What is the DSM 5 and Why Should You Care?

We invited Dr. Mark Bertin to try to answer this question. In this article, Dr. Bertin explains significant changes in how ADHD is classified and identified. It's complicated, but worth taking the time to read and understand! 

In an ongoing attempt to accurately describe diagnoses in the field of child development and psychiatry, The Diagnostic and Statistical Manual of Mental Disorders (DSM) is revised every ten years. Regarding ADHD, improved identification and understanding of its cause in the DSM 5 could go a long way to clarifying common public misperceptions. Issues such as apparent over-diagnosis in certain communities, and medication misuse, incite provocative headlines that often undermine care for people actually living with ADHD.

Classification Changes 

For starters, the DSM5 redefines ADHD as a neurodevelopmental disorder.  When previously grouped with conditions such as oppositional defiant disorder, ADHD could be easily misconstrued as primarily a behavioral condition.  It is not.  Many well-behaved individuals wrestle with more internal symptoms (such as difficulty with planning, organization and time management) alone.  This re-categorization offsets the common misconception that ADHD is merely a behavior problem.

Unsurprisingly for a neurodevelopmental disorder, ADHD evolves as the brain matures, typically shifting towards more internal manifestations. Because of this variability, the DSM5 removes the concept of ADHD subtypes (such as inattentive versus hyperactive). Instead, it describes ‘predominant' symptoms (e.g. ADHD with predominantly hyperactive features, or ADHD with predominantly inattentive features) and rates severity (mild to severe).  This is far more important than academic discussion of subtype because it is supports individuals, none of whom have exactly the same ADHD and all of whom will change over time.  However, some researchers do argue that certain individuals with inattention have a condition related to but distinct from ADHD.

The DSM5 also removes the old ‘exclusion criteria' stating ADHD and autism cannot be diagnosed together.   The neurodevelopmental field has become defined by the idea of ‘comorbidity' – not only can conditions occur together, they most often do.  This vital change ends years of distracting debate between the two possible diagnoses, when the frequent answer is that both are present.

Diagnostic Changes

At its simplest, clinicians identify ADHD from an ‘inattentive' or a ‘hyperactive/ impulsive' checklist of possible symptoms.  Diagnosis is based on observable, real life behaviors because physical tests (such as brain scans or computer tests) and neuropsychological testing do not yet accurately identify ADHD on their own.  The DSM5 broadens symptom explanations, helping providers recognize the wide range of ways ADHD reveals itself.

A core aspect of diagnosis remains documenting where ADHD impacts life.   If someone has ADHD traits that do not undermine anything at all, they do not have ADHD.   On the other hand, impairments no longer need be as broad as ‘failing school.'  Underperformance at work (but not getting fired), stressed relationships (short of divorce), poor self-esteem and countless other struggles relate to ADHD.  The DSM5, therefore, modifies the wording from ‘impairing' to ‘interfering with' life on a consistent basis.

In making a diagnosis, clinicians intend to show that ADHD symptoms represent a pattern across life.   The DSM5 still looks for symptoms in two settings, but now states that ADHD only need interfere with life in one. Many people experience apparently isolated difficulties; for example, someone may notice no concerns outside of academic difficulties. In reality ADHD most often affects broader details, even in this situation, but the most intense disruption may be more limited.

Managing Adult ADHD

Adults remain one of the most challenging areas of ADHD diagnosis.  With children, plentiful information to create a global picture is available from parents, teachers, therapists, and others.  Adults do not always have the same luxury, and diagnosis can be confounded by an emphasis on self-reporting.

The new DSM stresses the need for multiple information sources.   Spouses or partners may collaborate, and parents or school information may confirm early-onset symptoms.  While not always possible, this emphasis on broader documentation remains the ideal.

Additionally, the DSM5 asks for symptom onset described before twelve years of age, instead of seven.  Adults more accurately recall these later symptoms, and ADHD sometimes reveals itself only as expectations rise across childhood. Lastly, five instead of six symptoms of inattention or hyperactivity/impulsiveness are now required for adult diagnosis, as many ADHD symptoms resolve or become less obvious over time.

Adult ADHD represents an often-disabling impairment impacting jobs, families, and well-being.  While concerns have been raised that the DSM5 could lead to adult over-diagnosis, that is unlikely. With an estimated adult ADHD prevalence of around 4 - 5%, in one study only 10% of these adults reported being under care.  Increasing public awareness and facilitating diagnosis should only help people find the support they need.

Giving Attention to Executive Function

In spite of its name, ADHD is no longer seen as a disorder of attention, hyperactivity or impulsivity alone.  These symptoms occur as part of a larger umbrella of difficulties in executive function, representing all the cognitive abilities used to manage our lives, plan, and self-regulate.  Challenges with executive function clarify the need for everything from parenting and behavioral supports, to educational interventions, to the potential benefits and limitations of medication.

While a growing consensus defines ADHD in this way, the team that created the DSM5 version felt the research not quite conclusive.   Executive function is challenging to measure, and can be impaired in conditions other than ADHD.  Studies have even found individuals with ADHD who do not appear to have executive function impairments at all.   While on a practical level accurate ADHD diagnosis and effective treatment follow from an understanding of executive function, for now the textbook remains the same.

Looking Forward

For the sake of each individual with ADHD, we need to separate public health issues (which are real) from the medical impact of having ADHD (which is just as real).   Societal-level concerns change nothing for an accurately diagnosed individual wrestling with ADHD.  Misunderstandings and under-treatment will persist around ADHD until we define it as a chronic and highly heritable medical disorder of executive function.   While not yet addressing this larger ADHD view, the DSM5 steps forward toward a time when ADHD will be both accepted and skillfully addressed around the world.