Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis
- Oscar Bukstein, MD
Oscar Bukstein, MD
- Clinical Professor of Psychiatry
- University of Texas Medical School at Houston, Baylor College of Medicine
Attention deficit hyperactivity disorder (ADHD), one of the most common neuropsychiatric disorders of childhood and adolescence, often persists into adulthood . Studies have found that a majority of people diagnosed with ADHD in childhood continue to meet criteria for the disorder as adults . ADHD in adulthood is associated with significant impairment in occupational, academic, and social functioning.
Epidemiologic studies of adult ADHD have estimated the current prevalence to be 4.4 percent in the US and 3.4 percent internationally [1,3]; however, individual study results have varied widely. ADHD in adults is characterized by symptoms of inattention, impulsivity, and restlessness, resulting in functional impairment. Impairment in executive function is common. Emotional dysregulation is often seen in these patients.
This topic discusses the epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of ADHD in adults. Pharmacotherapy and psychotherapy of adult ADHD are reviewed separately. ADHD in children and adolescents is reviewed separately. (See "Pharmacotherapy for adult attention deficit hyperactivity disorder" and "Psychotherapy for adult ADHD" and "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis" and "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis" and "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis" and "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications" and "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents".)
Epidemiologic studies of adult ADHD have estimated the current prevalence to be:
●4.4 percent among 18 to 44 year olds in US, National Comorbidity Survey Replication .
- Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007; 190:402.
- Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnorm Psychol 2002; 111:279.
- Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163:716.
- van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, et al. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend 2012; 122:11.
- Hervey AS, Epstein JN, Curry JF. Neuropsychology of adults with attention-deficit/hyperactivity disorder: a meta-analytic review. Neuropsychology 2004; 18:485.
- Makris N, Biederman J, Monuteaux MC, Seidman LJ. Towards conceptualizing a neural systems-based anatomy of attention-deficit/hyperactivity disorder. Dev Neurosci 2009; 31:36.
- Seidman LJ, Biederman J, Weber W, et al. Neuropsychological function in adults with attention-deficit hyperactivity disorder. Biol Psychiatry 1998; 44:260.
- Buchsbaum MS, Haier RJ, Sostek AJ, et al. Attention dysfunction and psychopathology in college men. Arch Gen Psychiatry 1985; 42:354.
- Kovner R, Budman C, Frank Y, et al. Neuropsychological testing in adult attention deficit hyperactivity disorder: a pilot study. Int J Neurosci 1998; 96:225.
- Rapport LJ, Van Voorhis A, Tzelepis A, Friedman SR. Executive functioning in adult attention-deficit hyperactivity disorder. Clin Neuropsychol 2001; 15:479.
- Dinn WM, Robbins NC, Harris CL. Adult attention-deficit/hyperactivity disorder: neuropsychological correlates and clinical presentation. Brain Cogn 2001; 46:114.
- Willcutt EG, Doyle AE, Nigg JT, et al. Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-analytic review. Biol Psychiatry 2005; 57:1336.
- Kasparek T, Theiner P, Filova A. Neurobiology of ADHD From Childhood to Adulthood: Findings of Imaging Methods. J Atten Disord 2015; 19:931.
- Cortese S, Kelly C, Chabernaud C, et al. Toward systems neuroscience of ADHD: a meta-analysis of 55 fMRI studies. Am J Psychiatry 2012; 169:1038.
- Schweitzer JB, Faber TL, Grafton ST, et al. Alterations in the functional anatomy of working memory in adult attention deficit hyperactivity disorder. Am J Psychiatry 2000; 157:278.
- Valera EM, Faraone SV, Biederman J, et al. Functional neuroanatomy of working memory in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2005; 57:439.
- Durston S, van Belle J, de Zeeuw P. Differentiating frontostriatal and fronto-cerebellar circuits in attention-deficit/hyperactivity disorder. Biol Psychiatry 2011; 69:1178.
- Seidman LJ, Valera EM, Makris N, et al. Dorsolateral prefrontal and anterior cingulate cortex volumetric abnormalities in adults with attention-deficit/hyperactivity disorder identified by magnetic resonance imaging. Biol Psychiatry 2006; 60:1071.
- Arnsten AF. Fundamentals of attention-deficit/hyperactivity disorder: circuits and pathways. J Clin Psychiatry 2006; 67 Suppl 8:7.
- Robbins TW. Chemistry of the mind: neurochemical modulation of prefrontal cortical function. J Comp Neurol 2005; 493:140.
- Wilens TE. Mechanism of action of agents used in attention-deficit/hyperactivity disorder. J Clin Psychiatry 2006; 67 Suppl 8:32.
- Smith AK, Mick E, Faraone SV. Advances in genetic studies of attention-deficit/hyperactivity disorder. Curr Psychiatry Rep 2009; 11:143.
- Franke B, Faraone SV, Asherson P, et al. The genetics of attention deficit/hyperactivity disorder in adults, a review. Mol Psychiatry 2012; 17:960.
- Barkley RA. Executive Functions: What They Are, How They Work, and Why They Evolved, The Guilford Press, New York 2012.
- Barkley RA, Fischer M, Smallish L, Fletcher K. Young adult outcome of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psychiatry 2006; 45:192.
