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Literature Review
ADHD in Adults
A Review of the Literature
Megan A. Davidson
Queens University
Objective: ADHD presents significant challenges to adults. The current reviews goals are (a) to critically examine the
current state of knowledge regarding ADHD in adults and (b) to provide clinicians with practice-friendly information
regarding assessment, diagnosis, and treatment. Method: Searches of PsycINFO and Medline were conducted, and
reference lists from articles and books were searched for additional relevant references. Results/Conclusion: A valid and
reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview,
neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and
specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with
the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest
efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the
combination of cognitive behavioral therapy and medication. (J. of Att. Dis. 2008; 11(6) 628-641)
Keywords:
attention-deficit/hyperactivity disorder; adult ADHD assessment; adult ADHD treatment; diagnostic issues
628
Prevalence
The American Psychiatric Association (APA; 2000)
estimates that 3% to 7% of school-aged children have
ADHD. Historically, ADHD was considered to be principally a disorder of childhood, one that was generally
outgrown by adolescence and that was nonexistent by
adulthood (Ross & Ross, 1976). There is now clear evidence that ADHD symptoms continue through adolescence and adulthood (e.g., Barkley, Fischer, Smallish, &
Fletcher, 2002). The prevalence of ADHD in adults is
estimated to fall between 4% and 5% (Kessler et al.,
2005; Murphy & Barkley, 1996b).
Even though the persistence of ADHD beyond childhood is established, it is difficult to determine the extent
of this persistence. Only a small number of prospective
studies have followed samples of children with ADHD
into adulthood, and of these studies, only four have
Authors Note: Address correspondence to Megan A. Davidson,
Queens University, Department of Psychology, Humphrey Hall,
62 Arch St., Kingston, Ontario K7L 3N6, Canada; e-mail:
9md9@queensu.ca.
retained 50% or more of their original sample into adulthood (Barkley, Fischer, et al., 2002; Fischer, Barkley,
Edelbrock, & Smallish, 1990; Mannuzza, Klein, Bessler,
Malloy, & LaPadula, 1998; Rasmussen & Gillberg,
2001; G. Weiss & Hechtman, 1993). The results of
these four studies are mixed with respect to persistence.
G. Weiss and Hechtman (1993) conducted a prospective
follow-up study of hyperactive children. At the 15-year
follow-up (age M = 25 years), 66% of the original sample of hyperactive children reported at least one or more
symptoms of ADHD versus 7% of the control group. In
addition, 36% of the hyperactive sample had at least
moderate to severe levels of hyperactive, impulsive, and
inattentive symptoms, compared to 2% of the control
group. Rasmussen and Gillberg (2001) obtained similar
results: Of probands, 49% reported marked symptoms of
ADHD at age 22 years, compared to 9% of controls.
The studies by G. Weiss and Hechtman (1993) and
Rasmussen and Gillberg (2001) were limited by the fact
that formal diagnostic criteria were not used at any of
the outcome points in the studies. Mannuzza and colleagues (1998) corrected this methodological flaw by
following two cohorts of ADHD children using criteria
of the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) to assess the
disorder. The authors found that 40% of their initial
cohort and 43% of their second cohort met DSM-III criteria for ADHD at adolescent follow-up (age M = 18
years), compared to 3% and 4% of the comparison
groups. However, at adult follow-up (age M = 26
years), the rates of ADHD in the probands decreased to
8% and 4%, respectively. Barkley (2006) suggested that
these relatively low estimates of persistence are partly
because of the studys stringent selection criteria regarding aggression and antisocial behaviors. Finally, a fourth
prospective study, by Barkley, Fischer, et al. (2002),
evaluated hyperactive children and a control group at
ages 19 to 25 years using formal diagnostic criteria.
Based on self-report, ADHD was rare in the both groups
(5.0% and 0.0%, respectively) at follow-up. However,
ADHD was substantially higher using parent reports
(46.0% and 1.4%, respectively).
These four prospective studies show considerable discrepancy among the rates of ADHD persistence into
adulthood. These discrepancies are likely because of a
number of variables, including variations in the criteria
used for diagnosis (Riccio et al., 2005), selection criteria,
sources of information, changes in source of information, and changes in diagnostic criteria (for a review, see
Barkley, 2006). Thus, because of these issues, and issues
with the current diagnostic criteria, the persistence of
ADHD into adulthood is difficult to estimate.
