Steven V. Faraone, PhD

Andrew and Craig, jump in and talk about what do you do when an adult comes into your office with, think they have ADHD symptoms, you can document that but you're having a hard time documenting a childhood onset. Let me first ask Craig, what do you, what do you do about that?

 That's a situation I see in practice all the time, in fact, many times, the patient doesn't even come in for, because of ADHD, they come in saying that they have depression or anxiety, and I just, I can smell it, the ADHD is in the back of my neck, stand up, and I just get the feeling by listening to this person's thought process, that they have ADHD. And I become like a detective, archaeologist, trying to reconstruct that childhood history, and I find that it often is there. What I like to say is that they kind of brute force there, brute forced IQ'd their way through it, they were maybe smart, had some resources, parents that were supportive, maybe could get them into schools that had a good staff to student ratios, tutors, they had certain advantages, and also they probably worked 2 or 3 times harder than the neurotypical children to get to those same kinds of results. Looking back and figuring out, what did it look like when you studied? Did you have 2 or 3 different textbooks out at the same time while you had a TV on and the radio? Well, if that seems normal to you, then you might have had ADHD and you just didn't realize because you didn't know any different, looking for what they thought was normal but that we realize, as clinicians, is more consistent with an ADHD pattern and how they were able to compensate for it is how I look for that diagnosis.

: You know, this is an area where I think DSM-V also helped us, and that is raising the age at which you need to have shown onset of symptoms from before the age of 7 up to the age of 12. It's very hard for adults to describe what they were like when they were four and 5 years old, and I love Craig's analogy of being an archaeologist, it's hard sometimes to document that for people to be able to tell you more about what they were like in their twin years, you know, that kind of thing. The other thing, quickly, is, something that differs is, very often when kids present, it's for ADHD, and pretty much that's what they're presenting with, that's what their complaint with, because there's problems with school or behavior. Adults, as Craig said, are usually not presenting with ADHD, sometimes they go, I think I have ADHD, very often they're presenting with the comorbidity first. Kids, ADHD and then I look for the comorbidity, in adults, often the other way around.

: And the other challenge with the adults is that usually you're just getting information from the patient who's in front of you, you don't have as much opportunity to get observer input, so the adult probably isn't bringing in their spouse in, to the assessment evaluation, whereas with kids, we at least have some of the advantages of hearing from the parents or teachers or other observers of the child's symptomatology, the poor adult with ADHD might not only have trouble remembering what it was like for them in childhood, but they also don't have someone with them to report the symptoms as seen through their spouse's eyes, for example. It is often an added challenge with the adult patients.

That's right, and I think we should add a little bit to let our listeners know that the age of onset, the current age of onset of 12, in the DSM, is of course arbitrary, they had to pick a number, but there's no switch in the brain that turns off at age 12 and says you can no longer have ADHD, but I of course would warn listeners that, when you diagnose people with later onset of ADHD, just be very careful and do a much better work of their current condition, I'm sure all of you have seen patients who come in and looks like they maybe have onsets of 18 or 19, can you comment on what you do on those cases?

: Well, I usually think that it's there, I think Craig said it extremely well, I had a professor who used to say, IQ points can compensate for a lot, and a lot of times these kids are very bright and, one of the things I look for, too, is underachievement, not meeting their potential, maybe this is a kid who has off the charts IQ, but they're getting Bs, you know, that's not appropriate for them, I would say, but maybe have somebody with a parent who is extremely organized and able to really help compensate and then, it's only when the person gets out into the real world or into college and they have to start managing things that things show up, so, I dig pretty hard and I just suspect it's there.

You know, that's a great point, because I've had, I've had more than a few colleagues tell me that this patient thinks he has ADHD, but went to medical school or went to law school, he's a high achiever, how can he possible have ADHD? And the answer is, there's actually a lot of research out there, some of which I did, which shows that people who have high IQs and ADHD, they're doing worse in life than people with high IQs who don't have ADHD, and they do need help, they should, people, we shouldn't discriminate against high IQ people because they are good achievers, because they can do better if they're properly treated.

