Do the diagnostic criteria for ADHD need to change? Comments on the preliminary proposals of the DSM-5 ADHD and Disruptive Behavior Disorders Committee

Abstract

The purpose of this commentary is to discuss the recent proposals for revision of the diagnostic criteria made by the DSM-5 ADHD and Disruptive Behavior Disorders Committee. The major concerns with the current diagnostic criteria for ADHD and hence the main suggestions for change focused on the general structure and organization of subtypes, the number, content and distribution of criteria, the age of onset criteria, the ascertainment of cross-situationality and the inclusion and exclusion criteria. Suggestions for change in these areas have been made in order that these changes can be tested in field trials before being finalised. Whilst several of the proposed revisions are relatively uncontentious e.g., the elaborated symptoms criteria, the identification of ADHD as a disorder of both behavioural and cognitive functioning, the situational and developmental dependence of symptoms, the permission to diagnose ADHD in the presence of an autism spectrum disorder, clarification of the relationship between ADHD and irritable mood and the importance of getting information from teachers and other third parties. Several of the other proposed changed are more contentious and will require extensive field testing to assess their impact on validity, reliability and clinical usefulness. These include changes to the way in which individuals with inattention but no hyperactivity/impulsivity are classified, the addition of four new impulsivity symptoms, a reduction in the number of symptoms required to meet criteria for older adolescents and adults and the raising of the age of onset to 12 years of age.

Appendices

Appendix 1: American Psychiatric Association DSM-5 ADHD and Disruptive Behavior Disorders Work Group criticisms of DSM-IV ADHD

General structure and subtyping

• Subtypes are unstable over time.

• Some critics view inattention (I) and hyperactivity–impulsivity (HI) as separate elements within a complex disorder. However, the structure of the subtypes (that include a mixture of both HI and I) does not reflect that. Others view I and HI as arbitrarily divided elements of a continuous-trait dimension. The current subtype structure offends both schools of criticism.

• Predominantly inattentive ADHD is one of the most frequently used diagnoses in very large samples f treated children. Many of these children show few, if any, manifestations of hyperactivity. However, the current subtype structure does not accurately allow for purely inattentive children.

• The existence of subtype entities lends weight to their being real although evidence to support their differentiation (as defined in the DSM-IV) in nature is limited.

Number, content and distribution of criteria

• The representation of hyperactivity, inattention, and impulsivity in the criterion set is uneven and, thus, differentially weights some features over others. Impulsivity is underrepresented, and inattention is overrepresented.

• Subtype organization leads to threshold artefacts, e.g., ten criteria may be present (five in inattention and five in hyperactivity), and the child would not be eligible for a diagnosis.

• Certain manifestations of adult ADHD are not well represented in the criteria, including the decline in the number of criteria with age without a reduction in impairment.

• Criteria are sparely described, and this enhances criterion variance, which is a major problem in everyday use.

• The large number of criteria is difficult for clinicians to remember.

Age of onset

• Age of onset was set arbitrarily and there are many reports of cases with an onset after age 7.

Appendix 2: Proposed revision of diagnostic criteria for ADHD in DSM-5

Attention deficit hyperactivity disorder

The disorder consists of a characteristic pattern of behavior and cognitive functioning that is present in different settings where it gives rise to social and educational or work performance difficulties. The manifestations of the disorder and the difficulties that they cause are subject to gradual change being typically more marked during times when the person is studying or working and lessening during vacation.

Superimposed on these short-term changes are trends that may signal some deterioration or improvement with many symptoms becoming less common in adolescence. Although irritable outbursts are common, abrupt changes in mood lasting for days or longer are not characteristic of ADHD and will usually be a manifestation of some other distinct disorder.

In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school. Examination of the patient in the clinician’s office may or may not be informative. For older adolescents and adults, confirmatory observations by third parties should be obtained whenever possible.

• A. Either (1) and/or (2).

  • 1. Inattention Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only four symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

    • (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (for example, overlooks or misses details, work is inaccurate).

    • (b) Often has difficulty sustaining attention in tasks or play activities (for example, has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

    • (c) Often does not seem to listen when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction).

    • (d) Frequently does not follow through on instructions (starts tasks but quickly loses focus and is easily sidetracked, fails to finish schoolwork, household chores, or tasks in the workplace).

    • (e) Often has difficulty organizing tasks and activities. (Has difficulty managing sequential tasks and keeping materials and belongings in order. Work is messy and disorganized. Has poor time management and tends to fail to meet deadlines.)

    • (f) Characteristically avoids, seems to dislike, and is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework or, for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

    • (g) Frequently loses objects necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

    • (h) Is often easily distracted by extraneous stimuli. (for older adolescents and adults may include unrelated thoughts.).

    • (i) Is often forgetful in daily activities, chores, and running errands (for older adolescents and adults, returning calls, paying bills, and keeping appointments).

  • 2. Hyperactivity and impulsivity Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only four symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

    • (a) Often fidgets or taps hands or feet or squirms in seat.

    • (b) Is often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).

    • (c) Often runs about or climbs on furniture and moves excessively in inappropriate situations. In adolescents or adults, may be limited to feeling restless or confined.

    • (d) Is often excessively loud or noisy during play, leisure, or social activities.

    • (e) Is often “on the go,” acting as if “driven by a motor.” Is uncomfortable being still for an extended time, as in restaurants, meetings, etc. Seen by others as being restless and difficult to keep up with.

    • (f) Often talks excessively.

    • (g) Often blurts out an answer before a question has been completed. Older adolescents or adults may complete people’s sentences and “jump the gun” in conversations.

    • (h) Has difficulty waiting his or her turn or waiting in line.

    • (i) Often interrupts or intrudes on others (frequently butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

    • (j) Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

    • (k) Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

    • (l) Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

    • (m) Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).

• B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12.

• C. The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).

• D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

• E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Specify based on current presentation

• Combined presentation If both criterion A1 (inattention) and criterion A2 (hyperactivity–impulsivity) are met for the past 6 months.

• Predominately inattentive presentation If criterion A1 (inattention) is met but criterion A2 (hyperactivity–impulsivity) is not met and three or more symptoms from criterion A2 have been present for the past 6 months.

• Predominately hyperactive/impulsive presentation If criterion A2 (hyperactivity–impulsivity) is met and criterion A1 (inattention) is not met for the past 6 months.

• Inattentive presentation (restrictive) If criterion A1 (inattention) is met but no more than two symptoms from criterion A2 (hyperactivity–impulsivity) have been present for the past 6 months.