What are the DSM‑5 diagnostic criteria for Attention‑Deficit/Hyperactivity Disorder?

DSM-5 Diagnostic Criteria for ADHD

To diagnose ADHD, clinicians must verify that DSM-5 criteria are met through documentation of specific symptom thresholds, age of onset before 12 years, functional impairment in at least two settings, and exclusion of alternative explanations. 1, 2

Core Symptom Requirements

Children (Ages 6-12)

• Six or more symptoms from either the inattentive category OR the hyperactive-impulsive category (or both for combined presentation) must be present 1
• Symptoms must persist for at least 6 months 2

Adolescents and Adults (Age 12+)

• Five or more symptoms from either the inattentive category OR the hyperactive-impulsive category (or both for combined presentation) must be present 2
• This represents a lower threshold than for younger children, reflecting developmental changes in symptom expression 2, 3

Preschool Children (Ages 4-5)

• DSM-5 criteria can appropriately identify ADHD in this age group, though determining symptom presence across multiple settings is particularly challenging 1, 4

Mandatory Age of Onset Criterion

• Several symptoms must have been present before age 12 years, even when retrospective documentation is limited 1, 2, 5, 3
• This represents a critical change from DSM-IV, which required onset before age 7 2
• For adolescents presenting without prior diagnosis, clinicians must establish that manifestations existed before age 12 through collateral history 1, 5

Cross-Situational Impairment Requirement

• Symptoms and functional impairment must be documented in two or more major settings (home, school, work, social activities, or occupational environments) 1, 4, 2, 5
• Information must be obtained from multiple sources: parents/guardians, teachers, other school personnel, and mental health clinicians involved in care 1, 2, 5
• For adolescents, obtain information from at least two teachers or alternative sources such as coaches, school counselors, or community activity leaders 1

Common pitfall: Diagnosing ADHD when symptoms are reported in only one setting often reflects situational or contextual problems rather than true ADHD 4

Three Presentation Types

The DSM-5 defines distinct presentations based on symptom patterns 1:

1. Predominantly Inattentive Presentation (314.00 [F90.0]): Meets symptom threshold for inattention but not hyperactivity-impulsivity 1

2. Predominantly Hyperactive-Impulsive Presentation (314.01 [F90.1]): Meets symptom threshold for hyperactivity-impulsivity but not inattention 1

3. Combined Presentation (314.01 [F90.2]): Meets symptom thresholds for both inattention and hyperactivity-impulsivity 1

4. Other Specified and Unspecified ADHD (314.01 [F90.8]): Used when clinically significant ADHD-like impairment exists but full criteria cannot be verified, typically due to insufficient information from multiple settings or inability to confirm symptom onset before age 12 4

Mandatory Exclusion Criteria

Before assigning an ADHD diagnosis, clinicians must rule out alternative explanations 1, 2:

• Symptoms are NOT better explained by oppositional behavior, defiance, hostility, or failure to understand tasks 2
• Symptoms are NOT better explained by another mental disorder: psychotic disorder, mood disorder, anxiety disorder, dissociative disorder, or personality disorder 2
• For adolescents, strongly consider whether substance use, depression, or anxiety are present as mimicking or comorbid conditions 1, 5
• Trauma experiences, posttraumatic stress disorder, and toxic stress must be evaluated as potential alternative explanations 1, 5

Critical pitfall for adolescents: Certain substances like marijuana can mimic ADHD symptoms, and adolescents may feign symptoms to obtain stimulant medication for performance enhancement 1

Required Comorbidity Screening

• Screening for comorbid conditions is mandatory, not optional, as the majority of children with ADHD meet criteria for another mental disorder 1, 4, 2, 5

Screen for:

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use 1, 2, 5
• Developmental conditions: learning disabilities, language disorders, autism spectrum disorders 1, 2, 5
• Physical conditions: tics, sleep disorders 1, 2

Note that sleep disorders are not diagnostic criteria for ADHD but should be screened as possible comorbid conditions that might mimic ADHD symptoms 4

Functional Impairment Documentation

• Clear evidence that symptoms interfere with or reduce quality of functioning in interpersonal, academic, or occupational domains is required 2
• The ability to consistently complete tasks suggests absence of significant functional impairment and contradicts the core ADHD symptom of inattention 4

Subthreshold Presentations

• Children demonstrating ADHD-like behaviors who do not fully meet DSM-5 criteria may still benefit from behavioral interventions such as parent training in behavior management 1, 4
• These programs do not require a specific diagnosis to be beneficial and allow treatment of functionally impairing symptoms while avoiding premature diagnostic labeling 4
• Diagnostic criteria should be closely reviewed with additional information from multiple settings before concluding criteria are not met 1, 4