Dr Luis Rohde

Professor David Coghill

DSM-IV to DSM-5™: updates to diagnostic criteria for ADHD

In a plenary session at MoM VIII, Dr Luis Rohde (Hospital de Clinicas de Porto Alegre, Brazil) reviewed key updates to the ADHD diagnostic criteria in the DSM-5™ guidelines,1 particularly highlighting the following points:

  • Deletion of the exclusion of pervasive developmental disorder (PDD): ADHD may now be diagnosed in individuals with PDD (this was previously excluded by DSM-IV)
  • Lower symptomatic threshold for adults: at least five symptoms of inattention or hyperactivity/impulsivity are now required to support diagnosis of ADHD in individuals aged ≥17 years (compared with six or more symptoms for younger individuals, which was required for all individuals in DSM-IV)
  • Broader age of onset criterion: symptoms must have been present prior to age 12 years to support an ADHD diagnosis (compared with 7 years in DSM-IV).

Since these updates expand the limits for ADHD, potentially increasing prevalence rates,2 Dr Rohde cautioned that careful assessment is needed to avoid overdiagnosis.

Audience questions: overdiagnosis versus early diagnosis
Audience questioning suggested that what might be viewed as ‘overdiagnosis’ may in fact reflect diagnosis prior to the development of complications, which could facilitate early intervention. In response to this comment, Professor David Coghill (Royal Children’s Hospital, Melbourne, Australia) described a longitudinal study in which hyperactive preschoolers went on to incur greater health costs than non-hyperactive controls,3 supporting the concept of early intervention for ‘at-risk’ individuals.

In a subsequent presentation, Professor Asherson highlighted that the ADHD diagnostic criteria in the DSM-5™ guidelines have also been updated to include more age-appropriate examples of symptoms in adults.1

However, Professor Philip Asherson (King’s College London, UK) cautioned that early intervention would be a matter of judgement, since not everyone with higher levels of ADHD symptoms will go on to develop the disorder.

Potential limitations of current approaches to ADHD diagnosis

Dr Rohde also drew attention to research suggesting that some clinicians may diagnose ADHD without corroboration of symptoms by a second information source, and some may not fully assess comorbidities.4,5

In addition, Professor Asherson explained that while DSM-5™ has good clinical utility, it may not provide a full picture of ADHD.

Professor Philip Asherson: The DSM was not designed to reflect all the symptoms and impairments of ADHD. It has good clinical utility but also lacks some scientific validity, so we have to be much more open to what ADHD is, in terms of trying to understand the genetics and neurobiology; and more generally, from a clinical perspective, we need to spend more time describing and detailing the broader expression of ADHD.

Other tools to support the diagnosis and initial assessment of ADHD

During MoM VIII, other tools described as useful in supporting the diagnosis and initial assessment of ADHD included:

Audience questions: the importance of thorough assessment
When the audience questioned the value of an extensive initial assessment of ADHD, Professor Coghill emphasised the importance of accurate diagnosis and detection of any comorbidities. He referred the audience to the integrated approach outlined by the Dundee ADHD Clinical Care Pathway.6

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington. DC: American Psychiatric Association. 2013.
  2. Matte B, Anselmi L, Salum GA, et al. ADHD in DSM-5: a field trial in a large, representative sample of 18- to 19-year-old adults. Psychol Med 2015; 45: 361-373.
  3. Chorozoglou M, Smith E, Koerting J, et al. Preschool hyperactivity is associated with long-term economic burden: evidence from a longitudinal health economic analysis of costs incurred across childhood, adolescence and young adulthood. J Child Psychol Psychiatry 2015; 56: 966-975.
  4. Leslie LK, Weckerly J, Plemmons D, et al. Implementing the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder Diagnostic Guidelines in Primary Care Settings. Pediatrics 2004; 114: 129-140.
  5. Yuki K, Bhagia J, Mrazek D, et al. How does a real-world child psychiatric clinic diagnose and treat attention deficit hyperactivity disorder? World J Psychiatry 2016; 6: 118-127.
  6. Coghill D, Seth S. Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway. Child Adolesc Psychiatry Ment Health 2015; 9: 52.