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ADHD exerts a substantial toll on the lives of its sufferers and their families.1,19 This article explores the social and personal impact of ADHD on the lives of adults with this disorder, and the clinical challenges and opportunities for improving patient care through appropriate diagnosis and treatment.
ADHD has a wide-ranging impact on adult lives, manifesting as educational, interpersonal, physical, emotional, and work-related difficulties. Adults with ADHD, especially those with comorbid conduct or oppositional defiant disorder histories, are more likely to engage in behaviors resulting in incarceration.
Because the DSM-IV-TR indicates that impairments from ADHD must have an onset during childhood, diagnosis involves establishing the presence of symptoms during childhood as well as assessing current impairment.22 The DSM-IV-TR requirement for manifestation of symptoms before 7 years of age relies on parental, peer, or self-memories of childhood occurrences or records for verification. Differences in ADHD presentation based on culture and gender pose another diagnostic challenge. Maintaining a high index of suspicion for the presence of ADHD in adults is a key aspect in making a correct diagnosis. After screening, accurate diagnosis of ADHD requires a multifaceted approach including assessments of history, present symptoms, and functional impairment (Table 4).15,40,51,53 An accurate diagnosis requires sufficient presenting symptoms from the patient, with a pervasive course since childhood, and confirmation of childhood symptoms by an outside informant. Complete evaluation of an adult with suspected ADHD should also include assessment of comorbid psychiatric diagnoses and underlying medical conditions.52 Some medical conditions may have symptoms overlapping those of ADHD or can themselves account for certain attentional symptoms. Once the diagnosis is made, patient involvement is a key element in the success of managing ADHD in adults. Stimulants are the first line of treatment for ADHD.3 Stimulants, including methylphenidate and amphetamines, have been widely and successfully used in children for decades.
In 2005, the possibility of suicidal ideation with atomoxetine led to an FDA boxed warning similar to that for antidepressant medications for children and adolescents, but no such warning was required in adults based on analysis of the adult studies.
The FDA has recently approved the use of two long-acting stimulants in adults with ADHD: a prolonged-release formulation of methylphenidate and lisdexamfetamine dimesylate, a long-acting prodrug.
In June 2008, the FDA approved the use in adults of a formulation of methylphenidate (MPH) in which the drug is released via an osmotic release oral system (OROS). In April 2008, the FDA approved the use in adults of a new once-daily stimulant, lisdexamfetamine dimesylate (LDX), the first long-acting prodrug indicated for the treatment of ADHD in children and adults. In addition to pharmacotherapy, nonpharmacologic interventions, such as helping the patient restructure their environment, develop organizational skills, and create better coping strategies, may be beneficial in adults with ADHD.16 Because ADHD affects the entire family, treatment interventions may involve the spouse and children in restructuring of task sharing, planning, and day-to-day functioning.
Adult ADHD remains under-recognized, underdiagnosed, and undertreated by clinicians in the US. Stimulants that have been used in the pediatric ADHD population for decades are effective and well tolerated in adults. The development of diagnostic tools and treatment guidelines, coupled with the use of effective and tolerable medications and effective management of comorbid conditions, should improve the quality of care for adult patients with ADHD. Methods: Four hundred PCPs who have patients with ADHD, bipolar disorder, depression, generalized anxiety disorder (GAD), or obsessive-compulsive disorder completed a public release survey assessing their experiences and attitudes on diagnosing and treating these disorders. Results: Forty-eight percent of PCPs felt uncomfortable diagnosing adult ADHD and 44% reported that there were no clear diagnostic criteria.
The principal goal of this study was to examine the experiences and attitudes of primary care physicians (PCPs) regarding the diagnosis and treatment of ADHD in adults through a public release survey.
Somewhat contrary to the reported lack of knowledge and understanding of adult ADHD, only 26% of respondents concurred that ADHD is a condition that the vast majority of children outgrow (Figure 3). Only 35% of respondents reported that they would diagnose adult ADHD without referring patients to a specialist, whereas the vast majority reported that they would diagnose major depression (98%) and GAD (97%) themselves (Figure 4).
