DSM-5 Diagnostic Criteria for ADHD

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has a long history of revisions and is essential to a mental health professional’s work.  If you're a mental health provider, you most likely work from the DSM-5, one of the more recent manual versions. 

An even newer version called the Diagnostic and Statistical Manual of Mental Disorders Version 5 Text Revision (DSM-5-TR) has been available since 2022.

The DSM-5 made many updates in the classification of Attention-Deficit Hyperactivity Disorder (ADHD) from the earlier version DSM-IV.  If you're a clinician who works with clients who have or potentially have ADHD, being aware of the changes in the most recent versions of the DSM can help you diagnose and treat ADHD more accurately.

There were seven changes from the DSM-IV to the DSM-5.  The DSM-5-TR did not update any of the diagnostic criteria for ADHD.  The seven changes help clarify ADHD symptomology so clinicians can understand the disorder's presentation more accurately.  The added examples help individuals recognize symptoms they might be experiencing and can help clinicians tailor assessments for ADHD based on the criteria.

A Brief History of ADHD Classification in the DSM

Attention Deficit Hyperactivity Disorder (ADHD) classification in the DSM has changed significantly over the years.  According to a 2013 article published in Neuropsychiatry, the ADHD diagnosis first appeared in the DSM-II and was called Hyperkinetic Reaction of Childhood and focused heavily on motor activity.

In the DSM-III, it was renamed Attention Deficit Disorder with or without hyperactivity and shifted more towards targeting problems with attention, concentration, and focus.  The revised version of the DSM-III in the 1980s is where the term Attention-Deficit Hyperactivity Disorder (ADHD) first appeared.

The DSM-IV added three subtypes of ADHD: inattentive, hyperactive-impulsive, and combined.  The DSM-5 made several updates to the criteria for diagnosis of ADHD.  These changes were made to capture the symptomology present in individuals with ADHD more accurately.

What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is characterized by three major classifications of symptoms: inattention, hyperactivity, and impulsivity.  One major part of ADHD is a lack of executive functioning skills.  Executive functioning skills help you set and achieve goals and regulate behavior.  These skills can be very challenging for individuals with ADHD.

The DSM-5 states that there is a prevalence rate of ADHD in children of approximately 5%, and the disorder affects about 2.5% of adults.  Some 2020 research suggests that males are diagnosed with females at double the rate. 

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Many of the criteria required to meet an ADHD diagnosis present differently in females, and sometimes, females with ADHD aren't diagnosed until later in life or are misdiagnosed with other mental health conditions.

ADHD causes impairments in functioning that must be present across multiple settings such as school, work, or home.  While it used to be thought of as a disorder only diagnosed in childhood, more people are receiving ADHD diagnoses now as adults.  The increase may be due to gender differences in diagnosis, as males often tend to show more overt signs of the disorder at a young age.

If you have or treat ADHD as a clinician, knowing that treatment can be helpful is essential.  Psychotherapy with a clinician who is versed in treating ADHD can help you learn skills for improving focus and concentration and managing executive dysfunction.

ADHD can also be treated with medication; a 2023 overview reports medication for ADHD is often the first line of treatment.  Treatment with medication is often broken into two categories: stimulant and non-stimulant medications.  Both types of medication can help treat ADHD.

The overview reports that stimulant medication is effective in about 70% of patients with ADHD.  Non-stimulant medications still show effectiveness, though they are not quite as effective as stimulant medications.  You should also consult with your doctor about what options may be suitable for you if you're considering ADHD medication.

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What's new in the DSM-5?

The DSM-5 made many changes to the symptom criteria for those with ADHD.  These changes made it easier to classify and diagnose ADHD throughout the lifespan.  While previous versions of the DSM stated this disorder mainly occurred and was diagnosed in childhood, researchers now know that many adults also deal with ADHD.

Classification of ADHD

The first significant change that was made in the DSM-5 was removing ADHD from the category of disorders that occur in infancy, childhood, and adolescence and moved it to the category of Neurodevelopmental Disorders section.

This change helps account for ADHD diagnosis across the lifespan, and not just in childhood, as many individuals don't get diagnosed until later in life.

Added Examples for each Criteria

The criteria for ADHD are the same from the DSM-IV to the DSM-5; however, in the DSM-5, the second significant change adds examples to each of the requirements, for example:

One of the criteria from the DSM-IV states:

"Frequently struggles to maintain focus on tasks or during play activities."

The DSM-5 takes it a step further by stating:

"Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).”

The added examples help clarify the situations included in the criteria.

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Classification from "Some" symptoms to "Several"

Another change from the DSM-IV to the DSM-5 was classifying "some" symptoms of hyperactivity, impulsivity, and inattention to "several" symptoms.  The shift from "some" to "several" helps change how symptoms of ADHD are diagnosed across different settings such as school, work, or home.