629
Diagnostic Issues
Use of DSM-IV Criteria in Adults
Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose
ADHD in children (Lahey et al., 1994), and there is general agreement that ADHD can be reliably diagnosed in
children through the use of these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in
adults is much less clear (Riccio et al., 2005) and continues to be an area of controversy within the literature
(Faraone, Biederman, & Feighner, 2000).
In diagnosing ADHD in adults, clinicians and
researchers in North America most often use the criteria
set out by the fourth edition, text revision of DSM (DSMIV-TR; APA, 2000). Three subtypes of ADHD are recognized: ADHD combined type (ADHD-C; both inattentive
and hyperactiveimpulsive symptoms), ADHD predominantly inattentive type (ADHD-I), and ADHD predominantly hyperactiveimpulsive type (ADHD-H). Among
adults with ADHD, the ADHD-I subtype is the most
common diagnosis (Erk, 2000).
The use of DSM-IV criteria for ADHD in adults has
been criticized. Barkley (1998) suggests that applying
current ADHD criteria to adults is not developmentally
sensitive. The DSM-IV criteria for ADHD were designed
for and selected based on studies with children (Riccio
et al., 2005), and validation studies of ADHD criteria in
adults have not been conducted (Belendiuk, Clarke,
Chronis, & Raggi, 2007). Because of this, it has been
suggested that the symptom lists in DSM-IV may be
inappropriately worded for adults and that diagnostic
thresholds may be too stringent or restrictive when
applied to adults (Heiligenstein, Conyers, Berns, &
Smith, 1998). Moreover, some symptoms, such as procrastination, overreacting to frustration, poor motivation,
insomnia, and time-management difficulties, are common complaints of adults with ADHD, but they are not
included in DSM-IV. Finally, the level of impairment
caused by ADHD symptoms may be different between
adults and children, and symptoms will likely affect
more domains in adults (e.g., marital, familial, occupational, etc.).
Indeed, longitudinal studies demonstrate a developmental influence on ADHD symptoms. In general,
ADHD symptoms appear to decrease as age increases:
Prospectively derived data in clinical and epidemiological samples of children, adolescents, and young adults
demonstrate an overall reduction of ADHD symptoms
over time (Hart, Lahey, Loeber, Applegate, & Frick,
1995; Heiligenstein et al., 1998; Levy, Hay, McStephen,
630
Differential Diagnosis
Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric
conditions (Pary et al., 2002), including major depression,
bipolar disorder, generalized anxiety, obsessivecompulsive
disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning
disabilities (Searight, Burke, & Rottnek, 2000). For
example, differential diagnosis of ADHD from mood and
conduct disorders may be difficult because of common
features such a mood swings, inability to concentrate,
memory impairments, restlessness, and irritability (Adler,
2004). Differential diagnosis of learning disabilities
can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson
& Farrugia, 1997).
631
high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were
more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly,
quit, or been fired from a job and had a history of poorer
educational performance and more frequent school disciplinary actions against them than did adults without
ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD,
often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia,
1997). Adults with ADHD often have strong feelings of
incompetence, insecurity, and ineffectiveness, and many
of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).
Clinical Interview
Psychosocial Functioning
In addition to comorbid psychiatric disorders, adults
with ADHD often complain of psychosocial difficulties.
Indeed, Biederman et al. (1993) found a much higher
rate of separation and divorce among adults with ADHD
than among controls, and their sample of adults with
ADHD had lower socioeconomic status, poorer past and
current global functioning estimates, and higher occurrence of prior academic problems relative to the control
group. Likewise, Murphy and Barkley (1996a) documented
632
633
accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology
(Murphy & Schachar, 2000). Research also suggests that
semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in
adults (Epstein & Kollins, 2006). However, this literature
is quite young, and more research is needed to corroborate these findings.
Neuropsychological Testing
Neuropsychological testing plays a meaningful role in
the assessment of ADHD. However, Barkley (2006)
urges caution in interpreting such data, as there is no single test or battery of tests that has adequate predictive
validity or specificity to make a reliable diagnosis of
ADHD. In adult ADHD, neuropsychological testing is
most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of
current functioning.
