Demystifying the DSM Definition of ADHD

Demystifying the DSM-IV(TR) definition of Attention Deficit Hyperactivity Disorder (ADHD) can be a rather bewildering endeavor. If you have read the medical criteria for diagnosing ADHD, you might be feeling confused and skeptical. The qualifications for ADHD are broad and seem like they could be applied to anyone. If you are a family member or someone diagnosed with ADHD, it can sometimes be challenging to understand why the ADHD label even exists in the first place. What does it all mean for you? Here are a few hits that will help in understanding what in the world the DSM means by “ADHD”.

The term DSM stands for the Diagnostic and Statistical Manual. It is written by psychologists and psychiatrists from the American Psychological Association (APA). ADHD is often times referred to as ADD. ADHD is the most current medical term, but both are widely understood to mean the same thing.

There are five essential characteristics of an individual with ADHD according to the DSM-IV(TR):

“1) Persistent pattern of inattention and/or hyperactivity/impulsivity that is more frequently displayed and more severe than is typically observed in individuals at comparable level of development.

2) Some hyperactive-impulsive or inattentive symptoms must have been present before seven years of age.

3) Some impairment from the symptoms must be present in at least two settings.

4) There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning.

5) The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder.”

There are some important things to note here that are potentially confusing. You may be reading the first essential characteristic, and thinking to yourself “What is beyond the typical behavior of kids? Isn’t this what a lot of kids are like? What does it mean by ‘inattention’ and ‘hyperactivity/impulsivity’?” You are right to ask those questions. Lots of kids are overactive. Lots of kids have difficulty paying attention. While mental health labels can feel confining and sometimes insulting, they serve two important purposes. First they allow for accurate and effective treatment. If you don’t know what the problem is, then you can not fix it. Second, if you ever need assistance from Disability Services (i.e. getting extended time on an exam) you need to have an official diagnosis. Understanding the symptoms can be difficult when, for example, you are from a family with a history of ADHD. What is “normal” to you might look very different than what is actually “average” compared to the rest of the world. It is important to get multiple outside opinions in order to piece together a clear picture. Ask teachers, friends, peers, family, and anyone who sees you regularly about what patterns they have seen.
The symptoms and behaviors of ADHD are divided into two general categories: inattention and hyperactivity/impulsivity. An individual may show more of one set of symptoms than the other, but BOTH must be present. There are over a dozen symptoms given, but a child must exhibit SIX from each subset. The full list can be seen here: adhdtesting.org/dsm-iv.htm
Here are a select few quoted examples from the DSM regarding inattention:

Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities. Often has difficulty distaining attention in tasks or play activity. 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).

And regarding hyperactivity/impulsivity:

Often fidgets with hands or feet or squirms in seat. Often leave 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 and adults, may be limited to subjective feelings of restlessness). Often interrupts or intrudes on others (e.g. butts into conversations or games).

Inattention is often mistaken for forgetfulness, flakiness, or laziness. Hyperactivity can look like a lack of inhibition or care for consequences. These are negative misconceptions that can take a toll on a person’s self-esteem and success in the classroom or work. You may notice that a lot of the behaviors from the DSM sound like what a child or pre-teen would do, and more so for boys than girls. Adults and girls are more likely to exhibit more subtle symptoms of ADHD and thus may be more difficult to diagnose. From a young age girls are taught to be passive and quiet. So instead of disrupting class, a girl with ADHD may either find ways of entertaining herself (doodling, daydreaming, etc.) or may become depressed and anxious because she has difficulty fitting into “normal” behavior and blames herself for it. Girls are far more likely than boys to place blame on themselves for bad things, and give credit to others (or “luck”) for good things. For more information regarding ADHD in girls and women, I recommend reading “Understanding Women with AD/HD” by Kathleen Nadeau and Patricia Quinn. In adults, their energy levels are different; they know themselves better and have learned strategies to compensate. They are also in very different settings. So ADHD for an adult may look a lot different, but the basic ideas of inattention and hyperactivity/impulsivity are the same. For helpful information and interesting reading about adults with ADHD I recommend “You Mean I’m Not Lazy, Stupid or Crazy?!” by Kate Kelly and Peggy Ramundo.

Going back to the original five features of ADHD, the second feature is a bit more helpful and easy to understand. ADHD cannot be diagnosed unless there are symptoms present before the age of seven. This does not mean that you cannot be diagnosed if there are no documentations of your behavior at that age. Often times just the recall of memories by yourself or close family members is enough to meet this criteria.

The third feature is essential. A person cannot be diagnosed if their symptoms are only present in school, or only present at home. It must occur in more than one setting. This is to ensure that the behavior is not caused by outside factors (like maybe a boring teacher or bullying sibling).

The fourth criteria is a bit tricky. Someone cannot be diagnosed with ANY mental disorder unless it is so severe that it interferes with that person’s daily life. ADHD may go undiagnosed for years because the individual has above average intelligence and knows how to compensate for their difficulties. They may not feel overwhelmed by tasks until they are in college or starting a new family and have lots of responsibilities. Often times a parent will have their child diagnosed with ADHD, then realize that they may also have it. If you are an adult with ADHD, this pattern may sound very familiar.

The fifth criteria is fairly self-explanatory. If you are diagnosed with some other disorder (such as bi-polar disorder or post-traumatic stress disorder) or physical disease (thyroid disease is commonly confused with ADHD), your symptoms must not be completely explained by that previous diagnosis. That is NOT to say that you cannot have multiple diagnoses with ADHD. It is actually fairly common for someone with ADHD to also be diagnosed with depression or anxiety or any number of other comorbid disorders (occurring simultaneously but independent of each other). If you have already been diagnosed with some other disorder, it is still advisable to talk to a mental health professional about your ADHD concerns.

No two ADHD people act the same or have the same exact symptoms. The most important thing for that person is getting the help and attention they need, whether they have the ADHD diagnosis or not. If you or someone you know is forgetful, gets frustrated, anxious or depressed easily, and is struggling on a daily basis, it is time to seek help. The only way to do that is by talking with a licensed mental health professional.

References:
American Psychiatric Association. (2000). Attention-deficit and disruptive behavior disorders. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed., pp 85-93). Arlington: Author.
Kelly, K. & Ramundo, P. (2006) You Mean I’m Not Lazy, Stupid or Crazy?!: The Classic Self-Help Book for Adults with Attention Deficit Disorder. Scribner.
Nadeau, K & Quinn, P (2002) Understanding Women with AD/HD. Advantage Books.


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