Journal of Psychopathology and Behavioral Assessment

https://doi.org/10.1007/s10862-020-09797-5

Changes in College Student Endorsement of ADHD Symptoms

across DSM Edition
Elizabeth K. Lefler 1 & Anne E. Stevens 2 & Anna M. Garner 1 & Judah W. Serrano 2 & Will H. Canu 3 & Cynthia M. Hartung 2

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Changes were made in DSM-5 to address the criticism that ADHD symptoms in DSM-IV were not developmentally appropriate
for adults. Specifically, parenthetical examples were added to symptoms, and the symptom threshold was lowered. ADHD
diagnosis in college students in particular is a growing concern. It was hypothesized that changes to the ADHD symptoms across
DSM editions would result in higher symptom endorsement rates in this group. To this end, 3877 college students rated their own
ADHD symptoms using DSM-IV and DSM-5 symptom wording. College students with a past diagnosis of ADHD (n = 435)
endorsed slightly more symptoms with the updated DSM-5 wording (an additional 0.41 ADHD symptoms). In addition, 5.2%
more college students met the new, lowered DSM-5 symptom threshold as compared to the older DSM-IV threshold. Changes to
DSM-5 Criterion A for ADHD increase symptom endorsement and the number of college students eligible for a diagnosis.

Keywords ADHD . College students . DSM-IV . DSM-5 . Criteria . Symptoms

Attention-deficit/hyperactivity disorder (ADHD) is recog- genders (APA 2013; Barkley et al. 2008). Indeed, approxi-
nized in the Diagnostic and Statistical Manual of Mental mately half of individuals diagnosed with ADHD in child-
Disorders, Fifth Edition (DSM-5; American Psychiatric hood continue to meet criteria in adulthood (Wilens et al.
Association [APA] 2013) as a neurodevelopmental disorder 2002), up to two-thirds do not meet full diagnostic criteria
distinguished by a persistent pattern of inattention, hyperac- but have significant ADHD-related impairment (Faraone
tivity/impulsivity, or both. One criticism of its predecessor, the et al. 2006), and still others are late-identified (i.e., receive
Diagnostic and Statistical Manual of Mental Disorders, their initial diagnosis in adulthood). The ADHD and
Fourth Edition (DSM-IV; APA 1994), was that the diagnostic Disruptive Behaviors Disorders Workgroup for DSM-5 set
symptoms for ADHD may not have been developmentally out to make changes to the criteria and symptoms of ADHD,
appropriate for older adolescents or adults (e.g., runs and in part to reflect the understanding of ADHD as a disorder that
climbs excessively; Bell 2011; Fedele et al. 2010; McGough affects adults (Coghill and Seth 2011).
and Barkley 2004). In fact, it has been understood for some In terms of diagnostic utility in older adolescents and
time that the symptoms of ADHD included in the DSM-IV adults, the DSM-IV ADHD symptoms were criticized for not
were developed with and for school-aged boys (Barkley capturing the heterogeneity and fluidity of the disorder across
et al. 2008; Lahey et al. 1994). However, ADHD is now the lifespan, potentially making diagnostic assessment in this
known to be a lifelong disorder that impacts all sexes and group difficult (Coghill and Seth 2011; Sibley and Kuriyan
2016; Sibley and Yeguez 2018). More specifically, the DSM-
IV ADHD symptoms did not include information on how the
* Elizabeth K. Lefler disorder affects adults, relied on symptom clusters derived
elizabeth.lefler@uni.edu from studies of children, and did not include behavioral char-
acteristics specific to adults (Bell 2011). Thus, the DSM-5
1
Department of Psychology, University of Northern Iowa, 1078 symptoms were changed slightly to address some of the per-
Bartlett Hall, Cedar Falls, IA 50614-0505, USA ceived limitations of the DSM-IV (Epstein and Loren 2013;
2
Department of Psychology, University of Wyoming, Laramie, WY, Sibley and Kuriyan 2016).
USA It is important to study even slight changes to DSM criteria
3
Department of Psychology, Appalachian State University, because of the impact these changes may have. Other disor-
Boone, N.C., USA ders in the DSM have undergone empirical scrutiny when their
 J Psychopathol Behav Assess

