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Diagnostic Manual of Psychiatric Disorders

Disorders / June 26, 2022

The Diagnostic and Statistical Manual of Mental Disorders includes standardized diagnostic criteria for many psychiatric disorders. First published by the American Psychiatric Association in 1952, the manual is used as a resource by the majority of mental health professionals. In its earlier editions, many clinicians considered the DSM merely a tool for researchers. Now, in an era of managed care, clinicians are often forced to rely on the standardized criteria in the DSM in order to remit insurance claims. And its impact goes even further. If a condition is acknowledged by the DSM, it can be credibly used in a legal defense, or in a disability claim. In the case of ADHD, a diagnosis can mean that a child is entitled to receive special educational services from his or her school district.

In its 50-year history, the DSM has been significantly updated four times-in 1968, in 1980, in 1987, and in 1994. It wasn't until the second edition was published in 1968 that a disorder resembling ADHD appeared in the DSM. The "hyperkinetic reaction of childhood" was defined as a type of hyperactivity. It was characterized by a short attention span, hyperactivity, and restlessness.

In the third edition of the manual (DSM-III) published in 1980, the name of this childhood disorder was changed to Attention Deficit Disorder (ADD), and its definition was expanded. The new definition was based on the assumption that attention difficulties are sometimes independent of impulse problems and hyperactivity. Therefore, the disorder was redefined as primarily a problem of inattention, rather than of hyperactivity. In keeping with this approach, two subtypes of ADD were presented in DSM-III-ADD/H, with hyperactivity, and ADD/WO, without hyperactivity.

The inclusion of ADD/WO has been the subject of debate ever since. When the third edition of the manual was revised in 1987 (DSM-IIIR), the name of the disorder and its diagnostic criteria had been overhauled, once again emphasizing hyperactivity. The authors now called it Attention Deficit Hyperactivity Disorder (ADHD), and consolidated the symptoms into a unidimensional disorder, without any subtypes at all. This definition did away with the possibility that an individual could have the disorder without being hyperactive.

After the publication of the DSM-IIIR, a variety of studies were published supporting the existence of ADD without hyperactivity, and the definition was changed again in the fourth, and most recent, edition of the manual published in 1994 (DSM-IV). The authors did not change the name ADHD, but the symptoms were divided into two categories-inattentive and hyperactive/impulsive-and three subtypes of the disorder were defined: ADHD, Primarily Inattentive; ADHD, Primarily Hyperactive/Impulsive; and ADHD, Combined Type.

The DSM-IV listing attempts to describe the typical manner in which ADHD manifests in affected children-when symptoms appear, when parents and caretakers can reasonably expect the symptoms to attenuate, and what factors may complicate the diagnosis of ADHD.

The DSM-IV urges clinicians to use caution when considering an ADHD diagnosis under certain circumstances. The manual notes, for example, that it is difficult to diagnose ADHD in children who are younger than 4 or 5 years of age because the variability in normal behavior for toddlers is much greater than that of older children. It also recommends that evaluators use caution in diagnosing adults with ADHD solely on the adults' recollection of symptoms they experienced as a child. This "retrospective data, " according to the DSM-IV, is sometimes unreliable.

Below are the current diagnostic criteria for ADHD, taken from the text-revised edition of the DSM-IV, which was published in the summer of 2000. Note that this excerpt comprises only a fraction of the DSM-IV's entry on ADHD, and it should be used only for informational purposes. It is not intended for self-diagnosis or for use by anyone other than a qualified health professional.

(A) Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level;

  • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • often has difficulty sustaining attention in tasks or play activities
  • often does not seem to listen when spoken to directly
  • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • often has difficulty organizing tasks and activities
  • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  • is often easily distracted by extraneous stimuli
  • is often forgetful in daily activities
(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
  • often fidgets with hands or feet or squirms in seat
  • often leaves seat in classroom or in other situations in which remaining seated is expected
  • often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  • often has difficulty playing or engaging in leisure activities quietly
  • is often "on the go" or often acts as if "driven by a motor"
  • often talks excessively
  • often blurts out answers before questions have been completed
  • often has difficulty awaiting turn
  • often interrupts or intrudes on others (e.g., butts into conversations or games)

(B) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

(C) Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

(D) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

(E) The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder).