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ADHD in the DSM

DSM (1952)

​The following information describes the history of ADHD in the Diagnostic and Statistics Manual (DSM), the manual that details the criteria for different psychological conditions. The DSM is now on its 5th revision.​ Note that material presented in "quotes" are directly taken from the source material.

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The term "ADHD" or its predecessors (as described below) did not appear in the DSM. The terms that most closely related a set of behaviours that would later evolve into ADHD were

"Minimal Brain Dysfunction” or “Hyperkinetic Impulse Disorder”, though these were not formal diagnostic categories in the DSM.

 

For example, Minimal Brain Dysfunction was used to "describe those children with at least near-average intelligence whose learning and behavioral disabilities are the consequence of certain perceptual, cognitive, and attentive dysfunctions." (Stamm & Kreder, 1979).

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DSM-II (1968)

The precursors of ADHD that first officially appeared in the DSM II  (1968) was 
308.0 Hyperkinetic reaction of childhood (or adolescence)*  
 

”This disorder is characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behaviour usually diminishes in adolescence."

During this era of ADHD history, the condition was believed to occur only in childhood, with individuals outgrowing these features as the entered adolescence.  The diagnostic criteria were brief (the above was literally all it had in DSM II).

"In 1961, Ritalin was approved for treatment of “behavior problems” in children. By the late ’60s, “minimal brain dysfunction” had been broken down into smaller categories that included “dyslexia,” “brain disorders,” and “hyperactivity.” “Hyperactivity” became associated with school-aged children, identified mostly based on classroom performance and behavior." (Romeo, 2021).
 

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Changes to ADHD Diagnosis Over Time

Compiled from CDC (2024); Xu et al., (2018)

DSM-III (1980)

ADHD appeared as Attention Deficit Disorder (ADD) in the DSM-III (1980) and included two subtypes: ADD with Hyperactivity and ADD without Hyperactivity.  To be diagnosed, the child must experience: 


Category A -  Inattention - at least three of the following:

  1. "Often fails to finish things he or she starts

  2. Often doesn't seem to listen

  3. Easily distracted

  4. Has difficulty concentrating on schoolwork or other tasks requiring

  5. Sustained attention

  6. Has difficulty sticking to a play activity"
     

 Category B - Impulsivity - at least three of the following:

  1. "Often acts before thinking

  2. Shifts excessively from one activity to another

  3. Has difficulty organizing work (this not being due to cognitive impairment)

  4. Needs a lot of supervision

  5. Frequently calls out in class

  6. Has difficulty awaiting turn in games or group situations

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Category C -  Hyperactivity -  at least two of the following:

  1. Runs about or climbs on things excessively

  2. Has difficulty sitting still or fidgets excessively

  3. Has difficulty staying seated

  4. Moves about excessively during sleep

  5. Is always "on the go" or acts as if "driven by a motor"

 

Category D - The behaviours must show up before the age of seven.

Category E - The behaviours must be present for at least six months.

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Included a "Residual Type" where child was diagnosed with ADD with hyperactivity, but hyperactivity is no longer present. 

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DSM-III-TR (Text Revision, 1987)

The criteria changed to include a description of the impact of the features in the DSM-III-TR (1987). The features were not broken down by inattention, impulsivity, or hyperactivity, but were combined into one list of features: 


Category A - Displaying at least eight of the following features for a minimum of 6 months:

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  1. "Often fidgets with hands or feet or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)

  2. Has difficulty remaining seated when required to do so

  3. Is easily distracted by extraneous stimuli

  4. Has difficulty awaiting turn in games or group situations

  5. Often blurts out answers to questions before they have been completed

  6. Has difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension), e.g., fails to finish chores

  7. Has difficulty sustaining attention in tasks or play activities

  8. Often shifts from one uncompleted activity to another

  9. Has difficulty playing quietly

  10. Often talks excessively

  11. Often interrupts or intrudes on others, e.g., butts into other children's games

  12. Often does not seem to listen to what is being said to him or her

  13. Often loses things necessary for tasks or activities at school or at home (e.g., toys, pencils, books, assignments)

  14. Often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking
     

Category B - Onset before the age of seven.

Category C - Does not meet the criteria for a Pervasive Developmental Disorder.

 

Criteria for severity of Attention-deficit Hyperactivity Disorder:

  • Mild: Few, if any, symptoms in excess of those required to make the diagnosis and only minimal or no impairment in school and social functioning.

  • Moderate: Symptoms or functional impairment intermediate between "mild" and "severe."

  • Severe: Many symptoms in excess of those required to make the diagnosis and significant and pervasive impairment in functioning at home and school and with peers.

In DSM-III and DSM-III-TR, the prevalence (i.e., number of people with the condition)  of ADD/ADHD was ~ 3%, with the condition more being more likely to be diagnosed in boys versus girls. 
 
Familial pattern: In DSM-III, the familial pattern was "unknown." By DSM-III-TR (7 years later), ADHD was believed to be more common in first-degree biologic relatives of people with ADHD than in the general population.

DSM-IV (1994) and DSM-IV-TR (text revision, 2000)

DSM-IV (1994) and DSM-IV-TR (2000) first introduced subtypes for ADHD. 

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314.00 Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type

This subtype is given if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months.

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314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type  This subtype is given if  six (or more) symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) have persisted for at least 6 months

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314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type

This subtype is given if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months.

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Category A - Inattention: Must have 6 (or more) of: 

  1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

  2. Often has difficulty sustaining attention in tasks or play

  3. Often does not seem to listen when spoken to directly

  4. 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)

  5. Often has difficulty organizing tasks and activities

  6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

  7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

  8. Is often easily distracted by extraneous stimuli

  9. Is often forgetful in daily activities

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Category B - Hyperactivity/Impulsivity: Must have 6 (or more) of:

  1. Often fidgets with hands or feet or squirms in seat

  2. Often leaves seat in classroom or in other situations in which remaining seated is expected

  3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

  4. Often has difficulty playing or engaging in leisure activities quietly

  5. Is often "on the go" or often acts as if "driven by a motor"

  6. Often talks excessively

  7. Often blurts out answers before questions have been completed

  8. Often has difficulty awaiting turn

  9. Often interrupts or intrudes on others (e.g., butts into conversations or games)

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Also required:

Some hyperactive-impulsive or inattentive symptoms must be present before age 7 years

Symptoms must be present in two or more settings (e.g., at school [or work] and at home).

There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Individuals who currently have symptoms that no longer meet full criteria are coded as  "In Partial Remission"

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During DSM-IV era, ADHD was more frequent in males than in females, with male-to-female ratios ranging from 4:1 to 9:1, depending on the setting (i.e., general population or clinics)


Key Changes in DSM-5 included:
1. raising the age of onset from age 7 to age 12,
2. Adding adult criteria (described below),
3. ADHD became recognized as a lifespan condition, rather than a condition of childhood,
4. Subtypes re-coined as "presentations'

The prevalence of ADHD changed from ~ 6% during DSM-III to DSM-IV eras to ~10% in DSM-5 (Xu et al., 2018)

DSM-5 (2013) 

They switched from Roman numerals to numbers with the 5th edition. 

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DSM-5 included specific rules for diagnosing criteria ADHD in children and adults. 

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Category A - Inattention

Six (or more) features for children or five (or more) features individuals 17+ years old that lasts for  at least 6 months:

  1. Often fails to give close attention to details or makes careless mistakes.

  2. Often has difficulty sustaining attention.

  3. Often does not seem to listen when spoken to directly.

  4. Often does not follow through on instructions and fails to finish tasks.

  5. Often has difficulty organizing tasks and activities.

  6. Often avoids or dislikes tasks requiring sustained mental effort.

  7. Often loses things necessary for tasks.

  8. Is easily distracted by extraneous stimuli.

  9. Is often forgetful in daily activities.

 

Category B -  Hyperactivity and Impulsivity

Six (or more) features for children or five (or more) features individuals 17+ years old that lasts for  at least 6 months:

  1. Often fidgets or squirms in seat.

  2. Often leaves seat when remaining seated is expected.

  3. Often runs or climbs in inappropriate situations (or feels restless).

  4. Often unable to play or engage in activities quietly.

  5. Is often “on the go” or acts as if “driven by a motor.”

  6. Often talks excessively.

  7. Often blurts out answers before questions are completed.

  8. Often has difficulty waiting turn.

  9. Often interrupts or intrudes on others.

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ADHD Presentations (formerly called subtypes)

  • Combined Presentation: Criteria met for both inattention and hyperactivity-impulsivity.

  • Predominantly Inattentive Presentation: Criteria met for inattention but not hyperactivity-impulsivity.

  • Predominantly Hyperactive/Impulsive Presentation: Criteria met for hyperactivity-impulsivity but not inattention.

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Additional Criteria

  • Several features must be present before age 12.

  • Features must be present in two or more settings (e.g., home, school, work).

  • There must be clear evidence of interference with social, academic, or occupational functioning.

References

​American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders.​

American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.).​

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.).

​American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.).

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

CDC (2024). ADHD Throughout the Years. www.cdc.gov

Romeo, J. (2021). ADHD: The history of diagnosis. JStor Daily. https://daily.jstor.org/adhd-the-history-of-a-diagnosis/

Stamm, J. S., & Kreder, S.V. (1979). Minimal Brain Dysfunction: Psychological and Neurophysiological Disorders in    

     Hyperkinetic Children. In: Gazzaniga, M.S. (eds) Neuropsychology. Handbook of Behavioral Neurobiology, vol 2. Springer,      Boston, MA. https://doi.org/10.1007/978-1-4613-3944-1_6

Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder Among       US Children and Adolescents, 1997-2016. JAMA Netw Open. 2018;1(4):e181471.              
      https://doi.org/10.1001/jamanetworkopen.2018.1471

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