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TYPE Perspective
PUBLISHED 10 January 2023
DOI 10.3389/fpsyt.2022.1064141
OPEN ACCESS
EDITED BY
Martin Whitely,
Curtin University, Australia
REVIEWED BY
Carolyn Quadrio,
University of New South
Wales, Australia
Melissa K. Raven,
University of Adelaide, Australia
*CORRESPONDENCE
Juho Honkasilta
juho.honkasilta@helsinki.fi
†These authors have contributed
equally to this work
SPECIALTY SECTION
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
RECEIVED 07 October 2022
ACCEPTED 07 December 2022
PUBLISHED 10 January 2023
CITATION
Koutsoklenis A and Honkasilta J (2023)
ADHD in the DSM-5-TR: What has
changed and what has not.
Front. Psychiatry 13:1064141.
doi: 10.3389/fpsyt.2022.1064141
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©2023 Koutsoklenis and Honkasilta.
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not comply with these terms.
ADHD in the DSM-5-TR: What
has changed and what has not
Athanasios Koutsoklenis1† and Juho Honkasilta2*†
1Department of Primary Education, Democritus University of Thrace, Alexandroupolis, Greece,
2Faculty of Educational Sciences, University of Helsinki, Helsinki, Finland
In this article, we critically review the changes made to the DSM-5 Text
Revision published in 2022 regarding the diagnostic entity of Attention
Deficit/Hyperactivity Disorder (ADHD). We structure our critique around
three points. The first discusses the acknowledgment of ADHD as a
neurodevelopmental disorder. The second examines the definition of ADHD
provided in the updated edition of the manual. The third scrutinizes the
changes in the diagnostic criteria for ADHD and assesses whether these
changes make the diagnosis more accurate. We conclude that DSM’s latest
edition does not escape the logical and scientific pitfalls of its predecessor.
DSM-5-TR keeps the faith in the neo-Kraepelinian paradigm by explicitly and
implicitly cultivating the essentialist medical scientific metaphor of disorder,
creating the illusion that it represents scientific progress that validates ADHD
as a neurodevelopmental disorder.
KEYWORDS
ADHD, DSM-5-TR, revisions, American Psychiatric Association, diagnosis, diagnostic
manual
1. Introduction
From the publication of the third edition in 1980 and on, the Diagnostic and
Statistical Manual of Mental Disorders (DSM) has embraced psychiatry as a branch of
medicine by committing to a “neo-Kraepelinian” cause-effect biomedical framework
with the assumption that biological discoveries will eventually establish the somatic
etiology of separate and independent mental diseases (1). This paradigm shift was
not based on promising scientific discoveries but on pragmatic consensus [see, for
a discussion (2,3)]. By the time of publishing DSM-5 in 2013, the continuous
medicalization of natural human responses led by APA became increasingly critiqued
within psychiatry [e.g., (3)], mental health sector [e.g., (4)], practitioners, and academia
in general. Debates surrounding the critical reception of DSM-5 primarily relate to the
pseudo-scientific nature of the manual and its normalizing power (5).
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In this opinion paper, we critically review the changes
made to the DSM-5 Text Revision published in 2022 regarding
the diagnostic entity of Attention Deficit/Hyperactivity
Disorder (ADHD). We structure our critique around three
points. The first discusses the acknowledgment of ADHD as
a neurodevelopmental disorder. The second examines the
definition of ADHD provided in the updated edition of the
manual. The third scrutinizes the changes in the diagnostic
criteria for ADHD and assesses whether these changes make the
diagnosis more accurate. We point out how DSM-5-TR keeps
the faith in the neo-Kraepelinian paradigm by explicitly and
implicitly cultivating the essentialist medical scientific metaphor
of disorder.
