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Comprehensive Psychiatry 68 (2016) 56 – 59
www.elsevier.com/locate/comppsych

New DSM-5 criteria for ADHD — Does it matter?

Tohar Rigler a , Iris Manor b , Adie Kalansky a , Zamir Shorer a , Iris Noyman a , Yair Sadaka a,⁎
a
Soroka Medical Center, Beer Sheva, Israel
b
Geha Mental Health Center, Petach Tikva, Israel

Abstract

Objective: The new Diagnostic Statistical Manual (DSM) requires the presence of fewer symptoms to make a diagnosis of adult ADHD
while the criteria for diagnosis in childhood are unchanged as compared to previous editions. This study examines the prevalence of adults
meeting the revised DSM-5 symptoms cutoff as compared to the previous DSM-IV symptoms cutoff.
Method: This study is part of a larger nationwide study that evaluated the use of, and the attitudes toward, ADHD medications by university
students. 445 students from four major university faculties were surveyed and filled out questionnaires for our study.
Results: The proportion of participants that met the minimum threshold of six out of nine current symptoms in either of the two DSM-IV
symptom domains (inattentive presentation and hyperactive/impulsive presentation) for ADHD was 12.7% while the proportion that met the
minimum threshold of five symptoms in either of the DSM-5 symptom domains was 21%.
Conclusion: Since the new DSM requires fewer current symptoms for a diagnosis of ADHD, a significant increase (65%) was observed in
the number of participants meeting the new cutoff as compared to the old DSM-IV symptoms cutoff. This increase in the number of adults
meeting symptoms cutoff may affect the rates of adults diagnosed with ADHD. Using the new criteria may identify more adults with ADHD
and fewer diagnoses will be missed. However, meeting the new symptoms cutoff should be considered within the overall clinical context to
prevent over-diagnosis.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction work related difficulties, drug and alcohol addiction, and

legal troubles [10–16]. In an attempt to more accurately
Attention deficit hyperactivity disorder (ADHD) is the characterize the experience of affected adults, the criteria of
most common neurobehavioral disorder in childhood [1,2]; a ADHD have been updated in the DSM-5.
significant number of individuals diagnosed with ADHD as The main changes to the DSM-5 edition include changing
children continue to experience the disorder as adults. the required age of onset from seven years to twelve years,
According to a United States national comorbidity survey and requiring fewer symptoms to diagnose adult ADHD.
conducted in 2006 based on the Diagnostic and Statistical Under the DSM-IV's previous guidelines, during childhood
Manual of mental disorder (DSM) IV criteria, the estimated at least six out of nine symptoms must be present to be
prevalence of ADHD among adults was 4.4% [3]. diagnosed in either of the two domains of ADHD, inattentive
As individuals with ADHD move from childhood to subtype or hyperactive/impulsive subtype. Having six
adolescence and adulthood, there are fewer DSM ADHD symptoms or more in both symptom domains was required
symptoms present, and the severity of these symptoms tends for the diagnosis of ADHD combined subtype. Under the
to decrease [4–9]. However, these adolescents and young DSM-IV's guidelines, a potential lower cutoff was suspected
adults are prone to significant academic, interpersonal and for adolescents and adults, but the exact cutoff was not
defined. The new DSM-5 criteria now require only five
symptoms per category for diagnosis to reflect recent
⁎ Corresponding author at: Soroka Medical Center, Pediatric Depart- findings that there is a decline in symptoms as patients age.
ment, Beer Sheva, Israel, 84101.
The diagnosis of ADHD is contingent upon the presence
E-mail addresses: tohar_2@hotmail.com (T. Rigler),
dr.iris.manor@gmail.com (I. Manor), adiekalansky@gmail.com of other conditions in addition to meeting ADHD symptoms
(A. Kalansky), zshorer@bgu.ac.il (Z. Shorer), iris@noyman.com criteria. These include the presence of symptoms before age
(I. Noyman), yair.sadaka@gmail.com (Y. Sadaka). 12 and evidence that the symptoms interfere with or reduce
http://dx.doi.org/10.1016/j.comppsych.2016.03.008
0010-440X/© 2016 Elsevier Inc. All rights reserved.
 T. Rigler et al. / Comprehensive Psychiatry 68 (2016) 56–59 57