Ratings of the quality of adult ADHD screening tools were significantly worse compared to screening tools for the other target disorders. A significant number of respondents (13%) reported that they refer adult ADHD patients to specialists for treatment because many of the pharmacologic treatments, such as methylphenidate and amphetamines, are psychostimulants and controlled substances (Figure 6). While the results of this survey indicate that adult ADHD is generally accepted by PCPs, it also highlighted a need within the primary care community for more education and training in diagnosing and treating adults with the disorder. Although the willingness of PCPs to diagnose and treat adult ADHD without deferring to a specialist was strikingly low when compared with MDD and GAD, the majority of respondents reported that they would be more active in diagnosing and treating adult ADHD if they had an easy-to-use, validated screening tool. The majority of respondents also reported that they would be more active in treating adult ADHD if non-stimulant medications that were not controlled substances were available.
Although the prevalence of adult ADHD is comparable to that of MDD and GAD, this survey highlighted a potential need amongst PCPs for more education and training in adult ADHD. May 3, 2010 by Gina Pera Leave a Comment To read the two-part story that accompanies this chart, click here to visit Gina’s Adult ADHD Relationships blog. ADHD as Good-News And Bad-News DiagnosisTo read the two-part story that accompanies this chart, click here to visit Gina’s Adult ADHD Relationships blog. Assessments of ADHD in adults remained largely unchanged in the DSM-IV-TR published in 2000.7 As McGough and Barkley8 noted, the DSM criteria have never been validated in adults, do not include developmentally appropriate symptoms and thresholds for adults, and fail to identify some significantly impaired adults who could benefit from treatment.
A search of PubMed was conducted to identify relevant studies and critical reviews on the assessment and diagnosis of adults with ADHD. The three major subtypes of ADHD are described in the DSM-IV-TR7: the combined type (most frequently diagnosed in adults), the predominantly inattentive type, and the predominantly hyperactive-impulsive type (Table 1). Current DSM-IV-TR criteria may not accurately represent adult symptom manifestation even among adults who continue to experience significant impairment. The potential consequences of ADHD in adults have been described in several studies.21,23,29,32,33 Awareness of some of the educational, social, and occupational problems experienced by many adults with ADHD may prompt the identification of these people. To evaluate functional impairments associated with ADHD, Biederman and colleagues33 conducted a telephone-interview survey of a community sample of 500 adults (mean age=32 years) who reported having been diagnosed with ADHD, and 501 sex- and age-matched adults who did not have ADHD (controls; mean age=33 years). Barkley and colleagues32 assessed outcomes in 158 respondents rigorously diagnosed as hyperactive in childhood and 81 community controls who were followed up for ≥13 years. Diagnosis of ADHD in adults may be challenging because, like all psychiatric disorders, no objective medical or neuropsychological test can be used to make or confirm the diagnosis, and there is no established consensus on the specific symptom cluster for ADHD in adults.15 Making the diagnosis in an adult requires using different resources than are often available when making the diagnosis in a child. Adult patients with ADHD often have similar educational, occupational, and social impairments.
Adults with ADHD experiencing symptoms for years frequently develop compensatory strategies that help minimize the observable manifestation of impairments, thereby hiding symptoms from others.14 These compensatory strategies can complicate the diagnosis of ADHD by making impairments less evident to clinicians.
Comorbid ADHD is common in patients with other psychiatric disorders and comorbid psychiatric disorders are evident in a high proportion of adults with ADHD. Similar patterns of a high prevalence of these disorders in adults with ADHD are seen in data from the NCSR27 and from the 10-nation WHO survey.28 In both surveys, ADHD was assessed according to DSM-IV criteria, and other DSM-IV disorders were assessed using the WHO Diagnostic Interview. Several major self- and clinician-rated scales are currently available to assess whether an adult meets the DSM-IV-TR criteria necessary for a diagnosis of ADHD. Neuropsychological testing is generally reserved for cases of diagnostic uncertainty or for educational reasons.