symptoms or categories or diagnostic thresholds changed be- Sibley and Kuriyan (2016) examined the impact of the
tween DSM-IVand DSM-5. For instance, Flament et al. (2015) changes to DSM symptom wording in a sample of 78 6th
noted that the prevalence of ‘full threshold’ eating disorders and 9th grade children (71% male; 66% Hispanic; all with
more than doubled with the changes that took place between combined or predominantly hyperactive/impulsive presenta-
DSM-IV and − 5 (which included the addition of binge eating tions). These 11- to 15-year-old children and adolescents
disorder). Conversely, when post-traumatic stress disorder underwent thorough diagnostic assessments for ADHD (i.e.,
(PTSD) was similarly studied, Kilpatrick et al. (2013) found structured clinical interviews, parent and teacher ratings of
that prevalence rates decreased from DSM-IV to −5, and symptoms and impairment). The dependent variables were
Claassen-van Dessle et al. (2016) reported that the DSM-5 parent ratings on both DSM-IV and DSM-5 iterations of the
threshold was twice as difficult to meet as the DSM-IV thresh- 18 ADHD symptoms. Parent ratings of ADHD increased by
old for somatoform/somatic symptom disorder. Given the an average of 1.15 symptoms (across all 18 symptoms) when
wide fluctuations caused by changes to the DSM criteria, it moving from the DSM-IV wording to the DSM-5 wording,
follows to carefully study these changes. In fact, when Matte and this change was most pronounced for the inattention
et al. (2015) studied the DSM changes to ADHD in a sample symptoms (Sibley and Kuriyan 2016). Thus, the parenthetical
of 18- and 19-year-olds, they found a 27% increase in preva- wording changes led to increased symptom endorsement by
lence with the introduction of the DSM-5 changes. parents in a group of 11- to 15-year-olds. Sibley and Yeguez
(2018) extended this research with a group of 10- to 16-year-
old children and adolescents (70% male and 77% Hispanic)
Changes to ADHD Criterion A in DSM-5 who also had well characterized ADHD. The results from this
2018 study showed a 0.57 symptom endorsement increase in
For the purposes of the current study, the changes to Criterion parent ratings of inattention when moving from DSM-IV
A are central. Criterion A, which includes the 18 individual wording to DSM-5 wording, but no statistically significant
ADHD symptoms and the symptom threshold, was changed increase impulsivity (Sibley and Yeguez 2018).
a) to include parenthetical examples for a majority of the For individuals 17 years of age and older, there is also a
symptoms to better reflect the disorder in adolescents and need to consider the symptom threshold change in Criterion A
adults, and b) to require the presence of only 5 symptoms in addition to the parenthetical wording changes. That is, it is
(instead of 6) in either the inattention or hyperactivity/ important to fully understand the implications of changing the
impulsivity domains for those 17 years and older (APA diagnostic threshold from 6 symptoms to 5 symptoms for
2013; Epstein and Loren 2013). Notably, the core meaning those 17 years and older. These concurrent changes (i.e.,
of the 18 symptoms (and two symptom domains; inattention changes to both the wording of the symptoms via parentheti-
and hyperactivity/impulsivity) was retained, but the parenthet- cal additions and the diagnostic threshold) make it difficult to
ical behavioral examples of 14 of the symptoms were modi- ascertain the diagnostic impact of either of the changes indi-
fied or added. As three examples, the parenthetical example vidually. If DSM-5 Criterion A turns out to be more appropri-
“paying bills” was added to the core symptom “is often for- ate for adults, it could be that the added parenthetical examples
getful in daily activities;” the example “reviewing lengthy for 14 symptoms made the difference, or that the lowered
papers” was added to the core symptom “often avoids, dis- threshold was the catalyst. On the other hand, making both
likes, or is reluctant to engage in tasks that require sustained of these changes at once might prove to have been an
mental effort;” and the example “cannot wait for turn in con- overcorrection if unnecessary overdiagnosis occurs. The cur-
versation” was added to the core symptom “often blurts out an rent paper will add to the growing effort to determine the effect
answer before a question has been completed” in an attempt to of these DSM changes for ADHD in adults.
make the symptoms more appropriate for older adolescents
and adults (APA 2013, p. 59–60). It should be noted that some
researchers have suggested a change to the core symptoms ADHD in Emerging Adulthood
themselves, not just the parenthetical examples, and have pro-
posed entirely new symptoms for adults (Barkley et al. 2008; Accurate diagnosis of ADHD in emerging adulthood (18–
Fedele et al. 2010). For example, some new symptoms spe- 25 years; Arnett 2000) may be of particular importance, given
cific to adult behaviors that have been suggested include “pro- the impairment caused by the disorder and the unique chal-
crastinate or put off doing things until the last minute” and lenges during this stage of life (e.g., increased social indepen-
“have difficulties managing my money or credit cards” dence, increased financial independence, the demands of
(Barkley et al. 2008, p. 195–199). These symptoms could higher education or a new career). Emerging adulthood is
have been added as core ADHD symptoms in the DSM for distinguished by continued brain development especially as
adults; however, DSM-5 ADHD Criterion A was amended in a related to executive functioning, unique environmental con-
decidedly more conservative way. texts (Arnett 2000), and vulnerability to comorbid
J Psychopathol Behav Assess

psychological disorders (e.g., anxiety, depression) which are worldwide in children is not as pronounced in adulthood
common during this developmental period, especially for in- (Willcutt 2012). Specifically, Willcutt (2012) reported a 2.3
dividuals with a history of ADHD (Meinzer et al. 2013). male:1 female ratio in children, but a 1.6 male:1 female ratio
Emerging adults may be at heightened risk for late-identified in adults. Further, there is some evidence that emerging adult
ADHD due to the increased executive functioning demands, women in college may have higher rates of ADHD symptoms
as well as the set of social, romantic, academic, and occupa- and related impairment than their male counterparts (Fedele
tional impairment that they face (Barkley 2015). et al. 2012). The reasons for this change are not well under-
One subset of emerging adults are those who are enrolled in stood. In addition, there is a growing body of evidence sug-
college. These young adults are tasked with executive func- gesting that the pattern of ADHD comorbidity differs for men
tioning demands such as attending lectures, writing papers, and women with the disorder. For example, Anastopoulos
reading long articles/books, staying organized, and planning et al. (2018) found that emerging adult women with ADHD
ahead; all of these are difficult for people with ADHD (Lefler were more likely than their male counterparts to have a co-
et al. 2016). While these academic tasks are similar to what morbid diagnosis, and particularly depression and anxiety.
might have been experienced in high school, the challenge is These sex differences in comorbid diagnoses may impact
amplified because higher education is a period of increased men and women differentially, and therefore suggest the need
independence, less structured time, and heightened rigor. for additional study. Finally, it has been suggested that all
Thus, developmentally appropriate diagnosis of ADHD dur- studies of psychopathology examine issues of sex and gender
ing the college years may be of particular importance, given where possible to avoid the problem of gender-neutral re-
the well-documented academic impairment in this group search (Hartung and Lefler 2019; Howard et al. 2017);
(Advokat et al. 2011; Barkley et al. 2008; Barkley 2015; ADHD is not immune from this problem.
Rabiner et al. 2008) and the availability of academic accom-
modations which may provide some relief (DuPaul et al.
2017). It is true that a majority of children with ADHD do Current Study
not go on to attend a 4-year university (approximately 70% do
not; Kuriyan et al. 2013); but for those who do, there is In sum, ADHD criterion A was changed in some important
marked impairment. ways in the most recent iteration of the DSM. These changes
Hartung et al. (2019) conducted a study of emerging adult need to undergo empirical scrutiny so that researchers and
college students to examine the impairment students face clinicians can better understand the diagnostic implications.
when they have elevated ADHD symptoms. They found that This should be done with various samples of individuals with
there is not a significant difference in impairment across col- ADHD, including emerging adults enrolled in college who
lege students who endorse 4, 5, or 6 symptoms of inattention have many ADHD-related impairments. Sibley and Kuriyan
or hyperactivity (via DSM-IV wording; Hartung et al. 2019). (2016) and Sibley and Yeguez (2018) found increased ADHD
That is, students endorsing 5 symptoms did not endorse sig- symptom endorsement from DSM-IV to DSM-5 wording in
nificantly more impairment than students endorsing 4 symp- children and adolescents, Matte et al. (2015) found an in-
toms, suggesting that the symptom cutoff of 5 might not be creased prevalence from DSM-IV to −5 in emerging adults,
particularly valid for differentiating those who may or may not and Hartung et al. (2019) found some support for a lowered
qualify for a diagnosis, especially given the executive function diagnostic threshold given the impairment faced by college
demands of college. In fact, Barkley and others have sug- students exhibiting sub-threshold ADHD symptoms. We aim
gested that a cutoff of 4 symptoms would be optimal for adults to add to this body of work by examining ADHD symptom
(Barkley et al. 2008; Hartung et al. 2019; Vitola et al. 2017). endorsement via DSM-IV and DSM-5 ratings in a large sample
Therefore, because significant impairment may begin at 4 of emerging adult college students.
symptoms of ADHD in college students (a technically sub- More specifically, the aim of the current study is to assess
threshold level), and because the DSM-5 introduced changes how the changes in DSM-5 ADHD symptom wording may
to Criterion A, the current study is designed to take a step impact symptom endorsement among college student men
toward better understanding the impact of these changes in and women via self-report, and how this in turn may impact
college-enrolled emerging adult men and women. potential diagnostic identification given the lowered symptom
threshold. Based on the findings of Sibley and Kuriyan (2016)
and Sibley and Yeguez (2018), Hypothesis 1 is that emerging
Sex Differences in ADHD adult college students will endorse more symptoms on the
DSM-5 iteration of the ADHD symptoms than the DSM-IV
Sex differences in emerging adults with ADHD are also im- iteration of these symptoms. To expand on this, Hypothesis 2
portant to understand. A meta-analysis of the prevalence of states that the 14 ADHD symptoms which received additional
ADHD suggested that the male preponderance observed parenthetical examples will be endorsed at higher rates via the
 J Psychopathol Behav Assess

