Blog by Dr. Thomas E. Brown

DSM-5 Changes in ADHD Diagnostic Criteria

Posted by Dr. Thomas E. Brown on July 5th, 2013


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.

 

ADHD is widely misunderstood, even by many professionals in healthcare and education

Posted by Dr. Thomas E. Brown on May 6th, 2013


Recently a number of media reports have expressed alarm about the increasing number of children and adults being diagnosed and treated for ADHD.  There have also been news reports about some colleges and universities refusing to provide ADHD assessments or medication for students because of concern about increased use of ADHD medications by students who have not been adequately evaluated or diagnosed with ADHD.

Much of this fear appears to be based on fundamental misunderstandings of ADHD—what it actually is, what causes it, how it can be appropriately assessed, and what medications used to treat it actually do and don’t do.  One reason for this lack of understanding is that most physicians and other health care providers are provided little or no professional education about ADHD. The unfortunate effect of this lack of training is that many medical professionals are unaware of how to provide appropriate assessment and ongoing treatment for ADHD.

Some health care providers attend continuing education courses or workshop sessions to learn about ADHD, but coverage of this very common disorder in the curriculum of most medical and nursing schools is superficial, outdated, and often non-existent.  Similar problems exist in most textbooks and curricula for professional education of teachers and school psychologists

Some common misunderstandings of ADHD include

  • Failure to understand that most persons with ADHD can focus very well on a few specific activities in which they have strong personal interest or when they are afraid that something very unpleasant will happen very quickly if they don’t take care of this task  right now. This leads many to think that persons with ADHD simply lack willpower and could work much more effectively all the time if they really wanted to. It is difficult for many to understand why these shortcomings can’t be fixed simply by more effort. They don’t see that most of these operations are unconsciously determined by automaticity.
  • Failure to understand that ADHD is not an “all-or-nothing” experience like pregnancy where one either is or is not. It is more like depression.  Everyone gets sad and bummed out sometimes, but we don’t diagnose a person as clinically depressed if they are just unhappy once in a while.  All of the symptoms of ADHD are problems everyone has sometimes, but diagnosis of ADHD should be made only when a person is significantly and chronically impaired by those symptoms.
  • Failure to understand that medications for ADHD cure nothing; they do not eradicate ADHD impairments as an antibiotic might cure an infection. For about 80% of those diagnosed with ADHD, prescribed medications can significantly alleviate ADHD symptoms.  However, the benefits of these medications end when the medication wears off each day, just as eyeglasses provide no improvement of vision while they are not being worn.
  • Failure to understand that none of the medications for ADHD work effectively for everyone diagnosed and that the amount and timing of stimulant medication for a given individual has not much to do with age, weight, or severity of symptoms. It depends upon how sensitive that person’s body is to that medication and how quickly they metabolize it. Ongoing fine-tuning of dose and timing is essential for successful treatment.
  • Failure to understand that the risks of not treating ADHD effectively are far greater than the risks of providing appropriate treatment. Any medical treatment carries some risks for some people. These risks are minimal for most persons with ADHD so long as their overall health is adequate and their ADHD treatment is appropriately designed and adequately monitored. Risks of not providing appropriate treatment for ADHD include risks of significant problems with education and learning, employment, driving, family interactions, social relationships, self-management and self-esteem. Inadequate treatment also heightens risk of substance use disorder, depression and anxiety disorders.

There is great need for more adequate science-based coverage about ADHD in the media. There is also urgent need for more adequate science-based information about ADHD in the professional education of all health care providers and educators working with children and adults.