In a study of 213 adults who met DSM-IV criteria for ADHD and 145 matched comparison subjects, Biederman and colleagues70 found that 31% of subjects with ADHD had executive function deficits. The persistence of ADHD symptoms into adolescence and adulthood in many patients strongly supports the concept that ADHD is a lifelong disorder for many patients. Accurately diagnosing ADHD is critically important, as highlighted by the findings of Barkley and colleagues32 and Biederman and colleagues.33 These studies demonstrate that missed diagnosis and the absence of treatment were associated with educational, occupational, and social impairments in adaptive functioning, as well as an increased risk of substance use disorder. The symptoms, deficits, and consequences associated with ADHD have a profound negative impact on the lives of patients and their families. Controlled studies1,20 demonstrate that adults with untreated ADHD have poorer educational performance and attainment, significantly more marriages, greater likelihood of problems making friends, and a higher incidence of interpersonal problems than those without ADHD. In a study at the Utah State Prison of 102 randomized male inmates 16–64 years of age, 26 received a positive diagnosis of ADHD (having significant symptoms both as children and adults). Nonetheless, it is prudent to be alert for suicidality in all patients with ADHD regardless of the choice of treatment and, in particular, in those patients with comorbid mood, anxiety, and substance use disorders. Its prevalence and the absence of relevant professional clinical training indicate a need to educate physicians and other healthcare providers who encounter the challenging task of diagnosing ADHD in adults. Management of ADHD in adulthood requires the clinician to rule out fairly common medical conditions, such as hypertension, that may be exacerbated by stimulant treatment. Improved recognition and treatment of ADHD should result in improved productivity in academic, work, and home environments, and should enhance quality of life for both patient and family.
Seventy-five percent rated the quality and accuracy of existing adult ADHD diagnostic tools as either poor or fair.
Lastly, physicians were asked to rate the frequency that they refer patients to a specialist for the treatment of each of the target disorders and the reasons why they collaborate with or defer to a specialist when diagnosing adult ADHD. This correlated with the finding that respondents consider themselves significantly more knowledgeable about both MDD and GAD than they are about bipolar disorder, OCD, or ADHD (Figure 1). However, 72% reported that it is more difficult to diagnose ADHD in adulthood than in childhood (Figure 3). Respondents reported that they were most likely to refer adult patients seeking a diagnosis of ADHD to either a psychiatrist (86%) or psychologist (55%; Figure 5). Seventy-five percent of respondents reported that they thought the quality and accuracy of diagnostic tools for adult ADHD was either poor or fair (Figure 7).
Seventy-five percent of respondents indicated that they would take a more active role in diagnosing and treating adult ADHD if effective, non-stimulant medications that were not controlled substances were available (Figure 3).
Although the majority of respondents reported that they thought the underlying symptoms of ADHD are the same for children and adults, they indicated that they thought adults manifest these symptoms differently than children and that the disorder is more difficult to diagnose in adulthood than in childhood. It should be noted that since this survey was conducted, the Adult ADHD Self-Report (ASRS) v1.1 Screener has been developed and validated.

Around the same time that this survey was conducted, the first non-stimulant medication, atomoxetine, was approved and released for the treatment of adult ADHD. However, follow-up investigations into the current PCP awareness of adult ADHD are needed as new, easy-to-use screening tools for adult ADHD and non-stimulant and novel stimulant medications have been developed in the 6 years since the survey was conducted.
Occasionally, though, I will post related information of particular interest to the partners of adults with ADHD. Goodman is director at the Adult Attention Deficit Disorder Center of Maryland, at Johns Hopkins at Green Spring Station in Lutherville, as well as assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine in Baltimore.
The guidelines do not further elaborate on the concept, but Faraone and colleagues10 examined adults with both late-onset ADHD (83% had an age-of-onset between 7 and 12 years of age) and subthreshold ADHD symptoms.
