Reply to “Beyond the ‘Overdiagnosis’ Narrative: Understanding Adult ADHD Through DSM-5”

Am J Manag Care. 2026;32(Spec. No. 3):SP181-SP182. https://doi.org/10.37765/ajmc.2026.89909

We welcome the input and opportunity for discussion. There is much on which we can agree, including that attention-deficit/hyperactivity disorder (ADHD) is a lifelong neurobiological condition; the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5) criteria “describe the effects of executive functioning deficits rather than the deficits themselves”; and that there are systemic failures and “clinical constraints that prevent high-quality assessment.” We appreciate the concern that our original commentary did not sufficiently address the DSM-5’s expansion to identify undiagnosed adults or the systemic pressures faced by prescribers.¹ Our focus, however, was on overdiagnosis in clinical settings, where oversimplified messaging may contribute to referrals based on symptoms that overlap with other mental health concerns, rather than ADHD’s core neurobiological deficits.

With respect to the overdiagnosis and underdiagnosis of ADHD, we are both correct. In epidemiological contexts, with lower base rates of ADHD, we would expect lower sensitivity and underdiagnosis. The rate of ADHD in adults has been estimated at 2.5%,² which would suggest a high potential for underdiagnosis in representative population samples. In contrast, samples of treatment-seeking individuals have higher base rates of ADHD, leading to possible overdiagnosis due to poor specificity. In outpatient psychiatry clinics, the rate of ADHD was 27%,³ allowing a greater risk of overdiagnosis. In fact, when a 2-stage assessment was conducted, the rate dropped to 14.6%, supporting our argument for a more detailed evaluation, rather than reliance on DSM-5 criteria.

Where we may differ is that we would like to see the DSM continue to evolve. The letter author asserts that “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.” We believe that even if training and time pressure were not an issue, clinicians are still at risk for misdiagnosing ADHD due to the criteria.

Although inattentive ADHD is the most common form,⁴ problems with attention are common in other psychiatric conditions. To avoid confusion and improve diagnostic accuracy, the DSM-5 should include inattentive symptoms of ADHD in a way that is clearly distinguishable from attention difficulties seen in other conditions, by targeting the neurobiological deficits.

Here’s an example of our suggestion:

Current DSM-5 criterion 1b: “Often has difficulty sustaining attention in tasks or play activities (eg, has difficulty remaining focused during lectures, conversations, or lengthy reading).”⁵

Revision suggestion: “Often demonstrates distractibility to environmental stimuli that are typically ignored by others, resulting in internal distress and/or observable behavioral challenges (eg, distracted by noises others can easily ignore).”

The revised wording focuses on the same issue as DSM-5 criterion 1b: inattention. However, instead of saying “difficulty sustaining attention in tasks,” which can be caused by extraneous factors, our revision targets the core problem—difficulty filtering internal and external stimuli—a central feature of inattention in ADHD. By focusing on this underlying neurobiological issue, the diagnosis becomes clearer and helps distinguish ADHD-related attention problems from those caused by stress, emotions, or the environment.

This is just 1 example to illustrate that improved DSM-5 criteria for diagnosing ADHD in adulthood could reduce misdiagnosis and overdiagnosis.

Author Affiliations: Department of Psychological Sciences, Kent State University (SMA, JWH), Kent, OH; Giant Eagle Pharmacy (BLT), Akron, OH.

Source of Funding: None.

Author Disclosures: The authors report 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 (SMA); drafting of the original manuscript (SMA); contributing important intellectual content and editing the manuscript (SMA, BLT, JWH); and final approval (SMA, BLT, JWH).

Send Correspondence to: Salayna M. Abdallah, MA, BS, Kent State University, 3502 Ivanhoe Dr, Kent, OH 44240. Email: salaynaabdallah@gmail.com.

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. Song P, Zha M, Yang Q, Zhang Y, Li X, Rudan I. The prevalence of adult attention-deficit hyperactivity disorder: a global systematic review and meta-analysis. J Glob Health. 2021;11:04009. doi:10.7189/jogh.11.04009
3. Adamis D, Flynn C, Wrigley M, Gavin B, McNicholas F. ADHD in adults: a systematic review and meta-analysis of prevalence studies in outpatient psychiatric clinics. J Atten Disord. 2022;26(12):1523-1534. doi:10.1177/10870547221085503
4. Cortese S, Bellgrove MA, Brikell I, et al. Attention-deficit/hyperactivity disorder (ADHD) in adults: evidence base, uncertainties and controversies. World Psychiatry. 2025;24(3):347-371. doi:10.1002/wps.21374
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association Publishing; 2013. Accessed January 12, 2026. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596