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Adult attention deficit hyperactivity disorder is persistence of attention deficit hyperactivity disorder (ADHD) in adults. It is a neurodevelopmental disorder, meaning symptoms must present in childhood.[1][2] Specifically, for ADHD, multiple symptoms must have been present before age 12, according to DSM-5 diagnostic criteria.[1][2][3][4] This cutoff age of 12 is a change from the previous requirement of symptom onset prior to age 7 in the DSM-IV to add flexibility in the diagnosis of adults.[2][5] ADHD was previously thought to be a childhood disorder that improved with age, but recent research has disproved this. Approximately two thirds of childhood cases of ADHD continue into adulthood with varying degrees of symptom severity that change over time and continue to significantly affect individuals' daily functioning in multiple domains.[6][7]

This new insight on ADHD is further reflected in the DSM-5 which lists ADHD as a 'lifespan neurodevelopmental condition' and has distinct requirements for children and adults. Per DSM-5 criteria, children (age 17 or younger) must display 'six or more symptoms in either the inattentive or hyperactive-impulsive domain, or both' for diagnosis of ADHD. Adults need only demonstrate at least five symptoms in either domain to meet diagnostic criteria.[2][5] The International Classification of Diseases 11th Revision (ICD-11) also updated its diagnostic criteria to better align with the new DSM-5 criteria, but in a change from the DSM-5 and the ICD-10, while it lists the key characteristics of ADHD, the ICD-11 does not specify an age of onset, required number of symptoms that should be exhibited, or a duration of symptoms.[5]

A final update to the DSM-5 from the DSM-IV is a revision in the way it classifies ADHD by symptoms, exchanging "subtypes" for "presentations" to better represent the fluidity of ADHD features displayed by individuals as they age.[2][5]

The three presentations of ADHD are:
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  • Predominantly Inattentive Presentation (ADHD-I)
  • Predominantly Hyperactive-Impulsive Presentation (ADHD-HI)
  • Combined Presentation (ADHD-C)

Symptom manifestation and severity of ADHD is highly diverse and varies among individuals.[8] Hyperactive symptoms, specifically, often decrease starting in adolescence. [9] Inattention is a more common presentation in adult ADHD, manifesting as difficulty starting and completing tasks, forgetfulness, difficulty focusing, disorganization, and persistent tardiness.[6][9]

ADHD can only be diagnosed by a licensed clinician.[10] Diagnosis is made clinically via a comprehensive, structured interview to obtain a full history of the individual's current and childhood symptoms and their negative impact on daily functioning. A complete medical history should also be obtained, as the rates of coexistent conditions (comorbidities) with ADHD are high.[5][11][12] Supplemental history obtained from people close to the individual in different settings (e.g., parents, siblings, partners, teachers, coworkers, employers) can be helpful in confirming a diagnosis.[10]

ADHD is a highly genetically influenced condition, meaning it commonly runs in families.[2][5][6][13] Individuals with a first-degree relative with ADHD demonstrate a risk of ADHD 4-5 times higher than the general population rate and prevalence rates around 20%.[11] The rate of inheriting the disorder is estimated to be about 76% among children and adolescents and between 70-80% among adults.[6][11] The exact causes of ADHD are still not fully understood, but non-genetic biological risk factors (e.g., low birthweight, events during pregnancy) and environmental factors are also thought to play a role in the development of ADHD.[10][11][13]

Effective management of ADHD generally requires a combination of psychoeducation (teaching affected individuals about ADHD and its presentation and effects), behavioral interventions (e.g., cognitive behavioral therapy (CBT)), pharmacotherapy (treatment utilizing medication), and coaching for ADHD.[9][11] Psychostimulants, or simply stimulants, are considered the first-line medication for the treatment of ADHD. Particularly for adults, amphetamines (e.g., dexamphetamine) are considered the most effective medication.[7][9][11]

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Classification and Diagnosis

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In accordance with the updates to the DSM-5, published in 2013, the other criteria necessary for a diagnosis of ADHD in adults are as follows[2][12]:

  • Symptoms have been present for at least 6 consecutive months
  • Symptoms do not match the individual's level of development
  • Several symptoms onset before age 12 years
  • Several symptoms manifest in two or more domains (e.g., home, school, work)
  • Symptoms disrupt or diminish social, academic, and occupational performance
  • Symptoms cannot be better explained by another psychiatric disorder

Screening for ADHD in Adults

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ADHD can only be diagnosed by a licensed clinician, and the first step to do so is via screening with validated tools to screen for ADHD in adults.[9][10][11] The adult ADHD Self Report Rating Scale (ASRS) is a validated screening tool recognized by the World Health Organization (WHO) with a sensitivity and specificity of 91.4% and 96.0%, respectively.[11] Screening can guide clinical decision making toward the proper diagnostic and treatment methods, can prevent further negative outcomes, and can reduce medical costs that result from underdiagnosis.[9][11] Individuals who should be screened for ADHD include any adult with a chronic history of behaviors consistent with inattention, hyperactivity, impulsivity, restlessness, as well as emotional instability that started in childhood or early adolescence.[11] Due to its high rates of heritability, adults with a first-degree relative with ADHD should also be screened.[6][11][13] Other high-risk groups that should be screened include adults with a history of chronic mental health disorders (e.g., anxiety, depression, bipolar disorder), due to the high rates of comorbidity; adults within the criminal justice system or with a history of behavioral issues; and adults with multiple physical diseases.[1][11]