Age of Onset

The DSM-5 changed the age at which symptoms were first noticeable.  The DSM-IV criteria often state that symptoms must've been present before age 7.  The DSM-5 changed this to symptoms that were present before age 12.

Changes in the Subtypes

The DSM-5 has also upgraded the language regarding the subtypes of ADHD.  The ADHD subtypes include:

·        Inattentive presentation

·        Hyperactive/Impulsive presentation

·        Combined presentation

The DSM-IV splits the different criteria into A1 and A2 for the subtypes.  The DSM-5 has more specific language, such as:

"Predominantly inattentive presentation: If enough symptoms of inattention but not hyperactivity/impulsivity were present for the past six months."

This specificity can help clinicians diagnose ADHD subtypes more easily without referring to the A1 and A2 criteria.

Comorbid Diagnosis with Autism Spectrum Disorder

The DSM-IV didn't include ADHD to be diagnosed with Autism Spectrum Disorder (ASD).  The DSM-V criteria changed, allowing a comorbid diagnosis of ADHD and ASD.  The two often have overlapping symptoms and can be diagnosed together.

Research from 2022 suggests that when Autism Spectrum Disorder is present in an individual, about 50-70% of the time, there is also comorbid ADHD.  The growing literature in this area may account for the updated comorbid diagnosis in the DSM-5, as the literature continues to note a significant overlap.

Symptom Threshold Changes

For adult ADHD, the DSM-5 requires five symptoms to be met to qualify for a diagnosis of ADHD.  The previous version of the DSM needed six symptoms to be present to meet the criteria for ADHD.  The five symptoms across both subtypes are necessary to diagnose ADHD.

Were any changes made to ADHD in the DSM-5-TR?

The DSM-5-TR was a text revision edition that came out in March of 2022 that updated criteria for many mental health disorders.  There were no changes made to ADHD criteria from the DSM-5 to the DSM-5-TR.

ADHD remains classified as a neurodevelopmental disorder that is characterized by inattention, hyperactivity, and impulsivity.

How do I find the ADHD classification in the DSM-5?

In the DSM-5-TR, you can find the ADHD classification under the Neurodevelopmental Disorders section.  If you're a clinician who references the DSM-5 often, you can buy tabs to mark each section of the DSM-5 so you can quickly flip to the section of the DSM-5 that you need.

More specifically, you can find the ADHD on page 59 of the DSM-5.  If you're a clinician who works with ADHD, this may help you find it easier in the DSM-5 in the future.

Overview of Changes in the DSM-5

The Diagnostic and Statistical Manual has had several revisions over the years and is published by the American Psychiatric Association.  The most recent version of the DSM is the DSM-5-TR.  The DSM-5 established new criteria for ADHD that make it more inclusive of symptoms and provide examples of what ADHD may look like.

There were seven total changes made from the DSM-IV to the DSM-5.  These changes help clinicians better classify and diagnose the symptoms of ADHD.  The revised symptoms with examples make it clear what symptoms of ADHD could look like.

If you're a mental health professional who treats clients with ADHD, it's important to understand the symptoms of ADHD.  Some people deal with symptoms beyond what's listed in the DSM-5, and they can cause a client significant distress.

Understanding the clinical criteria for ADHD is one piece of the puzzle.  Obtaining continuing education in ADHD and having a clearer picture of the presentation of this disorder can help you grow and engage in better treatment modalities with your clients.

Resources:

• American Psychiatric Association.  (2022).  Attention Deficit Hyperactivity Disorder.  In Diagnostic and Statistical Manual of Mental Disorders.  (5th ed., text rev.).

• American Psychiatric Association (2013).  Highlights of Changes from DSM-IV-TR to DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf

• Epstein J. & Loren R. (2013, October 1).  Changes in the Definition of ADHD in the DSM-5: Subtle but Important.  Neuropsychiatry.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955126/

• Hours, C et al. (2022, February 28).  ASD and ADHD Comorbidity: What Are We Talking About?  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8918663/

• Magnus, W. et al. (2023, August 8).  Attention Deficit Hyperactivity Disorder.  Stat Pearls.  https://www.ncbi.nlm.nih.gov/books/NBK441838/

• Stibbe, T. et al. (2020, October 15).  Gender differences in adult ADHD: Cognitive function assessed by the test of attentional performance.  PLoS One.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561166/

• Substance Abuse and Mental Health Services Administration.  (2016).  DSM-5 Changes: Implications for Child Serious Emotional Disturbance.  https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t3/

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About the author

Marissa Moore

Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.

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