2. Placement within
“neurodevelopmental disorders”
As in its predecessor, ADHD is placed within the manual’s
chapter “Neurodevelopmental Disorders”. According to the
DSM-5-TR neurodevelopmental disorders “are characterized
by developmental deficits or differences in brain processes
that produce impairments of personal, social, academic, or
occupational functioning” (p. 36). The authors of the manual
assert that issues relevant to the placement of ADHD have
been resolved by the available data “with the preponderance
of evidence supporting placement in the “Neurodevelopmental
Disorders” chapter” [(6), p. 13]. This assertion is strengthened
in section “Risk and Prognostic Factors”, which is more
detailed than in DSM-5. The authors state that heritability is
approximately 74% and that genome-wide association studies
(GWAS) “have identified a number of loci enriched in
evolutionarily constrained genomic regions and loss-of-function
genes as well as around brain-expressed regulatory regions.”
(p. 72).
However, as the authors of DSM-5-TR themselves
explicitly admit, the discoveries that could confirm ADHD
as a neurodevelopmental disorder have not yet materialized.
Specifically, DSM-5-TR authors state that “no biological
marker is diagnostic for ADHD” and that “meta-analysis of
all neuroimaging studies do not show differences between
individuals with ADHD and control subjects”, thus “no form
of neuroimaging can be used for diagnosis of ADHD” [(6), p.
73]. Apart from what is already stated in DSM, there is no hard
evidence available in the literature which proves that ADHD is
a brain disorder—something that denotes a deficit in people’s
brains [for a discussion, see American Psychiatric Association
(7), Batstra et al. (8), Schleim (9)].
The authors of DSM also leave unmentioned that the 74%
heritability estimate stems from twin-studies, which as a method
cannot reliably disentangle genetic from environmental factors
for psychiatric presentations [see, Joseph (10)]. GWAS on the
other hand yield a heritability estimate of 22%, and their
suggestive findings mentioned in the manual are yet lacking
convincing replication [e.g., (11)]. This challenges research to
account for the ∼50% gap in the assumed familial transmission
of ADHD, however, the authors of DSM have remained silent
about this.
The DSM-5-TR retains the same comment on the role
of social context as its predecessor. More specifically, it
is stated that “signs of the disorder may be minimal or
absent when the individual is receiving frequent rewards
for appropriate behavior, is under close supervision, is in a
novel setting, is engaged in especially interesting activities, has
consistent external stimulation (e.g., via electronic screens),
or is interacting in one-on-one situations (e.g., the clinician’s
office)” [(6), p. 71]. It is apparent that this statement
contradicts the conceptualization of ADHD provided in the
manual by undermining its existence as neurodevelopmental
disorder; how can frequent rewards, close supervision, novel
settings and interesting activities make a neurodevelopmental
disorder disappear?
Moreover, the DSM-5-TR includes a new and very
interesting statement in the “Prevalence” section: “prevalence
is higher in special populations such as foster children or
correctional settings” [(6), p. 72]. By merely stating the fact
without further discussion about psychosocial factors related
to ADHD diagnoses among population living in such settings,
the DSM-5-TR implies the role the alleged neurodevelopmental
disorder plays in these adverse life trajectories. The likelihood
that these children and young people have experienced trauma
and abuse at homes [see, for example, (12,13)] is not mentioned.
Other social factors that correlate with the manifestation of
inattentive, compulsive and/or hyperkinetic behaviors are not
discussed, such as poverty and socioeconomic hardship (14,15),
childhood trauma (16,17), child maltreatment (18), death in
the family (19), low family cohesion (20), parental psychiatric
disorder (19), parental separation (19), parental criminality (19),
household dysfunction (21), familial incarceration (14) and
parental long-term unemployment (22).
Leaving these factors out of the manual does not weaken the
neurodevelopmental hypothesis of behaviors and functioning
associated with the diagnostic category, as brain is a plastic
organ which development is affected by adverse life experiences.
However, silence about the complexity of the role of psychosocial
factors for the development of inattentive, compulsive and
hyperkinetic behaviors throughout the manual, and particularly
in connection with ADHD and foster or correctional setting,
implies essentialism. This bias toward biopsychological factors
is strengthened in section “Risk and Prognostic Factors”, where
psychosocial factors are vaguely referred to by noting that
“[f]amily interaction patterns in early childhood are unlikely
to cause ADHD but may influence its course or contribute
to secondary development of conduct problems” [(6), p. 73].