the quality of two or more life settings (social, school, or the size of the respective university campus (Table 1).
work) and that the symptoms are not better explained by Students were sampled from each year of their university
another mental disorder. training to represent their different levels of training.
However, since the new criteria changes require fewer Sample size calculated by CDC EPI Info 7 with
symptoms to suspect ADHD, it may significantly affect the confidence level of 95%. The relative sample of students
overall prevalence of adults meeting the new symptom and residents in each field studied is presented.
criteria, and it may affect overall predictive values of the
DSM criteria which may eventually influence the number of 2.3. Questionnaire
adults diagnosed with ADHD. This pilot study examines the
The questionnaire included five different sections.
prevalence of adults meeting the revised symptoms cutoff in
Section 1 included demographics and background informa-
the DSM-5 as compared to the previous DSM-IV criteria.
tion (age, sex, institution, level of training). Section 2
To our knowledge, no similar publications have examined
included the 18 DSM symptoms for ADHD (based on Adult
this matter.
ADHD Self-Report Rating Scale). Section 3 included the
relative academic achievements of the participants. Section 4
asked about the attitudes of the students and residents with
2. Materials and methods regard to the use of and the effect of ADHD medications for
2.1. Study design people with and without a diagnosis of ADHD. Section 5
asked about the study participants' previous official
This study received institutional review board approval. diagnosis with ADHD and about previous experience with
The study was conducted from September 2013 to January ADHD medications.
2014. This study is a part of a larger national study that
evaluates the use of and the attitudes toward ADHD 2.4. Statistical analysis
medications by pediatric residents and university students
Chi square test was used to evaluate statistical signifi-
studying medicine, psychology, and engineering. Represen-
cance in the analysis of contingency tables using Graph Pad
tative samples of 445 students were taken from these
Quick Calcs.
populations to participate in the current study. University
student participants were approached by a study coordinator
during scheduled class time and received the study 3. Results
questionnaire to fill out immediately. The short question-
naires were completed and collected within the interaction A total of 445 students and pediatric residents were
with the study coordinator. About 80% of the approached sampled from four major representative university faculties.
students returned the questionnaire. Questionnaires were The demographic characteristics of the population sampled
randomly sampled for further analysis to represent the for this study are depicted in Table 2.
relative number of students in each academic faculty, and the
various level of training as further discussed below. Medical 3.1. ADHD DSM symptoms criteria
residents were approached during their department's morn-
ing meeting during a one day study visit to their hospital. The proportion of participants that met the minimum
threshold of six out of nine symptoms in either of the two
2.2. Study sample DSM-IV symptom domains (inattentive domain and hyper-
active/impulsive domain) for ADHD was 12.7% while the
Four major universities and five major hospitals were proportion of participants that met the minimum threshold of
sampled. Sample size was determined based on CDC EPI five symptoms in either of the DSM-5 symptom domains for
Info 7 with a 95% confidence level. In total, 445 students and ADHD diagnostic criteria was 21% (Fig. 1). The new criteria
residents were sampled from a total of 7980 students and
medical residents who attended these universities and
Table 2
participated in the hospital pediatric residencies during the
Demographic characteristics.
course of the study. To equally represent students from
Study population Total
different universities, samples were proportionally based on
Gender: female, n (%)/male, n (%)/NI 203 (46%)/236 (53%)/6 (1%)
Average age (SD) 26.7 (3.8)
Table 1 Faculty, n (%)
Sample size. Medicine 131 (29%)
Psychology 123 (27%)
Pediatric Engineering Psychology Medical Confidence Engineering 133 (30%)
residents students students students Level Pediatric residents 58 (13%)
58 133 123 131 95% Previous diagnosis, n (%) 58 (13%)
100 3652 1860 2368 Number Number (n), not inclusive (NI), standard deviation (SD).
58 T. Rigler et al. / Comprehensive Psychiatry 68 (2016) 56–59