Woods and his colleagues (2002) reviewed the role of
neuropsychological evaluation in the diagnosis of adults
with ADHD. In their review of 35 studies, the authors
found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and
normal control participants on at least one measure of
executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation,
implement the plan, make adjustments, and successfully
complete the task; Riccio et al., 2005) or attention.
Moreover, Woods et al. found that the most prominent
and reliable executive function and attention measures
that differentiated adults with ADHD were Stroop tasks
(Stroop, 1935) and continuous performance tests (CPTs).
Stroop tasks are complex word- and color-naming procedures that require visual attention and response inhibition, whereas CPTs are computer-based tasks that assess
attentional lapses, vigilance, and impulsivity (Spreen &
Strauss, 1998). In addition, Woods et al. found that verbal letter fluency tasks (i.e., generating words beginning
with a specific letter or words belonging to a specific category) and auditoryverbal list learning tasks (e.g.,
California Verbal Learning test; Delis, Kramer, Kaplan,
& Ober, 1987) were also able to discriminate between
adults with ADHD and controls. However, the authors
caution that the validity of these findings is somewhat
hindered by limitations of the studies reviewed, including methodological and sample variability, a restricted
range of interpretive techniques, and uncertain discriminant validity of the neuropsychological assessment procedures in distinguishing ADHD from other psychiatric
or neurological conditions.
634
Schoechlin and Engel (2005) also attempted to determine neuropsychological test performance differences in
adults with ADHD. The authors performed a meta-analysis
integrating 24 empirical studies reporting results of at
least 1 of 50 neuropsychological tests comparing adults
with ADHD to controls. The authors categorized each of
the tests into 1 of 10 functional domains: verbal intelligence, visualfigural problem solving, abstract verbal
problem solving with working memory, executive function, fluency, simple attention, sustained attention,
focused attention, verbal memory, and figural memory.
For each of the 10 domains, a pooled effect size (d) was
calculated. Adults with ADHD showed significant performance deficits in 8 of the 10 domains. Small effect
sizes (d between .18 and .26) were found for the domains
of visual memory, visual problem solving, and executive
function. The highest effect sizes (d between .50 and .60)
were found for verbal memory, focused attention, sustained attention, fluency, and abstract verbal problem
solving with working memory. In these domains, ADHD
patients scored approximately one half of an SD lower
than did the control participants.
The findings of Schoechlin and Engel (2005) are
somewhat inconsistent with those of Woods et al. (2002).
Although both studies noted differences between adults
with ADHD and controls on tasks of verbal memory and
fluency, Schoechlin and Engel did not find that performance on executive function tasks was a strong predictor
of the distinction between adults with ADHD and controls. This nonsignificant finding may have occurred for
a few reasons. The authors also note that there is no
commonly accepted definition of executive function.
Schoechlin and Engel chose to separate more basic
aspects of executive function such as working memory
and inhibition from higher-level functioning. If ADHD
affects some aspects of executive function more than
others, their decision to not include all measures that are
discussed as executive functions may have decreased
their effect size.
