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Sensible and perplexing changes in ADHD diagnostic criteria (DSM-V)

Taking a Closer Look at ADHD Attention Deficit DisorderThe Amer­i­can Psy­chi­atric Asso­ci­a­tion recently pub­lished DSM-V, the first major revi­sion to the diag­nos­tic man­ual for psy­chi­atric dis­or­ders since 1994. In DSM-V, ADHD is included in the sec­tion on Neu­rode­vel­op­men­tal Dis­or­ders, rather than being grouped with the dis­rup­tive behav­ior dis­or­ders, i.e., Oppo­si­tional Defi­ant Dis­or­der and Con­duct Dis­or­der. This change bet­ter reflects the way ADHD is cur­rently conceptualized.

Below I review changes that have been made to the actual diag­nos­tic cri­te­ria for ADHD.

Core symp­toms

A com­mon crit­i­cism of the ADHD diag­nos­tic cri­te­ria has been that the core symp­toms reflect how the dis­or­der presents in school age chil­dren and does not cap­ture how it presents in older ado­les­cents and adults. Because of this, some have argued that dif­fer­ent symp­tom sets should be devel­oped for dif­fer­ent age groups. How­ever, the new diag­nos­tic cri­te­ria essen­tially retain the same symp­toms as before.

The 9 inat­ten­tive symp­toms are:

  1. often fails to give close atten­tion to details or makes care­less mis­takes in school­work, work, or dur­ing other activ­i­ties (e.g. over­looks or misses details, work is inaccurate).
  2. often has dif­fi­culty sus­tain­ing atten­tion in tasks or play activ­i­ties (e.g., has dif­fi­culty remain­ing focused dur­ing lec­tures, con­ver­sa­tions, or lengthy reading).
  3. often does not seem to lis­ten when spo­ken to directly (e.g., mind seems else­where, even in the absence of any obvi­ous distraction).
  4. often does not fol­low through on instruc­tions and fails to fin­ish school work, chores, or duties in the work place (e.g., starts tasks but quickly loses focus and is eas­ily sidetracked).
  5. often has dif­fi­culty orga­niz­ing tasks and activ­i­ties (e.g., dif­fi­culty man­ag­ing sequen­tial tasks; dif­fi­culty keep­ing mate­ri­als and belong­ings in order; messy, dis­or­ga­nized work; has poor time man­age­ment; fails to meet deadlines).
  6. often avoids or is reluc­tant to engage in tasks that require sus­tained men­tal effort (e.g. school­work or home­work; for older ado­les­cents and adults, prepar­ing reports, com­plet­ing forms, review­ing lengthy papers).
  7. often loses things nec­es­sary for tasks or activ­i­ties (e.g., school mate­ri­als, pen­cils, books, tools, wal­lets, keys, paper­work, eye­glasses, mobile telephones).
  8. is often eas­ily dis­tracted by extra­ne­ous stim­uli (e.g., for older ado­les­cents and adults may include unre­lated thoughts).
  9. is often for­get­ful in daily activ­i­ties (e.g., doing chores, run­ning errands; for older ado­les­cents and adults, return­ing calls, pay­ing bills, keep­ing appointments).

The only dif­fer­ence from DSM-IV is that all symp­toms are fol­lowed by exam­ples of dif­fer­ent ways they may show up, includ­ing ways they would appear in older ado­les­cents and adults. Thus, although the symp­tom list remains the same, the inclu­sion of devel­op­men­tally appro­pri­ate exam­ples should help guide clin­i­cians eval­u­at­ing older ado­les­cents and adults.

The 9 hyperactive-impulsive symp­toms are:

  1. often fid­gets with or taps hands or squirms in seat.
  2. often leaves seat in sit­u­a­tions when remain­ing seated is expected (e.g., leaves his or her place in the class­room, in the office or other work­place, or in other sit­u­a­tions that require remain­ing in place).
  3. often runs about or climbs in sit­u­a­tions where it is inap­pro­pri­ate (e.g., in ado­les­cents or adults, may be lim­ited to feel­ing restless).
  4. often unable to play or engage in leisure activ­i­ties quietly;
  5. is often “on the go” act­ing as if “dri­ven by a motor” (e.g., is unable to be or uncom­fort­able being still for extended time, as in restau­rants, meet­ings; may be expe­ri­enced by oth­ers as being rest­less or dif­fi­cult to keep up with).
  6. often talks excessively.
  7. often blurts out answers before ques­tions have been com­pleted (e.g., com­pletes people’s sen­tences; can­not wait for turn in conversation).
  8. often has dif­fi­culty await­ing turn (e.g., while wait­ing in line).
  9. often inter­rupts or intrudes on oth­ers (e.g. butts into conversations,games, or activ­i­ties. may start using other people’s things with­out ask­ing or receiv­ing per­mis­sion; for ado­les­cents and adults, may intrude into or take over what oth­ers are doing).