DSM-5 wording than the DSM-IV wording, and that this will retrospective self-reports of a past ADHD diagnosis; the meth-
be most pronounced in the inattention symptoms (i.e., odology of the current study did not allow for full evidence-
Hypothesis 2 is a symptom-by-symptom analysis). based diagnostic assessments. Nevertheless, as can be seen,
Additionally, because the symptom threshold was lowered this group did indeed display elevated current ADHD
from 6 to 5 symptoms from DSM-IV to DSM-5, Hypothesis symptomology and impairment.
3 is that significantly more college students will meet the
DSM-5 symptom cutoff as compared to the DSM-IV symptom Procedures
cutoff. Next, Hypothesis 4 states that significant impairment
will begin at 4 symptoms of ADHD for college students. This The study was approved by the Institutional Review Board of
hypothesis is based on the findings of Hartung et al. (2019), record for this multisite study. College student participants
and will help us understand whether the changes to ADHD were recruited through web-based participant management
Criterion A help accurately identify college students with sig- systems at each of the four universities as part of a larger study
nificant impairment. Finally, biological sex was considered in (only relevant measures are described herein). Participants
these analyses as sex differences in adult ADHD have been earned research participation points for their psychology
documented (Fedele et al. 2012), and it is important to con- courses. Students voluntarily agreed to participate; they gave
sider sex in psychopathology research (Hartung and Lefler informed consent online, and were then directed to an online
2019). survey platform on which they completed a number of ques-
tionnaires. They completed the DSM symptoms sets in a
counterbalanced fashion via this online platform.
Method
Measures
Participants
Demographics Form Participants reported their biological sex,
Participants were 3877 undergraduate students from four uni- gender identity, age, race/ethnicity, and other demographic
versities in the Rocky Mountain, Midwest, and Mid-Atlantic information.
regions of the United States. These participants were from two
waves of a large multi-site college ADHD study. Participants DSM-IV Symptoms (APA 1994) A self-report checklist was
reported their biological sex (64.9% female, 35.0% male, created based on the exact wording of the 18 ADHD symp-
0.1% intersex), gender identity (64.3% female, 35.0% male, toms in the DSM-IV (APA 1994). Participants rated their cur-
0.6% non-binary/gender fluid/queer, 0.1% transgender), and rent ADHD symptoms using this scale: 0 (never/rarely), 1
age (M = 19.18 years; SD = 1.36). The sample was 82.5% (sometimes), 2 (often), or 3 (very often). Symptoms were
White, 5.6% Hispanic/Latino, 4.8% Asian/Asian American, counted as endorsed if the participant indicated that it occurred
2.6% African American, 2.6% Biracial, 0.6% American often or very often (i.e., symptom count). In the current study,
Indian or Pacific Islander, and the remaining participants internal consistency reliability was excellent for inattention
elected not to report. No exclusionary criteria were set, apart (α = .93) and good for hyperactivity/impulsivity (α = .88).
from restricting the age range to 18–25 years.
In addition to this full sample, a sub-sample was used for DSM-5 Symptoms (APA 2013) A self-report checklist was cre-
some of the analyses in the current study. Specifically, those ated based on the exact wording of the 18 ADHD symptoms
who self-reported a lifetime diagnosis of ADHD were includ- in the DSM-5 (APA 2013), including the added parenthetical
ed in this sub-sample. This past ADHD group was used be- clarifications. Participants rated their current ADHD symp-
cause in a high-functioning community sample such as this toms using this scale: 0 (never/rarely), 1 (sometimes), 2
(i.e., college-enrolled emerging adults), psychopathology (often), or 3 (very often). Symptoms were counted as endorsed
symptom endorsement in general, as well as ADHD symptom if the participant indicated that it occurred often or very often
endorsement in particular, is low. This past ADHD group (n = (i.e., symptom count). In the current study, internal consisten-
435) included 11.2% of the full sample. The biological sex of cy reliability was excellent for inattention (α = .93) and good
the past ADHD sub-sample did not differ from the full sample for hyperactivity/impulsivity (α = .88).
(63.9% female; χ2 = .557[2, n = 3852], p = .757). However, as
anticipated, the past ADHD sub-sample had significantly Weiss Functional Impairment Rating Scale (Weiss 2000) The
higher current ADHD symptoms (M = 6.94 symptoms versus Weiss Functional Impairment Rating Scale (WFIRS) is a 70-
M = 2.15 symptoms; t[3850] = 25.76, p < .001) and signifi- item self-report measure of impairment in 7 domains of life
cantly higher average impairment (M = 0.66 impairment rat- (i.e., family, work, school, life skills, self-concept, social, and
ing versus M = 0.39 impairment rating; t[3848] = 14.92, risk). Participants rate whether or not they are experiencing
p < .001) than the full sample. To be clear, these were impairment on a 4-point scale ranging from never or not at all
J Psychopathol Behav Assess

