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Key points
- ADHD is defined by clinical characteristics, as there are no definitive other tests.
- There should be new criteria that reflect changing ideas about ADHD like considering the context of electronic distractions and comorbidities.
- Family history should always be part of the assessment.
In our last blog post (Part 2 of 3), we mentioned biologically-based tools that might allow doctors to objectively diagnose ADHD in the coming century. However, we are not there yet. Today, we take a look at how we imagine clinical criteria for ADHD might change even sooner, in the next decade or two.
Currently, the American Psychiatry Association's DSM (Diagnostic and Statistical Manual) is the bedrock of diagnosis. This book (currently on edition 5) is the product of expert discussions and committee meetings where leaders in the field review evidence and agree on what should - and should not - be part of the diagnosis of ADHD (and other psychiatric disorders). In the interest of space, we will not list all criteria here but provide a link: ADHD DSM-5 criteria.
Others have created and suggested criteria. Drs. Hallowell and Ratey, authors of the seminal work "Driven to Distraction," have proposed adult ADHD criteria, and Dr. Russell Barkeley has developed rating scales.
Here are some of our own ideas for future criteria consideration:
1. Separate ADHD criteria for adults and children:
Current DSM criteria are essentially the same whether you are age 7, 17, 37, or 67. The only difference is the minimum number of criteria you have to meet as a child vs. adult (6 for kids vs. 5 for adults 17 and over, in either the hyperactive/impulsive category or inattentive category).
However, kid and adult lives are very different: Like going to school versus work - these activities require different cognitive skills and often have different behavioral expectations. A second distinction is being cared for by parents versus being independent. We would propose school-age (through college) criteria versus separate adult criteria. Adults and children simply lead very different lives, and ADHD has very distinct consequences in adults compared to children. For example, adult ADHD criteria might include car accidents, getting fired frequently, or certain types of run-ins with the law. Similarly, adult criteria might focus more squarely on interpersonal difficulties with spouses or romantic partners, as opposed to teachers in school.
Adults also have coping mechanisms kids don't. Some adults with ADHD haven’t “grown out of” their core attentional and organizational issues but compensate by relying, or even over-relying, on skills they didn’t have as children. An example is a child who frequently loses things but grows into an extremely careful and organized adult, at least in some areas of their life. This can even superficially resemble features of Obsessive-Compulsive Disorder (OCD) and it's only by careful questioning about the psychological and behavioral origins of this behavior that a diagnostician can detect the difference.
2. Distinguishing “hyperactive” vs. “impulsive.”
The current “3 core components” of ADHD are inattention, hyperactivity, and impulsivity, yet "presentations" of ADHD are limited to "inattentive", "hyperactive/impulsive" or "combined". In other words, DSM-5 lumps core hyperactive and impulsive features together diagnostically. This is based on historical and other considerations, but hyperactivity and impulsivity are distinguishable practically and behaviorally. Hyperactive traits are characterized by a physical “need to move”. Impulsive traits include a tendency to do or say things without inhibition and can include increased risk-taking behavior. While rare, we have seen cases of “predominantly impulsive” ADHD in adults, without any significant symptoms of either hyperactivity or inattention, although (as with other presentations) other core ADHD features may have been more evident in childhood.
3. Adding emotional issues as a “core component” of ADHD.
There is a growing body of evidence that people with ADHD have an additional 'core' dysfunction in emotional regulation, including a tendency for fluctuating moods and increased anxiety. This may actually be more prominent in adults than in children and could contribute to increasing issues with low self-esteem, interpersonal conflict, and anxiety as ADHDers age1. Should this be recognized as an additional “core component” of ADHD?
4. How much should continuity over the lifespan be considered?
Current criteria stress continuance of some variety of ADHD symptoms (though with changes in presentation) across the lifespan.
We agree that ADHD is a lifelong condition. But as noted above, symptoms can be less obvious in adulthood because the adult patient has adapted their lifestyle and developed coping mechanisms that compensate partly for their ADHD. The reverse can also be true: Sometimes it is difficult to elicit a clear history of childhood ADHD symptoms in an adult who clearly has the disorder. This can be due to many factors, including the presence of substantial parental involvement and academic intervention as a child, psychological and cultural denial on the part of the patient and/or their parents, homeschooling or a non-traditional education instead of the traditional classroom experience, or even that the patient is so darned smart that their inattentiveness never caused any noticeable problems in grade or high school, but has become a problem in college or professionally.
5. Should electronic distractions be considered?
We believe that people who spend significant amounts of time on screens and other electronic devices could diminish their attention span and in that way, develop or worsen ADHD symptoms. Currently, this is not explicitly addressed in DSM-5. For example, if a teen is on recreational screens (Instagram, TikTok, etc.) 8 hours a day and has trouble concentrating in her real life, should this be a consideration either for or against the diagnosis?
6. ...And what about electronic/biometric tests for ADHD?
Building on the last point, current continuous performance tests (CPT-3, visual TOVA, etc) for ADHD that are supposed to offer objective evidence of inattention and impulsiveness, are often screen-based. How accurate are these likely to be for a naturally competitive patient who is an expert "gamer" because of all the time he spends daily on screens - although he can't pay attention, get organized, or make headway elsewhere in his life? Other psychiatric comorbidities (see below) can also affect performance on these tests. That said, these and other automated tests are getting increasingly sophisticated as digital, AI, eye/activity-tracking, and other technologies rapidly march forward. We should be prepared for the increasing presence of these types of tests in the ADHD diagnostic sphere.
7. How to interpret comorbidities.
As with all other psychiatric disorders, the criteria for ADHD in DSM-5 include the phrase, “The symptoms are not better explained by another mental disorder.” Every diagnosis in the DSM-5 includes this phraseology, meaning the clinician should always consider other diagnoses as well as the one under primary consideration, and choose the one (or fewest) diagnosis/es that explain the patient’s symptoms. This is a very sensible and basic principle across medicine, but it is scientifically a bit outdated in terms of applicability to mental disorders: Clinical and basic scientific research support that there is a lot of biological overlap and comorbidity among psychiatric disorders generally. For ADHD, there is high comorbidity with depression, anxiety, OCD, and substance abuse. Often symptoms of these other conditions are substantially improved by adequate treatment of ADHD and vice versa. Should future editions of DSM more explicitly recognize this, not just for ADHD but for other psychiatric disorders as well?
8. Family history of ADHD.
Drs. Hallowell and Ratey have included this in their ADHD criteria, and we agree. Current estimates for the heritability of ADHD average about 70% and go as high as 90%. There are reasons not to make this an absolute criterion for ADHD (for example, different concepts and biases towards attentional issues and other mental disorders in previous generations). That said, we always ask about family history of attentional issues, and it is exceedingly rare (as in single digits in a hundred patient evals) that a patient reports that no other family member has attentional problems. So, in our opinion taking a family history should always be part of the assessment, and when it is positive it’s another reason to strongly consider the diagnosis.
In the 22nd century, unpredictable cultural shifts, basic research, and clinical research will all lead to changes in how we define ADHD. But it’s not too early to start considering how our definition of ADHD should be modified sooner rather than later.
References
Barkley, R. A. (2010). Deficient Emotional Self-Regulation: A Core Component of Attention-Deficit/Hyperactivity Disorder. Journal of ADHD and Related Disorders 1, 5-37,
Graziano, P. A. & Garcia, A. (2016). Attention-deficit hyperactivity disorder and children’s emotion dysregulation: A meta-analysis. Clin Psychol Rev 46, 106-23,
https://apsard.org/adhd-and-emotional-dysregulation/#:~:text=One%20of%2….
