access to social, economic, and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories, and the full execution of disapproval, rejection, exclusion, and discrimination. 

    After the publication of stigma literature, Dr. Meyer (2003) put forward the minority stress theory, which means “excess stress that individuals from stigmatized social categories are exposed as a result of their social, often a minority, position”. Researchers defined these stressors as unique, chronic, and socially based (1).

    Unfortunately, LGBT individuals are exposed to both of these two concepts intensely. Health disparities observed in LGBT populations do not reflect psychological issues inherent to LGBT individuals but rather are the result of persistent stigma directed toward them. Fear of coming out, rejection sensitivity, concealment, and discrimination elevate the risk of depression, post-traumatic stress disorder, substance use, and self-destructive and suicidal behaviors among LGBT individuals). I want to give a simple statistic for understanding the situation better. LGBT youth make up 40% of all young people experiencing homelessness (only 3.8% of Americans identify themselves as gay, lesbian, bisexual or transgender). Therefore, they are more likely to face physical or sexual abuse, sexually transmitted diseases, and mental health issues.

    We can still add other negative effects of stigma on LGBT health, but there are some interventions aimed at reducing stigma’s health impacts among this population. A recent study showed that structural interventions in school policies and practices may protect sexual minority youth against the risk of suicide. There is also another study that tested the efficacy of cognitive behavioral therapy for helping gay and bisexual men. This intervention resulted in significant reductions in depression, alcohol use, and HIV (human immunodeficiency virus) risk behavior (2).

    Why am I writing about this topic? There are several reasons, but the main one is that…. I am gay (I was in the closet, but this is my first declaration of my sexual orientation publicly) and I experienced (and I am still experiencing) stigma and minority stress first-hand. It was too tough when I didn’t have enough knowledge about what was going on. However, after research, my view on these issues improved and I tried to avoid the effects of stigma and minority stress. By writing this article, I want to increase the awareness of this health issue reach out to LGBT individuals who also suffer from stigma, and make them know that they are not alone.

References:

1- Hatzenbuehler, M. L., & Pachankis, J. E. (2016). Stigma and Minority Stress as Social Determinants of Health Among Lesbian, Gay, Bisexual, and Transgender Youth: Research Evidence and Clinical Implications. Pediatric clinics of North America, 63(6), 985–997.

2- Hafeez, H., Zeshan, M., Tahir, M. A., Jahan, N., & Naveed, S. (2017). Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus, 9(4), e1184.

In addition to vaccines, in family medicine, I am frequently taught the importance of patient education for disease prevention. For example, a newly sexually active patient is educated on the importance of condom use for sexually transmitted disease (STD) prevention. As STDs are often transmitted via bodily fluids, it only makes sense for physicians to promote physical barriers like condoms to help lower the risk of STD infections in patients.

When it comes to mental illness, I again wonder what its preventive education analogue could be. Poor mental health often contributes to deterioration in social, physical (e.g. increased substance use/abuse risk), and economic (e.g. increased poverty risk) well-being, all of which in turn affect the overall health of a patient. Should it not be of importance, then, to prevent a development of a mental health disorder in an at-risk individual, with minor signs of mental disorders or genetic risk factors for mental illness? 

Today, there are diseases like Alzheimer’s disease where AChe inhibitors have been trialed on for use almost analogous to vaccines. The term and idea of “mental hygiene” has existed since the early 1900s including but not limited to promoting a healthy lifestyle and mental health, also analogous to preventive medical care. However, no current clear preventive protocols seem to be in practice on either a national level or a community level. 

As a third year medical student, I have yet to fully understand the intricacies of a disease process or the healthcare system. At the same time, because I am not yet bound by the current ways-of-doing, I continue to ponder on the possibility of developing preventive care of prevalent mental disorders, starting from identifying at-risk populations, all the way to providing generalized ‘vaccine-like’ care for mental illnesses. Could we start with including mental illnesses in the assessment of family histories of illnesses (in patient history taking) in our medical education system, to identify at-risk patients? Would providing at-risk patients with a clear, well-developed education on coping-mechanisms, cognitive behavior therapies and medication counseling be a good start? What are your thoughts?

References:

https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html

https://publichealth.jhu.edu/departments/mental-health/about/origins-of-mental-health

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2408392

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9360426

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178190

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9360426

A 2022 publication titled “Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups” highlights some of the many concerns and reasons why diversity is not only acceptable but critically needed in medical research1. A common ground concept to appreciate this need would be the statistical question of “How generalizable is this research to the public?” Take Alzheimer’s disease, a current hot trend in medical research due to the millions of individuals affected by Alzheimer’s and other related dementias. At the current moment, there is no complete cure, and most medications are for the reduction of symptoms or delay in the progression of the disease. A complete reversal, such as Amoxicillin’s effect on otitis media, does not currently exist, prompting a rapid race to find the cure. When researching potential hazards and behaviors that can increase the risk of Alzheimer’s, we do see some common ground: inactivity, family history, and smoking to name a few. However, if we take one step back and break down the demographics, we see that the NIH in 2021 has identified that Black Americans are 1.5-2x more likely than White Americans to get Alzheimer’s disease and other related dementias 2. But why is that one might ask? The answer is not as simple as the question asked, and due to the multifactorial nature of Alzheimer’s disease, it is easy to confuse cause/effect and blame various triggers when a much greater question must be asked. Let’s dive into this question.

