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.
The Diagnostic and Statistical Manual of Mental Disorders lists
the symptoms required to establish a diagnosis of ADHD. Throughout the 50 year
history of the manual, these criteria--the official definition of ADHD--have
evolved with each new edition. This is a short history of that evolution, plus
the currently accepted criteria.
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
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
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
(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 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
- 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
- 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
(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).
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