Thus, ADHD is assumed to expose affected individuals to being
vulnerable to adversities.
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Essentialist neuropathological premise are also assumed
in the section “Diagnostic Features”, in which it is stated
that the “essential feature of attention-deficit/hyperactivity
disorder (ADHD) is a persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with functioning or
development” [(6), p. 70]. It is difficult to comprehend how
children’s” own behaviors interfere with development without
explicating what kinds of development trajectories are in
question: neurodevelopment, school success, employment,
health or what? The non-biological developmental trajectories
are listed as functional consequences, thus, implying that
it is neurological development that is interfered here.
Understandably the logic here is that inattentive and/or
hyperactive-impulsive behaviors affect ability to function,
which in turn affects development, including that of the
brain. However, these behaviors let alone their potential
interferences with functioning imply psychosocial, societal,
and sociocultural aspects of development that in turn can
have biopsychological effects—not the other way around. And
again, this implied assertion of neuropathology—or whatever is
assumed to cause inattention and/or hyperactivity-impulsivity
that interferes development—is overtly invalidated by the
authors themselves by stating the lack of evidence supporting
brain disorder hypotheses.
3. Definition
The definition of ADHD remains the same in DSM-5-TR in
comparison to DSM-5. More specifically, it is stated that “ADHD
is a neurodevelopmental disorder defined by impairing levels of
inattention, disorganization, and/or hyperactivity-impulsivity.
Inattention and disorganization entail inability to stay on
task, seeming not to listen, and losing materials necessary for
tasks, at levels that are inconsistent with age or developmental
level. Hyperactivity-impulsivity entails overactivity, fidgeting,
inability to stay seated, intruding into other people’s activities,
and inability to wait— symptoms that are excessive for age
or developmental level” [6, p. 37]. This definition retains
the circular logic of the previous edition, that is “if A
then B, and if B then A.” (23). For the case of ADHD
specifically, this is translated to: “if an individual has attention
deficit hyperactivity disorder it is because he is inattentive,
disorganized and hyperactive-impulsive, and if an individual is
inattentive, disorganized and hyperactive-impulsive it is because
he has ADHD.
Without concrete and objective evidence of an identifiable
brain disorder there is nothing that explains behaviors
associated with ADHD diagnosis. ADHD as a diagnostic
entity remains a descriptive classification of behaviors, not an
explanation for them. When behaviors are explained by using
a descriptive classification, adhering to circular reasoning is
inescapable. Tautology is thus inevitably disguised as scientific
explanation (24). A characteristic example of this tautology is
evident in the section “Functional Consequences of Attention-
Deficit/Hyperactivity Disorder”. The section states that “ADHD
is associated with reduced school performance and academic
attainment” [(6), p. 73] which are already entailed in the
diagnostic criteria in the first place. Thus, with “nothing for
ADHD to be actually tied to, all that remains are observations
about behavior [sic], which then act as both an indicator of,
and the defining criteria for, that initial disorder” [(23), p. 251].
In circular reasoning the argument refers to nothing outside
of itself.
4. Diagnostic criteria
The diagnostic criteria for ADHD in DSM-5-TR remained
identical with those that appear in the previous edition. In a
recently published paper [i.e., (25)] we have provided a thorough
critique of the accuracy of DSM-5 diagnostic criteria for ADHD.
To do that we have used as a blueprint the criticism for
descriptive diagnoses articulated by Kirk et al. (24). In our paper
we concluded that DSM-5 diagnostic criteria for ADHD are
ambiguous, redundant, and arbitrary (25). We also concluded
that they are ableist in the sense that they fortify normality and
that they pay inadequate attention to context and agency (25).
Since no changes were made in the diagnostic criteria for ADHD
in the DSM-5-TR our critique can be applied as such. Therefore,
we assert that no “precision” and subsequently no “enhanced
precision” can be claimed for the diagnostic criteria of ADHD
in the revised edition.
