Unpacking "Severe ADHD": Why the Term Isn't Quite Right (and What We Mean Instead)

Embracing Freedom: A Boy with ADHD on His Skateboard

Scrolling through a Facebook ADHD support group recently, I stumbled upon a comment that read, "I was diagnosed with severe ADHD." The ensuing discussion highlighted a common misconception, with responses ranging from agreement to outright dismissal, claiming "there's no such thing as severe ADHD." As a parent who vividly remembers their child's early years, often describing their son's combined-type ADHD as "severe" due to his profound hyperactivity and the significant challenges it presented, I understand why this term might resonate. However, from a clinical perspective, it's crucial to clarify why "severe ADHD" isn't a formal diagnostic category and what the diagnostic criteria actually tell us.

The sentiment behind describing ADHD as "severe" is often deeply rooted in the lived experience. When symptoms of inattention, hyperactivity, and impulsivity are pervasive, significantly interfere with daily functioning, and lead to substantial impairment in multiple settings – academic, social, and familial – it feels severe. For many parents, like myself, witnessing a child struggle intensely with self-regulation, focus, and managing their energy can feel overwhelming, leading us to use language that reflects the magnitude of the challenge.

What Does the DSM-5-TR Say?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) is the authoritative guide used by mental health professionals to diagnose psychiatric conditions. When it comes to Attention-Deficit/Hyperactivity Disorder (ADHD), the DSM-5-TR (American Psychiatric Association [APA], 2022) does not use "severe ADHD" as a diagnostic specifier in the same way it might classify the severity of, for instance, a major depressive disorder (e.g., mild, moderate, severe).

Instead, the DSM-5-TR outlines three presentations of ADHD:

• Predominantly Inattentive Presentation: Characterized by significant difficulties with attention and organization, but less prominent hyperactivity/impulsivity.

• Predominantly Hyperactive/Impulsive Presentation: Marked by excessive motor activity, fidgeting, restlessness, and impulsive behaviors, with less prominent inattentive symptoms.

• Combined Presentation: When an individual meets the criteria for both inattention and hyperactivity/impulsivity.

  
  

My son, for example, had a combined presentation, and his hyperactivity was indeed profound, making a calm moment a rare occurrence.

Crucially, the DSM-5-TR does include a severity specifier for ADHD, but it's based on the degree of functional impairment, not an inherent "severity" of the disorder itself (APA, 2022). These specifiers are:

• Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairment in social or occupational functioning.

• Moderate: Symptoms or functional impairment between "mild" and "severe" are present.

• Severe: Many symptoms in excess of those required to make the diagnosis are present, or several symptoms are particularly severe, and symptoms result in marked impairment in social or occupational functioning.

  
  

Therefore, while a clinician might note "ADHD, Combined Presentation, Severe" in a diagnostic summary, the "severe" refers to the impact of the symptoms on the individual's life – their ability to succeed in school, maintain friendships, or function effectively at home – rather than implying a qualitatively different or more extreme form of ADHD itself. It indicates that the individual experiences significant and pervasive difficulties due to their ADHD symptoms, requiring more intensive support and intervention (Cortese et al., 2021).

Why This Distinction Matters

Understanding this nuance is vital for several reasons:

1. Accurate Communication: Using precise terminology ensures that healthcare providers, educators, and family members are all speaking the same language when discussing a diagnosis. This clarity is essential for effective treatment planning and support.

2. Stigma Reduction: Labeling ADHD as inherently "severe" could inadvertently contribute to greater stigma. Focusing on functional impairment allows for a more nuanced understanding of how ADHD affects individuals, promoting empathy and appropriate accommodations.

3. Treatment Planning: While the diagnosis of ADHD doesn't change, the level of impairment guides the intensity and type of interventions. An individual with "severe" impairment will likely require a more comprehensive and multi-faceted treatment approach, potentially including medication, behavioral therapy, educational accommodations, and parent training (Knapp et al., 2022).

HC Telepsych NP

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Cortese, S., Adamo, N., Mohr-Jensen, C., & Jentsch, F. (2021). Diagnostic approaches and clinical management of attention-deficit/hyperactivity disorder (ADHD). Journal of Clinical Medicine, 10(16), 3740. https://doi.org/10.3390/jcm10163740

Knapp, L., O’Callaghan, C., & McCarthy, J. J. (2022). Management of attention-deficit/hyperactivity disorder in children and adolescents. Journal of Pediatric Health Care, 36(2), 241-249. https://doi.org/10.1016/j.pedhc.2021.10.003