We might come to the conclusion that if Black Americans are about twice as likely than White Americans to get Alzheimer’s disease, there would be a greater participation in research with the Black community to best serve their generations. However, quite the opposite is true, where Washington University School of Medicine in St Louis highlights in their Winter 22-23 magazine: “African Americans make up about 20% of U.S. Alzheimer’s patients, but only about 2% of Alzheimer’s clinical trial participants.” Again, we might scratch our heads asking but why? Again, the multifactorial nature of this situation comes back into place, creating this cycle of a self-perpetuating sociological phenomenon I would coin as Asper’s Circle. In this circle, there is a growing issue that affects a certain population, and despite how one might think there would be a greater rush to solve the issue, the opposite happens, causing even more people to suffer and for the issue to be prolonged longer than it should be. However, this circle needs to be stopped rapidly, and the solution might not be simple, but possible if we all work together with compassion. 

The first and foremost step in eliminating this noxious cycle is by opening a loving and communicating ear with each other. Another tenant of Asper’s Circle is the need for an additional community to assist with breaking the circle or else the circle continues to withstand or get worse. Therefore, one good way to help increase diversity in Alzheimer’s disease research is by having Non-Black communities extend communication and build trust with the Black communities in hopes of better educating and listening to the needs of such communities. Through education and communication, we can understand the concerns and address any fears or issues that cause such gaps in research participation. Likewise, while my example here is Black communities with Alzheimer’s disease, this is not limited to that specific demographic but should extend to all minority communities. Over 12% of older Adults in the Hispanic/Latino community are diagnosed with Alzheimer’s disease, placing them as one of the highest-risk category minority groups 3. Alzheimer’s Association reports that 1 in 3 Native American Elders will develop Alzheimer’s disease 4. The need to help other communities goes on but that is not to say that any group is weak, per our attention and support should be extended to those in need just like how a brother or sister would reach out and save a sibling that fell from the scooter. By gaining the trust of minority communities, through social communication and listening, we might perhaps see an increase in research participation from different minorities. This all comes back to the golden rule, treat others how you want to be treated. As such, due to historic mistreatment and misunderstandings, there has been a rift between minority communities and thankfully with greater awareness will come greater change and a peaceful loving solution. 

A big reason why there is a high rate of minority individuals who develop Alzheimer’s disease can be attributed to the stressful environmental factors that perpetuate neurological pathologies. Poor work environments, poor social support, poor food nutrition consumption, and so on. While Alzheimer’s disease research tries to bring into the aspect of generalizability, there will always be nuances specific to minority communities that contribute to greater risk. One example is the ABCA7 gene. “ABCA7 has been shown to have a stronger effect size than the apolipoprotein E (APOE) ɛ4 allele in African American/Black adults” according to the 2022 research publication ABCA7, a Genetic Risk Factor Associated with Alzheimer’s Disease Risk in African Americans 5. Specific cultural and racial factors can disproportionately increase the risk of diseases in certain minority communities, and therefore, there should be an increased demand for research within said communities in order to better understand the nuances and resolve the problem with a cure. 

Therefore, it is important to understand why diversity is not a political issue in the research sense, but rather one of critical need, to help you and I, and everyone else around us. While I bring in Alzheimer’s disease, my discussion here is not limited to that one pathology. There are multitudes of conditions, from heart to lungs and eyes to ears, all affecting different ethnic and racial groups with different factors contributing to the progression and even digression of said pathologies. With that being said, the more research participation from different minority groups we have, the more we can understand these triggers and better help different communities. With low research participation, comes low data, and that does no one any good. Certainly, I, being a Mediterranean from parental ancestry, am thankful for the studies on different Greek and Iraqi groups, as it better helps me understand the niche medical nuances within both these communities that will affect me differently than someone from halfway across the globe. And while perhaps my background is not, for example, Vietnamese, that is not to say that I should neglect anyone who is Vietnamese and only focus on my blood. If we can eliminate the mindset of focusing on ourselves, and instead show compassion to others, there perhaps will be half the number of medical problems in this world. Therefore, diversity is not a mere buzzword, but a need, in research, for the cure of different conditions, and to understand many things we currently do not know about said conditions without a greater quantity of participants from different minority groups. 

References:

1-National Academies of Sciences, Engineering, and Medicine; Policy and Global Affairs; Committee on Women in Science, Engineering, and Medicine; Committee on Improving the Representation of Women and Underrepresented Minorities in Clinical Trials and Research. Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups. Bibbins-Domingo K, Helman A, editors. Washington (DC): National Academies Press (US); 2022 May 17. PMID: 36137057. https://pubmed.ncbi.nlm.nih.gov/36137057/

2- https://www.nia.nih.gov/news/data-shows-racial-disparities-alzheimers-disease-diagnosis-between-black-and-white-research

3- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5874398/ Vega IE, Cabrera LY, Wygant CM, Velez-Ortiz D, Counts SE. Alzheimer’s Disease in the Latino Community: Intersection of Genetics and Social Determinants of Health. J Alzheimers Dis. 2017;58(4):979-992. doi: 10.3233/JAD-161261. PMID: 28527211; PMCID: PMC5874398.

4- https://www.alz.org/help-support/resources/native-americans#:~:text=As%20many%20as%201%20in,some%20other%20form%20of%20dementia.5- Stepler KE, Gillyard TR, Reed CB, Avery TM, Davis JS, Robinson RAS. ABCA7, a Genetic Risk Factor Associated with Alzheimer’s Disease Risk in African Americans. J Alzheimers Dis. 2022;86(1):5-19. doi: 10.3233/JAD-215306. PMID: 35034901. https://pubmed.ncbi.nlm.nih.gov/35034901/