Saylor Keith E, Buermeyer Curtis M, Spencer Thomas J, Barkley Russell A
NeuroScience, Inc., Old Georgetown Road Manor House, 5612 Spruce Tree Ave., 3rd floor, Bethesda, MD 20814, USA.
J Clin Psychiatry. 2002;63 Suppl 12:23-8.
The DSM-IV diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) have proved useful in providing a common language for diagnosing, treating, and researching the disorder. Despite the utility of current ADHD diagnostic criteria, sophisticated theoretical conceptualizations of the etiology of ADHD have described a much more complex disorder that includes a range of neuropsychological impairments (such as working memory deficits and other executive dysfunction) and underlying structural and functional neuropathology (e.g., caudate nucleus volume, frontal lobe activity). Inattention, hyperactivity, and impulsivity, the hallmark triumvirate symptoms of ADHD, may be better viewed as some of the many meaningful symptoms with roots in executive-functioning impairment. Outcomes of brain-imaging studies, public skepticism about diagnosis and treatment, and a demand for meaningful clinical outcomes of treatment point to a considerable need to broaden treatment-outcome criteria beyond the DSM-IV domains. The wide-ranging decrements in adaptive function and quality of life reported by parents of children diagnosed with ADHD further support core executive dysfunction. Emerging findings concerning medication-related improvements in adaptive functioning (e.g., social, emotional, academic), as well as the rapid search for the neuropathology that may underlie these improvements, are fueling interest in the assessment of adaptive function in clinical trials. In a series of ongoing clinical trials of a novel nonstimulant medication for ADHD, many parents reported significant improvements in the lives of their children beyond the DSM-IV criteria. These parental reports, despite their inherent sources of error, underscore the importance of including broader and more meaningful clinical outcome assessment in clinical trials. Research protocols that omit parental interviews that assess adaptive and executive function may well overlook several meaningful and consequential medication-related improvements.
《精神疾病诊断与统计手册》第四版（DSM-IV）中注意力缺陷多动障碍（ADHD）的诊断标准已被证明有助于为该疾病的诊断、治疗和研究提供一种通用语言。尽管当前ADHD诊断标准具有实用性，但对ADHD病因的复杂理论概念化描述了一种更为复杂的疾病，其中包括一系列神经心理学损伤（如工作记忆缺陷和其他执行功能障碍）以及潜在的结构和功能神经病理学（如尾状核体积、额叶活动）。注意力不集中、多动和冲动是ADHD的标志性三联征症状，或许可以更好地被视为源于执行功能障碍的众多有意义症状中的一部分。脑成像研究的结果、公众对诊断和治疗的怀疑以及对有意义的治疗临床结果的需求表明，迫切需要将治疗结果标准扩展到DSM-IV领域之外。被诊断患有ADHD的儿童的家长报告的适应性功能和生活质量的广泛下降进一步支持了核心执行功能障碍。关于药物治疗在适应性功能（如社交、情感、学业方面）改善的新发现，以及对可能是这些改善基础的神经病理学的快速探索，正激发人们对临床试验中适应性功能评估的兴趣。在一系列正在进行的针对一种新型ADHD非兴奋剂药物的临床试验中，许多家长报告他们孩子的生活有了超出DSM-IV标准的显著改善。这些家长报告尽管存在固有的误差来源，但强调了在临床试验中纳入更广泛、更有意义的临床结果评估的重要性。忽略评估适应性和执行功能的家长访谈的研究方案很可能会忽略一些与药物相关的有意义且重要的改善。