Clinical considerations and available instruments for assessment and diagnosis of ADHD in adults are reviewed below.
As noted above, another category, ADHD-NOS, is included for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet all criteria for ADHD. In contrast, 58% endorsed an ADHD subtype that includes symptoms of hyperactivity-impulsivity. Barkley and colleagues26 have recommended the adoption of nine criteria for the diagnosis of ADHD in adults (Table 3). In the studies reviewed below, most of the respondents with ADHD were not receiving treatment for ADHD. The adults with ADHD were significantly less likely to have graduated from high school than those without ADHD (7% vs. With children, parents or teachers see the child intensely for significant time periods, but in adults, there is often no one person who sees the patient throughout the day (a reporter from work may miss symptoms at home and a significant other may under-report symptoms at work).
Many adults with ADHD may have failed to live up to their potential and present with problems related to diminished educational achievement or vocational training. For example, the inattentive symptoms seen with ADHD may resemble concentration impairments that occur in major depressive disorder (MDD), dysthymia, posttraumatic stress disorder, and generalized anxiety disorder (GAD).
High rates of mood, anxiety, and substance use disorders have been reported in community studies of adults with ADHD and in national and international surveys. Seidman69 reported that >70 tests are available to assess neuropsychological functioning in adults with ADHD.
Although the symptoms of ADHD seen in pediatric patients may shift as patients enter adulthood, the consequences of adult symptoms of ADHD are no less serious. Because of the high prevalence rate of ADHD relative to other Axis I psychiatric disorders, clinicians should be aware of the symptoms and adult manifestations of ADHD and include screening in every adult psychiatric evaluation. Young adults with attention deficit hyperactivity disorder: subtype differences in comorbidity, educational, and clinical history.
The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Young adult outcome of hyperactive children: adaptive functioning in major life activities.
Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community.
Cognitive-behavioral therapy for ADHD in medication-treated adults with continuous symptoms. Screening and diagnostic utility of self-report attention deficit hyperactivity disorder scales in adults. Adult attention-deficit hyperactivity disorder: assessment guidelines based on clinical presentation to a specialty clinic. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state. Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members.
Parent and teacher ratings of ADHD symptoms: psychometric properties in a community-based sample. Self- and informant reports of executive function on the BRIEF-A in MCI and older adults with cognitive complaints.
Impact of psychometrically defined deficits of executive functioning in adults with attention deficit hyperactivity disorder.
The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation.
Barriers to diagnosing ADHD in adults include diagnostic criteria developed and field-tested in children, nonspecificity of symptoms, high incidence of comorbid disorders that could mask or distract from the ADHD diagnosis, variation in presenting symptoms by gender and ethnicity, and lack of definitive diagnostic tools.
An additional 22 inmates showed varying patterns of ADHD symptoms throughout childhood and adulthood, while seven had exhibited ADHD symptoms only during childhood, and seven showed ADHD symptoms only as adults.33 Of 129 inmates of a German prison for adolescent and young adult male prisoners, ADHD (using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition34 criteria) was diagnosed in 45%. Further, symptoms may become apparent only in more challenging situations, such as at home with its demands for multitasking, and be less prominent in a work environment chosen for its suitability for ADHD.16,54 Adaptive skills, intelligence quotient, and environmental demands may make it difficult to enumerate the six of nine symptom criteria or to validate the two-domain criterion of the DSM-IV-TR. A recent study identified a group of 79 adults who fulfilled all criteria for ADHD except for onset of symptoms before 7 years of age. The critical factor in distinguishing many of these conditions from ADHD is the absence of childhood cognitive or behavioral symptoms consistent with ADHD.
Providing long-term support and encouragement at follow-up sessions is intrinsic to the treatment process and can also serve to significantly increase the often poor treatment adherence seen in ADHD. The selection of short-acting or long-acting ADHD treatments varied by specialty, with long-acting agents representing 56% of primary care prescriptions, 64% of psychiatrist prescriptions, and 79% of pediatric prescriptions.