(0) to often or very much (3). The WFIRS is a good measure of with only the past ADHD sub-sample (n = 435; Fig. 1). The
impairment in college students (Canu et al. 2016), with excel- full sample was not used for these analyses because a majority
lent internal consistency reliability in past studies (Hartung of the full sample reported 0 or 1 total symptoms of ADHD,1
et al. 2019). In the current study, internal consistency reliabil- whereas the past ADHD sample showed more variability in
ity was also excellent; α = .96. symptom counts. DSM edition was used as the repeated mea-
sure, and one ANOVA each was conducted for: (a) inattention
symptoms only, (b) hyperactivity/impulsivity symptoms only,
Results and (c) total ADHD symptoms (i.e., both inattention and hy-
peractivity combined). The hypothesis was supported for in-
Data Preparation attention, such that symptom endorsement increased from
M DSM-IV = 3.86 to M DSM-5 = 4.23 (F(1, 434) = 10.72,
ADHD symptom counts were used for the current analyses. A p = .001, ηg2 = .003 [small]). The hypothesis was not support-
symptom was coded as endorsed if the participant marked that ed impulsivity/impulsivity. Symptom endorsement increased
it occurred often or very often, and coded as not endorsed if the from MDSM-IV = 2.66 and MDSM-5 = 2.71 but this was non-
participant marked never or sometimes. Symptom counts were significant (F(1, 434) = 0.34, p = .560). Finally, the hypothesis
used because the research question in the current study con- was supported for total ADHD symptoms, such that total
cerns diagnostic thresholds, and thus symptom endorsement is symptom endorsement increased from MDSM-IV = 6.53 to
key. Thus, participants could endorse 0 to 9 inattention symp- MDSM-5 = 6.94 (F(1, 434) = 5.99, p = .015, ηg2 = .002 [small];
toms, and 0 to 9 hyperactivity/impulsivity symptoms. For the see Fig. 1).
WFIRS, a total mean was calculated. A WFIRS mean could These analyses were also conducted using Mixed
range from 0 (indicating no impairment) to 3 (indicating max- ANOVAs with DSM edition as the within-subjects factor
imum impairment on every single item). Several effect sizes and biological sex as the between-subjects factor to test for
will be reported herein given the various analyses used: gen- sex differences. Biological sex was not significant in the
eralized eta squared (hypothesis 1; Bakeman 2005), odds ra- Mixed ANOVA, suggesting that the above results with both
tios (hypothesis 2), Cramer’s v (hypothesis 3), and eta squared men and women (i.e., the repeated measures ANOVAs with
(hypothesis 4). Effect size magnitude will be reported per 435 participants) are the most appropriate analyses to report.
Cohen (1988) standards (Lakens 2013). In addition, as men-
tioned above, some analyses were conducted with the entire Hypothesis 2 Next, Sibley and Kuriyan (2016) and Sibley and
sample (N = 3877), whereas others were conducted only with Yeguez (2018) also found differences across individual
a sub-sample of participants who endorsed a past ADHD di- ADHD symptoms, with odds ratios ranging from 4.67 to
agnosis (n = 435). The sample used in each analysis is 11.00. For the current study, symptom-by-symptom endorse-
indicated. ment between DSM-IV and DSM-5 editions were similarly
compared, and it was hypothesized that the 14 individual
symptoms which received additional parenthetical examples
Hypothesis Testing in DSM-5 would be endorsed at a higher rate via DSM-5
wording. Using McNemar’s chi-square tests, we examined
Hypothesis 1 To test the first hypothesis, that ADHD symptom whether participants with a self-reported past diagnosis of
endorsement would increase from DSM-IV to DSM-5, three ADHD (n = 435) endorsed particular symptoms at different
within-subjects, repeated-measures ANOVAs were conducted rates (i.e., DSM-IV Inattention Symptom 1 compared to
DSM-5 Inattention Symptom 1, and so on).
9
When compared to the DSM-IV endorsement rate, five
8
DSM-5 inattention symptoms were endorsed at significantly
7
6
higher rates than their DSM-IV counterparts. Specifically,
5
DSM-5 Inattention Symptoms 1 (i.e., often fails to give close
4
attention to details; p = .005), 2 (i.e., often has difficulty sus-
3 taining attention in tasks or play activities, p < .001), 3 (i.e.,
2 often does not seem to listen when spoken to directly;
1 p = .033), 4 (i.e., often does not follow through on instruc-
3.86 4.23 2.66 2.71 6.53 6.94
0 tions; p = .045), and 7 (i.e., often loses things necessary for
Inattention* Hyperactivity/Impulsivity Total ADHD*
tasks or activities; p = .042) were endorsed significantly more
DSM-IV DSM-5

1
Fig. 1 ADHD symptom endorsement change by DSM edition; past When the full sample (N = 3877) was used to test this hypothesis, the results
ADHD sub-sample (n = 435) Note. * indicates a significant difference were non-significant.
 J Psychopathol Behav Assess

Table 1 Symptom-by-Symptom Endorsement Rates by DSM Edition in the Past ADHD Sample (n = 435)

Inattention Symptoms DSM-IV DSM-5 χ2 p value OR

(%) (%)

1. Often fails to give close attention to details or makes careless 40.0 46.4 7.76 .005* 1.46
mistakes in schoolwork, at work, or during other activities
(e.g., overlooks or misses details, work is inaccurate).
2. Often has difficulty sustaining attention in tasks of play 50.1 62.3 20.96 < .001* 1.58
activities (e.g., has difficulty remaining focused during
lectures, conversations, or lengthy reading).
3. Often does not seem to listen when spoken to directly 31.0 35.9 4.49 .033* 1.38
(e.g., mind seems elsewhere, even in the absence of
any obvious distraction).
4. Often does not follow through on instructions and fails 32.9 37.6 4.01 .045* 1.36
to finish schoolwork, chores, or duties in the workplace
(e.g., starts tasks but quickly loses focus and is easily
sidetracked).
5. Often has difficulty organizing tasks and activities 44.0 46.5 1.05 .305 –
(e.g., difficulty managing sequential tasks; difficulty
keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails
to meet deadlines).
6. Often avoids, dislikes, or is reluctant to engage in tasks 49.5 48.6 0.09 .769 –
that require sustained mental effort (e.g., schoolwork or
homework; for older adolescents and adults, preparing
reports, completing forms, reviewing lengthy papers).
7. Often loses things necessary for tasks or activities 32.6 37.0 4.10 .042* 1.39
(e.g., school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted by extraneous stimuli (for adolescent 61.2 63.0 0.53 .466 –
and adult, may include unrelated thoughts).
9. Is often forgetful in daily activities (e.g., doing chores, running 46.5 46.7 0.00 1.00 –
errands; for older adolescents and adults, returning calls,
paying bills, keeping appointments).

