For most individuals with ADHD, symptoms persist at least into late adolescence and early adulthood—often much longer. For many, this disorder of the brain’s management system not only persists, it becomes more problematic during the inevitable challenges of early adulthood in which one has to manage much more for oneself. Yet, in the years of transition to adulthood, obtaining adequate assessment and treatment for ADHD is often more difficult than at any other point during the lifespan.
In the US the majority of children with ADHD are identified and treated by pediatricians until they graduate from high school. But assessment and treatment of ADHD in older adolescents and young adults tends to be hit-or-miss once they complete high school and beyond. After leaving high school, some continue to be followed by their pediatricians whom they rarely see if they attend college far from home. Some seek help from an adult primary care physician, many of whom have had virtually no training in diagnosing and treating ADHD. And some who have adequate resources may seek care from a psychiatrist. But many late adolescents and young adults with ADHD do not get any continuing treatment for this disorder at all.
Prevalence and persistence of ADHD
ADHD is not rare among late adolescents and young adults. The National Comorbidity Survey of Adolescents found the prevalence rate of ADHD to be 9% in a large sample of 17- to 18-year-olds.1 In that group the ratio of males to females was 3 to 1. About half of the 9% were identified as having severe ADHD.
For most, ADHD does not remit during young adulthood. A 10-year follow-up study of boys who had received a diagnosis of ADHD in childhood found that 35% of those in their early twenties fully met DSM diagnostic criteria for ADHD and 22% still met at least half of the diagnostic criteria and had significant impairment.2 A follow-up study of girls demonstrated that after 11 years 33% still met full diagnostic criteria for ADHD and 29% continued to meet partial criteria with impairment.3
Moreover, at all age levels ADHD is highly comorbid with other psychiatric disorders.4 A meta-analysis of 21 general population studies of children found that the likelihood of anxiety disorders, depressive disorders, or oppositional/conduct disorders among children with ADHD is respectively 3 times, 5.5 times, and 10.7 times the prevalence of those disorders in the general population of children.5
The National Comorbidity Survey Replication found that adults aged 18 to 44 years with ADHD had more than 6 times the likelihood of having at least one additional psychiatric disorder at some point in their life relative to adults without ADHD. The most common comorbidities were anxiety disorders, mood disorders, impulse disorders, and substance use disorders.6
Functional impairments in young adults
ADHD during late adolescence and early adulthood tends to be associated with significant impairment in multiple domains. One cross-sectional study of young adults with ADHD and matched controls aged, on average, 24 years, found many significant differences between young adults with ADHD and those who did not have this disorder. Those with ADHD tended to have fewer years of education, were less likely to be attending full-time university, had lower grade point averages, and had lower personal incomes despite comparable IQ and similar socioeconomic backgrounds (Table 1).7
A longitudinal study of boys who had had a diagnosis of ADHD versus non-ADHD controls collected information from the youths and their parents each year from age 19 to 32 years (Table 2).8 By age 32, fewer of the young adults with ADHD had earned a 4-year degree and graduate degrees. Occupational experiences were similarly lopsided. Those with ADHD were more likely ever to have been fired from a job, more likely to have been laid off, and more likely to have ever quit a job because they did not like it. By age 32, significantly more in the ADHD group were unemployed and not in school while significantly more in the control group were employed and also in school. Data analysis showed that academic problems and a childhood diagnosis of ADHD were statistically significant predictors of job loss independent of IQ, parental education, high school achievement, disciplinary problems, and post–high school education.
Dr Brown is Assistant Clinical Professor of Psychiatry at the Yale Medical School in New Haven, CT, and Associate Director in the department of psychiatry of the Yale Clinic for Attention and Related Disorders. He has directed CME courses on ADHD at the American Psychiatric Association annual meetings for the past 15 years. He reports that he has received research support from Shire, consults for Ironshore, and receives publication royalties from Yale University Press, American Psychiatric Publishing, Routledge, Jossey-Bass/Wiley, and Pearson.
1. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). J Am Acad Child Psychiatry. 2010;49:980-989.
2. Biederman J, Petty CR, Evans M, et al. How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD. Psychiatry Res. 2010;77:299-304.
3. Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010; 167:409-417.
4. Brown TE, ed. ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults. Washington, DC: American Psychiatric Publishing; 2009.
5. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40:57-87.
6. 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;163:716-723.
7. Stavro GM, Ettenhofer ML, Nigg, JT. Executive functions and adaptive functioning in young adult attention-deficit/hyperactivity disorder. J Int Neuropsychol Soc. 2007;13:324-334.
8. Kuriyan AB, Pelham WE Jr, Molina BSG, et al. Young adult educational and vocational outcomes of children diagnosed with ADHD. J Abnorm Child Psychol. 2013;4:27-41.
9. Dalsgaad S, Ostergaard SD, Leckman JF, et al. Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet. 2015;385:2199-2196.
10. Hedden SL, Kennet J, Lipari R, et al, for the Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health; 2015. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed November 30, 2015.
11. Brown TE. A New Understanding of ADHD in Children and Adults: Executive Function Impairments. NY: Routledge; 2013.
12. Brown TE. Attention Deficit Disorders: The Unfocused Mind in Children and Adults. New Haven, CT: Yale University Press; 2005.
13. Barkley RA. Barkley Deficits in Executive Function Scale (BDEFS). NY: The Guilford Press; 2011.
14. Brown TE. Brown Attention-Deficit Disorder Scales for Adolescents and Adults. San Antonio, TX: The Psychological Corporation; 1996.
15. Conners CK, Erhardt D, Sparrow E. CAARS Adult ADHD Rating Scales. Toronto, Ontario, Canada: Multi-Health Systems; 1999.
16. Brown TE. Smart But Stuck: Emotions in Teens and Adults With ADHD. San Francisco: Jossey-Bass; 2014.
17. Ramsay JR, Rostain AL. Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. 2nd ed. NY: Routledge; 2015.