Updated DSM-IV-TR diagnostic criteria that recognize adult-specific symptoms and reconsider age-threshold criteria for symptom onset are needed.
Significant cardiac disease in most cases precludes the use of stimulants in both adults and children.
Future research may demonstrate whether intervention for ADHD can reduce morbidity and mortality from tragic outcomes associated with ADHD such as increased rates of motor vehicle accidents, suicide, and substance abuse and dependence. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning.
Prospective study of tobacco smoking and substance dependencies among samples of ADHD and non-ADHD participants.
Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults. Stability of executive function deficits into young adult years: a prospective longitudinal follow-up study of grown up males with ADHD.
A psychoeducational program for children with ADHD or depression and their families: results from the CMAP Feasibility Study.
A randomised, double-blind, placebo-controlled trial of dexamphetamine in adults with attention deficit hyperactivity disorder. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial.
Long-term safety and effectiveness of mixed amphetamine salts extended release in adults with ADHD. A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults.
Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder.
A double-blind, placebo-controlled, crossover study of osmotic release oral system methylphenidate in adults with ADHD with assessment of oppositional and emotional dimensions of the disorder. Lisdexamfetamine dimesylate and mixed amphetamine salts extended-release in children with ADHD: a double-blind, placebo-controlled, crossover analog classroom study. A double-blind, randomized, placebo- and active-controlled, 6-period crossover study to evaluate the likability, safety, and abuse potential of lisdexamfetamine dimesylate (LDX) in adult stimulant abusers. Psychotherapy of attention deficit hyperactivity disorder in adults: a pilot study using a structured skills training program.
A Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnosis, Treatment.
Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. Adults with ADHD benefit from cognitive behaviorally oriented group rehabilitation: a study of 29 participants. Only 34% of respondents answered that they were either very or extremely knowledgeable about adult ADHD (Figure 1).
Nearly half of respondents reported that they were not confident in their ability to diagnose ADHD in adults (48%) and believe that there are no clear criteria for diagnosing adults with the disorder (44%; Figure 3).

Fifty-two percent of respondents attributed inexperience or lack of confidence as the primary reason for collaborating with or deferring to specialists when diagnosing adult ADHD, and 22% reported that they believed adult ADHD to have no clear diagnostic criteria (Figure 6).
Eighty-five percent of respondents indicated that they would take a more active role in diagnosing and treating adult ADHD if an easy-to-use, relatively quick to administer screening tool was developed and validated by physicians or institutions they respect (Figure 8). Additionally, the first pro-drug stimulant, lisdexamfetamine dimesylate, with a reduced overdose toxicity and drug tampering, was recently approved for the treatment of pediatric and adult ADHD.33-37 Together with the availability of novel extended-release formulations of traditional psychostimulants and the advent of non-stimulant and safer stimulant medications as viable treatment options, the reluctance to treat adult ADHD amongst the primary care community may be reduced.
Second, the survey was conducted in 2003 and there has likely been an increase in the awareness and familiarity of adult ADHD amongst PCPs as well as the general population.
Young adult outcome of attention deficit hyperactivity disorder: a controlled 10 year follow-up study. Adult outcome of hyperactive boys: educational achievement, occupational rank, and psychiatric status. Attention deficit hyperactivity disorder in adults: a guide for the primary care physician. The prevalence and correlates of adult ADHD in the united states: results from the national comorbidity survey replication. Attention deficit hyperactivity disorder in adults: comorbidities and adaptive impairments. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Validity of the world health organization adult ADHD self-report scale (ASRS) screener in a representative sample of health plan members.
Multiple daily-dose pharmacokinetics of lisdexamfetamine dimesylate in healthy adult volunteers. The effect of stimulant treatment for ADHD on later substance abuse and the potential for medication misuse, abuse, and diversion.