Hyperactivity/Impulsivity Symptoms DSM-IV (%) DSM-5 (%) χ2 p value OR

1. Often fidgets with or taps hands or feet or squirms in seat. 61.4 61.6 0.00 1.00 –
2. Often leaves seat in situations when remaining seated is 13.2 16.4 3.52 .059 –
expected (e.g., leaves his or her place in the classroom,
in the office or other workplace, or in other situations
that require remaining in place).
3. Often runs about or climbs in situations where it is 14.6 17.1 1.69 .193 –
inappropriate (Note: In adolescents or adults, may be
limited to feeling restless).
4. Often unable to play or engage in leisure activities quietly. 20.2 17.6 1.64 .200 –
5. Is often “on the go,” acting as is “driven by a motor” 36.0 36.7 0.05 .826 –
(e.g., is unable to be or uncomfortable being still for
extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult
to keep up with).
6. Often talks excessively. 42.1 40.7 0.36 .550 –
7. Often blurts out an answer before a question has been 24.4 27.7 3.02 .081 –
completed (e.g., completes people’s sentence; cannot
wait for turn in conversation).
8. Often has difficultly waiting his or her turn 26.0 26.7 0.06 .807 –
(e.g., while waiting in line).
9. Often interrupts or intrudes on others (e.g., butts into 29.8 27.9 0.91 .341 –
conversations, games, or activities; may start using
other people’s things without asking or receiving
permission; for adolescents and adults, may intrude
into or take over when others are doing).

Note. OR = odds ratio. * = p < .05. Bold wording represents the wording additions made between DSM-IV and DSM-5 (APA, 2013, p. 59–60)
J Psychopathol Behav Assess

often when compared to the comparable DSM-IV symptoms; change is statistically significant, χ2 = 1391.47 (1, N =
see Table 1 for summary of endorsement rates by DSM edi- 3877), p < .001, Cramer’s v = .599 (large). It is important to
tion. All 5 of these symptoms are among the 14 total that note that not all of these individuals would necessarily go on
received new parenthetical examples in DSM-5. Odds ratios to meet full diagnostic criteria (i.e., age of onset, duration,
for these significant differences in inattention symptom en- impairment); only symptom count was assessed in these chi
dorsement ranged from 1.36 to 1.58 (small). As for individual square tests. Symptom cutoffs are necessary but not sufficient
hyperactivity/impulsivity symptoms, no significant differ- for diagnosis.
ences emerged from the chi-square comparisons (Table 1). In addition to this chi square test, to further analyze the
These McNemar’s chi-square tests were also conducted third hypothesis we calculated the percent of individuals
separately for men and women with a self-reported past diag- in the full sample (N = 3877) who would meet the symp-
nosis of ADHD. Interestingly, when this was done for men, tom cutoffs of 4, 5, or 6 symptoms with DSM-IV and
only one symptom was rated significantly differently from DSM-5 wording, for any ADHD presentation (Table 2).
DSM-IV to DSM-5. Specifically, Inattention Symptom 2 was This helps disentangle the two simultaneous changes
endorsed more often with the DSM-5 wording (p = .027) for made to ADHD Criterion A because each change can be
men. On the other hand, when women were analyzed, six viewed separately.
individual symptoms were rated significantly more frequently The data presented in Table 2 were also calculated sepa-
with the DSM-5 wording: Inattention Symptoms 1, 2, 3, and 4 rately for men and women. The percent of women endorsing
(respectively, p = .040, <001, .027, and .013); as well as ADHD symptoms was uniformly numerically larger than the
Hyperactivity Symptoms 3 (i.e., often runs about or climbs, percent of the full sample, and the percent of men was uni-
p = .024) and 7 (i.e., often blurts out an answer, p = .006). formly numerically smaller than the percent of the full sample.
These additional two hyperactivity/impulsivity symptoms However, chi square tests revealed that none of these differ-
are also among the 14 symptoms that received new parenthet- ences were statistically significant, suggesting that the data in
ical examples in DSM-5. Please note that the lack of signifi- Table 2 is an accurate depiction of the data across biological
cance for men might be due to low power (Faul et al. 2007); sex (tables with analyses by sex available upon request).
thus, the results presented in Table 1 are not broken down by
sex (tables with analyses by sex available upon request). Hypothesis 4 Finally, we were interested in determining
whether the DSM-5 wording changes impacted the ability of
Hypothesis 3 To test the third hypothesis, that significantly the symptoms to predict impairment in the entire sample (N =
more college students would meet the DSM-5 cutoff of 5 3877). To this end, we compared total impairment mean
symptoms (with the DSM-5 wording) as compared to the scores at different levels of symptom endorsement via DSM-
DSM-IV cutoff of 6 symptoms (with the DSM-IV wording), 5 wording. As was done by Hartung et al. (2019) with DSM-
we first calculated the percent of individuals in the entire sam- IV symptom wording, we conducted one-way ANOVAs with
ple (N = 3877) who met each DSM edition threshold, and con- the two ADHD symptom dimensions (i.e., inattention and
ducted a Pearson chi square test. This chi square test was hyperactivity/impulsivity) predicting total WFIRS impair-
conducted for the percent of the entire sample who met any ment, but as worded in the DSM-5. As was done by Hartung
ADHD symptom threshold for DSM-IV versus −5 (i.e., those et al., we divided the full sample into those with low ADHD
who met the threshold for inattention or hyperactivity/ endorsement (i.e., 0–2 symptoms), high ADHD endorsement
impulsivity or both). The percent of the sample who endorsed (i.e., 7–9 symptoms), and those with 3, 4, 5, and 6 as separate
any ADHD DSM symptom threshold increased from 10.5% groups, resulting in 6 symptom endorsement groups. We hy-
(n = 406; with the DSM-IV wording and cutoff of 6) to 15.7% pothesized that significant impairment would begin at 4 symp-
(n = 607; with the DSM-5 wording and cutoff of 5). This toms for college students.