- Barkley R, Murphy KR, Fischer M. ADHD in Adults: What the Science Says, Guilford Press, New York 2008.
- Weiss G, Hechtman L. Hyperactive Children Grown Up: Empirical Findings and Theoretical Considerations, 2nd ed, The Guileford Press, New York 1993.
- Barkley RA, Brown TE. Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr 2008; 13:977.
- Barkley RA, Cox D. A review of driving risks and impairments associated with attention-deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. J Safety Res 2007; 38:113.
- Rapport LJ, Friedman SR, Tzelepis A, Van Voorhis A. Experienced emotion and affect recognition in adult attention-deficit hyperactivity disorder. Neuropsychology 2002; 16:102.
- Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. J Clin Psychiatry 2006; 67:524.
- Hodgkins P, Arnold LE, Shaw M, et al. A systematic review of global publication trends regarding long-term outcomes of ADHD. Front Psychiatry 2011; 2:84.
- Dalsgaard S, Østergaard SD, Leckman JF, et al. Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet 2015; 385:2190.
- Mannuzza S, Klein RG, Bessler A, et al. Adult psychiatric status of hyperactive boys grown up. Am J Psychiatry 1998; 155:493.
- Weiss G, Hechtman L, Milroy T, Perlman T. Psychiatric status of hyperactives as adults: a controlled prospective 15-year follow-up of 63 hyperactive children. J Am Acad Child Psychiatry 1985; 24:211.
- Küpper T, Haavik J, Drexler H, et al. The negative impact of attention-deficit/hyperactivity disorder on occupational health in adults and adolescents. Int Arch Occup Environ Health 2012; 85:837.
- Karam RG, Breda V, Picon FA, et al. Persistence and remission of ADHD during adulthood: a 7-year clinical follow-up study. Psychol Med 2015; 45:2045.
- Agnew-Blais JC, Polanczyk GV, Danese A, et al. Evaluation of the Persistence, Remission, and Emergence of Attention-Deficit/Hyperactivity Disorder in Young Adulthood. JAMA Psychiatry 2016; 73:713.
- Moffitt TE, Houts R, Asherson P, et al. Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am J Psychiatry 2015; 172:967.
- Caye A, Rocha TB, Anselmi L, et al. Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood: Evidence From a Birth Cohort Supporting a Late-Onset Syndrome. JAMA Psychiatry 2016; 73:705.
- Biederman J, Mick E, Faraone SV. Normalized functioning in youths with persistent attention-deficit/hyperactivity disorder. J Pediatr 1998; 133:544.
- Sobanski E, Brüggemann D, Alm B, et al. Psychiatric comorbidity and functional impairment in a clinically referred sample of adults with attention-deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci 2007; 257:371.
- Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 2000; 157:816.
- Cumyn L, French L, Hechtman L. Comorbidity in adults with attention-deficit hyperactivity disorder. Can J Psychiatry 2009; 54:673.
- Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2004; 65 Suppl 3:3.
- Mannuzza S, Klein RG, Klein DF, et al. Accuracy of adult recall of childhood attention deficit hyperactivity disorder. Am J Psychiatry 2002; 159:1882.
- Haavik J, Halmøy A, Lundervold AJ, Fasmer OB. Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother 2010; 10:1569.
- Taylor A, Deb S, Unwin G. Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): a systematic review. Res Dev Disabil 2011; 32:924.
- Sandra Kooij JJ, Marije Boonstra A, Swinkels SH, et al. Reliability, validity, and utility of instruments for self-report and informant report concerning symptoms of ADHD in adult patients. J Atten Disord 2008; 11:445.
- Erhardt D, Epstein JN, Conners CK, et al. Self-ratings ofADHD symptoms in adults II: Reliability, validity, and diagnostic sensitivity. J Atten Disord 1999; 3:153.
- Harrison AG, Nay S, Armstrong IT. Diagnostic Accuracy of the Conners' Adult ADHD Rating Scale in a Postsecondary Population. J Atten Disord 2016.
- www.hcp.med.harvard.edu/ncs/asrs.php (Accessed on April 01, 2014).
- Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med 2005; 35:245.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Polanczyk G, Caspi A, Houts R, et al. Implications of extending the ADHD age-of-onset criterion to age 12: results from a prospectively studied birth cohort. J Am Acad Child Adolesc Psychiatry 2010; 49:210.
- Rigler T, Manor I, Kalansky A, et al. New DSM-5 criteria for ADHD - Does it matter? Compr Psychiatry 2016; 68:56.
- Pettersson R, Söderström S, Nilsson KW. Diagnosing ADHD in Adults: An Examination of the Discriminative Validity of Neuropsychological Tests and Diagnostic Assessment Instruments. J Atten Disord 2015.
- Geller B, Williams M, Zimerman B, et al. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord 1998; 51:81.
- CLINICAL MANIFESTATIONS
- Executive dysfunction
- Hyperactivity (restlessness)
- Emotional dysregulation
- Other impairments, health and social problems
- Adult manifestations
- Rating scales
- - Conners’ adult ADHD rating scale (CAARS)
- - Adult ADHD self-report scale
- DSM-5 diagnostic criteria
- Diagnostic Interview for ADHD in adults
- Differential diagnosis
- SUMMARY AND RECOMMENDATIONS