Diagnostic ADHD symptoms according to DSM, ICD, Wender-Utah, etc

Author: Ulrich Brennecke
Review 10/2024: Dipl.-Psych. Waldemar Zdero

The symptom catalogs listed below are alternative classifications of ADHD. They should not be applied schematically, which is already evident from the fact that several alternative symptom lists exist.
These are not treatment guidelines.

The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a catalog first published in 1952 (as an alternative to ICD 6)¹ by the American Psychiatric Association (APA), the American psychiatric society. The 5th edition, DSM 5, was published in May 2013. The revised version DSM-5-TR from March 2022 did not change the ADHD criteria and only added a few sentences and clarifications.²³

ICD is the catalog of the World Health Organization (WHO), the international health organization. The current version is ICD 10. ICD 11, which came into force in January 2022, was not yet available in German translation in September 2024.⁴
The DSM IV incorporated the ICD 9 catalog numbers for psychiatric diseases and is therefore a separate part of the ICD. DSM and ICD arose from the need to statistically record which diseases occur how frequently.

The DSM and ICD are therefore not really instruments for diagnosing diseases, but rather serve to statistically record and classify diagnoses. Such statistical classifications are particularly important for health insurance companies. In terms of medical diagnosis from the perspective of optimal treatment, however, they should not be accorded the same importance.

ATTENTION: DSM and ICD only name the diagnosis-relevant symptoms. In addition to the diagnosis-relevant symptoms, there are other symptoms that often result originally from a disorder (here: from ADHD), but which can also arise from other disorders, making them less suitable for distinguishing between disorders.

What is relevant to treatment, however, is the totality of all symptoms. To base treatment solely on the symptoms of the DSM or ICD would therefore be medical or therapeutic malpractice.
⇒ List of symptoms according to manifestations

• 1. DSM
  • 1.1. DSM 5
  • 1.2. DSM IV (outdated, only applied to children)
  • 1.3. ADHD and subtypes in the DSM
• 2. ICD 10
• 3. ICD 11
• 4. Wender Utah criteria for adults
• 5. Adult criteria according to Hallowell / Ratey
• 6. Limits of DSM and ICD
  • 6.1. DSM and ICD only name diagnostic symptoms, not all symptoms
  • 6.2. Statistics do not change diseases
  • 6.3. DSM / ICD are aids, not bibles

1. DSM¶

While DSM-IV still classified ADHD in the group of behavioral disorders, DSM 5 has assigned ADHD to the group of neurodevelopmental disorders. In DSM 5, the age up to which the first symptoms must have appeared was also raised to 12 years, the number of symptoms required from the age of 17 was reduced from 6 to 5 and ASD is no longer considered a diagnosis of exclusion. The concept of subtypes has been replaced by the concept of presentation forms (manifestations). DSM 5 also emphasizes more strongly that the symptoms must occur in different areas of life and that several (external) assessors should be involved.

1.1. DSM 5¶

Inattention

• Often fails to pay close attention to details or makes careless mistakes in schoolwork, work or other activities
• Often has difficulty maintaining attention for long periods of time during tasks or games
• Often does not seem to listen when addressed directly
• Often does not follow instructions fully and often fails to complete schoolwork, chores or duties at work (loss of concentration; distraction)
• Often has difficulties organizing tasks and activities (e.g. messy, disorganized work; does not meet deadlines and time limits)
• Often avoids, dislikes or is reluctant to perform tasks that require prolonged mental effort (e.g. participation in class; filling out forms)
• Often loses items that are necessary for tasks or activities (e.g. school supplies, pens, books, tools, wallet, keys, paperwork, glasses, cell phone)
• Is often easily distracted by external stimuli or irrelevant thoughts
• Is often forgetful in daily activities (e.g. running errands, paying bills, keeping appointments)

Hyperactivity/impulsivity

• Often fidgets with his hands or feet, beats time with them or squirms in his seat
• Often leaves his seat in situations where this is disruptive
• Often runs around or climbs in inappropriate situations (in adolescents or adults, a subjective feeling of restlessness is sufficient)
• Is often unable to play quietly or participate quietly in leisure activities
• Is often “on the go” or acts “as if driven” (e.g.: can no longer stay quietly in one place, or feels very uncomfortable, e.g. in restaurants)
• Often talks excessively
• Often blurts out an answer before the question is finished or finishes the sentences of others
• Finds it difficult to wait for his/her turn (e.g. when waiting in line)
• Frequently interrupts or disturbs others (e.g. bursts into conversations, games or other activities; uses other people’s things without asking first; in adults: interrupts or takes over activities of others)