Table 2 Percent of the Full

Sample (N = 3877) Who Meet DSM-IV ADHD (any presentation) DSM-5 ADHD (any presentation)
Various Symptom Thresholds by
DSM-IV and − 5 Wording Symptom Threshold % n % n

≥6 10.5 406 11.5 446

≥5 14.5 564 15.7 607
≥4 20.1 779 21.2 822

Note. This does not constitute a full diagnosis, as it does take other diagnostic criteria into account (i.e., age of
onset, multiple settings, impairment, etc.). Symptoms thresholds are necessary but not sufficient for a diagnosis
Chi square tests comparing all percentages in this table were uniformly statistically significant at p < .001
 J Psychopathol Behav Assess

Table 3 WFIRS Impairment Means by DSM-5 Inattention Symptoms For women, impairment is the same at 3 and 4 symptoms of
(N = 3877)
inattention, and 4 symptoms of inattention elicited statistically
WFIRS Total Impairment the same level of impairment as 5 and 6 symptoms (a table
with analyses by sex available upon request).
Number of Symptoms n M (SD) Likewise, the hyperactivity/impulsivity ANOVA was sig-
0–2 2952 (.01)
nificant, F(5, 3865) = 183.15, p < .001, η2 = .192 (large). The
.31a results of the Tukey’s post hoc comparisons can be seen in
3 216 (.02) Table 4. Mean impairment was not significantly different for
.61b participants who endorsed 3, 4, or 5 hyperactivity symptoms
4 196 (.00)
.75c
(see Table 4 for details).
5 125 (.03) When this analysis was run separately for men and women,
.78c the results were quite similar to the full sample. For men,
6 98 (.03) impairment increased significantly at 3 symptoms of hyperac-
.79c
7–9 284 (.02)
tivity, and 3 symptoms elicited statistically similar impairment
.94d as 4 and 5 symptoms. For women, impairment increased sig-
nificantly at 3 symptoms of hyperactivity, and 3 symptoms
Note. WFIRS = Weiss Functional Impairment Rating Scale. WFIRS elicited statistically similar impairment as 4, 5, and 6 symp-
Impairment responses ranged from 0 to 3. Means without common su-
toms (a table with analyses by sex available upon request).
perscripts are significantly different (p < .05) from one another

The inattention ANOVA was significant, F(5, 3865) =

346.88, p < .001, η 2 = .310 (large). The results of the
Discussion
Tukey’s post hoc comparisons can be seen in Table 3. As
The results of the current study suggest that college students
predicted, mean impairment was not significantly different
with a self-reported past diagnosis of ADHD endorse slightly
for participants who endorsed 4, 5, or 6 symptoms; however,
more symptoms of ADHD when responding to DSM-5 symp-
those who endorsed 3 symptoms demonstrated statistically
tom wording than DSM-IV symptom wording. This was a
significantly less impairment than those with higher symptom
small but significant increase in overall symptom endorse-
endorsement.
ment (i.e., just under an additional half a symptom), suggest-
When this analysis was run separately for men and women,
ing that the parenthetical examples added for 14 of the 18
the results were quite similar to the full sample. For men,
ADHD symptoms may have improved the utility of DSM
impairment increased significantly at 4 symptoms, and 4
ADHD symptoms for this emerging adult population.
symptoms elicited statistically the same amount of impairment
Further, when the symptoms were examined individually in
as any higher level of symptom endorsement. However, 3
our past ADHD sample, five inattention symptoms in partic-
symptoms and 6 symptoms were also statistically similar.
ular (i.e., inattention symptoms 1, 2, 3, 4, & 7) were endorsed
Table 4 WFIRS Impairment Means by DSM-5 Hyperactivity/
more frequently via DSM-5 wording than DSM-IV wording.
Impulsivity Symptoms (N = 3877) Interestingly, when men and women were analyzed separately,
women also showed increased endorsement of two
WFIRS Total Impairment hyperactivity/impulsivity symptom (i.e., hyperactivity symp-
Number of Symptoms n M (SD) toms 3 & 7). On the whole, these changes are perhaps not as
stark as for other DSM disorders that underwent wholesale
0–2 3230 (.01) categorical changes (such as the addition of a new category
.35a of eating disorder which contributed to a doubling of the
3 214 (.02)
.69b
overall eating disorder prevalence rate; Flament et al. 2015),
4 142 (.03) but are nonetheless important.
.74b The findings of these first two sets of analyses supported
5 108 (.03) our first two hypotheses and are similar to findings in samples
.75b,c
6 65 (.04)
of adolescents with ADHD (i.e., Sibley and Kuriyan 2016;
.94c,d Sibley and Yeguez 2018). The Sibley papers reported larger
7–9 112 (.03) symptom endorsement increases (i.e., 1.15 symptom increase
.94d overall or .57 increase in inattention, versus our .41 overall
Note. WFIRS = Weiss Functional Impairment Rating Scale. WFIRS
symptom increase), but also had samples of mainly adolescent
Impairment responses ranged from 0 to 3. Means without common su- boys with higher symptomology. Thus, all participants in
perscripts are significantly different (p < .05) from one another these previous samples were adolescents with confirmed
J Psychopathol Behav Assess

