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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

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:1
    • For children, six or more of the symptoms (Table) have persisted for at least 6 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 instructions1
    • For older adolescents and adults (age 17 and older), five or more symptoms are required (Table)1
  • Several inattentive or hyperactive-impulsive symptoms present prior to age 12 years1
  • Several inattentive or hyperactive-impulsive symptoms present in two or more settings (e.g. at home, school or work; with friends or relatives; in other activities)1
  • Clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning1
  • 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).1

DSM-5TM diagnostic criteria for ADHD: symptoms of inattention, hyperactivity and impulsivity. 

Symptoms of inattention Symptoms of hyperactivity and impulsivity
Often fails to give close attention to detail or makes mistakes Often fidgets with or taps hands and feet, or squirms in seat
Often has difficulty sustaining attention in tasks or activities Often leaves seat in situations when remaining seated is expected
Often does not seem to listen when spoken to directly Often runs and climbs in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restless)
Often does not follow through on instructions and fails to finish schoolwork or workplace duties Often unable to play or engage in leisure activities quietly
Often has difficulty organising tasks and activities Is often ‘on the go’, acting as if ‘driven by a motor’
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort Often talks excessively
Often loses things necessary for tasks or activities Often blurts out answers before a question has been completed
Is easily distracted by extraneous stimuli Often has difficulty waiting their turn
Is often forgetful in daily activities Often interrupts or intrudes on others

Do you think the diagnostic criteria for ADHD in the DSM-5TM described above have meant that you see fewer cases of undiagnosed ADHD in your clinical practice compared with before the DSM-5TM was introduced?

Presentations of ADHD

Individuals with ADHD may present with both inattention and hyperactivity/impulsivity, or one symptom pattern may predominate.1

How much does the disease presentation of ADHD vary between different patients? | Dr Joel Young | Rochester Centre for Behavioral Medicine, Michigan, USA

Three presentations of ADHD are defined in DSM-5™ based on the predominant symptom pattern for the past 6 months:1

  • Combined presentation – 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
  • Predominantly inattentive presentation – diagnosed if ≥6 symptoms of inattention (but <6 symptoms of hyperactivity/impulsivity) have persisted for ≥6 months
  • Predominantly hyperactive/impulsive presentation – 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 6 months with full criteria met previously, and the symptoms still result in impairment in social, academic or occupational functioning)1 and the current severity of the disease.1

The current severity of ADHD should also be specified:1

  • Mild – 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
  • Moderate – symptoms or functional impairment between ‘mild’ and ‘severe’ are present
  • Severe – 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.

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

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2004.
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