The potential consequences of ADHD in these adults include major functional impairments in education, work performance, and family and community life. ADHD inattention symptoms can also resemble the distractibility of a manic or hypomanic episode. The results suggest that many people with ADHD do not have these deficits and that reliance on neuropsychological testing to make a diagnosis will miss most of those affected.
During clinical evaluation, symptom assessment is essential but not sufficient to diagnose this disorder.
Goodman is director of the Adult Attention Deficit Disorder Center of Maryland at Johns Hopkins at Green Spring Station, assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, and director of Suburban Psychiatric Associates, LLC. Given the relatively high prevalence of ADHD compared with other psychiatric disorders, clinicians should maintain a high index of suspicion and integrate screening for ADHD into all routine psychiatric evaluations. Recent data from Verispan13 indicates that prescriptions for ADHD medications for adults ≥18 years of age grew steadily from January 2003 through October 2007. Interviewing family members greatly improves the clinician’s ability to correctly identify ADHD, as others often remember impairments that the patient has forgotten or failed to recognize.
When examined by patient age, long-acting agents accounted for 78% of ADHD prescriptions in pediatric patients (0–17 years of age), but only 49% of adult ADHD prescriptions.
Clinical trials of LDX in children have demonstrated significant improvements in ADHD rating scale scores compared with placebo and consistent times to maximum plasma LDX levels among the subjects.111,112 Similar results have been seen in adults. Meanwhile, clinicians can improve patient care and provide a better quality of life for these patients and their families by maintaining a high index of suspicion for ADHD, making screening for the disorder an intrinsic part of the standard psychiatric evaluation, and implementing a multifaceted approach to the diagnosis and treatment of adult ADHD. Sixty-five percent reported deferring to specialists to diagnose adult ADHD, compared to 2% for depression and 3% for GAD. Furthermore, only 13% of respondents reported that they had received very or extremely thorough clinical training in adult ADHD which was significantly less than all of the other target disorders except for OCD (Figure 2). Seventy-three percent of respondents reported that the underlying symptoms of ADHD are similar in children and adults but the manifestations of these symptoms differ throughout the life course (Figure 3). Furthermore, only 5% of respondents reported that they make the final decision regarding medication when treating adult ADHD with 42% reporting that they collaborate with specialists and 53% reporting that they refer their adult ADHD patients to specialists.
However, only ~50% of respondents indicated that screening tools for adult ADHD should be based on the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition23 criteria for diagnosing ADHD in children (Figure 8). Diagnosis should be based on clinical assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for ADHD. Those with subthreshold symptoms, however, had milder impairments and lacked the familial pattern, suggesting this might not be a valid diagnosis.
For example, in a study of 221 adults with ADHD (mean age 38.7 years) by Spencer and colleagues,17 70% of the subjects were of the combined type, 27% the inattentive type, and 3% the hyperactive-impulsive type.
Additionally, in a review of the literature on ADHD and correctional health care, Eme35 reported a 25% prevalence of ADHD among inmates. Furthermore, some hyperactivity symptoms of ADHD, such as motoric restlessness and excessive talking, can be difficult to distinguish from the symptoms of restlessness in GAD or psychomotor agitation associated with mania, hypomania, or MDD. Furthermore, in a study by Alpert and colleagues,47 childhood-onset ADHD was diagnosed in >16% of 116 adults enrolled in a treatment program who had a current episode of MDD. As a case in point, baseline investigator ratings were stronger predictors of treatment outcome than baseline patient self-report scores on the Conners Adult ADHD Rating Scale.68 Rating scales can also be used to measure patient response to treatment and changes in quality of life. Instead, Seidman highlighted five tests that most consistently differentiated people with ADHD from controls and were used in ≥7 studies.
Additionally, the results of several studies suggest that neuropsychological testing cannot definitively distinguish between those with ADHD and those without.71-74 This further highlights the importance of clinical assessment in making a correct diagnosis of ADHD in adults. The chronicity and pervasiveness of ADHD symptoms, as well as impairment due to ADHD symptoms, are critical to the correct diagnosis of ADHD in adults.