ADHD, whereas our past ADHD sample was only defined by not change significantly when the analyses were conducted
retrospective self-report. In addition, the larger differences separately by biological sex. Overall, 5.2% more college stu-
found in the adolescent samples (Sibley and Kuriyan 2016; dents from our entire sample (N = 3877) met the DSM-5
Sibley and Yeguez 2018) were based on parent-report of symptom threshold of 5 with DSM-5 wording, as compared
ADHD symptoms, whereas the current sample was based on to the DSM-IV symptom threshold of 6 with DSM-IV wording
self-report only. This difference is notable because variations (for any ADHD presentation). However, this analysis takes
across reporters has long been documented in the diagnosis of both DSM-5 ADHD Criterion A changes into account simul-
ADHD (Burns et al. 2003), and in particular, some evidence taneously: both the added parenthetical wording changes and
suggests that collateral-reports of adult ADHD symptoms the symptom threshold changes. It is important to also under-
might be more accurate than self-reports (Sibley et al. 2012). stand each of these changes in isolation.
Therefore, it is important that the current findings be con- To this end, the percentages in Table 2 demonstrate the
firmed (or disconfirmed) with collateral reports in the future. separate impact of the DSM-5 Criterion A wording changes
Moreover, because the current sample was entirely drawn versus the threshold change. As can be seen in Table 2, the
from emerging adults enrolled in college, they might represent change to the symptom cutoff (i.e., the change lowering the
a high functioning subset of those with ADHD. Thus, perhaps symptom cutoff from 6 symptoms to 5) was more impactful
it makes sense that the current sample of college students did than the parenthetical wording changes. For instance, the pro-
not show as much movement between DSM-IV and − 5 as the portion of the full sample who would meet any ADHD thresh-
samples of adolescents (Sibley and Kuriyan 2016; Sibley and old increased from 10.5% to 14.5% (a change of 4%) when
Yeguez 2018) because the current sample reported relatively moving from a 6-symptom threshold to a 5-symptom thresh-
low levels of symptomology (leaving less room for movement old with constant DSM-IV wording. Conversely, when keep-
between DSM versions). However, when examining the added ing a 6-symptom threshold but changing the parenthetical
parenthetical examples in DSM-5, they certainly seem more wording only increases endorsement from 10.5% to 11.5%
relevant for emerging adult college students as compared to (a change of 1%). As noted above, when both changes (i.e.,
younger adolescents (e.g., “reviewing lengthy papers,” APA symptom threshold and parenthetical wording) are made si-
2013, p. 59), suggesting that the DSM-5 updates should have multaneously, the proportion increases from 10.5% to 15.7%
been more impactful in the current sample than in the Sibley (a change of 5.2%).
samples. In addition, the adolescent samples were predomi- Essentially, the symptom threshold change was much more
nantly boys whereas the current sample was primarily women; impactful than the parenthetical wording changes. To be sure,
it is possible that some of the noted differences between the this does not mean that 5% more college students will (or
Sibley findings and those herein are due to this differential sex should) be diagnosed; just that this additional proportion of
ratio across studies. More research is certainly warranted to college students are eligible for a diagnostic assessment. As
understand the implications of the changes to the ADHD stated above, the symptom threshold is necessary but not suf-
symptoms in adults. ficient for a diagnosis. Of course, an evidence-based, multi-
Like Sibley and Yeguez (2018), who found an increase for informant, multi-method diagnostic assessment with an em-
inattention but not hyperactivity across DSM editions in phasis on impairment is the appropriate way to render a diag-
parent-ratings of adolescents, and Vitola et al. (2017) who nosis of ADHD (Ramsay 2015). Nonetheless, the symptom
found that adult ADHD is largely comprised of inattention, cutoff change from 6 symptoms to 5 across DSM editions does
we similarly found the most change in self-reported inatten- increase the number of college students who might be referred
tion symptoms (with the exception of 2 hyperactivity symp- for this type of evidence-based assessment.
toms in women). As for the lack of movement in the It is important to reiterate here that the changes to DSM-5
hyperactivity/impulsivity symptoms: it could be that even ADHD Criterion A were conservative. As has been discussed,
with the added parenthetical statements, the symptoms are Criterion A changes from DSM-IV to −5 included both addi-
simply more appropriate and valid for children. On the other tional parenthetical examples and a threshold change for older
hand, this could be a floor effect, as endorsement rates for the adolescents and adults (APA 2013). However, Barkley et al.
hyperactivity symptoms were quite low regardless of edition (2008) had suggested a wholesale change to the core symp-
(see percentages in Table 1). Thus, the current findings sug- toms themselves. That is, instead of trying to make the symp-
gest that the added parenthetical statements to the inattention tom “runs about or climbs in situations where it is inappropri-
symptoms in DSM-5 were successful insofar as they slightly ate” relevant for adults as was done for DSM-5, Barkley et al.
increase endorsement by college students. (2008) would have replaced that core symptom with some-
Next, as hypothesized (i.e., Hypothesis 3), significantly thing like “drives at excessive speeds” (p. 193). This broader,
more emerging adult college students met the symptom more sweeping change remains an option for DSM-6 ADHD
threshold of 5 symptoms (i.e., the new DSM-5 cutoff) versus Criterion A. In addition, it is possible that the added paren-
6 symptoms (i.e., the old DSM-IV cutoff). These results did thetical statements could be improved to be more fitting/
 J Psychopathol Behav Assess