4. Discussion

This study examines the prevalence of university students

and pediatric residents meeting the new DSM-5 require-
ments (meeting five out of nine criteria) of the DSM-5 versus
the requirements (six out of nine criteria) of the DSM-IV.
As expected, since current DSM-5 criteria require fewer
symptoms, a significant increase (65%) was observed in the
number of participants meeting the updated symptoms cutoff
(21% vs. 12.7%).
We suggest using self-rating scale measures for adult ADHD
diagnosis cautiously since using self-reported ratings can lead to
Fig. 1. The proportion of participants that met the symptoms cutoff of very high rates of ADHD diagnosis. The change from six to five
DSM-5 versus DSM-IV in any of the symptoms domain. Ped = pediatric symptoms as a cutoff for each symptom domain in the new
residents, med = medicine, psy = psychology, en = engineering.
DSM-5 significantly influenced the number of adults meeting
ADHD symptoms cutoff based on self-reported symptoms.
Thus, the presence of significant impairment should be
emphasized as a crucial requirement for diagnosis of ADHD.
yielded a significantly higher proportion of students that could The findings of this study must be tempered by the fact
potentially be diagnosed with ADHD (chi square test, two-tailed that the evaluation of symptoms cutoff is based on self-rated
P value is less than 0.0001), with a 65% increase in the number scales. Also, meeting the ADHD symptoms cutoff is not
of participants meeting the new DSM symptoms cutoff. sufficient for the diagnosis of ADHD. The diagnosis of
ADHD may be diagnosed in any of the following ADHD requires the presence of other conditions in addition
subtypes: inattentive, hyperactive/impulsive, and combined to symptoms. This includes the presence of symptoms before
subtype. We have evaluated the effect of using the new age 12 and evidence that the symptoms interfere with or
DSM-5 on each category separately. As demonstrated in Fig. reduce the quality of two or more life settings (social, school,
2, 4% of the participants met symptoms cutoff for inattentive or work) and that the symptoms are not better explained by
subtype by DSM-IV while 6.5% met the DSM-5 symptoms another mental disorder. These additional criteria are
cutoff (62% increase, chi square test, two-tailed P value essential for a proper diagnosis of ADHD. For example,
equals 0.05). Similarly, 4% of the participants met criteria for Willcutt et al. [17], examined prevalence rates and found that
hyperactive/impulsive subtype by DSM-IV while 6.5% met ratings of ADHD symptoms from a single rater gave a
the DSM-5 criteria (62% increase, chi square test, two-tailed prevalence in the range of 9% (parent ratings) to 13%
P value equals 0.05). When evaluating the combined (teacher ratings). However when all criteria were applied, the
subtype, 4.7% of the participants met DSM-IV criteria prevalence for the diagnostic criteria was estimated to be
while 8% met the DSM-5 criteria (70% increase, chi square only 5.9%. These finding suggest that incorporating all
test, two-tailed P value equals 0.009). necessary criteria would drop the prevalence rate from 21%
to around 10% in our study population. Accordingly, in our
study, 13% of the participants reported an ADHD diagnosis
made by a physician.
In our study both the rate of adults meeting symptoms
cutoff (21%), and the rate of previous ADHD diagnosis
made officially by a physician (13%) are relatively high. In
the literature, adult ADHD prevalence ranges between 1.2%
and 7.3% [3,18]. We believe that these differences are due to
the unique population examined in our study: medical
residents and high achieving university students, most of
them in relevant fields of medicine and psychology. These
students have experienced demanding and prolonged
cognitive efforts that may have revealed ADHD functional
deficits and they are expected to be familiar with the
condition and the overall benefits of diagnosing and treating
it. Though the prevalence of ADHD among this population is
Fig. 2. Meeting DSM-5 versus DSM-IV symptoms cutoff for different unclear, previous studies have already found higher rates of
ADHD clinical subtypes: inattentive, hyperactive/impulsive and combined.
Meeting symptoms cutoff for any of the clinical subtypes was increased at
ADHD medication use among these students. In 2006, an
least by 62%. HYPER = HYPERACTIVE/IMPULSIVE, INATTEN = internet survey in the USA found that 5.9% of students use
INATTENTIVE. ADHD medications [19]. However, much higher rates of
 T. Rigler et al. / Comprehensive Psychiatry 68 (2016) 56–59 59

