Use of DIVA-5

According to the DSM-5, ascertaining the diagnosis of ADHD in adults involves determining the presence of ADHD symptoms during both childhood and adulthood.

The main requirements for the diagnosis are that the onset of several ADHD symptoms occurred during childhood (< age 12) and that this was followed by a lifelong persistence of the characteristic symptoms to the time of the current evaluation. The symptoms need to be associated with significant clinical or psychosocial impairments that affect the individual in two or more life situations.

In order to simplify the evaluation of each of the 18 symptom criteria for ADHD in childhood and adulthood, the interview provides a list of concrete and realistic examples, for both current and retrospective (childhood) behavior. The examples are based on the common descriptions provided by adult patients in clinical practice. Examples are also provided of the types of impairments that are commonly associated with the symptoms in five areas of everyday life: work and education; relationships and family life; social contacts; free time and hobbies; self-confidence and self-image.

Because ADHD in adults is a lifelong condition that starts in childhood, it is necessary to evaluate the symptoms, course and level of associated impairment in childhood, using a retrospective interview for childhood behaviors. Whenever possible the information should be gathered from the patient and supplemented by information from informants that knew the person as a child (usually parents or close relatives). The DIVA usually takes around 1 to 1,5 hours to complete.

The DIVA only asks about the core symptoms of ADHD required to make the DSM-5 diagnosis of ADHD, and does not ask about other co-occurring psychiatric symptoms, syndromes or disorders. However comorbidity is commonly seen in both children and adults with ADHD, in around 75% of cases. For this reason, it is important to complete a general psychiatric assessment to enquire about commonly co-occurring symptoms, syndromes and disorders. The most common mental health problems that accompany ADHD include anxiety, depression, bipolar disorder, substance abuse disorders and addiction, sleep problems and personality disorders, and all these should be investigated. This is needed to understand the full range of symptoms experienced by the individual with ADHD; and also for the differential diagnosis, to exclude other major psychiatric disorders as the primary cause of ‘ADHD symptoms’ in adults.

Adjustments DIVA-5 – March 15, 2019

After publication of the Dutch DIVA-5, we received several questions about how to interpret the cut off of symptoms for ADHD in childhood in the DSM-5.

The DSM-5 states on one hand that 6/9 criteria of Inattention and/or Hyperactivity/Impulsivity are required, at least during 6 months, but also that only 'several' symptoms are needed before age 12. In order to improve uniform understanding and management of this definition of childhood ADHD, the DIVA Foundation decided to adjust the text in DIVA-5 to solve the issue.

The DSM-5 uses the term “several” – but what does this mean?
There are a few publications that have had to define this term for their research (i.e. how to estimate prevalence of DSM-5 ADHD) and they all use the definition of 3 or more. The Oxford English dictionary states “More than two but not many”.

The second question is whether 3 or more would be across both domains (i.e. 3 out of 18) or in either domain (i.e. 3 out of 9 in one of each domain). The wording in DSM-5 is “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”. Our interpretation is that the several here applies to either inattention OR hyperactivity-impulsivity. This also makes more sense, since 1 in one domain plus 2 in the other domain (i.e. 3 in total) would be a normal level of symptoms for a very large number of people. Having 3 or more in one domain or the other therefore seems a reasonable definition. As we need an algorithm to calculate a childhood diagnosis using any DIVA-5, we concluded that 3 or more symptoms would be the best value for 'several'.

This has been adjusted and clarified in the text and scoreform of the Dutch and Korean DIVA-5 that were already online, and will be implemented the same way in all languages that use DIVA-5.