These are only slightly mod­i­fied ver­sions of the hyperactive-impulsive symp­toms from DSM-IV. As was done for the inat­ten­tive symp­toms, how­ever, the new DSM-V gen­er­ally includes devel­op­men­tally appro­pri­ate exem­plars of these symp­toms in older ado­les­cents and adults.

Num­ber of symp­toms required and dura­tion of symptoms

To pos­si­bly war­rant a diag­no­sis of ADHD, indi­vid­u­als younger than 17 must dis­play at least 6 of 9 inat­ten­tive and/or hyper­ac­tive impul­sive symp­toms. This is the same num­ber as was required in DSM-IV.

For indi­vid­u­als 17 and above, how­ever, only 5 or more symp­toms are needed. This change from DSM-IV was made because of the reduc­tion in symp­toms that tends to occur with increas­ing age. The expla­na­tion for this change pro­vided on the DSM-V web site is that a slightly lower symp­tom thresh­old is suf­fi­cient to make a reli­able diag­no­sis in adults.

As in DSM-IV, the symp­toms must be present for at least 6 months to a degree that is judged to be incon­sis­tent with an individual’s devel­op­men­tal level.

Addi­tional diag­nos­tic criteria

As in DSM-IV, a suf­fi­cient inat­ten­tive and/or hyper­ac­tive impul­sive symp­toms is only the ini­tial cri­te­ria that must be met for ADHD to be diag­nosed. Addi­tional diag­nos­tic cri­te­ria, and mod­i­fi­ca­tions that have been made to these, are pre­sented below.

Age of onset criteria

In DSM-IV, the age of onset cri­te­ria was “some hyperactive-impulsive or inat­ten­tive symp­toms that caused impair­ment were present before age 7 years.” This reflected the view that ADHD emerged rel­a­tively early in devel­op­ment and inter­fered with a child’s func­tion­ing at a rel­a­tively young age.

In DSM-V this has been revised to “sev­eral inat­ten­tive or hyperactive-impulsive symp­toms were present prior to 12 years.” Thus, symp­toms can now appear up to 5 years later. And, there is no longer the require­ment that the symp­toms cre­ate impair­ment by age 12, just that they are present.

The ratio­nale for the older age of onset is that research pub­lished since DSM-IV did not iden­tify mean­ing­ful dif­fer­ences in func­tion­ing, response to treat­ment, or out­comes in indi­vid­u­als whose symp­toms were present at younger vs. older ages. How­ever, there is also no longer the require­ment for symp­toms to cause impair­ment. This com­bi­na­tion — older age of onset and remov­ing the impair­ment require­ment — is clearly more lenient.

Mul­ti­ple set­tings requirement

In DSM-IV, symp­toms were required to cause some impair­ment in at least 2 set­tings. Thus, not only did symp­toms need to be evi­dent in more than one set­ting, e.g., both school and home, but they also had to under­mine the child’s func­tion­ing in mul­ti­ple settings.

DSM-V has changed this to “sev­eral inat­ten­tive or hyperactive-impulsive symp­toms are present in two or more set­tings.” Thus, symp­toms must only be evi­dent in more than one con­text but don’t have to impair an individual’s func­tion­ing in mul­ti­ple contexts.

This is also more lenient.

Need for clin­i­cally sig­nif­i­cant impairment

DSM-IV required “clear evi­dence of clin­i­cally sig­nif­i­cant impair­ment in social, aca­d­e­mic, or occu­pa­tional functioning.”

This has been changed to “…clear evi­dence that the symp­toms inter­fere with, or reduce the qual­ity of, social, aca­d­e­mic, or occu­pa­tional functioning.”

I believe this is a sig­nif­i­cant change. In DSM-IV, indi­vid­u­als could meet symp­tom cri­te­ria, i.e., show at least 6 of 9 inat­ten­tive and/or hyperactive-impulsive symp­toms and not be diag­nosed if symp­toms were not judged to be suf­fi­ciently impair­ing. Requir­ing clin­i­cally sig­nif­i­cant impair­ment is a higher bar than requir­ing symp­toms to ‘..inter­fere with or reduce the qual­ity of’ an individual’s per­for­mance in impor­tant life domains. In fact, it is dif­fi­cult to imag­ine how one could dis­play a suf­fi­cient num­ber of symp­toms to pos­si­bly war­rant the diag­no­sis with­out this inter­fer­ing with one’s social, occu­pa­tional, or aca­d­e­mic functioning.

How this change is inter­preted by clin­i­cians will be very impor­tant. Sup­pose a stu­dent seems to have the poten­tial to earn all A’s in school. If ADHD symp­toms result in the stu­dent receiv­ing A’s and B’s, is that suf­fi­cient inter­fer­ence for the stu­dent to be diag­nosed with ADHD? This is the type of judge­ment that all pro­fes­sion­als involved in diag­nos­ing ADHD will need to make as the DSM-V offers no clear guide­lines on this issue.

