Professor Samuele Cortese Hello, everyone. My  name is Samuele Cortese. I am an NIHR Research   Professor and a Professor of Child and Adolescent  Psychiatry at the University of Southampton in the   UK. I’m also a Professor of Child Neuropsychiatry  at the University of Bari in Italy and Adjunct   Professor with NYU in the United States. This  presentation is about the “Differences Between   the ICD-11 and the DSM-5 TR Criteria in Terms of  ADHD.” So, before starting my presentation, this   is my disclosure of possible conflict of interest,  and let’s move now to the presentation itself. So, I will start from the DSM-5 TR,  Text Revision criteria, as you know,   these have been published in 2022, and these  are the most recent criteria from the DSM,   the Diagnostic Statistical Manual of  Mental Disorders that are available. And,   according to the DSM-5 TR criteria, to diagnose  ADHD we need a number of requirements. So,   the first is a persistent pattern of inattention  and/or hyperactivity-impulsivity. I highlighted   in red, actually, two key terms here,  persistent, but, also, and/or, and these   tell us that actually the presentation, the  clinical presentation, of these individuals   may be characterised by inattention and  hyperactivity-impulsivity, or any of the two. So, when it comes to persistent pattern,  actually, this is better defined in another   series of criteria, that, in terms  of inattention, specified that to   diagnose ADHD we need six or more of the  following, and there is quite a long list,   examples, basically, of inattention. And it’s  important to appreciate that these need to be   inconsistent with the developmental level and,  also, they need to have an impact in daily life. This is also the list, similarly, of  hyperactivity and impulsivity that   are lumped together in this list, and, once  again, according to the DSM-5 Text Revision,   we need six or more of these symptoms  that have persist at least for six month.  However, the list of symptoms, and the number  of symptoms, is not enough to diagnose ADHD. The   previous that I highlighted was just one of the  criteria, criterion A, however, there are other   important criteria. So, the second, the B, is  that several of these symptoms of inattention,   and/or hyperactivity-impulsivity, need to  be present before the age of 12. Once again,   this is not a magic number, it just means that we  are talking about a neurodevelopmental condition   that usually starts early in life, even though  this notion is currently being challenged by   some evidence showing a possible late onset of  ADHD, but this is still matter of discussion. The criterion C highlights that these symptoms  need to be present in two or more settings,   or environments, such as, home or school, or work,  or with friends, or in other activities. Another   important criterion, the D, highlights that  these symptoms need to interfere with normal   functioning, so they need to be associated  with an impairment. And, finally, criterion E,   which is probably the most important, at  least clinically, highlights that these   symptoms do not occur exclusively during the  course of other disorders, other conditions,   that are characterised, as well, by the presence  of inattention, and/or hyperactivity-impulsivity,   so this comes, of course, to the  issue of the differential diagnosis. Importantly, when it comes to the criteria of the  DSM-5 Text Revision, we have what they call the   “specifiers.” So the different ways these  symptoms can cluster can be presented in   this so-called “combined presentation,” if,  basically, we have symptoms both of inattention   and hyperactivity-impulsivity. But, also, in  the predominantly inattentive presentation,   when mainly – the symptoms are mainly inattention,  and the predominantly hyperactive-impulsive   presentation, where the majority of the symptoms  refer to the hyperactive-impulsive domain. So, I like to highlight the terminology that it is  used, actually, we used to call these “types,” or   “subtype,” this has been replaced by presentation  to highlight, actually, that these symptoms can   change, this cluster can change over time. So it  is not a static type, a static presenta – subtype,   but it is really a presentation which changes over  time. Importantly, it is also worth highlighting   that the so-called “predominantly inattentive  presentation” basically mirrors what we used to   call “ADD.” I still hear a lot of colleagues,  and parents, and patient themselves referring   to “ADD,” so attention-deficit disorder  without hyperactivity. This terminology   is quite old now. Officially it does not exist any  longer, so the correct terminology would be ADHD,   predominantly inattentive presentation, but  still a lot of people use the term “ADD.” Right, so – and, also, if we look  at the criteria of the DSM-5 TR,   they basically group the severity  according to mild, moderate or severe. Now,   these are the main criteria, but there are another  couple of aspects that I think is important to   highlight when it comes to the DSM-5 TR criteria.  