: I think it's important to take into account compensation-

Compensation, yes. Craig had mentioned that social, emotional, intellectual scaffolding that scaffolds the patient in their early years and then, when they leave the home, some of that scaffolding falls apart and they fall with it, for sure.

Videos

Drs Stephen Faraone, Theresa Cerulli, Craig Chepke, and Andrew J. Cutler discuss how to diagnose adults with ADHD based on patient presentation.

Diagnosing Adults With ADHD Based on Patient Presentation

Dr Cerulli, can you provide a brief overview of how diagnosis and management of ADHD may differ between pediatric and adult patients?

: The challenging word in that sentence is brief, but I will do my best, on this topic, let's start with the similarities with diagnosing and managing ADHD in pediatric and adult patients, because there are some similarities, certainly, and that's the clinical interview with a doctor, rating skills are still the gold standard, right, we don't have a blood test, we don't do MRIs, it's still us, as clinicians, that are the diagnostic tool, which is why I appreciate all of you listening to our call today, learning and understanding how to best assist our patients, because that is what we are here to do. Besides the clinical interviewing and rating skills, next, I want to mention that for kids, you'll see neuro-psychtesting done, that is not standard of care, it's nice when it's available, nice when you can get it covered through insurance, but it's sensitivity and specificity of using neuro-psychtesting to diagnose ADHD, it's not great, it's in the 60% plus percentile, so not necessary for the diagnosis of ADHD, but helpful in kids to at least look at the comorbid learning disabilities, which about 20, 25% of the time you will find learning disabilities that coexist with ADHD, you don't want to miss some opportunities for academic accommodation for those students. You see that, in pediatric, that is one of the differentiating points, though, with adult ADHD, we generally can't get neuro-psychtesting covered, we're not so much screening for learning disabilities in the adult population, when we're looking for the ADHD, you'll often not have that as something to access in the adult diagnostic workup, the neuro-psychtesting. Other similarities let's look at our oldy but goody DSM criteria, a lot of similarities, one of the differences when we went from DSM-IV to DSM-V in diagnosing childhood versus adults with ADHD was the number of symptom domains. For kids, now, for DSM-V you need 6 of the 9 inattentive symptoms and or 6 of the 9 hyperactive impulsive symptoms. For adults, defined as age 17 and up, interestingly, for ADHD, 17 years old and up, those patients, it's 5 of the 9 symptoms of inattention and, or 5 of the 9 symptoms of hyperactivity and impulsivity needed for the diagnosis, we loosened the criteria on the adult side. Challenges, I would say, in both kids and adults, are making the diagnosis, you really must screen for the comorbidities that both can present like ADHD when it's not, the comorbidities may themselves be causing inattentive problems and you could misdiagnose the ADHD when it's the depression, or sleep disorders, or anxiety causing the problem with attention, concentration. Additionally, you can have the comorbidities with the diagnosis of ADHD, you're screening for and really trying to tease out the symptomatology which may be indicative of both diagnosis, ADHD and the comorbidity. The complication, shifting up to the adults, besides the comorbidities are there with both kids and adults, in fact, about 75% of the time, if you're diagnosed with ADHD, you're going to have at least one comorbidity and the data shows 60% of the time you're going to have 2 or more comorbidities with you ADHD, that's kids and adults, the type of comorbidity may shift a bit, and this is where I want to emphasize the challenges with adult, diagnosing adult ADHD, the, some of the comorbidities may be things like substance abuse, you see that more, or worry more in adults than hopefully with our kiddos, right? And then also, the complex medical histories that many of our adults can present with, that certainly on the treatment side, can become very challenging, people that have problems with blood pressure, other cardiovascular diseases in adulthood, we want to be very careful diagnostic and on the treatment side.

Experts in ADHD compare the diagnosis and management of ADHD in adults and children.