Diagnosing ADHD in Adults

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If an individual screens positively for ADHD, diagnosis is made clinically through a thorough, systematic interview with the aim of obtaining a full history of the individual's current symptoms and how those symptoms have inhibited their performance in daily activities. A history of childhood symptoms must also be obtained.[5][10][11] Whenever possible, supplemental information should be obtained from sources close to the individual (e.g., parents, siblings, significant other, colleagues) about the individual's symptom presentation and impairments in different settings.[2][10] These additional informants can aid the clinician in diagnosing ADHD in an adult because adults might not accurately recall childhood symptoms. Additionally, tend to inaccurately report current symptom severity and impairment, due either to poor self-awareness or the development of coping mechanisms throughout their lifetime to manage symptoms of undiagnosed ADHD.[1][11][12] In addition to determining current symptoms, the clinical interview to diagnose ADHD should also evaluate for coexisting medical and mental health disorders, as there can be significant overlap in symptoms of ADHD and other conditions.[9][10][11][12][14]

Validated Tools to Aid in Screening/Diagnosis of ADHD in Adults

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ADHD cannot be diagnosed via rating scales, neuropsychological tests, or brain imaging alone, but these can be used to support a diagnosis of ADHD as well as to quantify current severity and impairment of symptoms.[10][12][14]

  • Adult ADHD Self-Report Scale (ASRS)[11]
  • Wender Utah Rating Scale[11]
  • Diagnostic Interview for ADHD in Adults, third edition (DIVA-5)[12][15]
    • DIVA-5-ID (adapted version for people with intellectual disability)[11][15]
  • ACE+ (semi-structured diagnostic interview to assess for ADHD in adults, >16 years)[11]
  • Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID)[11][12]
  • Adult ADHD Clinical Diagnostic Scale (ACDS v1.2)[12]
  • Continuous Performance Tests (CPTs) (cognitive tests of attention and executive function)[16]

Signs and Symptoms

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If hyperactive-impulsive symptoms persist into adulthood, they present as excessive talking, fidgeting, restlessness and discomfort, an inability to sit still or relax, and impatience.[9]


There are many differences in the way ADHD manifests in adults compared to children. Notably, the prevalence of ADHD presentations differs between children and adults.[12][17]

There are many differences in the way ADHD manifests in adults compared to children. Notably, the prevalence of ADHD presentations differs between children and adults.[12][17] Whereas

Presentation of ADHD in Adult Males

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Treatment

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Similarly, exercise, sufficient sleep and nutritious food are also known to have a positive effect. Within school and work, reasonable accommodations may be put in place, such as by structuring work tasks, and setting up clear rules and limits for tasks.


Children under treatment will migrate to adult health services if necessary as they transit into adulthood, however diagnosis of adults involves full examination of their history.