As the above sug­gests, remov­ing the need for ‘clin­i­cally sig­nif­i­cant impair­ment’ can make it eas­ier to meet full diag­nos­tic cri­te­ria for ADHD and thus increase the per­cent­age of the pop­u­la­tion who qual­ify for the diag­no­sis. I wish that I under­stood the ratio­nale for this change, but there is no expla­na­tion of this pro­vided on the DSM-V web site.

Rule out alter­na­tive expla­na­tions for symptoms

As in DSM-IV, the final cri­te­ria is deter­min­ing that an indi­vid­u­als ADHD symp­toms are not bet­ter accounted for by another men­tal dis­or­der. In DSM-IV, this was stated as:

The symp­toms do not occur exclu­sively dur­ing the course of a per­va­sive devel­op­men­tal dis­or­ders, schiz­o­phre­nia, or other psy­chotic dis­or­der and are not bet­ter accounted for by another men­tal disorder.”

This has been changed to “The symp­toms do not occur exclu­sively dur­ing the course of a schiz­o­phre­nia or other psy­chotic dis­or­der and are not bet­ter accounted for by another men­tal disorder.”

Thus, what has changed is that per­va­sive devel­op­men­tal dis­or­der no longer rules out the diag­no­sis of ADHD. Actu­ally, in DSM-V the per­va­sive devel­op­men­tal dis­or­der cat­e­gory has been renamed ‘Neu­rode­vel­op­men­tal Dis­or­ders’. How­ever, unlike in DSM-IV, ADHD can now be diag­nosed in con­junc­tion with Autism Spec­trum Dis­or­der. In the past, ADHD would have been ruled out based on the assump­tion that ADHD symp­toms were always bet­ter explain by the child’s autism.

Minor change in sub­type designation

In DSM-IV, there were 3 ADHD subtypes:

Com­bined Type for indi­vid­u­als who showed at least 6 inat­ten­tive and 6 hyperactive-impulsive symp­toms, in addi­tion to meet­ing all the other criteria;

Pre­dom­i­nantly Inat­ten­tive Type when suf­fi­cient inat­ten­tive but insuf­fi­cient hyperactive-impulsive symp­toms were present; and,

Pre­dom­i­nantly Hyperactive-Impulsive Type when suf­fi­cient hyperactive-impulsive symp­toms inat­ten­tive but insuf­fi­cient inat­ten­tive symp­toms were present.

In DSM-V these cat­e­gories have been retained, but are now referred to as Com­bined pre­sen­ta­tion, Pre­dom­i­nantly inat­ten­tive pre­sen­ta­tion, and Pre­dom­i­nantly hyperactive-impulsive pre­sen­ta­tion. I sus­pect this word­ing change reflects a desire to move from the more sta­tic lan­guage of ‘types’ to use ter­mi­nol­ogy that bet­ter reflects the flu­id­ity and change in how the dis­or­der may present in the same indi­vid­ual over time.

New require­ment to spec­ify severity

DSM-V also requires clin­i­cians to spec­ify the sever­ity level of a client’s ADHD as either Mild, Mod­er­ate, or Severe.

Mild is restricted to cases where there are few, if any, symp­toms beyond those required to make the diag­no­sis and no more than minor impair­ment in func­tion­ing. In DSM-IV, where clin­i­cally sig­nif­i­cant impair­ment was required, these indi­vid­u­als would not be diagnosed.

Mod­er­ate is sim­ply defined as symp­toms or func­tional impair­ment between ‘mild’ and ‘severe’. Peo­ple in this cat­e­gory may not nec­es­sar­ily show clin­i­cally sig­nif­i­cant impair­ment and thus also would not have been diag­nosed under DSM-IV.

Severe is reserved for cases with many symp­toms in excess of those required for the diag­no­sis, or sev­eral symp­toms that are espe­cially severe, or marked impair­ment result­ing from symptoms.

New cat­e­gories for indi­vid­u­als not meet­ing full criteria

DSM-IV had a cat­e­gory called ADHD Not Oth­er­wise Spec­i­fied (NOS) for indi­vid­u­als who dis­played promi­nent symp­toms but who did not meet required criteria.

In DSM-V, this has been changed to Other Spec­i­fied ADHD and Unspec­i­fied ADHD. The for­mer is used when full cri­te­ria are not met, symp­toms that are present cre­ate clin­i­cally sig­nif­i­cant dis­tress or impair­ment in func­tion­ing, and the clin­i­cian chooses to con­vey why full cri­te­ria are not met. For exam­ple “Other spec­i­fied ADHD with insuf­fi­cient inat­ten­tion symp­toms”. Unspec­i­fied ADHD should be used in the same cir­cum­stance except that the clin­i­cian chooses not to spec­ify the rea­son that full cri­te­ria are not met and mak­ing a more spe­cific diag­no­sis is not possible.

