The Need for New Symptom Tests and Diagnostic Criteria for ADHD in Adults

Most clinicians today evaluate adult ADHD symptoms through one of two lenses: strictly adhering to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the view of the informed clinician or researcher who adjusts these criteria based on the relevant research literature.

More often than not, the latter considers the DSM-5 criteria on its own too narrow and confining – even problematic – for accurately assessing an adult’s symptoms of attention deficit hyperactivity disorder (ADHD or ADD). And they are right. The DSM-5 criteria for ADHD — from arbitrary age cut-offs to ambiguous symptom descriptions — is concerning because it does not accurately reflect the observed experiences of individuals in this specific population or applicable research. The informed ADHD clinician knows this and uses first-hand clinical and research knowledge to develop effective management and treatment strategies. Which raises the question: Is the DSM-5 helping or hurting the accurate diagnosis of ADHD in adults?

According to the DSM-5, an ADHD diagnosis in adults is warranted, in part, if:

The ADHD symptoms listed in the DSM were developed for children. We can see this in the phrasing of certain symptoms, such as “can’t play quietly” or “driven by a motor” in the hyperactive/impulsive items. These phrasings don’t translate well to the adult experience. Few adults with ADHD would use these terms to describe their daily experience with the condition, leaving clinicians to extrapolate these items into clinical practice with adults.

Some DSM-5 symptoms do include parenthetical clarifications meant to capture adolescent and adult experiences. These changes may have led to a rise in ADHD diagnoses, because they count as additional symptoms even when the root symptom they modify is not endorsed. But the lingering issue is that these phrases were essentially invented by DSM-5 committees. Little to no effort was made to empirically test them for their relationship to ADHD, to the root symptom they clarify, and to the extent they facilitate accurate diagnosis. Additionally, no guidance was offered as to whether these phrases should clarify existing symptoms or be treated as “new” symptoms. This is a significant problem.

Our recent research found a very low correlation between many of these clarifications and their root symptoms in the DSM-5. In the parenthetical comment for the inattentiveness symptom of seeming absentmindedness when spoken to, for example, the symptom actually appears to be as much or more related to anxiety, making it a poor symptom for ADHD.

It may be best for clinicians to simply ignore these parenthetical comments for now, and work with the patient to get a better understanding of symptoms, which can certainly stand to be reworked in both domains.

The DSM-5’s list of symptoms associated with ADHD – especially those reflecting inattention, should be renamed or broadened for adults. A better way to think about and detect these symptoms are as problems with executive functioning (EF). These metacognitive functions – self-awareness, working memory, self-motivation, and more – allow us to meet goals. With ADHD, persistence is deficient for a variety of reasons rooted executive dysfunction:

The DSM-5 lists too many unspecific and inapplicable symptoms of hyperactivity for adults. Paying more attention to cross-modal presentations of impulsivity provides a better method of assessment:

The following symptoms of impulsivity are not stated outright in DSM-5 criteria, but they are significant facets of adult ADHD:

The DSM-5 states that several symptoms of ADHD must present before age 12 to merit a diagnosis. But nature does not respect a number like “12” — the onset of ADHD symptoms in people’s lives can actually occur at any point in time. In the vast majority of cases, ADHD symptoms do present before age 18 or 21. But there’s still a small percentage (up to 10 percent) who fit outside these parameters, or who may even develop acquired ADHD. An extreme sports athlete, for example, who sustained lots of head traumas can theoretically develop a form of ADHD secondary to traumatic brain injury (TBI).

What’s more, parents of children with ADHD tend to inaccurately recall the age of onset of symptoms. Most parents are actually off by about three to five years, far later than actually documented in charts, according to our research. Adults make the same mistake when assessing their own symptoms. Thus, the age of onset criterion is too unreliable for us in diagnosis.

Clinicians should still ask the patient about age of onset, but age should not be a lynchpin for core diagnostic purposes. One rule of thumb is to subtract three to five years from the age provided as likely reflecting a more accurate onset. But in general the age of onset should be ignored as a diagnostic criterion.

It’s also critical to note that the DSM’s symptom threshold or cutoff for a diagnosis of ADHD was based on field trials that included more boys than girls. Clinicians should factor in these discrepancies by using rating scales that have norms that are unique to each sex. This is especially so when evaluating girls and women. As for the five-symptom threshold requirement for diagnosis, research has shown that four symptoms, at least for adults, is enough to indicate the presence of ADHD.

How much ineffective functioning is enough to prove the presence of ADHD? While vague in the DSM-5, true impairment may be determined by clinicians looking at the major domains — health, occupation, education, driving, relationships — and assessing whether adverse or negative consequences have occurred because of ADHD behaviors. These negative consequences can include but are not limited to:

ADHD adversely affects self-awareness, which can cause individuals to under-report symptoms and levels of impairment. To counter this, self-reports must be corroborated by someone who knows the patient well. These accounts should also be checked against documented records.

Why does weak or incomplete DSM-5 criteria matter? ADHD is one of the most impairing outpatient disorders. If left undiagnosed and untreated (or improperly diagnosed and treated), ADHD can impact quality of life and pose significant health problems. ADHD, however, remains among the most treatable disorders in psychiatry.

The components of an optimal ADHD treatment program should include:

I also recommend that adults learn about and choose ADHD-friendly occupations. These professions typically allow for more physical movement, require fewer periods of sustained attention, are more flexible, provide for more immediate feedback and accountability, and play to the individual’s strengths.

The content for this article was derived from the ADDitude Expert Webinar “Navigating the Life Stages of ADHD: Key Concerns in Diagnosing and Treating Adults with ADHD” by Russell Barkley, Ph.D. (available as ADDitude ADHD Experts Podcast episode #323), which was broadcast live on September 8, 2020. Dr. Barkley is a Clinical Professor of Psychiatry at Virginia Commonwealth University Medical Center in Richmond, VA and is the author of Taking Charge of Adult ADHD (#CommissionsEarned) (Guilford Press), among many other books, clinical manuals, and rating scales.

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