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Front. Psychiatry, 30 May 2013 | http://dx.doi.org/10.3389/fpsyt.2013.00049

Diagnostic criteria in attention deficit hyperactivity disorder – changes in DSM 5

  • Medical Faculty, University of Freiburg, Freiburg, Germany

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in childhood, affecting large numbers of children throughout the world.

Because of the knowledge evolved from ADHD research, today’s challenges are vast, including changes in terminology, fears of over-diagnosis, and over-medication of children.

What began as a case description, has now evolved in clinical trials, leading from observations of behavior to advances in neuroscience. The biggest challenge remains in the correct diagnosis of ADHD, though.

With a worldwide prevalence of approximately 5%, ADHD is very common (Polanczyk et al., 2007). ADHD in the United States even shows a prevalence among 8- to 15-years-olds of 8.7% and only a third of the ADHD patients have been treated consistently during the past year (Froehlich et al., 2007). In another age group (18- to 44-year-olds) the prevalence is about 4.4% (Kessler et al., 2006).

Male patients are six times more often diagnosed with ADHD in childhood than female patients and three times more often in the adolescence. The prevalence seems to be equivalent in all levels of IQ and socioeconomic status (Gaub and Carlson, 1997; Levy et al., 1997; Smalley et al., 2000; Pastor and Reuben, 2008).

The core symptoms of ADHD in DSM-IV-TR criteria (American Psychiatric Association, 2000) include inattention on the one hand and hyperactivity and impulsivity on the other hand, both having to be consistent to a degree that is maladaptive and inconsistent with developmental level, e.g., a 3-year-old’s behavior is to be expected different from an 8-year-old’s behavior.

Additional criteria include the chronicity of ADHD symptoms, meaning that there has to be a persistence of symptoms at least for 6 months, pervasiveness of ADHD symptoms (ADHD symptoms have to be present in different settings and locations, or at least in more than one location, e.g., family, community, workplace), some hyperactive-impulsive or inattentive symptoms must have been present before the age of 7 years and there must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning, e.g., you may have one of the symptoms, but if it is not impairing you or interfering with your functioning, a diagnosis cannot be made. At last but not least, the disturbance does not occur exclusively during the course of other serious mental disorders (e.g., pervasive developmental disorder/autism, schizophrenia, other psychotic disorder).

In the current DSM, there are three different ways of diagnosing ADHD. There is the combined type, e.g., both core symptoms are met for the past 6 months; there is the predominantly inattentive type and finally the predominantly hyperactive-impulsive type.

But what are the strengths of DSM-IV criteria? The committee of experts that has developed the DSM-IV criteria catalog clearly uses rigorous and empirically derived criteria, has looked at all rating scales for diagnosing ADHD and has reviewed the ADHD literature. Additionally, the impairment criterion has been given greater emphasis in the past few years.

Nevertheless there are certain weaknesses and controversies of DSM-IV criteria and it is important to have a second look: the age of onset criterion may not be justified (the age of 7 years does seem very restrictive), diagnostic item sets may be inappropriate for different developmental periods (e.g., not being able to sit quietly in a chair does not seem to be the right diagnostic item set for an adult, he does not need to listen or doesn’t want to), diagnostic thresholds may not apply to older age groups (>16 years), there is no gender distinction in diagnostic thresholds and there is no lower age limit defined (<4 years).

So what are potential changes in DSM 5 criteria (American Psychiatric Association, 2013)? For a start, the age onset criterion shall be increased from 7 years of age to 12 years of age. Then there is the intent to contextualize and illustrate diagnostic item sets to fit lifespan (e.g., inattention in a child versus an adolescent versus an adult). Additionally, there are up to four new criteria for impulsivity (there have been only three dimensions compared to inattention or hyperactivity). And finally, the number of criteria needed for adolescents and adults is likely to be revised, for data has suggested two to three from all three dimensions (subtypes for inattention, hyperactivity, and impulsivity) would be best, which will probably increase the prevalence dramatically.

References

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edn. Washington: American Psychiatric Association, 85–93.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5. Washington: American Psychiatric Association, 103–106.

Froehlich, T. E., Lanphear, B. P., Epstein, J. N., Barbaresi, W. J., Katusic, S. K., and Kahn, R. S. (2007). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch. Pediatr. Adolesc. Med. 161, 857–864. doi: 10.1001/archpedi.161.9.857

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Gaub, M., and Carlson, C. L. (1997). Gender differences in ADHD: a meta-analysis and critical review. J. Am. Acad. Child Adolesc. Psychiatry 36, 1036–1045. doi:10.1097/00004583-199708000-00011

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Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., et al. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am. J. Psychiatry 163, 716–723. doi: 10.1176/appi.ajp.163.4.716

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Levy, F., Hay, D. A., McStephen, M., Wood, C., and Waldman, I. (1997). Attention-deficit hyperactivity disorder: a category or a continuum? J. Am. Acad. Child Adolesc. Psychiatry 36, 737–744. doi:10.1097/00004583-199706000-00009

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Pastor, P. N., and Reuben, C. A. (2008). Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004–2006. Vital. Health Stat. 10, 1–14.

Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., and Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am. J. Psychiatry 164, 942–948. doi: 10.1176/appi.ajp.164.6.942

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Smalley, S. L., McGough, J. J., Del’Homme, M., NewDelman, J., Gordon, E., Kim, T., et al. (2000). Familial clustering of symptoms and disruptive behaviors in multiplex families with attention-deficit/hyperactivity disorder. J. Am. Acad. Child Adolesc. Psychiatry 39, 1135–1143. doi:10.1097/00004583-200009000-00013

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Citation: Steinau S (2013) Diagnostic criteria in attention deficit hyperactivity disorder – changes in DSM 5. Front. Psychiatry. 4:49. doi: 10.3389/fpsyt.2013.00049

Received: 29 April 2013; Accepted: 16 May 2013;
Published online: 30 May 2013.

Edited by:

Ahmet O. Caglayan, Yale University, USA

Reviewed by:

Hasan Kandemir, Harran University, Turkey

Copyright: © 2013 Steinau. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and subject to any copyright notices concerning any third-party graphics etc.

*Correspondence: sarah.steinau@uniklinik-freiburg.de