DSM-5 Changes in ADHD Diagnostic Criteria

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In May, 2013 the American Psychiatric Assn. published a new edition of their Diagnostic & Statistical Manual of Mental Disorders, the reference widely used for diagnosing ADHD and other psychiatric disorders. In this 5th edition there were some useful changes in the diagnostic criteria for ADHD, but there were also some unfortunate omissions.

Useful changes:

  • Age of onset: previously, diagnosis of ADHD required that at least some symptoms of ADHD had been present in the individual by age 7 years. DSM-5 raised the age criterion to having several ADHD symptoms present by age 12 years or earlier.
  • Fewer symptoms required for adults: previously the diagnosis of ADHD required at least 6 of the 9 listed symptoms of inattention and/or 6 of the 9 symptoms of hyperactivity/ impulsivity. Now just  5 symptoms from either set are required for diagnosis of persons 17 years or over.
  • Examples of adult symptoms: previously most of the listed examples of symptoms were childhood behaviors not common in adolescents or adults with ADHD; some examples of common adult ADHD symptoms have been added.
  • Comorbidity with autistic spectrum disorders:  previously the diagnosis of ADHD was not supposed to be made for individuals diagnosed with a disorder on the autistic spectrum.  DSM-5 allows diagnosis of both disorders when criteria for both are met.

Importantly, the DSM-5 does note more explicitly than did its predecessor that “Typically, symptoms vary depending on context within a given setting. Signs of the disorder may  be minimal or absent when the individual is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e.g. via electronic screens), or is interacting in one-on-one situations (e.g. the clinician’s office).”

Although these changes are useful, this version of the DSM does not very adequately reflect scientific advances in understanding ADHD that have emerged over the 13 years since the last revision or the 19 years since the edition which introduced research-based changes in the diagnostic criteria for ADHD.

  • DSM-5 retains the behaviorally-focused emphasis of previous versions of the manual and does not adequately reflect the underlying cognitive difficulties, the syndrome of executive function impairments, which have been found to be the core of ADHD. 
  • DSM-5 does not adequately address the important role of emotions in ADHD. It does not pick up the impaired motivational aspect of emotions which makes it so difficult for many with ADHD to get started on or sustain effort for tasks not intrinsically interesting to them. And it does not include any symptoms that reflect characteristic problems of persons with ADHD in modulating their experience and expression of emotions.
  • DSM-5 does not recognize the importance of problems in regulating sleep and alertness which have been identified in research on ADHD in children and adults. 

One of the researchers who contributed to the difficult work of revising ADHD diagnostic criteria for DSM-5 once gave an early report on the proposed changes for a group of clinicians and researchers. After being peppered with many queries about “Why haven’t you included this or that in your changes?” the presenter reminded the group, “The DSM follows the field; it does not lead it!”  There is good reason for us to be grateful to those who worked hard to update DSM-5. There is also good reason for us to look to other sources to continue to update and increase our understanding of this complex disorder.

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