The DSM-5 criteria for ADHD are arbitrary, vague, and riddled with overlap
STUDY: Szymaniak K et al, Acta Neuropsychiatrica 2026;
STUDY TYPE: Review
FUNDING: Independent
Background
ADHD diagnoses have surged in recent years, but it’s not clear why. Improved detection? Overdiagnosis? These Australian researchers from the University of Sydney argue that the diagnosis itself is the problem.
The Argument
The authors identify four core problems with the current criteria.
Arbitrary symptom thresholds. Why six symptoms and not five? Why age 12 and not 7? The age cutoff was raised from 7 to 12 in DSM-5 without evidence to justify the change. Dropping the age cutoff triples the estimated adult prevalence of ADHD, from 2.6% to 6.8%.
Vague symptoms. Words like “often” and “several” mean different things to different clinicians and patients. Phrases like “careless mistakes” and “talks extensively” are subjective, which makes the diagnosis unreliable across raters.
Symptoms overlap. Symptoms like “loses things,” “forgetful,” and “fails to finish tasks” all trace back to the same core process: poor sustained attention. The list adds length without adding diagnostic precision.
Symptoms overlap with normal. Forgetting appointments, missing deadlines, and feeling “on the go” are common human experiences, especially in people juggling heavy demands. Without a clear biological marker, the line between disorder and normal variation is a judgment call.
The authors also challenge the early-onset criterion. Retrospective recall of childhood symptoms is notoriously inaccurate. Only about 55% of adults correctly recall whether they had ADHD symptoms as children.
Practice Implications
- As one who uses structured diagnostic testing for ADHD, I sympathize. The DSM-5 criteria seem to ask the same question many different ways.
- Tightening up the concept may help, but just as important is to look for other causes like sleep apnea, sleep deprivation, psychiatric disorders, traumatic brain injury, and medical disorders… keeping in mind that some have both ADHD and those other causes.
- Learn how to diagnose and treat ADHD in people with bipolar disorder in our Carlat podcast, part I and II.
— Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