At this point we would also like to refer to the
categories of “Other Specified Attention-Deficit/Hyperactivity
Disorder” and “Unspecified Attention-Deficit/Hyperactivity
Disorder”1that were also present in the previous edition.
Both categories apply when “symptoms characteristic of
attention deficit/ hyperactivity disorder that cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do
not meet the full criteria for attention-deficit/hyperactivity
disorder or any of the disorders in the neurodevelopmental
disorders diagnostic class” [(6), p. 77]. That is, an individual is
1 The category “Other Specified Attention-Deficit/Hyperactivity
Disorder” is used in situations in which the clinician chooses to
communicate the specific reason that the presentation does not
meet the criteria for attention-deficit/hyperactivity disorder or any
specific neurodevelopmental disorder. The category ‘Unspecified
Attention-Deficit/Hyperactivity Disorder’ is used ‘in situations in which
the clinician chooses not to specify the reason that the criteria are
not met for attention deficit/hyperactivity disorder or for a specific
neurodevelopmental disorder, and includes presentations in which there
is insucient information to make a more specific diagnosis [(6), p. 77].
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diagnosed regardless of not meeting the diagnostic criteria for
the disorder.
In DSM-5, differences between males and females in
the frequency of ADHD (more frequent in males) and the
presentation of primarily inattentive features (females more
likely) were briefly discussed under section “Gender-related
Diagnostic Issues”. No explicit or implicit reference to potential
causes or factors leading to these differences were made. DSM-
5-TR presents two changes in this section. The tittle is changed
to “Sex- and Gender- Related Diagnostic Issues”, making a
conceptual distinction between biological notion of sex and
psychological, social, historical, and cultural aspects related to
biological sex (i.e., gender). Also, one sentence is added, stating
that differences in “ADHD symptom severity may be due to
differing genetic and cognitive liabilities between sexes” [(6),
p. 73].
Thus, in contrast to the previous edition, the authors of
DSM-5-TR explicitly imply the connection between inherent
features and the manifestation of so-called symptoms according
to sex. This attribution is strengthened by making a distinction
between sex and gender yet saying nothing about gender-
related factors (there is also silence about gender in “Culture-
Related Diagnostic Issues” section). Instead, diagnostic issues
related to sex and gender are reduced to biopsychological
aspects and assumptions related to female/male binary (i.e., sex)
(26). This is an example of essentialism. ADHD is portrayed
as having a fixed essence (i.e., genetic, neurodevelopmental
dysfunction) attributable to differences in binary sexes. This
completely disregards the socially constructed roles, behaviors,
expressions, and identities related to gender pluralism let alone
how sociocultural aspects (e.g., gender roles, cis normativity)
are intertwined with psychosocial aspects that may manifest as
behaviors deemed “symptoms” [see, for example, (27)].
Culture-related normative assumptions regarding behaviors
are discussed in the section about “Culture-Related Diagnostic
Issues” in similar fashion to the previous version of the manual,
that is, cultural bias in diagnostic practices is acknowledged.
Some apparent improvements have also taken place, suggesting
the need for “culturally competent diagnostic practices [. . . ]
in assessing ADHD” [(6), p. 73]. In addition to the previous
version, the interconnectedness of social class, race, and
ethnicity in both seeking for the diagnosis for schooling (namely
“non-Latinx White” parents) and affecting informant symptom
rating are mentioned. Also, DSM-5-TR has been reviewed and
revised by a Work Group on Ethnoracial Equity and Inclusion,
which can be seen in replacement of “Latino” with “Latinx”,
and in acknowledging of social oppression and racialization and
their interconnectedness with diagnosing.
In line with the previous version, ADHD is portrayed
as a neurodevelopmental condition within an individual
caused by natural development processes over which etiology
psychosocial, societal or cultural factors have no power. Instead,
these factors seem to be portrayed as hindering the adequate
detection and diagnosis of the condition, as evidenced in
the following statement: “Underdetection may result from
mislabeling of ADHD symptoms as oppositional or disruptive
in socially oppressed ethnic or racialized groups because of
explicit or implicit clinician bias)” [(6), p. 73]. Bluntly put,
it is of importance to apply culturally competent practices in
diagnosing members of socially oppressed ethnic or racialized
groups to ensure correct diagnosis.
