ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

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?

ADHD in Adults: Diagnostic Problems and Solutions

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

• the individual meets five out of nine listed symptoms of inattentiveness and/or five out of nine listed symptoms of hyperactivity/impulsivity
• symptoms were present before age 12
• symptoms are persistent and significantly interfere with major life activities and/or result in significant suffering

Problem: DSM Symptoms Do Not Reflect Adult ADHD

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.

[Read: Your Complete ADHD Diagnosis and Testing Guide]

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.

Solution: Adjust the Adult ADHD DSM to Reflect Executive Dysfunction

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 individual is time-blind; there is a lack of attention to future events and preparing for them over time
• The individual is less likely to resist goal-irrelevant distractions
• The individual has trouble re-engaging with the task after their attention has been diverted (indicative of deficient working memory)

[Learn: The Adult ADHD Mind – Executive Function Connections]

Solution: Expand the Adult ADHD DSM to Include Disinhibition

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:

• Motor disinhibition (hyperactivity): This declines markedly with age so that by adulthood, it’s reflected in seat restlessness and internal, subjective feelings of restlessness and needing to be busy. External motor function should factor less heavily into the adult assessment.
• Verbal: Excessive speech and lack of inhibition around others. By adulthood, verbal impulsivity actually becomes a standout symptom.

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

• Cognitive impulsivity: Impulsive decision-making and poor contemplation
• Motivational impulsivity: Greater discounting of future (delayed) rewards – the individual can’t generate the motivation to complete a task if the reward is too distant. They may opt for an immediate reward instead because they more steeply devalue the delayed reward as a function of its delay than do typical adults.
• Emotional impulsivity: Absolutely central to ADHD, this realm is defined as impulsive expression of raw emotions and poor self-regulation of strong emotions. There’s an immaturity in the inhibition of emotion that characterizes ADHD and separates it from a mood disorder like disruptive mood dysregulation disorder (DMDD) or BPD.

Problem: ADHD Onset Age is Arbitrarily Fixed in DSM

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.

Solution: Subtract Years and Differentiate by Sex

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.

Problem: DSM Definition of ‘Impairment’ is Subjective

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:

• Being held back a grade
• Being kicked out of school
• Losing your driver’s license
• Difficulties with work-related promotions
• Marital/cohabiting problems and violence
• Impaired parenting
• Accidental injuries
• Risky sexual behavior
• Substance abuse

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.

ADHD in Adults: Treatment

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:

• Awareness: The patient should understand that ADHD is a broader problem with executive functioning, and it can be highly impairing without treatment. The patient should “own” their disorder and feel like a committed stakeholder in the treatment plan.
• Medication: Moderate to severe ADHD absolutely warrants medication; this is the most effective treatment available – bar none. Along with medication, clinicians should encourage patients to engage in preventive medical and dental care, given the known health risks, earlier mortality risk, and reduced life expectancy linked to ADHD.
• Behavior modification: Cognitive behavior therapy (CBT) targeting the executive function deficits, coaching, and mindfulness training are just some ways to change behaviors to reduce impairment from ADHD in adults.
• Accommodations: Changes to the workplace, home, and/or educational setting should hit at the weak points of performance and executive function. This means
  • externalizing time by using analog clocks and timers
  • offloading memory by putting information onto notes
  • increasing self-motivation by seeking external accountability

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.

ADHD in Adults: Next Steps

• Self-Test: Do I Have ADHD? Symptom Screener for Adults
• Download: “Do I Have ADHD?” Your Free Guide
• How-To: Choosing a Professional to Diagnose and Treat Your ADHD

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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