The Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM), used in the USA and the rest of the world for the formal diagnosis of attention-deficit hyperactivity disorder (ADHD), was released by the American Psychiatric Association in 2013 and replaces the previous version (Diagnostic and Statistical Manual of Mental Disorders – 4th Edition [DSM-IV]).1,2
The DSM-5TM defines ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, has symptoms presenting in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities), and negatively impacts directly on social, academic or occupational functioning. Several symptoms must have been present before age 12 years.1
Overview of the DSM-5TM medical classification system for ADHD
- A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
- Six or more of the symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Please note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), five or more symptoms are required
- Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years
- Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities)
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning
- The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)
Whilst the fundamental diagnostic criteria for ADHD have not changed in the DSM-5TM compared with the previous version, the DSM-5TM has been updated to more accurately characterise the experience of adolescents and adults with ADHD. This has been achieved with the inclusion of additional examples to illustrate the types of ADHD-related behaviours that adolescents and adults with ADHD may exhibit, as well as ADHD-related behaviours that children may exhibit.1 Furthermore, adults and adolescents (aged ≥17) are required to present with a minimum of five (rather than six) symptoms, and symptoms should have been present before age 12 (not before age 7), recognising that adult recall of precise childhood onset is difficult.1,2 A pervasive developmental disorder (autism spectrum disorder) is no longer an exclusion criterion.1 ADHD is now listed in the new category of ‘Neurodevelopmental Disorders’, acknowledging the growing body of scientific evidence supporting brain development correlates with ADHD.3
The DSM-5TM notes that although motor symptoms of hyperactivity become less obvious in adolescence and adulthood, difficulties persist with restlessness, inattention, poor planning, and impulsivity. The DSM-5TM also acknowledges that a substantial proportion of children remain relatively impaired into adulthood.1
Presentations of ADHD
Individuals with ADHD may present with both inattention and hyperactivity/impulsivity, or one symptom pattern may predominate.1 Three presentations of ADHD are commonly referred to: combined-type, inattentive-type and hyperactive/impulsive-type (Table 1). According to the DSM-5TM classification system, the appropriate presentation of ADHD should be indicated based on the predominant symptom pattern for the last six months.1
Table 1: Presentations of ADHD1
|Presentations of ADHD1|
|All three core features are present and ADHD is diagnosed when ≥6 symptoms of hyperactivity/impulsivity and ≥6 symptoms of inattention have been observed for ≥6 months||
Diagnosed if ≥6 symptoms of inattention (but <6 symptoms of hyperactivity/impulsivity) have persisted for ≥6 months
Diagnosed if ≥6 symptoms of hyperactivity/impulsivity (but <6 symptoms of inattention) have been present for ≥6 months
Furthermore, the DSM-5TM also states that it must be specified whether the individual with ADHD is in “partial remission” (when partial ADHD criteria have been met for the past six months with full criteria met previously, and the symptoms still result in impairment in social, academic or occupational functioning); and the current severity of the disease (Table 2).1
Table 2: Current severity of ADHD1
|Current severity of ADHD1|
Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning
Symptoms or functional impairment between “mild” and “severe” are present
Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present; or the symptoms result in marked impairment in social or occupational functioning
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. Washington, DC: American Psychiatric Association, 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2004.
- American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5. Available at www.dsm5.org/Documents/changes from dsm-iv-tr to dsm-5.pdf. Last accessed May 2015.
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New eLearning Module on the burden and diagnosis of adult ADHD, supported by Professor Philip Asherson, is now available.
This booklet has been created to assist with clinical assessment of adult patients with ADHD using DSM-5TM criteria and the ASRS checklist.
Interactive module: Rating scales used for the assessment of ADHD prior to formal diagnosis
How do current guidelines measure up in managing ADHD?