Diagnosis and Management of Adults ADHD Compared to Children

: Thank you for joining the Around the Practice Psychiatric Times Program on the management of ADHD. I'm Stephen Faraone, professor and vice-chair for research in the department of psychiatry at SUNY Upstate Medical University in Syracuse, New York. My colleagues now, introduce themselves, Doctor Cerulli.

 I'm Theresa Cerulli, I am a neuropsychiatrist in practice in the Boston area, president and medical director of my multidisciplinary practice, Cerulli & Associates in North Andover, Massachusetts, and I'm a lecturer and clinical supervisor at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

 Hi, my name is Craig Chepke, I'm a psychiatrist and medical director of Excel Psychiatric Associates, a private practice in Huntersville, North Carolina, and I'm also a clinical assistant professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York.

 I'm Doctor Andrew Cutler, I'm thrilled to be here with my good friends and colleagues. I am a clinical associate professor of psychiatry also at SUNY Upstate Medical University, where we obviously have a very strong ADHD department, and I'm the chief medical officer of the Neuroscience Education Institute, and I work remotely from Lakewood Ranch, Florida.

In addition to reviewing the diagnosis and management of ADHD with these experts in the field, we will also present 3 patient cases and talk through approaches to treatment. I'm going to start with a question that's very easy, what is the incidence and prevalence of attention deficit and hyperactivity disorder in the adult population? There are many studies, probably the best in the United States, by puts the prevalence at about 4.5%, that means about 12 million adults in the United States have attention deficit and hyperactivity disorder. It also means many of them are in your practices and require treatment.

 Yes, no problem. You know, Steve, this is sort of the classic numbers that we hear, and there's also controversy about how often ADHD persists from childhood into adulthood, but I think it's fair to say that some of our estimates are looking at point prevalence, periods in time, but certainly my clinical experience, when I follow people over time sometimes the presentation can wax and wane, either the symptomatology or the impairments, and sometimes it has to do with the environment, its stressors and various things going on. There's a recent study that was published by Margaret Sibley and colleagues that suggests this may be the case.

That's very true, Andy, the cross-sectional studies suggest that about a third of people with ADHD will not have ADHD in adulthood when examined one point in time. And we don't know if this waxing and waning will be validated in other studies, but that's important data to look for, in the future, it tells the clinician that, if their patient appears to go into remission, you still need to follow up and make sure that the ADHD symptoms don't reemerge, because maybe the patient is facing new challenges that lead to symptom expression.

: And Steve, that's exactly what we do in my clinic. My area of interest within neuropsychiatry has been ADHD for the past 20 years, and part of me was already interested when I was doing my neuropsychiatry fellowship and working with adults with ADHD and what I've seen in clinical practice is this waxing and waning picture of ADHD symptomatology that even, if someone isn't meeting full criteria for ADHD, they're often still symptomatic and having functional impairments with ADHD, and depends on what's going on in their lives that may exacerbate and, or help to improve symptomatology in the way it presents, I picture, thinking like MS, this remitting relapsing picture, of course, with ADHD, that's how I explain to my patients, it's more rare to see somebody go into quote remission and stay in remission with their ADHD, it is this kind of a sine wave, sine wave curve that I think about, with the longitudinal perspective.

: One point that I'd like to make is that, the DSM-V did a good job of is that it moved ADHD to the neurodevelopmental disorder section, right between autism and specific learning disorder, and just like we tend not to think that people grow out of autism, that I tend to think that people don't grow out of ADHD, it's just they may get into situations and environments where they have coping skills, they have other advantages, as my colleagues have mentioned, and that they may not meet criteria, which, there again, the criteria were designed for children and adolescents, not adults, so we have that problem as well when looking at prevalence of adults with ADHD.