stimulant use were reported in students in competitive emphasize informant reports, DSM items, and impairment. J Consult
faculties such as psychology (35%) [20] and among medical Clin Psychol 2012;80(6):1052-61.
[9] Barkley RA. Challenges in diagnosing adults with ADHD. J Clin
students (14%) [21]. Psychiatry 2008;69(12):e36.
We did not attempt to evaluate the effect of the new DSM [10] Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent
threshold for age of onset. However, other studies have outcome of hyperactive children diagnosed by research criteria: I. an 8-
examined the effect of the changes made in the new DSM year prospective follow-up study. J Am Acad Child Adolesc
criteria with a focus on the age of onset. Lin et al. found adult Psychiatry 1990;29(4):546-57.
[11] Fischer M, Barkley RA, Edelbrock CS, Smallish L. The adolescent
ADHD patients with an older age of onset were actually outcome of hyperactive children diagnosed by research criteria: II.
more symptomatic than those with an earlier age of onset academic, attentional, and neuropsychological status. J Consult Clin
[22]. An interesting study done by Moffitt et al. examined a Psychol 1990;58(5):580-8.
cohort from birth to age 38, and found that the childhood [12] Barkley RA. Global issues related to the impact of untreated attention-
ADHD and adult ADHD groups comprise virtually non- deficit/hyperactivity disorder from childhood to young adulthood.
Postgrad Med 2008;120(3):48-59.
overlapping sets: 90% of adult ADHD lacked a history of [13] Charach A, Yeung E, Climans T, Lillie E. Childhood attention-deficit/
childhood ADHD [23]. These findings suggest that the age hyperactivity disorder and future substance use disorders: comparative
of onset may be less significant in diagnosing adult ADHD. meta-analyses. J Am Acad Child Adolesc Psychiatry 2011;50(1):9-21.
Furthermore, the meaning of self-rated ADHD symptoms in [14] Lee SS, Humphreys KL, Flory K, Liu R, Glass K. Prospective
association of childhood attention-deficit/hyperactivity disorder
adults is unclear since it does not reflect the same entity of
(ADHD) and substance use and abuse/dependence: a meta-analytic
childhood ADHD, or adults who had ADHD when they review. Clin Psychol Rev 2011;31(3):328-41.
were young. [15] Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ.
Long-term school outcomes for children with attention-deficit/
hyperactivity disorder: a population-based perspective. J Dev Behav
References Pediatr 2007;28(4):265-73.
[16] Kuriyan AB, Pelham Jr WE, Molina BS, Waschbusch DA, Gnagy EM,
[1] Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer Sibley MH, et al. Young adult educational and vocational outcomes
JC, et al. Mental health surveillance among children — United States, of children diagnosed with ADHD. J Abnorm Child Psychol
2005–2011. MMWR Surveill Summ 2013;62(Suppl 2):1-35. 2013;41(1):27-41.
[2] Akinbami LJ, Liu X, Pastor PN, Reuben CA. Attention deficit [17] Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity
hyperactivity disorder among children aged 5–17 years in the United disorder: a meta-analytic review. Neurotherapeutics 2012;9(3):490-9.
States. NCHS Data Brief 1998–2009;2011(70):1-8. [18] Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demyttenaere
[3] Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, K, et al. Cross-national prevalence and correlates of adult attention-deficit
et al. The prevalence and correlates of adult ADHD in the United hyperactivity disorder. Br J Psychiatry 2007;190:402-9.
States: results from the National Comorbidity Survey Replication. Am [19] Teter CJ, McCabe SE, LaGrange K, Cranford JA, Boyd CJ. Illicit
J Psychiatry 2006;163(4):716-23. use of specific prescription stimulants among college students:
[4] Hart EL, Lahey BB, Loeber R, Applegate B, Frick PJ. Developmental prevalence, motives, and routes of administration. Pharmacotherapy
change in attention-deficit hyperactivity disorder in boys: a four-year 2006;26(10):1501-10.
longitudinal study. J Abnorm Child Psychol 1995;23(6):729-49. [20] KG Low. Illicit use of psychostimulants among college students: a
[5] Fischer M, Barkley RA, Fletcher KE, Smallish L. The stability of preliminary study. Psychol Health Med 2002;7:283-287.
dimensions of behavior in ADHD and normal children over an 8-year [21] Finger G, Silva ER, Falavigna A. Use of methylphenidate among medical
followup. J Abnorm Child Psychol 1993;21(3):315-37. students: a systematic review. Rev Assoc Med Bras 2013;59(3):285-9.
[6] Willoughby MT. Developmental course of ADHD symptomatology [22] Lin YJ, Lo KW, Yang LK, Gau SS. Validation of DSM-5 age-of-onset
during the transition from childhood to adolescence: a review with criterion of attention deficit/hyperactivity disorder (ADHD) in adults:
recommendations. J Child Psychol Psychiatry 2003;44(1):88-106. comparison of life quality, functional impairment, and family function.
[7] Sibley MH, Pelham Jr WE, Molina BS, Gnagy EM, Waschbusch DA, Res Dev Disabil 2015;47:48-60.
Garefino AC, et al. Diagnosing ADHD in adolescence. J Consult Clin [23] Moffitt TE, Houts R, Asherson P, Belsky DW, Corcoran DL, Hammerle M,
Psychol 2012;80(1):139-50. et al. Is adult ADHD a childhood-onset neurodevelopmental disorder?
[8] Sibley MH, Pelham WE, Molina BS, Gnagy EM, Waxmonsky JG, Evidence from a four-decade longitudinal cohort study. Am J Psychiatry
Waschbusch DA, et al. When diagnosing ADHD in young adults 2015;172(10):967-77.