How the DSM-5 Fails People with ADHD — and a Better Way to Diagnose

October 3, 2023

Approximately 25 years ago, when ADDitude published its first newsletter, the diagnosis of ADHD was based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Version III-C. The DSM-IV diagnostic criteria adopted two years later were the most scientifically validated to date.

Its 18 symptoms were evenly divided into two lists: problems with inattention vs. problems with hyperactivity-impulsivity. To warrant a diagnosis, a patient had to exhibit at least six symptoms on either list, suffer impairment in one or more major life activities (home, school, community, peers), and begin experiencing symptoms by age seven. Furthermore, the symptoms could not be better explained as those of another condition.

Yet, problems remained. The committee handling ADHD criteria for the DSM-5 hoped to improve the DSM’s rigor and diagnostic accuracy. It proposed recommendations that reflected independent research findings. Sadly, many of those recommendations were rejected by higher-ranking committees, perhaps partly out of fear they would significantly increase the prevalence of ADHD diagnoses. Thus, the ADHD criteria in the DSM-5, released in 2013, represented only modest improvements.

The Problems with the DSM-5

The DSM-5 does not capture ADHD accurately because its criteria do not conceptualize ADHD as a disorder of executive functioning (EF) and self-regulation (SR). This limitation greatly narrows the concept of ADHD, trivializes its nature as just an attention deficit, and discourages diagnosing clinicians from focusing on the wider range of impairments inherent in ADHD. These impairments impact executive inhibition, self-awareness, working memory, emotional self-regulation, self-motivation, planning/problem-solving, and other functions not typically associated with ADHD. Ignoring them restricts diagnosis and, ultimately, treatment for many patients.

Why Qualifier Symptoms Should Go Unheeded

In the DSM-5, qualifier symptoms were added after each listing of a symptom to help clinicians understand the expression of that symptom beyond childhood. However, problems with these clarifiers include:

[Read: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.]

• None of these clarifications arose out of prior research that tested them for their affiliation with ADHD, for their relationship to the root symptom they are supposed to clarify, for their accuracy in detecting ADHD, or for their relationship to impairment in major life activities. They were simply invented by committee members in a meeting.
• Adding such new and untested symptoms may have broadened eligibility for the disorder by up to 6 percent in older teens and adults.
• Some clarifications seemed to correlate with anxiety, which could lead to cross-contamination of the ADHD criteria.

These clarifications also were not informed by any theory of ADHD, such as EF-SR theory.

So, until the status of these parenthetical clarifiers is better researched, clinicians would do best to ignore them in making a diagnosis of ADHD in a teen or an adult.

A Better Way to Diagnose ADHD

Clinicians can ensure more accurate diagnoses and more appropriate care by following these five recommendations:

#1. Avoid placing undue emphasis on hyperactive symptoms.

Six of the nine hyperactive-impulsive symptoms on the DSM list reflect excessive activity, even though impulsivity has been viewed as a more prevalent ADHD symptom for the last 40 years. At best, hyperactivity is reflective of early childhood disinhibition of motor movement and, later, the inability to regulate such movement to the demands of the situation (e.g., teacher’s instructions to complete desk work). Those symptoms decline steeply over development and are of little diagnostic value by late adolescence. This is one reason why clinicians before the 1980s thought the disorder was outgrown before adulthood, which we now know is false for most people.

[Research: Only 1 in 10 Children with ADHD Will Outgrow Symptoms]

#2. Look for additional symptoms of impulsivity.

Poor inhibition may manifest not just in speech (currently, the DSM criteria include only three verbal symptoms) but in motor behavior, cognition, motivation, and emotion. Clinicians should screen for any of the following manifestations:

• often fails to consider the consequences of their actions
• has trouble motivating to persist toward goals
• has trouble deferring gratification or waiting for rewards
• lacks willpower, self-discipline, drive, and determination
• seems unusually impatient, easily emotionally aroused and frustrated, and quick to anger

Abundant research shows that these aspects of poor self-regulation are as common in people with ADHD as are the traditional DSM symptoms and, with age, more so than the symptoms of hyperactivity.

#3. Think of inattention as affecting a range of executive function deficits in daily life…

…particularly those involving impaired self-awareness, working memory, self-organization, emotional self-regulation, self-motivation, and time management. This will encourage clinicians to broaden their focus beyond the DSM symptoms when conducting open-ended interviews and selecting rating scales.

After the evaluation is completed, clinicians should explain to clients why their condition is so serious, impairing, and pervasive across major domains of life. This will also help clinicians and parents appreciate why teens (and young adults) may seem to be outgrowing ADHD, based on DSM criteria, when they are far less likely to outgrow their EF-SR deficits (and that these impairments may increase with age).

#4. Use rating scales broken down by sex and not just age.

Research suggests that females in the general population, at least in childhood and adolescence, do not show the same symptom severity as their male peers.¹ This makes it harder for a female to meet the DSM criteria. Another complicating factor: because males were overrepresented in field trials for earlier versions of the DSM, the symptom threshold was male-biased.

#5. Don’t adhere too rigidly to diagnostic thresholds when there are clear signs of impairment.

Empirical research demonstrates that ADHD falls along a continuum in the general population. So, clinicians will see clients who don’t meet all of the DSM criteria, yet who are experiencing enough impairment that they sought a diagnosis. This means clinicians should diagnose ADHD if:

• Clients or their caregivers state that a child or teen has a high number of ADHD (and EF) symptoms (place above the 20^th–16^th percentile in severity) and there is evidence of impairment in major life activities, even if the client fails to meet all DSM-5
• Symptoms became evident sometime during development, usually before age 21–24, and the patient meets all other criteria. DSM-5 raised the age of onset for ADHD from age 7 to age 12, but research repeatedly shows that few people are reliable or accurate in recalling the age of onset of their symptoms. It is a mistake, therefore, to consider age of onset in diagnosing ADHD, where all other criteria are met.

DSM-5 ADHD Criteria Challenged: Next Steps

• Free 7-Part Series: The Clinicians’ Guide to Diagnosing ADHD
• Read: ADHD Is a Whole-Life Experience. The DSM Needs to Reflect That.
• Read: ADHD in Women and Girls — Why Female Symptoms Slip Through Diagnostic Cracks

Russell A. Barkley, Ph.D., is a retired clinical scientist, educator, and practitioner.

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