What I find a bit per­plex­ing is that these 2 diag­noses require clin­i­cally sig­nif­i­cant dis­tress or impair­ment from the ADHD symp­toms that are present while the full pre­sen­ta­tions do not. Thus, indi­vid­u­als given either of these diag­noses could actu­ally be more impaired from their ADHD symp­toms than those meet­ing full cri­te­ria. Per­haps this is because the Task Force respon­si­ble for the new ADHD cri­te­ria wanted to make sure there was severe impair­ment to assign any type of ADHD diag­no­sis in cases where the full com­ple­ment of nec­es­sary symp­toms was not evident.

Other note­wor­thy aspects of new diag­nos­tic guidelines

DSM-V spec­i­fies the diag­nos­tic cri­te­ria for ADHD but pro­vides no spec­i­fi­ca­tion for how clin­i­cians should acquire the infor­ma­tion needed to deter­mine if these cri­te­ria are met. This was true for DSM-IV and applies to all dis­or­ders in the DSM. There also con­tin­ues to be no rec­om­men­da­tion for any spe­cific diag­nos­tic test that should be used routinely.

Thus, as before, ADHD remains a clin­i­cal judg­ment that clin­i­cians make based on the infor­ma­tion they obtain using the meth­ods they choose to obtain it. Sug­gested eval­u­a­tion guide­lines from the Amer­i­can Acad­emy of Pedi­atrics can be found here.

Sum­mary and Implications

As dis­cussed above, there have been a num­ber of sub­tle but impor­tant changes to the diag­nos­tic cri­te­ria for ADHD. In my view, a note­wor­thy pos­i­tive change is the effort to make the cri­te­ria more sen­si­tive to the man­i­fes­ta­tion of ADHD in ado­les­cents and adults, both by includ­ing adult exem­plars for most symp­toms and slightly reduc­ing the num­ber of symp­toms required for the diag­no­sis among older individuals.

Given the absence of research data doc­u­ment­ing sig­nif­i­cant dif­fer­ences in func­tion­ing, response to treat­ment, or out­comes in indi­vid­u­als whose symp­toms were present at younger vs. older ages, increas­ing the age of onset for symp­toms from 7 to 12 seems rea­son­able. At a min­i­mum, there is noth­ing in the exist­ing research lit­er­a­ture that con­tra­dicts this change.

What is per­plex­ing is the deci­sion to replace the require­ment that symp­toms be asso­ci­ated with clin­i­cally sig­nif­i­cant impair­ment in social, academic,or occu­pa­tional func­tion­ing to what appears to be a clearly lower thresh­old. As you are prob­a­bly aware, there are many who believe that ADHD is sim­ply a med­ical term inap­pro­pri­ately attached to chil­dren who show largely ‘typ­i­cal’ behav­ior. With DSM-IV, one could argue against this by not­ing that the diag­no­sis was not made unless symp­toms sig­nif­i­cantly impaired the child’s func­tion­ing in impor­tant domains. Thus, the con­di­tion was reserved for indi­vid­u­als who strug­gled sub­stan­tially because of their symp­toms, which jus­ti­fies regard­ing the symp­toms as man­i­fes­ta­tion of a dis­or­der and not typ­i­cal behavior.

Now, how­ever, that is not really the case as the need for ‘clin­i­cally sig­nif­i­cant impair­ment’ has been changed to evi­dence that symp­toms inter­fere with or reduce the qual­ity of per­for­mance in impor­tant life domains. To me, that sounds like a much less strin­gent require­ment. For exam­ple, indi­vid­u­als who will be diag­nosed with the ‘mild’ spec­i­fier, and even some with the ‘mod­er­ate’ spec­i­fier under DSM-V guide­lines would not have met diag­nos­tic cri­te­ria — as I under­stand them — under DSM-IV. An increase in diag­noses may also result in more indi­vid­u­als being treated with med­ica­tion when this is not really nec­es­sary. On the other hand, this may also result in indi­vid­u­als obtain­ing ser­vices they could ben­e­fit from when this would not pre­vi­ously have been the case, e.g., accom­mo­da­tions at school.

What remains unknown, how­ever, is how clin­i­cians will inter­pret these new guide­lines and how much prac­ti­tion­ers actu­ally relax the impair­ment require­ment in their own eval­u­a­tions. If clin­i­cians make a care­ful effort to fol­low the new guide­lines, how­ever, as the devel­op­ers of the DSM-V would cer­tainly want, it is dif­fi­cult to imag­ine how the rate of ADHD diag­noses will not increase.

David Rabiner Attention Research Update– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity.  His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing.  He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

Pre­vi­ous arti­cles by Dr. Rabiner:

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