ADHD Across the Lifespan: An Evidence-Based Understanding From Research to Clinical Practice.
Accurate diagnosis requires a comprehensive clinical interview, including evaluation of past and present symptoms and longitudinal course and assessment of functional impairment.
The DSM-IV-TR would classify these patients as having a diagnosis of ADHD not otherwise specified (NOS) because they do not fulfill the age-at-onset criterion for ADHD.22 Gathering additional ADHD impairment data from family, friends, and school records from before 7 years of age can be helpful in many cases. It can also be helpful to obtain school records to identify or corroborate childhood manifestations of ADHD.40 However, valuable supplementary information from family members or school records may often be somewhat difficult to obtain for adult patients no longer residing near their parents or schools. Extended-release preparations of methylphenidate, dexmethylphenidate, mixed amphetamine salts, and lisdexamfetamine are approved by the US Food and Drug Administration for use in adults without age restrictions. Longer-acting forms of stimulants and nonstimulants can improve convenience and extend control of ADHD symptoms in challenging adult environments and potentially may help decrease, but by no means eliminate, the likelihood of stimulant abuse and diversion.
Eighty-five percent reported that they would be more comfortable diagnosing and treating adult ADHD if thorough, straightforward screening tools were validated and if there were effective medications that were neither stimulants nor controlled substances. Last, they were currently treating at least 30 adult patients per week with any combination of the target disorders, which were ADHD, bipolar disorder, MDD, GAD, or OCD. Seventy-seven percent of physicians reported that they believe that adult ADHD is not well understood by the medical community (Figure 3).
Among adults, the core ADHD symptoms of hyperactivity and impulsivity tend to diminish with age, and inattention becomes a predominant symptom domain.
A person with ADHD may have learned to check carefully at home to ensure that he or she has not forgotten something, and then may be chronically late for work resulting in a poor job review.
Similarly, the impulsive symptoms seen with ADHD may resemble the impulsivity characteristic of manic and hypomanic episodes38 or borderline personality disorder.7 Some of these complexities can be addressed during the clinical interview by asking questions using adult-specific language and context. The DSM-IV-TR criteria for ADHD still provide the basis for diagnosis despite several limitations involving the different manifestations of ADHD symptoms from childhood to adulthood, such as the possible attenuation of hyperactive-impulsive symptoms. It is important to remember that patients classified as having a diagnosis of ADHD NOS will also usually respond to approved treatments, as recently reported by Biederman and colleagues.58 In an open-label trial in 36 adults with late-onset ADHD NOS, an extended-release preparation of methylphenidate was associated with statistical and clinical improvement of ADHD symptoms.
In a recent analysis96 of US prescribing patterns, long-acting medications were still being used more commonly to treat ADHD in children and adolescents (78%) than in adults (49%), though adults may have even greater problems with treatment adherence and drug abuse and diversion than those ≤18 years of age. McGough and Barkley8 noted that in many cases patients who might have been diagnosed with the combined type as youths will appear to have the inattentive type in adulthood. Diagnostic accuracy rests on the longitudinal course of cross-sectional cognitive and behavioral symptoms tracked back to the age of onset. Core inattentive symptoms may continue into adulthood and often drive the presentation of ADHD in adults.
Moreover, comorbid ADHD is common in patients with many other psychiatric disorders and comorbid disorders are evident in many adults with ADHD.
Additional complexities to making an accurate diagnosis include patient coping strategies, symptom profiles that overlap with other DSM-IV-TR disorders, and frequent comorbidity with other DSM-IV-TR disorders.
This article reviews important considerations in diagnosing ADHD in adults and screening and diagnostic instruments that assist in accurate diagnosis of the disorder. Diagnosis may be assisted through the use of several recently developed screening and diagnostic instruments for assessment of ADHD in adults, specifically those that employ adult-specific language to circumvent some of the shortcomings associated with the child-centered DSM-IV-TR criteria for ADHD. New treatments on the horizon may offer options better fitting the needs of adults with ADHD.

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