An ADHD diagnosis is only possible if all general and specific observations are also available:

Necessary general observations

• It is a consistent pattern of inattention and/or hyperactivity/impulsivity that affects the level of functioning or development
• Several symptoms of this pattern appeared before the age of 12
  • Barkley recommends ignoring this figure and reports from his longitudinal studies in which people with ADHD sometimes showed ADHD symptoms for the first time between the ages of 18 and 24.⁵ Since the average person with ADHD develops ADHD symptoms at the age of 12, this means that half of the people with ADHD develop their first ADHD symptoms after this age.⁶ According to our observations, there are also many people with ADHD for whom the symptoms only became noticeable in adulthood (especially in women, even after the age of 30).
• Several symptoms of this pattern exist in two or more different areas of life (e.g. at home, at school or at work; with friends or relatives; during other activities)
• There is clear evidence that the symptoms interfere with or reduce the quality of social, educational or occupational functioning
• The symptoms cannot be better explained by another mental disorder (e.g. schizophrenia or psychotic disorder, affective disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)
  • Barkley points out that these disorders often occur comorbidly with ADHD⁷

Necessary special observations

• Inattention and hyperactivity/impulsivity must each be present as a minimum:
  • For children and adolescents (up to the age of 16): six out of nine symptoms
  • For adolescents (aged 17 and over) and adults: five out of nine symptoms .
    (see notes)
• The symptoms have occurred consistently over the last 6 months to an extent incompatible with the developmental stage
• The symptoms have a direct negative impact on social, educational and professional activities
• The symptoms are not exclusively an expression of defiance, hostility or difficulties in understanding.

Mood stability and emotional dysregulation are considered by DSM 5 to be associated features that support the diagnosis.⁸

Notes:
The updated European consensus on the treatment and diagnosis of ADHD from 2018 points out that there are now studies indicating that a cut-off of 4 symptoms in adults would be more correct for a correct ADHD diagnosis.⁸⁹¹⁰

1.2. DSM IV (outdated, only applied to children)¶

• At least 6 symptoms
  • From the area of inattention
    or
  • The area of hyperactivity/impulsivity
    or
  • From both areas together.
• Some of the symptoms before the age of 7.
• Impairment in at least two areas of life due to the symptoms.
• Symptoms not better explained by another mental Disorder or medical condition.

Inattention

• Often ignores details or makes careless mistakes
• Often has difficulty maintaining attention during tasks or games
• Often does not seem to listen when others speak to him/her
• Often does not follow instructions from others and cannot complete work
• Often has difficulty organizing tasks
• Has an aversion to tasks that require prolonged mental effort
• Frequently loses objects that he/she needs for activities
• Is often distracted by external stimuli
• Is often forgetful in everyday activities

Hyperactivity

• Frequently fidgets with hands or feet and slides around on the chair
• Frequently stands up in class or in other situations where staying seated is expected
• Frequently runs around or climbs excessively in situations where this is inappropriate (in adolescents or adults this may be limited to a subjective feeling of restlessness)
• Often has difficulty playing quietly or keeping quiet with leisure activities
• Is often “on the move” or often acts as if he/she is driven
• Often talks excessively

Impulsiveness

• Often blurts out answers before the question is finished.
• Can hardly wait for her/his turn.
• Interrupts and disturbs others frequently (e.g. bursts into other people’s conversations or games).

1.3. ADHD and subtypes in the DSM¶

• DSM III-R did not distinguish between subtypes.
• DSM IV differentiated ADHD according to subtypes.
• DSM V (May 2013) has again abandoned the subdivision into subtypes, as these suggest different types of ADHD. However, they are only different manifestations (forms of presentation).
• ICD also does not differentiate between subtypes.