This essentialist framework of Western psychiatry guided by
the DSM has long been criticized by feminist scholars within
and outside psychiatry, emphasizing the intersecting links
between psychological hardships and the broad social, economic
and political context [see, for example, the special issue by
Marecek and Gavey (28)]. While DSM-5-TR acknowledges the
intersecting axes of class and racial/ethnic categorization with
diagnostic judgments, it chooses to be oblivious and silent of
how various social categories (e.g., gender, class, racial/ethnic)
and broader contexts intersect with how behaviors and
functioning develop (i.e., biopsychosocial perspective) let alone
why they are diagnosed as neurodevelopmental disorders (i.e.,
sociocultural, and political perspectives) regardless of continues
incongruence of scientific rationale and clinical practices.
5. Discussion
As expected, DSM’s latest edition does not escape the
logical and scientific pitfalls of its predecessor (e.g., circular
reasoning, lack of explanatory power, accuracy related issues
of diagnostic criteria etc.). What is also pervasive in the
DSM-5-TR is an attempt to further solidify ADHD as a
neurodevelopmental disorder. Explicitly and implicitly, DSM-5-
TR creates the illusion that it represents real scientific progress
that validates ADHD as a neurodevelopmental disorder. In
contrast, scientific research on etiology and pathophysiology
of people diagnosed with ADHD rather questions the current
operationalization of ADHD as a categorical diagnosis in
line with the “neo-Kraepelinian” view of discrete boundaries
between health and disorder [e.g., 11]. Given DSM’s multifaceted
influence in organizing institutional (e.g., insurance eligibility,
disability payments, educational services, legal decisions),
academic (e.g., direction of research, fund allocations, course
and textbook contents), and social and psychological lives (e.g.,
identity recognition, stigma, empathy), [e.g., (25,29–31)], it
seems unlikely that DSM would recategorize its classifications
according to science it purports to adhere to.
Finally, we would like to underline the importance of the
influence of the DSM since an ADHD diagnosis can expose
those diagnosed to potential harm. We will briefly illustrate
two examples here through the lens of the relative age effect
phenomenon. First, research clearly shows an international,
cross-cultural pattern of a relative-age effect in the diagnosis
of ADHD [see, for a review (32)]. Children with medicalized
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Koutsoklenis and Honkasilta 10.3389/fpsyt.2022.1064141
behaviors are “railed” into certain ways of responses to those
behaviors. Findings from a recent cohort study suggest that
an ADHD diagnosis in childhood may not result in any
improvements in quality-of-life measures in adolescents and
may even negatively impact some outcomes, including the risk
of self-harm (33). Second, the relative age effect phenomenon
also concerns the pharmacological treatment for ADHD [see, for
a review, (34)]. Children are thus exposed to the adverse effects
of ADHD drugs which span from death, cardiac problems,
psychotic disorders (35) to reduced appetite, difficulty sleeping,
and abdominal pain (36).
On top of that, Panther et al. (37) found that most
ADHD drugs prescribed for very young children were off-
label, and raised concerns to lack of safety and efficacy
data. The United Nations (38) has expressed concerns about
the significant global increase in consumption of stimulants
such as Methylphenidate (common brand names include
Ritalin, Equasym, and Concerta). The report attributes this to
various causes such as an increase in the number of ADHD
diagnoses, misdiagnosis of ADHD, influential commercial
and/or aggressive pharmaceutical marketing practices, and
public pressure, such as parents’ associations lobbying for their
children’s right to access ADHD medication [see also (39)]. In
this regard, a recent meta-analysis of pediatric psychotropic drug
prevalence of ADHD in the Global North reports a lack of
systematic monitoring in most of the studied 23 countries (40).
DSM-5-TR is likely to contribute rather than avert these trends.
Author contributions
All authors listed have made a substantial, direct,
and intellectual contribution to the work and approved it
for publication.
Funding
The University of Helsinki has paid the fee for the
publication of this manuscript.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
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