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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. 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.

Therefore, clinicians need to evaluate the degree of compensation when assessing symptom severity. 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.
The potential consequences of ADHD in these adults include major functional impairments in education, work performance, and family and community life. In addition, impairment related to a few specific symptoms may have serious consequences even if problems only occur in a few situations.
ADHD inattention symptoms can also resemble the distractibility of a manic or hypomanic episode.
While the use of rating scales can provide valuable information, it is critical to filter patient reports through the prism of skepticism since patients may assess symptoms in settings in which they are less impaired (ie, tasks that they find easy or interesting) and not the more challenging ones. 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. Rating scales can be helpful in complementing the clinical interview, quantifying target symptoms, and measuring treatment response.
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. 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.
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.

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