According to this view, a distinction between subtypes is essential for the diagnosis and understanding of ADHD; for treatment, however, the differences are not yet significant, at least at present. We consider the subtypes with hyperactivity/impulsivity (ADHD-HI, ADHD-C) and dreaming, predominantly inattentive (ADHD-I) as different symptoms of one and the same underlying disorder, depending on the individual stress phenotype (the way stress manifests itself) of the person with ADHD.
SCT, Sluggish Cognitive Tempo, is now understood as an independent disorder, even if it has a very high degree of overlap with ADHD.
Since attention symptoms in humans can be detected developmentally at the earliest at the age of 6 to 7 years and at the latest at the age of 14 to 15 years, ADHD-C (hyperactivity/impulsivity + attention problems) is often only the age- and development-related subsequent stage of the ADHD-HI subtype (pure hyperactivity).
⇒ The subtypes of ADHD: ADHD-HI, ADHD-I, SCT and others

2. ICD 10¶

ICD 11 is expected for 1.1.2022.

Attention deficit disorder

• Is inattentive to task details, makes errors of care in tasks
• Is often unable to maintain attention during play or tasks
• Often does not seem to hear what he/she is told
• Often cannot fulfill tasks and duties (not due to oppositional behavior)
• Is impaired to organize tasks and duties
• Avoids unloved tasks that require stamina
• Frequently loses things that are important for carrying out tasks (e.g. pens)
• Is often distracted by external stimuli
• Is often forgetful in the course of everyday activities

At least 6 of the 9 symptoms mentioned occur over at least 6 months.

Overactivity

• Often flails his hands and feet or squirms in seats
• Leaves the classroom or in other situations where sitting is expected
• Frequently runs around or climbs excessively in situations where this is inappropriate
• Is often unnecessarily loud when playing or has difficulties with quiet leisure activities
• Persistent pattern of excessive motor activity that cannot be effectively influenced by social contact or prohibitions

At least 3 of the above 5 symptoms occur over at least 6 months

3. ICD 11¶

ICD 11 was adopted in January 2022, but is not yet available in German translation (as of September 2024).⁴ The Draft version of ICD 11 with regard to ADHD adopts the subtypes of the predominantly hyperactive/impulsive type, the predominantly inattentive type and the mixed type.

4. Wender Utah criteria for adults¶

Wender-Utah is a special symptom catalog for ADHD in adulthood

For a diagnosis in adulthood, the symptoms of attention deficit disorder and motor hyperactivity as well as two other of the 7 symptom groups must be present.¹¹

Attention deficit disorder

• Inability to follow conversations attentively
• Increased distractibility
• Forgetfulness

Motor hyperactivity

• Inner restlessness
• Inability to relax
• Inability to perform sedentary activities
• Dysphoria with inactivity

Affect lability

• Switch between neutral and depressed
  Mood
• Duration from a few hours to a maximum of a few days

Disorganized behavior

• Insufficient planning and organization of activities
• Tasks are not completed

Affect control

• Constant irritability, even for minor reasons
• Reduced frustration tolerance and short outbursts of anger

Impulsiveness

• Interrupting others in conversation
• Impatience
• Impulsive purchases
• Inability to delay actions in the process

Emotional overreactivity

• Inability to deal adequately with everyday stressors, sensory overload, black-outs

5. Adult criteria according to Hallowell / Ratey¶

The authors of the book “Obsessively Distracted”, Edward M. Hallowell and John Ratey, have proposed the following characteristics for recognizing ADHD in adults. The characteristics are vividly explained there using examples.¹²

The basic prerequisite is that the symptoms have been present since childhood and that other organic or psychological disorders are not better suited to explain the symptoms.

• Feeling of poor performance or of not having achieved the goals set
• Difficulties with the organization of everyday life
• Chronically putting things off,
  Effort to start something
• Pursuing many projects at the same time,
  Difficulties in seeing a thing through
• Tendency to say whatever comes to mind without the necessary consideration of whether the time or circumstances are appropriate
• Frequent hunting for high-level stimulation
• Lack of tolerance for boredom
• Easily distracted,
  Problems focusing attention,
  Tendency to switch off in the middle of a page or conversation or to wander off in thought
  often combined with the ability to hyperfocus
• Problems adhering to procedural rules or procedures
• Impatience, low frustration tolerance
• Impulsiveness in speech and action
• Tendency to worry incessantly, searching for topics of concern while at the same time disregarding or overlooking real dangers
• Feeling of insecurity
• Mood swings / mood instability
• Motor or inner restlessness
• Reduced self-esteem
• Inaccurate self-assessment
• Familial clustering of ADHD

Often creative, intuitive, intelligent (not a symptom, but often typical).

