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ADHD Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM), used
in the USA and the rest of the world for the formal diagnosis of attention-deficit
hyperactivity disorder (ADHD), was released by the American Psychiatric Association in
2013 and replaces the previous version (Diagnostic and Statistical Manual of Mental
Disorders – 4th Edition [DSM-IV]).1,2
The DSM-5TM defines ADHD as a persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, has symptoms presenting in
two or more settings (e.g. at home, school, or work; with friends or relatives; in other
activities), and negatively impacts directly on social, academic or occupational
functioning. Several symptoms must have been present before age 12 years.1
-impulsivity that interferes with
functioning or development

Six or more of the symptoms have persisted for at least six months to a degree that is
inconsistent with developmental level and that negatively impacts directly on social and
academic/occupational activities.

yperactive-impulsive symptoms were present prior to age 12 years
-impulsive symptoms are present in two or more settings (e.g. at
home, school, or work; with friends or relatives; in other activities)
evidence that the symptoms interfere with, or reduce the quality of, social, academic
or occupational functioning
disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)
Whilst the fundamental diagnostic criteria for ADHD have not changed in the DSM5TM compared with the previous version, the DSM-5TM has been updated to more accurately
characterize the experience of adolescents and adults with ADHD. This has been achieved
with the inclusion of additional examples to illustrate the types of ADHD-related
behaviors that adolescents and adults with ADHD may exhibit, as well as ADHD-related
behaviors that children may exhibit.1 Furthermore, adults and adolescents (aged ≥17) are
required to present with a minimum of five (rather than six) symptoms, and symptoms
should have been present before age 12 (not before age 7), recognizing that adult recall of
precise childhood onset is difficult.1,2 A pervasive developmental disorder (autism
spectrum disorder) is no longer an exclusion criterion.1 ADHD is now listed in the new
category of ‘Neurodevelopmental Disorders’, acknowledging the growing body of scientific
evidence supporting brain development correlates with ADHD.3
The DSM-5TM notes that although motor symptoms of hyperactivity become less obvious in
adolescence and adulthood, difficulties persist with restlessness, inattention, poor
planning, and impulsivity. The DSM-5TM also acknowledges that a substantial proportion of
children remain relatively impaired into adulthood.1
Presentations of ADHD
Individuals with ADHD may present with both inattention and hyperactivity/impulsivity,
or one symptom pattern may predominate. Three presentations of ADHD are commonly
referred to: combined-type, inattentive-type and hyperactive/impulsive-type (Table 1).
According to the DSM-5TM classification system, the appropriate presentation of ADHD
should be indicated based on the predominant symptom pattern for the last six months.
Combined
All three core features are
present and ADHD is
diagnosed when ≥6
symptoms of
hyperactivity/impulsivity
and ≥6 symptoms of
inattention have been
observed for ≥6 months –
Inattentive
Diagnosed if ≥6 symptoms
of inattention (but <6
symptoms of
hyperactivity/impulsivity)
have persisted for ≥6
months
Hyperactive/impulsive
Diagnosed if ≥6 symptoms
of hyperactivity/impulsivity
(but <6 symptoms of
inattention) have been
present for ≥6 months
Furthermore, the DSM-5TM also states that it must be specified whether the individual
with ADHD is in “partial remission” (when partial ADHD criteria have been met for the
past six months with full criteria met previously, and the symptoms still result in
impairment in social, academic or occupational functioning); and the current severity of
the disease (Table 2).1
Table 2: Current severity of ADHD
Mild
Current Severity of ADHD
Moderate
Few, if any, symptoms in
Symptoms or functional
excess of those required to
impairment between “mild”
make the diagnosis are
and “severe” are present
present, and symptoms
result in no more than minor
impairments in social or
occupational functioning
Severe
Many symptoms in excess of
those required to make the
diagnosis, or several
symptoms that are
particularly severe, are
present; or the symptoms
result in marked impairment
in social or occupational
functioning
Symptoms of ADHD
Three key features define attention-deficit hyperactivity disorder (ADHD)1 or hyperkinetic disorder
(HKD)2 – inattention, hyperactivity and impulsivity – and the contribution of each to an individual’s
presentation of ADHD varies from patient to patient.1 In some individuals, two or more features may
contribute in equal measure; in others, one feature may predominate.1
As different features of ADHD can impair functioning and quality of life in different ways, it is
important to accurately evaluate each patient’s unique symptomatic characteristics, using medical
classification systems such as the Diagnostic and Statistical Manual of Mental Disorders – 5th edition
(DSM-5TM) or the International Classification of Mental and Behavioral Disorders 10th revision (ICD10).1,2 Whereas the ICD-10 characterizes HKD by its “cardinal features” of impaired inattention and
overactivity, the DSM-5TM categorizes patients with ADHD by three main presentations: combinedtype, predominantly inattentive-type and predominantly hyperactive-impulsive-type.1
Inattention is characterized as an individual moving between tasks without completing
any one activity, seemingly losing interest in one task because they become diverted to
another.1,2 Individuals with inattention are often easily distracted and forgetful, and
experience difficulties when organizing activities. At school, children with ADHD may
struggle to listen and be frequently distracted; in the workplace, adults with ADHD may
appear as if their mind is elsewhere and their work may be messy and performed
carelessly (Figure 1).1
Hyperactivity refers to excessive motor activity,1,2 and may present differently
depending on the patient’s age.1 In children, it may present as the child running and
jumping around at inappropriate times, getting up from a seat when he or she is supposed
to remain seated, fidgeting and wriggling, or excessive talkativeness and noisiness.1,2 In
adolescents and adults, hyperactivity may manifest as inner feelings of extreme
restlessness and wearing others out with their activity (Figure 2).1
Impulsivity Individuals with impulsive tendencies can be reckless and appear impatient,
and are often disinhibited in social situations. They may find it difficult to wait their turn,
intruding on or interrupting others’ activities or blurting out answers to a question before
it has been completed (Figure 3).1,2 –