You raise a key point there, because when the DSM-5 was being created, some of us advocated that symptoms of emotional dysregulation should be added to the criteria, because they become more prominent in adolescence and adulthood than they are in childhood that, sometimes, what appears to be remission is really shifting its symptoms from hyper, lot of hyperactivity and inattention to more inattention, emotional dysregulation and executive disfunction. And this is something that clinicians must struggle with because the criteria have shifted. I want to also underline what Dr Cerulli said is that, if a patient has had history of ADHD and, after a period of time, they're only showing a few symptoms, they're still impaired, they still have ADHD, we don't require that they have to have the full symptom count to require treatment, it would be a mistake to deny treatment to those people.

Stephen Faraone, PhD; Theresa Cerulli, MD; Craig Chepke, MD, FAPA; and Andrew J. Cutler, MD, discuss the prevalence of adult ADHD.

Prevalence of Adult ADHD

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After reading this article, you will be familiar with:



• The differences between childhood and adult attention-deficit/hyperactivity disorder (ADHD).
• The extent of functional impairment with ADHD.
• The clinical scales that can be used to diagnose and measure adult ADHD.
• Available options for treating adult ADHD.



Who will benefit from reading this article?


Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.



Dr Faraone is professor of psychiatry and behavioral sciences, departments of psychiatry and behavioral sciences and neuroscience and physiology; Drs Antshel and Kunwar are assistant professors in the department of psychiatry and behavioral sciences at the State University of New York Upstate Medical University.

Drs Antshel and Kunwar report that they have no conflicts of interest concerning the subject matter of this article. Dr Faraone reports that he has received research support from Shire Pharmaceutical Development, Pfizer, NIMH, and the National Institute of Drug Abuse; and he is a consultant for Shire Pharmaceutical Development.



In the past 15 years, there has been an increasing awareness of the syndromal persistence of attention-deficit/hyperactivity disorder (ADHD) into adulthood. Once considered only a childhood disorder, ADHD has become increasingly recognized as a valid psychiatric disorder in adults.

 Proponents of ADHD as a valid adult diagnosis do not suggest that ADHD arises de novo in adulthood. Rather, adult ADHD is considered the natural continuation of childhood ADHD, albeit with a different topographical expression of symptoms. The focus of this article is to discuss what is known about ADHD in adults, with a particular emphasis on diagnosis and treatment strategies.



COMPARISONS WITH PEDIATRIC ADHD
Prevalence and symptoms


In children, the prevalence of ADHD is typically cited as between 3% and 5% of the general population while in adults, studies suggest that the prevalence is about 4%.

This is not surprising given that longitudinal research indicates that the majority (50% to 70%) of children with ADHD continue to show impairing symptoms as they age.

ADHD research in children and adults indicates that inattention and hyperactivity/impulsivity are the defining features of the disorder. For example, in a family study of ADHD, more than two-thirds of nonreferred adult relatives of children with ADHD reported current ADHD symptoms at levels comparable to those in pediatric participants with ADHD.

These data suggest that inattentive and hyperactive/impulsive symptoms are the defining features of ADHD in both clinically referred and nonreferred adults.

Despite the similar symptoms, several core DSM-IV ADHD symptoms (eg, hyperactivity) lessen or mollify over time.

 demonstrated that psychomotor activity levels decline after age 9 in the general population. Thus, "running about or climbing on things inappropriately" may have less predictive power as a diagnostic symptom in adulthood.

This has led to some diagnostic confusion and possibly underdiagnosis of adult ADHD.



In addition, teachers and school personnel are attuned to ADHD and are familiar with the disorder in children, while employers are likely to be less mindful of possible ADHD symptoms in adults. In the absence of a formal screening mechanism, adults with ADHD may also be less likely to be referred for treatment. Although the symptoms appear to be equally defining in children and adults, the topography of these symptoms may be quite different in adults, possibly contributing to ADHD underdiagnosis in adults.


Pediatric ADHD commonly co-occurs with multiple psychiatric disorders including mood, anxiety, and disruptive behavioral disorders.

Likewise, adult ADHD is associated with comorbid mood, anxiety, and substance use disorder diagnoses.