6. Limits of DSM and ICD¶

6.1. DSM and ICD only name diagnostic symptoms, not all symptoms¶

A diagnosis according to DSM IV, DSM 5 or IDC 10 / ICD 11 is often mentioned.
This designation is somewhat misleading. DSM and ICD are at least as much statistical catalogs as diagnostic manuals. They are by no means binding or solely valid diagnostic standards, even if they are often misunderstood as such.

DSM and ICD only list those symptoms of ADHD that are particularly suitable for distinguishing ADHD from other disorders and from those who are not affected.
For the treatment and therapy of ADHD, it is essential to know all the symptoms that ADHD can cause.
A list of over 40 ADHD symptoms can be found at ⇒ Total list of symptoms according to manifestations.

Unfortunately, we see time and again that doctors or therapists do not even recognize procrastination, the most common symptom caused by ADHD, as a symptom caused by ADHD. Procrastination can also be caused by other disorders. However, this does not excuse denying that ADHD can cause procrastination.
If doctors or therapists do not know all the symptoms that can be caused by a disorder (here: ADHD), this can lead to people with ADHD coming out of (ADHD) therapy even more destroyed than when they went in, because they are accused of having symptoms of their disorder that they are personally responsible for, instead of working with them to combat the symptom of the disorder. The same applies to many other symptoms, such as rejection sensitivity (offendedness; in many people with ADHD, this disappears as soon as stimulants take effect), emotional dysregulation and anxiety, which can also be original symptoms of ADHD (i.e. can be triggered directly by ADHD).
Very often, the original ADHD symptom of dysphoria with inactivity, which together with the equally common ADHD symptoms of anhedonia and listlessness often occurs in ADHD, is also misdiagnosed as depression.

6.2. Statistics do not change diseases¶

The changes from DSM I to DSM 5 have changed the statistical recording of diseases, but not their existence. In our understanding, illness is a subjective impairment of a person’s well-being that is so severe that either the person with ADHD wants to change something about it for themselves, which justifies treatment, or that it affects third parties to such an extent that treatment seems objectively necessary.
Whether the impairment of well-being is listed in the DSM or ICD, or has a billing number with a health insurance company, is sincerely irrelevant to the feeling of illness of the person with ADHD or the impairment of the environment. Conversely, in our view, it is not decisive whether symptoms that a person has are listed in the DSM or ICD if neither the person with ADHD nor third parties have a problem with them.

Krause quotes the chairman of the DSM IV editorial board, the psychiatrist Frances Allen, with the extremely correct and important critical statement: “The DSM must remain simple, but psychiatry does not have to. DSM diagnosis should only be a small part of the overall assessment“. And Allen goes on to criticize: “A nuanced psychiatry has become a checklist psychiatry that levels out individual differences…“.¹³

6.3. DSM / ICD are aids, not bibles¶

The DSM and ICD diagnostic criteria are valuable aids in determining which group the impairment of the person with ADHD belongs to. However, anyone who only asks about DSM or ICD symptoms and makes them the sole criterion for treatment shows that they are not really familiar with the actual problem or do not take the patient seriously.

As already mentioned, the fact that the DSM and ICD are only statistical tools and diagnostic manuals and cannot be used as the sole decisive diagnostic criteria is due to the fact that the two systems have already undergone many iterations with very different criteria and also differ from one another. It is not ADHD itself that has changed, but only the respective concepts of DSM and ICD. In addition, both DSM and ICD still lack important symptoms, such as dysphoria with inactivity, which is still only mentioned in Wender/Utah.
In any case, DSM IV and ICD 10 were only ever tailored to ADHD in children and adolescents.¹⁴
However, the symptoms of adults differ considerably. ⇒ ADHD in adults

The only thing that counts for people with ADHD is the hardship they suffer as a result of their illness, regardless of whether this is covered by a list of criteria or not.