relevant for older adolescents and adults. More research is changes to DSM-5 ADHD Criterion A are positive for emerg-
certainly warranted regarding how to best categorized adult ing adult college students. We base this opinion on the high
ADHD. levels of impairment faced by college students with elevated
ADHD symptoms (Barkley 2015; Hartung et al. 2019), and
Implications for Diagnosis the improvements that can be made when appropriate inter-
ventions are in place (DuPaul et al. 2017). That is, the benefit
There are at least two ways to interpret the concurrent changes of appropriate identification of college students with elevated
that took place in ADHD Criterion A for DSM-5. First, it ADHD symptoms and significant impairment outweighs the
could be suggested that these changes are positive as more potential risk of overdiagnosis, especially because this prob-
college students may be eligible for an ADHD diagnosis. lem can be limited with good evidence-based diagnostic as-
That is, because they are endorsing a total of almost an addi- sessment procedures.
tional half symptom with the changes to the wording, and they
now only need to endorse 5 symptoms rather than 6, in es- Limitations and Future Directions
sence a person is now approximately 1.5 symptoms “closer”
to the diagnostic threshold. This could be considered an im- The findings of this study should be understood in the context
provement, as impairment is quite high in this population even of its limitations. The participants in this study did not undergo
when individuals endorse fewer than the required 5 symptoms a thorough, evidence-based diagnostic assessment. In fact,
of ADHD. Indeed, Hypothesis 4 focused on this issue. We their overall ADHD endorsement was quite low in the entire
found that impairment significantly increased for college stu- sample. Even our past ADHD group was defined only by
dents with 4 symptoms of inattention, and with just 3 symp- retrospective self-report of a previous ADHD diagnosis.
toms of hyperactivity/impulsivity. This finding suggests that a Thus, this was a community sample of relatively high-
lowered diagnostic threshold is justified given the increased functioning emerging adults enrolled in 4-year colleges, and
impairment seen in individuals with even a few ADHD symp- even those with a previous ADHD diagnosis, by virtue of
toms in the college setting. Notably, the presence of even 3 being enrolled in college, were high-functioning. Further,
symptoms of hyperactivity/impulsivity in college students in- our sample was limited to students enrolled in psychology
creases impairment significantly, which might suggest that an courses; they were mostly female, mostly white, and mostly
emerging adult with several symptoms from this domain has a from the U.S. Insofar as this is representative of the U.S.
more severe manifestation of ADHD. college population, results are at least somewhat generalizable
Second, on the other hand, it could be argued that the DSM- therein. However, these results should not be assumed to gen-
5 Criterion A changes to both symptom wording and the di- eralize to other groups. Future researchers should aim to fill in
agnostic cutoff at the same time was an overcorrection. That these gaps so that we can better understand the implications of
is, because the symptom wording changes increase endorse- the changes that were made to the ADHD diagnostic nosolo-
ment by approximately half an ADHD symptom, and the gy. Next, our study was limited to self-report surveys. We
threshold change lowers the necessary number of symptoms attempted to gather collateral reports from our college student
from 6 to 5, perhaps the cutoff for older adolescents and adults sample (i.e., reports from their parents or other significant
was lowered too much, and will result in overdiagnosis. individuals), but were largely unsuccessful. We continue to
Overdiagnosis is certainly considered to be a problem by strive to collect this corroborating data so we can examine
some (e.g., Paris et al. 2015). However, Sciutto and other-report in addition to self-report, as there is some evi-
Eisenberg (2007) note that overdiagnosis becomes a problem dence that self-report of ADHD symptoms, even by adults,
only when false positives greatly outnumber false negatives, can be difficult to interpret (Du Rietz et al. 2016). Next, we
which they concluded is not the case for ADHD. Indeed, these considered only WFIRS overall impairment for our hypothe-
authors concluded that because of the well-documented under sis on impairment; it might be that impairment is more specific
identification of girls with ADHD, there might be an under-- to certain domains (e.g., school work), or even individual
diagnosis problem in some populations (Sciutto and items. Thus, a more specific examination of impairment is
Eisenberg 2007). It follows, then, that given the similar under warranted.
identification of ADHD in adults as in girls, overdiagnosis in
this population may not be of much concern. Conversely, Overall Conclusion
stimulant misuse on college campuses is a growing concern
(Hartung et al. 2013), and could be impacted if more college Our data suggest that the changes made to DSM-5 ADHD
students are eligible for an ADHD diagnosis. Criterion A will make it slightly “easier” for college-enrolled
Our position is that, if used cautiously (such as with emerging adults, who experience significant functional im-
evidence-based assessment [Ramsay 2015] and checks on in- pairment, to meet the diagnostic threshold for this disorder.
valid or exaggerated responses [e.g., Bunford et al. 2017]), the The combination of slight wording changes to 14 of the 18
J Psychopathol Behav Assess

symptoms (which made a small impact), and the lowering of Burns, Walsh, & Gomez. (2003). Convergent and discriminant validity of
trait and source effects in ADHD-inattention and hyperactivity/
the symptom cutoff from 6 symptoms to 5 (which made a
impulsivity measures across a 3-month interval. Journal of
bigger impact) will increase the number of college students Abnormal Child Psychology, 31, 529–541.
who are eligible for an ADHD diagnosis. Thus, we urge cli- Canu, W. H., Hartung, C. M., Stevens, A. E., & Lefler, E. K. (2016).
nicians to use caution and emphasize impairment and collat- Psychometric properties of the Weiss functional impairment rating
Scale: Evidence for utility in research, assessment, and treatment of
eral reports in the diagnostic process to avoid potential over-
ADHD in emerging adults. Journal of Attention Disorders. https://
diagnosis. However, we feel that the benefits of catching more doi.org/10.1177/1087054716661421.
true positive cases of ADHD in college outweighs the risks of Claassen-van Dessle, N., van der Wouden, J. C., Dekker, J., & van der
overdiagnosis, given the high impairment in this group. Horst, H. E. (2016). Clinical values of DSM-IV and DSM-5 criteria
for diagnosing the most prevalent somatoform disorders in patients
with medically unexplained physical symptoms (MUPS). Journal of
Compliance with Ethical Standards Psychosomatic Research, 82, 4–10. https://doi.org/10.1016/j.
jpsychores.2016.01.004.
Ethical Approval All procedures performed in studies involving human Coghill, D., & Seth, S. (2011). Do the diagnostic criteria for ADHD need
participants were in accordance with the ethical standards of the institu- to change? Comments on the preliminary proposals of the DSM-5
tional and/or national research committee and with the 1964 Helsinki ADHD and disruptive behavior disorders committee. European
declaration and its later amendments or comparable ethical standards. Child and Adolescent Psychiatry, 20, 75–81. https://doi.org/10.
1007/s00787-010-0142-4.
Informed Consent Informed consent was obtained from all individual Cohen, J. (1988). Statistical power analysis for the behavioral sciences
participants included in the study. (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.
Du Rietz, E., Cheung, C. H. M., McLoughlin, G., Brandeis, D.,
Banaschewski, T., et al. (2016). Self-report of ADHD shows limited
Conflict of Interest Elizabeth K. Lefler declares that she has no conflict
agreement with objective markers of persistence and remittance.
of interest. Anne E. Stevens declares that she has no conflict of interest.
Journal of Psychiatric Research, 82, 91–99. https://doi.org/10.
Anna M. Garner declares that she has no conflict of interest. Judah W.
1016/j.jpsychires.2016.07.020.
Serrano declares that she has no conflict of interest. Will H. Canu declares
DuPaul, G. J., Dahlstrom, H. I., Gormley, M. J., Fu, Q., Pinho, T. D., &
that he has no conflict of interest. Cynthia M. Hartung declares that she
Banerjee, M. (2017). College students with ADHD and LD: Effects
has no conflict of interest.
of support services on academic performance. Learning Disabilities
Research & Practice, 32, 246–256. https://doi.org/10.1111/ldrp.
12143.
Epstein, J. N., & Loren, R. E. A. (2013). Changes in the definition of
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