Comorbidity rates in adult ADHD do not differ as a function of gender; this is in contrast to the higher prevalence of externalizing disorder comorbidities observed in boys with ADHD.

ADHD in adults is not always comorbid with other psychiatric conditions, however, and some data suggest that uncomplicated ADHD exists in about 20% to 25% of adults with ADHD.


ADHD is a highly heritable condition (average heritability index = 0.76).

Family studies of pediatric ADHD suggest that the parents of children with ADHD are more likely than parents of other children to have ADHD themselves.

The same holds true in adult ADHD; offspring of parents with ADHD are more likely to have ADHD themselves.

 found a 57% prevalence of ADHD in children of adults with the disorder, which is much higher than the 15% prevalence of ADHD among siblings of children with ADHD.

Genetic factors appear to play a stronger role in those who continue to demonstrate clinically significant ADHD into adulthood than in those whose symptoms are in remission.

For example, a prospective ADHD study with a 4-year follow-up examined 140 boys with ADHD and 120 boys without ADHD at baseline. By midadolescence, 85% of the boys with ADHD continued to have the disorder. The prevalence of ADHD was significantly higher among the relatives of children with persistent ADHD than among relatives of children with ADHD whose symptoms were in remission.



Parents of persistent ADHD probands were 20 times more likely to have ADHD than parents of controls, whereas parents of nonpersistent ADHD probands showed only a 5-fold increased risk. Similarly, siblings of persistent ADHD probands were 17 times more likely to have ADHD than siblings of controls, while siblings of nonpersistent ADHD probands showed only a 4-fold increased risk.

When ADHD persists into adulthood, it is decidedly familial.




Significant functional impairment in educational, marital, interpersonal, and occupational realms and in motor vehicle operation is common in adult ADHD.

In fact, recently published longitudinal research findings indicate that ADHD in adults is a far more impairing disorder than many other disorders (eg, anxiety and mood disorders) across multiple domains of major life activities, especially educational and occupational functioning, money management, and management of daily responsibilities.

Adults with ADHD are also more likely to receive speeding violations and have their driver's license suspended.

These motor vehiclerelated infractions are not related to deficits in driving skills or knowledge.

Computer-simulated driving tests also demonstrate that adults with ADHD have more accidents and near-accidents.

Similar functional impairment findings have been seen in other studies that compared adults with ADHD and psychiatric control samples.

 compared adults with ADHD to age- and sex-matched psychiatric controls on educational and occupational achievement variables. Relative to psychiatric controls, adults with ADHD had fewer years of education and lower rates of professional employment. There is evidence that the lower rates of professional employment are not accounted for by comorbid psychopathology.



It is not surprising that adults with ADHD have lower rates of professional employment, given that academic underachievement and learning disabilities are common in children with ADHD.

A community study showed that the profile of impairments of adults with ADHD diagnosed in the community was similar to that seen in samples in whom ADHD was diagnosed in academic centers.

Likewise, data from adults with previously undiagnosed ADHD indicated more psychiatric comorbidity and functional impairments than did non-ADHD controls; even when unrecognized, ADHD in adults is functionally impairing.



Elevated prevalence of substance abuse/dependence has consistently been reported in adults with ADHD.

An estimated 17% to 45% of adults with ADHD have histories of alcohol abuse or dependence and 9% to 30% have histories of drug abuse or dependence.

A study of treatment-naive adults with ADHD found that the risk of substance abuse/dependence developing over the life span is 2-fold compared with adults who do not have ADHD (52% vs 27%, respectively). Although a history of conduct or bipolar disorders increases that risk, ADHD is an independent risk factor for later substance abuse/dependence.

Studies have shown that compared with adults who do not have ADHD, adults with comorbid ADHD and substance abuse/dependence have an earlier onset and a greater severity of substance abuse.



Likewise, findings indicate that ADHD is elevated in substance users.

Studies of substance-dependent populations report the prevalence of ADHD ranges from 15% to 25%.

