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

The 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.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Pre­vi­ous arti­cles by Dr. Rabin­er:

• Study: Promis­ing New Neu­rocog­ni­tive Inter­ven­tion for Preschool­ers with ADHD (TEAMS)
• Study: Fam­i­lies’ Per­spec­tives on ADHD and its Treatment