The first is the concept of ADHD in partial   remission, so when – or, basically, we don’t have  all the symptoms, and all the criteria which are   required for the diagnosis. But still individuals  who present ADHD in partial remission may still   be impaired, so this is why this category has been  highlighted in the DSM-5 TR, rightly so, I guess. Also, the important concept, which is really well  defined and established, according to the DSM-5   TR criteria, is the concept of variability of  symptoms. So, symptoms – the severity of symptoms,   and the impairment, is not consistent and constant  over time. There may be situations, such as those   where there is a close supervision or activities  that are especially interesting or the setting is   novel or in one-to-one situation or when – in  situations when there is a frequent reward for   the child, for the individual with ADHD, where  these symptoms are less evident. While in other   situations, where there is less supervision, the  activity is quite boring and the setting is quite   repetitive, monotonous, in all these situations  the symptomatology becomes more evident. Right, so, this was a quick overview and  a short explanation of the criteria for   ADHD in the DSM-5 TR. Now, of course,  we tend to be familiar with the DSM,   but in the majority of the countries, actually the  most used system, diagnostic system, and the one,   also, which is required from the administrative  point of view, is the ICD, the International   Classification of Disease, system. And before  moving to the current version and highlight the   differences between the ICD-11, which is actually  the current version, and the DSM-5 TR, I would   like to just quickly highlight and describe the  criteria in the previous ICD, so, the ICD-10,   because, arguably, still a lot of colleagues use  this and we are quite familiar with this version.  So, interesting, if we look at the ICD-10, we  don’t find ADHD in it. The closest classification,   the closest entity, we find  is the hyperkinetic syndrome,   but there is not – there was not such a thing  as ADHD in the ICD-10. So, what is hyperkinetic   syndrome? So, basically, we could say that roughly  it is equivalent to the combined presentation of   the DSM-5, and 5 TR, because, actually,  as you can see from the first criterion,   for the diagnosis of hyperkinetic syndrome, we  required at least six symptoms of inattention,   and at least three symptoms of hyperactivity,  and at least one symptoms of impulsivity. So,   according to this classification, we are not  able to diagnose the predominantly inattentive   presentation or the predominantly  hyperactive-impulsive presentation. The age of onset was set back then as seven  years, so I remen – I remind you that this   classification is quite outdated and this, as I  mentioned, has been then moved to 12 in the DSM-5.   The criterion of the impairment associated with  these symptoms was still present in this version,   and it was required to be in two  or more settings. And, importantly,   the last criterion established that if there  is another disorder which can account for the   symptoms of hyperactivity or inattention  or impulsivity, actually, we were not able   to diagnose ADHD as a comorbid condition,  so this has really changed in the DSM-5. Now, this was the ICD-10 and, as I said, I thought  it was important to highlight this key concept.   But let’s move now to the current version of the  ICD, namely the ICD-11, and let’s see to what   extent the criteria are similar, or not, to those  from the DSM-5 Text Revision. So, the first thing   to highlight is actually that, finally, we have  the same entity in terms of how it is called. So   ADHD is called “ADHD” also in the ICD-11, which is  quite good because it contributes to have the same   terminology in our research, and it is indicated  as attention-deficit hyperactivity disorder,   within the hyphen and the slash, but that is  the way it is, and it can be also indicated   as attention-deficit disorder with hyperactivity,  and attention-deficit syndrome with hyperactivity. Now, the structure of the criteria is similar  compared to the DSM-5 Text Revision. The key   difference that I have highlighted here is  that, actually, according to the ICD-11,   we don’t necessarily need any specific  number of symptoms. As you may remember,   according to the DSM-5 and 5 TR, we need at least  six symptoms in children and five in adolescents   and adults. But the wording of the ICD-11 has been  – is quite different from the one of the DSM-5,   as you can see, what the DS – the ICD-11  highlights is the presence of several symptoms. Now, this introduced, arguably, a – quite a  significant amount of variability. The rationale   for this was that the number of symptoms, the  required number of symptoms, has been criticised   by some in the field, highlighting, for instance,  situations where if you have six in terms of   inattention and zero of hyperactivity-impulsivity,  actually, that person would meet the criteria,   alongside the other criteria. But, let’s say,  if you have five symptoms of inattention,   and five symptoms of hyperactivity-impulsivity  in a child you sh – you could not diagnose ADHD,   which arguably is something that is quite  problematic. So, the number of symptoms, the   required number of symptoms, has been deleted, and  it has been replaced by several symptoms. And the   rest of the criteria are quite similar; this is  the list of symptoms of hyperactivity-impulsivity,   and the other criteria, as you can see here,  are really mirroring those from the DSM-5 TR. So, the last note I would like to highlight in  terms of criteria is that the ICD-11, and rightly   so, highlights the importance of cultural  aspects when diagnosing ADHD. So, for instance,   in some countries and cultures, hyperactive  behaviour in a boy may be seen as a sign of   strength rather than a deficit. So, we need  to be mindful of this where we interview   individuals from cultures which are different  from the one we are familiar with. While,   at the same time, this characteristic may be  seen as a very negative one in a girl. So,   once again, they’re interestingly – there  are interesting cultural features that we   should take into account and probably  study better also in terms of this. So, this, I think, was the  key messages that I wanted to   provide you with in this short presentation on  the differences between ICD-11 and DSM-5, 5 TR,   in terms of the diagnosis of ADHD. Thank you.