The presence of ADHD appears to potentiate the substance abuse/dependence, resulting in a more severe disorder and poorer outcomes.

The increased prevalence of substance abuse/dependence in ADHD has been reported in longitudinal studies that followed children with well-characterized ADHD into adulthood, as well as individuals with ADHD that is diagnosed in adulthood.

Finally, among those with substance abuse disorder, adults with ADHD have higher rates of separation and divorce and lower occupational achievement than their peers.


DSM-IV criteria for ADHD symptoms are based on earlier DSM editions, expert clinical opinion, and a field trial of the psychometric properties and utility of the item pool.

The proposed DSM-IV ADHD items were field-tested using a sample of 380 clinically referred children aged 4 to 17 years. The 18 items that appear in DSM-IV correlate highly with parent and teacher ratings of impairment and best differentiate ADHD from non-ADHD disorders.



Adults were not included in the ADHD field trials for DSM-IV. Thus, there was no attempt to assess the developmental appropriateness of the ADHD symptoms for diagnosing the disorder in adults. For example, DSM-IV symptoms such as "runs and climbs excessively" are clearly inappropriate for adults. Similarly, the cutoff score of 6 of 9 symptoms was based on pediatric data, which may be too restrictive for adults.

Unlike diagnosing ADHD in children, diagnosing ADHD in adults relies highly on self-report. Asking a 42-year-old man to recall behaviors before age 7 most likely introduces recall biases.



Stimulant medications are generally started at a low dosage and titrated as needed to optimize the symptom improvement without causing significant adverse effects. Common adverse effects are dry mouth, insomnia, decreased appetite, and headache. The optimal dosage is best determined by each patient's response. Traditionally, a trial with an immediate-release stimulant was undertaken before switching to a long-acting form; however, more recently, the American Academy of Child and Adolescent Psychiatry amended its practice parameters to recommend that long-acting agents be initiated first and titrated accordingly.

A stimulant is effective as long as it remains in the system and does not have long-lasting cumulative effects. Because immediate-release stimulants have to be taken multiple times, compliance can be an issue, especially in a population known to be forgetful and disorganized.



Atomoxetine is taken orally once or twice daily. Even with once-daily dosing, it provides full coverage in the evening with less rebound than may be observed with stimulants.

Atomoxetine also lacks the midbrain dopamine effects that have been linked to addictive potential.

There is also some evidence that atomoxetine may be particularly effective for adults with comorbid ADHD and depression.

Common adverse effects associated with atomoxetine are dry mouth, insomnia, nausea, decreased appetite, constipation, and sexual dysfunction. There is a black box warning for increased suicidal ideation in children but not in adults.

While the stimulants and atomoxetine are more commonly prescribed for adult ADHD, bupropion, modafinil, and desipramine have also been described as effective for managing ADHD and may be used as second-line agents.

Bupropion has demonstrated efficacy in open and controlled studies and may be particularly effective in adults with ADHD who have comorbid mood disorders.

Modafinil has also been shown to be efficacious for adult ADHD in 2 double-blind, randomized, placebo-controlled studies.

Rather than affecting dopamine and norepinephrine in the striatum, modafinil alters the balance of g-aminobutyric acid and glutamate. Desipramine has been shown to be efficacious for adult ADHD in a double-blind, placebo-controlled study.



Findings suggest that adults with ADHD are more likely to require polypharmacy than children with ADHD.

In addition, there is some evidence that baseline clinician ratings of ADHD symptoms are stronger predictors of pharmacotherapy treatment outcome than baseline patient reports.85




A psychosocial treatment component is generally recommended in addition to pharmacotherapy.

Although cognitive-behavioral therapy (CBT) has not been shown to be effective in children with ADHD, there are reasons to be optimistic that CBT may be effective in adults with ADHD. For example, CBT is generally more effective in adolescents than in preadolescents.