References

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  1. ^ a b c d Taylor, Lea E.; Kaplan-Kahn, Elizabeth A.; Lighthall, Rachel A.; Antshel, Kevin M. (2022). "Adult-Onset ADHD: A Critical Analysis and Alternative Explanations". Child Psychiatry & Human Development. 53 (4): 635–653. doi:10.1007/s10578-021-01159-w. ISSN 0009-398X.
  2. ^ a b c d e f g h "American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)", SpringerReference, Berlin/Heidelberg: Springer-Verlag, retrieved 2023-11-13
  3. ^ Soler-Gutiérrez, Ana-María; Pérez-González, Juan-Carlos; Mayas, Julia (2023-01-06). Tachibana, Yoshiyuki (ed.). "Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review". PLOS ONE. 18 (1): e0280131. doi:10.1371/journal.pone.0280131. ISSN 1932-6203. PMC 9821724. PMID 36608036.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  4. ^ Song, Peige; Zha, Mingming; Yang, Qingwen; Zhang, Yan; Li, Xue; Rudan, Igor (2021-02-11). "The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis" (PDF). Journal of Global Health. 11. doi:10.7189/jogh.11.04009. ISSN 2047-2978. PMC 7916320. PMID 33692893.{{cite journal}}: CS1 maint: PMC format (link)
  5. ^ a b c d e f g Posner, Jonathan; Polanczyk, Guilherme V; Sonuga-Barke, Edmund (2020). "Attention-deficit hyperactivity disorder". The Lancet. 395 (10222): 450–462. doi:10.1016/S0140-6736(19)33004-1. PMC 7880081. PMID 31982036.{{cite journal}}: CS1 maint: PMC format (link)
  6. ^ a b c d e Young, Susan; Adamo, Nicoletta; Ásgeirsdóttir, Bryndís Björk; Branney, Polly; Beckett, Michelle; Colley, William; Cubbin, Sally; Deeley, Quinton; Farrag, Emad; Gudjonsson, Gisli; Hill, Peter; Hollingdale, Jack; Kilic, Ozge; Lloyd, Tony; Mason, Peter (2020). "Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women". BMC Psychiatry. 20 (1). doi:10.1186/s12888-020-02707-9. ISSN 1471-244X. PMC 7422602. PMID 32787804.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  7. ^ a b Hartman, Catharina A.; Larsson, Henrik; Vos, Melissa; Bellato, Alessio; Libutzki, Berit; Solberg, Berit Skretting; Chen, Qi; Du Rietz, Ebba; Mostert, Jeanette C.; Kittel-Schneider, Sarah; Cormand, Bru; Ribasés, Marta; Klungsøyr, Kari; Haavik, Jan; Dalsgaard, Søren (2023). "Anxiety, mood, and substance use disorders in adult men and women with and without attention-deficit/hyperactivity disorder: A substantive and methodological overview". Neuroscience & Biobehavioral Reviews. 151: 105209. doi:10.1016/j.neubiorev.2023.105209.
  8. ^ Attoe, Darby E.; Climie, Emma A. (2023). "Miss. Diagnosis: A Systematic Review of ADHD in Adult Women". Journal of Attention Disorders. 27 (7): 645–657. doi:10.1177/10870547231161533. ISSN 1087-0547. PMC 10173330. PMID 36995125.{{cite journal}}: CS1 maint: PMC format (link)
  9. ^ a b c d e f g h Hackett, Adanna; Joseph, Rose; Robinson, Kevlin; Welsh, Jeremy; Nicholas, Joyce; Schmidt, Eric (2020). "Adult attention deficit/hyperactivity disorder in the ambulatory care setting". JAAPA. 33 (8): 12. doi:10.1097/01.JAA.0000684108.89007.52. ISSN 1547-1896.
  10. ^ a b c d e f g h Faraone, Stephen V.; Banaschewski, Tobias; Coghill, David; Zheng, Yi; Biederman, Joseph; Bellgrove, Mark A.; Newcorn, Jeffrey H.; Gignac, Martin; Al Saud, Nouf M.; Manor, Iris; Rohde, Luis Augusto; Yang, Li; Cortese, Samuele; Almagor, Doron; Stein, Mark A. (2021). "The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder". Neuroscience & Biobehavioral Reviews. 128: 789–818. doi:10.1016/j.neubiorev.2021.01.022. PMC 8328933. PMID 33549739.{{cite journal}}: CS1 maint: PMC format (link)
  11. ^ a b c d e f g h i j k l m n o p q r s t Kooij, J.J.S.; Bijlenga, D.; Salerno, L.; Jaeschke, R.; Bitter, I.; Balázs, J.; Thome, J.; Dom, G.; Kasper, S.; Nunes Filipe, C.; Stes, S.; Mohr, P.; Leppämäki, S.; Casas, M.; Bobes, J. (2019). "Updated European Consensus Statement on diagnosis and treatment of adult ADHD". European Psychiatry. 56 (1): 14–34. doi:10.1016/j.eurpsy.2018.11.001. ISSN 0924-9338.
  12. ^ a b c d e f g h i j Anbarasan, Deepti; Kitchin, Michael; Adler, Lenard A. (2020). "Screening for Adult ADHD". Current Psychiatry Reports. 22 (12). doi:10.1007/s11920-020-01194-9. ISSN 1523-3812.
  13. ^ a b c Hinshaw, Stephen P.; Nguyen, Phuc T.; O’Grady, Sinclaire M.; Rosenthal, Emily A. (2022). "Annual Research Review: Attention‐deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions". Journal of Child Psychology and Psychiatry. 63 (4): 484–496. doi:10.1111/jcpp.13480. ISSN 0021-9630.
  14. ^ a b Rajaprakash, Meghna; Leppert, Mary L. (2022-03-01). "Attention-Deficit/Hyperactivity Disorder". Pediatrics In Review. 43 (3): 135–147. doi:10.1542/pir.2020-000612. ISSN 0191-9601.
  15. ^ a b "DIVA Foundation - DIVA-5 - Use of DIVA-5". www.divacenter.eu. Retrieved 2023-11-17.
  16. ^ Arrondo, Gonzalo; Mulraney, Melissa; Iturmendi-Sabater, Iciar; Musullulu, Hande; Gambra, Leyre; Niculcea, Teodora; Banaschewski, Tobias; Simonoff, Emily; Döpfner, Manfred; Hinshaw, Stephen P.; Coghill, David; Cortese, Samuele (2023). "Systematic Review and Meta-analysis: Clinical Utility of Continuous Performance Tests for the Identification of Attention-Deficit/Hyperactivity Disorder". Journal of the American Academy of Child & Adolescent Psychiatry. doi:10.1016/j.jaac.2023.03.011.
  17. ^ a b Antshel, Kevin M.; Barkley, Russell (2020), "Attention deficit hyperactivity disorder", Handbook of Clinical Neurology, vol. 174, Elsevier, pp. 37–45, doi:10.1016/b978-0-444-64148-9.00003-x, ISBN 978-0-444-64148-9, retrieved 2023-11-14
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