What does the DSM say about ADHD?

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The Diagnostic and Statistical Manual of Mental Disorders (the DSM) is published by the American Psychiatric Association (APA) and is used to classify cognitive differences. It covers many different neurotypes and mental health issues including schizophrenia, bi-polar, gender dysphoria, and autism. It is used across the USA and UK and anyone who has been formerly diagnosed with neurodivergence will have had their embodiment ticked off from it’s pages.

What does the DSM say about ADHD?

“ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity […] symptoms that are excessive for age or developmental level.”

DSM 5 TR, 2022, pg. 32

The very first words used to describe ADHD are alarming and not particularly accurate. The words disorder, impairing and excessive are pathologising, suggesting that ADHD folk are somehow inadequate or imperfect neurotypical people. Personally, I prefer the term Attention Hyperactive for my own experiences as I don’t feel particularly disordered or deficient (see Attention Hyperactivity: ditching the disorder and deficit).

ADHD is split into three different ‘types’: inattentive, hyperactive-impulsive and combined (and a bonus diagnosis of unspecified ADHD, which they do not explain particularly well). The main types have a tick-box list – adults need to tick five to get diagnosis and children need to tick six. The reasoning behind this difference is never fully explained, the DSM simply focuses on the amount of which these ‘symptoms’ impair the person (or more usually the people around them).

Inattentive type includes:

  • Difficulty in organising tasks
  • A reluctance to do tasks that need sustained mental effort
  • Often makes careless mistakes in school work or written communication
  • Has difficulty sustaining attention
  • Does not seem to listen when spoken to
  • Often does not follow instructions
  • Is easily sidetracked and distracted by the outside environment as well as unrelated thoughts
  • Often loses things
  • Is often forgetful in daily activities

Hyperactive – impulsive type includes:

  • Interrupting in conversation and intruding on others
  • Often fidgets or squirms in seat
  • Often leaves seat in situations when remaining seated is expected
  • Excess of energy (which may manifest as restlessness in adulthood)
  • Often loud
  • Talks excessively
  • Often cannot wait for turn in conversation or tasks – often interrupting

[I have changed some of the language in these lists to make them more palatable, I got fed up by the third time of reading ‘failure’.]

From my experience, a lot of these behaviours and feelings are relatively accurate, us Attention Hyperactive folk do forget things and we do get excited during conversation and interrupt so we don’t forget what we want to say and the conversation doesn’t move on without us. I often talk excessively and quickly and do not understand when it’s my turn in conversation, it’s not a thing I do on purpose but it’s hard to know when others are finished with what they are saying. Confusion over rhetorical questions also doesn’t help!

The problem with these items is that they are seen as ‘symptoms’ – the physical manifestation of disorder, deficit and failure. Instead of the what they actually are, another way of being human (both infuriating and wonderful).

Also, it is made clear that these ‘symptoms’ do not occur during the course of psychosis or mental health crisis. This completely erases psychotic ADHDers and would make it difficult for a person to be diagnosed and supported with both psychosis and Attention Hyperactivity.

However, the DSM does go on to make several good points about the interaction between mental health issues and ADHD without construing the two (see ADHD isn’t a mental health condition). It explains how ADHDers often feel peer rejection and bullying due to our being different, and we are more likely to have anxiety disorders and major depressive disorders than are neurotypical people. By adulthood ADHD folk are more likely to engage in self harm and suicide attempt and may experience mood or conduct ‘disorders’ and substance use.

“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).”

DSM 5 – TR, 2022, pg. 61

So, the DSM admits that outward struggles lessen when ADHDers are treated as human beings with our own strengths, needs and interests. This does beg the question of why ADHD folk are not treated well within the education and medical systems but that is a conversation for another time.

This understanding of the ADHD / mental health overlap is not afforded to the section which suggests that ADHD children are more likely to have ‘externalising disorders’ such as oppositional defiant disorder and conduct disorders (what many of us understand to be a response to neglect and abuse).

Even more bizarrely the prevelance rates show that ADHD occurs less in adults than children “ADHD occurs in most cultures in about 5% of children and about 2.5% of adults (pg.61)” – where have all the ADHD adults gone!?

So, is the DSM painting an accurate picture of ADHD experience?

My answer is mixed – it is both affirming by talking of the real life struggles including neglect, abuse and bullying which many of us face, but also add to the very real harm by using pathologising language.

The DSM is both supporting ADHD folk whilst continuing the stigmatisation of us. It has definitely come along way since its inception in 1952 but there is still a long way to go.

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