Similarly, CBT may be effective for reducing functional impairments in adults with ADHD being treated with stimulants.

 developed a supplemental CBT program for adults with ADHD who were recieving medication. Initial results from a small-scale study of this manualized therapy have been showing significant benefits beyond those achieved by medication alone.

 have also created a CBT program for adults with ADHD. In their open study, 43 adults with ADHD were treated for 6 months with a combination of pharmacotherapy and CBT. Findings from this study suggest that the combined treatment approach was effective across both symptom and functional parameters.




Despite our increased understanding of adults with ADHD, there is much that we still do not know. For example, most of the adult ADHD research has used samples of college students or adults under the age of 40. Thus, we know far less about ADHD in middle age and beyond. Following children longitudinally across the life span also presents a unique method of tracking not only interindividual change but also intraindividual change. The use of cross-sectional research designs limits our ability to assess these parameters. As Barkley, Biederman, and others' longitudinal samples continue to age, we will know more about the continuation of ADHD in middle and late adulthood.

Pediatric ADHD is more common in boys than in girls.

This sex-based difference, however, appears less marked in adult ADHD.

Relative to boys with ADHD, lower rates of externalizing disorders in girls have been found.

The presence of an externalizing comorbid condition increases the likelihood that a child will be clinically referred for ADHD. Referral biases are possibly less salient for adults who, unlike children, can refer themselves for treatment. While this hypothesis has intuitive appeal, future studies should consider possible sex-based differences in ADHD across the life span.

Further research is needed to clarify whether the DSM-IV approach to ADHD should be modified for adults. DSM-IV recognizes developmental changes in the expression of ADHD in several ways. It cautions diagnosticians that with maturation, symptoms become less conspicuous. Older children may be restless and fidgety but not overly hyperactive. With age, inattention may predominate as tasks at school require increasing levels of attention. DSM specifies that symptoms are considered present only if they are maladaptive and inconsistent with developmental level.

DSM-IV includes the category of ADHD in partial remission for individuals (especially adolescents and adults) who currently have symptoms but no longer meet full criteria. The net effect of developmental changes is to make it more difficult for children with ADHD to meet criteria for the disorder as they get older. Although this reflects the true remission of the disorder to some extent, it may also be because of the use of insensitive diagnostic criteria.

For example, Barkley and colleagues

 examined the utility of DSM criteria for ADHD when used with adults, and they showed that only 6 to 8 symptoms were required to diagnose ADHD in adults. (DSM-IV stipulates that 12 symptoms must be present to diagnose ADHD.) The single symptom of "often being distractible" was sufficient to differentiate ADHD from typically developing adults while 5 to 7 more symptoms were needed to discriminate those with ADHD from clinic-referred adults. Inattention and verbal impulsivity symptoms were the best discriminators between patients with ADHD and clinical controls.

 Barkley's work as well as the work of others on the developmental sensitivity of ADHD symptoms has clear implications for the development of DSM-V.

Also relevant to DSM-V, the age-of-onset criterion (onset before 7 years) has virtually no empirical support.

Other investigators have argued that the onset criterion should be broadened to include midadolescence or more generically phrased as "onset in childhood."



Finally, as a function of educational and occupational impairments, clinicians may be asked to make recommendations concerning the need for and types of accommodations for those settings. In addition to a need for the clinician to be familiar with the standards of the Americans with Disabilities Act, which is required for obtaining such accommodations, it will also be important for future research to consider which accommodations are effective. For as often as they are used, there is remarkably little evidence that "extra time on tests" and/or "testing in a quiet, nondistracting environment" are effective for adults with ADHD.

Articles

In the past several years, there has been an increasing awareness of the syndromal persistence of ADHD into adulthood. Once considered only a childhood disorder, ADHD has become increasingly recognized as a valid psychiatric disorder in adults.

Steven V. Faraone, PhD

Articles

Diagnosing Adults With ADHD Based on Patient Presentation

Diagnosis and Management of Adults ADHD Compared to Children

Prevalence of Adult ADHD

Diagnosing and Treating ADHD in Adults