Woods et al. (2002) concluded that although a general
profile of attentional and executive function impairment
is evident in adults with ADHD, expansive impairments
in these domains (i.e., impairments on all attention and
executive function tasks) is not common. Their review
demonstrated inconsistencies in specific instruments
across studies, indicating that adults with ADHD may
not perform poorly on all attentional measures all the
time. This finding is not surprising given the fact that
adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given
the structure provided by the one-on-one testing environment (Barkley, 1998). In light of this, researchers
Malingering
Malingering is an important issue in ADHD diagnosis
and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal (APA, 1994). A diagnosis of
ADHD can provide an individual with a number of benefits, including stimulant medication, disability benefits,
tax benefits, and academic accommodations, and such
benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on
self-report measures and tests of neurocognitive functioning (Harrison, Edwards, & Parker, 2007; Sullivan,
May, & Galbally, 2007). Detection of faking can prove
difficult with adults in particular, as clinicians may not
have access to a parent or sibling who can attest to prior
history of ADHD symptoms. Moreover, adults often lack
developmental documentation such as report cards,
teacher evaluations, or prior psychological testing
reports (Quinn, 2003). Sullivan et al. (2007) examined
archived assessment cases of ADHD at a university
campusbased clinic and found that almost 50% of cases
failed one or more effort measures on the Word Memory
Test (Green, 2003; Green, Allen, & Astner, 1996; Green
& Astner, 1995), a symptom validity test designed to
detect suboptimal effort in the context of neuropsychological evaluations. In examining the performance of
university students feigning ADHD and comparing it to
the performance of non-ADHD and genuine ADHD
students, Harrison et al. (2007) demonstrated that the
symptoms of ADHD could easily be fabricated and that
simulators could be indistinguishable from those with
the disorder. Moreover, the authors found that students
Pharmacological Treatment
Pharmacotherapy is the principal form of treatment
for patients with ADHD (Pary et al., 2002), and its use in
adults is increasing. Castle, Aubert, Verbrugge, Khalid,
and Epstein (2007) examined trends in the use of medication to treat ADHD and found that 0.8% of adults use
medications to treat ADHD. Furthermore, treatment
prevalence for adults increased rapidly during the 5-year
study period (2000 to 2005), with an annual treatment
prevalence growth rate of 15.3%. The usefulness of pharmacotherapy is well established in children with ADHD
but not in adults with ADHD (Wilens, 2003). Wilens
(2003) reviewed the literature on the use of pharmacotherapy in adult ADHD and identified 15 studies
examining the efficacy of stimulants and 28 studies
examining the efficacy of nonstimulants.
635
636
Psychosocial Intervention
Because of the severity and pervasiveness of the
symptoms of ADHD, pharmacotherapy alone is an insufficient treatment of adult ADHD in upward of 50% of
cases (Wilens, Spencer, & Biederman, 2000). In addition, even though medications may offer improvements
on measures of core symptoms, these changes may not
always translate into satisfactory functional improvements (e.g., time management, organization, planning,
self-esteem; M. Weiss et al., 1999). For these reasons,
637
may not stem from willful wrongdoing and lack of caring (Barkley, 2006; Murphy, 2005).
Vocational counseling. Symptoms of ADHD can significantly impair workplace performance. Impulsivity,
inattention, disorganization, careless mistakes, poor time
management, and inconsistency can all lead to employment difficulties. Vocational counseling can help alleviate occupational difficulties by identifying strengths and
limitations and by matching adults to jobs that are well
suited for them (Barkley, 2006; M. D. Weiss & Weiss,
2004).
ADHD coaching. A personal ADHD coach aids the
patient in identifying goals and strategies to meet these
goals. Coaching is different from traditional therapy in
several ways, most notably in its focus on implementation of the clients goals. Therapy can focus on insight
and understanding, but coaching is more about action
and getting things done (Favorite, 1995).
Conclusion
ADHD is a lifelong neurobiological disorder that presents significant challenges to adults. Two important
clinical diagnostic issues have been highlighted in this
review. First, there are important differences between the
child and adult presentation of the disorder. As children
with ADHD grow into adolescence and adulthood, there
is generally an overall reduction of ADHD symptoms in
which hyperactiveimpulsive symptoms decline and
inattentive symptoms persist. Second, the DSM-IV criteria for ADHD must be cautiously used in adults, as these
criteria were designed for and selected based on studies
with school-aged children.
The assessment of ADHD in adults is often challenging
and complex, particularly given the fact that no litmus test
for diagnosing the disorder exists. Thus, to increase diagnostic accuracy, an assessment should be comprehensive
and include the use of symptom rating scales, interviews,
and neuropsychological testing and the corroboration of
patient reports with at least one other source who knows
the individual well (Barkley, 2006; M. D. Weiss & Weiss,
2004; Wilens et al., 2004). Although the diagnosis of
ADHD in adults can be both reliable and valid, there is a
strong need for the development of specific diagnostic criteria that are more sensitive and specific to adult functioning than are the existing criteria.
There exists a range of treatment optionsboth pharmacological and psychosocialfor adults with ADHD.
In terms of pharmacological interventions, the stimulants
methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine appear to have the
638
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