Beyond the “Overdiagnosis” Narrative: Understanding Adult ADHD Through DSM-5

Am J Manag Care. 2026;32(Spec. No. 3):SP180-SP181. https://doi.org/10.37765/ajmc.2026.89908

The article “Overdiagnosis of Adult ADHD Is Exacerbating the Stimulant Shortage,” published in the March 2025 issue of Population Health, Equity & Outcomes, examined the ongoing stimulant medication shortage for attention-deficit/hyperactivity disorder (ADHD) treatment.¹ It argued that the ongoing stimulant crisis is due primarily to inflated diagnosis rates in adults. Although the article raises valid concerns regarding inconsistent diagnostic quality, its central premise, that problems with the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5)² criteria are perpetuating the shortage by causing overdiagnosis in adults, is flawed. The authors claim that the DSM-5 criteria are flawed because they omit core features like executive functioning and emotion regulation deficits, subsequently putting providers “at risk of inappropriately diagnosing.” Although the authors raise important concerns about the criteria’s poor specificity, noting that many individuals without ADHD may endorse symptoms, the manuscript contains several critical flaws that undermine its conclusion. The article fails to acknowledge the fundamental paradigm shift marked by the DSM-5.

The DSM-5 reframed ADHD as a persistent neurobiological disorder across the life span, rather than a condition solely restricted to childhood. By focusing narrowly on the potential for false positives, the article dismisses the fact that the rise in adult diagnoses reflects necessary recognition, not unprecedented inflation. Many adults now meet DSM-5 criteria because they were historically undiagnosed and untreated. Although the article notes the importance of verifying symptom onset before age 12 years, it fails to analyze how this reclassification fundamentally broadened the population requiring diagnosis and treatment. The authors invoke “DSM-5 limitations” but fail to analyze the key structural revisions implemented specifically to facilitate adult diagnosis and reflect the condition’s trajectory in older individuals. These updates, such as reducing the number of required symptoms for adults and modifying symptom wording to be age-appropriate, directly influence diagnostic sensitivity and prevalence rates.

Furthermore, although the article cites Russell A. Barkley, PhD, on how adult ADHD presents differently, the authors focus exclusively on the criteria’s technical flaws (omission of core deficits) and resulting poor specificity. This narrow focus avoids discussing how the DSM-5 revisions were attempts to rectify the previous system’s failure to identify persistent ADHD. The argument that the DSM-5 is defective is based on providers being forced to rely on criteria that omit core deficits. However, the article provides compelling evidence that the root issue lies in clinical constraints and training deficits, not the manual. The authors note that many clinicians lack adequate training, and only 8% of primary care providers reported being extremely confident in their diagnostic ability. Providers often rely solely on DSM-5 criteria due to constraints that limit comprehensive neuropsychological assessments. A high-quality assessment requires at least 2 hours of extensive neuropsychological testing, which is unrealistic for many providers because of time and training constraints. Therefore, the problem is not inherently that the DSM-5 lacks specificity, but that the criteria are being misused in brief assessments due to inadequate training and time pressures. Misdiagnosis is thus a consequence of systemic failure to support clinicians, which is incorrectly attributed to the DSM-5 itself.

By concluding that “the overdiagnosis of ADHD may be the main reason for the shortage,” the authors place undue emphasis on clinician error while downplaying chronic regulatory failures governing stimulant supply. As Schedule II medications, their supply is controlled by the Drug Enforcement Administration (DEA), which has faced criticism from numerous professional bodies claiming that it restricted production quantities, which prevented manufacturers from meeting demand. Although the DEA refuted these claims and approved increased production quotas for 2025 and 2026, the imbalance between supply and demand continues. This focus on overdiagnosis ignores the systemic flaw of an outdated regulatory approach and historically stagnant DEA aggregate production quotas. The control inherent in the Schedule II classification, combined with supply quotas failing to match legitimate demand growth, ensured that when diagnostic recognition rose, the pharmaceutical supply system inevitably collapsed into a shortage. This imbalance between demand and a restricted supply is a primary, unaddressed driver of the shortage.

The article’s focus on overdiagnosis overlooks the substantial body of research suggesting that ADHD in adults has historically been, and remains, underdiagnosed. This is especially true given the DSM-5’s reclassification of ADHD as a lifelong neurobiological disorder. Moreover, the authors minimize the value of self-report by asserting that “self-report assessments of inattention alone are insufficient” and play a “minor role” in neuropsychological evaluations. This view neglects the complex dynamics of adult symptom reporting. Although objective assessment of core deficits is necessary, self-report remains an important component for assessing functional impairment over time. In fact, major clinical guidelines validate the use of self-report scales such as the Adult ADHD Self-Report Scale as a key component of comprehensive assessments. Minimizing the role of self-reporting contradicts the established practice of assessing the chronicity and pervasiveness of symptoms across different life settings.

The article focuses heavily on the risk of false positives (poor specificity) due to the DSM-5 criteria. However, by advocating for comprehensive, 2-hour neuropsychological testing as the primary method, the authors risk increasing false negatives by underestimating the variability of adult symptom presentation in structured environments. In fact, the DSM-5 itself warns that manifestations must be present in “more than one setting” and that symptoms may be “minimal or absent” when the individual is in a novel setting, under close supervision, or in a one-on-one situation, such as the clinician’s office. Relying narrowly on the results of high-stakes, time-bound evaluation could mask symptoms that are pervasive in daily life, thereby leading to underdiagnosis. This risk is particularly acute given that the current criteria describe the effects of executive functioning deficits rather than the deficits themselves.

In summary, blaming the stimulant shortage on overdiagnosis is a simplistic narrative that misrepresents the DSM-5’s necessary evolution. The crisis is not one of defective criteria but of systemic failures, including chronic regulatory mismanagement by the DEA, historical underdiagnosis, and clinical constraints that prevent high-quality assessment. Focusing on clinician error while ignoring these larger structural issues will not solve the shortage and risks further harming patients who have only recently been recognized.

Author Affiliation: Independent mental health care provider, Fort Lauderdale, FL.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and administrative, technical, or logistic support.

Send Correspondence to: Gintaras Razaitis, MD, Fort Lauderdale, FL 33301. Email: grazaitis@dranderson.us.

REFERENCES

1. Abdallah SM, Tipton BL, Hughes JW. Overdiagnosis of adult ADHD is exacerbating the stimulant shortage. Am J Manag Care. 2025;31(Spec. No. 3):SP145-SP149. doi:10.37765/ajmc.2025.89708
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association Publishing; 2013. Accessed October 25, 2025. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596