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.
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:
- 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).
- often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- 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).
- 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).
- 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).
- often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- is often easily distracted by extraneous stimuli (e.g., for older adolescents and adults may include unrelated thoughts).
- 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:
- often fidgets with or taps hands or squirms in seat.
- 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).
- often runs about or climbs in situations where it is inappropriate (e.g., in adolescents or adults, may be limited to feeling restless).
- often unable to play or engage in leisure activities quietly;
- 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).
- often talks excessively.
- often blurts out answers before questions have been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- often has difficulty awaiting turn (e.g., while waiting in line).
- 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: