Two approaches were taken. First, to cite the most established findings that have been replicated or demonstrated in systematic reviews and meta-analyses. Second, to highlight new emerging findings that require further research to confirm or refute initial findings. The text clarifies which of the newly emerging findings require further research.
SeriesAdult attention-deficit hyperactivity disorder: key conceptual issues
Section snippets
Attention-deficit hyperactivity disorder (ADHD) as a lifespan disorder
ADHD is classified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5) as a childhood-onset neurodevelopmental disorder, defined by the presence of developmentally inappropriate and impairing levels of inattention, hyperactivity, and impulsivity.1 Epidemiological surveys find that 5–6% of children meet DSM-IV criteria for ADHD,2, 3 with a slightly higher prevalence expected when DSM-5 criteria are applied.4 Meta-analysis of
The diagnostic construct of ADHD
For many years, researchers have argued that most mental health disorders reflect the extreme and impairing tail of one or more continuously distributed traits. Present research strategies, such as the Research Domain Criteria (RDoC), increasingly focus on delineating the underlying neurobiological substrates that underpin dimensions of psychopathology.20 Among these, ADHD is one of the best examples in which no point of rarity can be found in the distribution of ADHD symptoms and impairments
Rater effects and measurement of ADHD symptoms
One factor complicating the assessment of ADHD is the change in informant during development. Throughout most of childhood and early adolescence, the primary informants for diagnostic information are parents and teachers, who report mainly on the basis of observed behaviours. For this reason, the ADHD symptoms listed in DSM-IV/5 and International Classification of Diseases (10th edition; ICD-10) are largely descriptions of observed behaviours rather than subjective reports of mental state
Cognitive and neuroimaging markers of ADHD
Cognitive performance measures of attention and impulsivity have been suggested in neurocognitive studies as markers of ADHD symptoms, with several companies marketing different versions of continuous performance tasks (sustained attention and inhibitory control tasks that measure errors of omission, commission, and reaction time). The assumption made is that omission errors reflect behavioural inattention, commission errors reflect behavioural impulsivity, and reaction time variability
Characteristic features of ADHD that support the diagnosis
Focus on the mental state of adult patients with ADHD has been of more immediate clinical value than the use of cognitive or neuroimaging data. Symptoms such as feeling physically restless, emotional dysregulation, excessive mind wandering, and sleep-onset insomnia are all clinically relevant symptoms that are commonly seen in adult ADHD. Surprisingly, these symptoms are not well studied in ADHD despite their potential value in clinical practice.
Course and outcome
Reasons for the persistence and desistence of ADHD into adulthood are not well understood, but are of considerable interest because they identify potential targets for early prevention and treatment. Factors influencing course and outcome include general cognitive ability, severity of ADHD, causal factors (genes and environment), brain maturation and development, and the presence of co-occurring mental health and neurodevelopmental disorders.33 Protective factors, such as exercise,72 might also
Adult-onset ADHD: a potential new trajectory for the disorder
ADHD has been traditionally conceptualised as a neurodevelopmental disorder and is included under this umbrella term in DSM-5.1 Although some disorders known to have a neurodevelopmental trajectory, such as schizophrenia, do not necessarily begin in childhood, ICD-10 clearly defines that a neurodevelopmental disorder should have an onset during infancy or childhood. Thus, it is not surprising that age-of-onset during early childhood emerged as a key element in the definition of ADHD. However,
ADHD, treatment, and comorbidity
One reason for the under-diagnosis of ADHD by adult mental health services is the nature of the clinical syndrome, which shares characteristics with other common adult mental health disorders. These include clinical features associated with adult ADHD that do not form part of the present DSM-5 or ICD-10 diagnostic criteria. Examples include poor concentration, distractibility, restlessness, over-talkativeness, sleep problems, irritability, impulsiveness, and low self-esteem. However, in this
Conclusions
We conclude that ADHD should be recognised in the same way as other common adult mental health conditions, and that failure to recognise and treat ADHD is detrimental to the wellbeing of many patients seeking help for mental health problems. Although further research is needed to assess the effects of ADHD drug treatments in ADHD complicated by comorbidities, effective clinical management of ADHD should be an essential component of adult mental health care. A list of key points and research
Search strategy and selection criteria
References (98)
The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review
Neurotherapeutics
(2012)- et al.
Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative
Biol Psychiatry
(2009) - et al.
Childhood predictors of adolescent and young adult outcome in ADHD
J Psychiatr Res
(2015) Executive function and developmental disorders: the flip side of the coin
Trends Cogn Sci
(2012)- et al.
Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria
Drug Alcohol Depend
(2014) - et al.
Attention-deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a large-scale twin study
J Am Acad Child Adolesc Psychiatry
(1997) - et al.
Shared genetic influences between attention-deficit/hyperactivity disorder (ADHD) traits in children and clinical ADHD
J Am Acad Child Adolesc Psychiatry
(2015) - et al.
The neuropsychological effects of chronic methylphenidate on drug-naive boys with attention-deficit/hyperactivity disorder
Biol Psychiatry
(2007) - et al.
Ventral-striatal responsiveness during reward anticipation in ADHD and its relation to trait impulsivity in the healthy population: a meta-analytic review of the fMRI literature
Neurosci Biobehav Rev
(2014) - et al.
Delayed circadian rhythm in adults with attention-deficit/hyperactivity disorder and chronic sleep-onset insomnia
Biol Psychiatry
(2010)
Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder
J Affect Disord
The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults
J Am Acad Child Adolesc Psychiatry
Emotional dysregulation in adult ADHD and response to atomoxetine
Biol Psychiatry
Normalisation of frontal theta activity following methylphenidate treatment in adult attention-deficit/hyperactivity disorder
Eur Neuropsychopharmacol
Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-analytic review
Biol Psychiatry
Protection from genetic diathesis in attention-deficit/hyperactivity disorder: possible complementary roles of exercise
J Am Acad Child Adolesc Psychiatry
Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study
J Am Acad Child Adolesc Psychiatry
Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study
Lancet
Long-term efficacy and safety of treatment with stimulants and atomoxetine in adult ADHD: a review of controlled and naturalistic studies
Eur Neuropsychopharmacol
Diagnostic and Statistical Manual of Mental Disorders DSM 5
The worldwide prevalence of ADHD: a systematic review and metaregression analysis
Am J Psychiatry
Rethinking ADHD and LD in DSM-5: proposed changes in diagnostic criteria
J Learn Disabil
The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies
Psychol Med
A 6-year follow-up of a large European cohort of children with attention-deficit/hyperactivity disorder-combined subtype: outcomes in late adolescence and young adulthood
Eur Child Adolesc Psychiatry
ADHD in adults: what the science says
Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study
Am J Psychiatry
Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder
Br J Psychiatry
Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis
Br J Psychiatry
Is adult onset ADHD a distinct entity?
Am J Psychiatry
A meta-analysis of the prevalence of attention deficit hyperactivity disorder in incarcerated populations
Psychol Med
Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units
BMC Psychiatry
Prevalence of ADHD in nonpsychotic adult psychiatric care (ADPSYC): A multinational cross-sectional study in Europe
BMC Psychiatry
Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care
Arch Intern Med
Research domain criteria (RDoC): toward a new classification framework for research on mental disorders
Am J Psychiatry
DSM-IV combined type ADHD shows familial association with sibling trait scores: a sampling strategy for QTL linkage
Am J Med Genet B Neuropsychiatr Genet
Adults with attention-deficit hyperactivity disorder—diagnosis or normality?
Br J Psychiatry
Developmental trajectories of DSM-IV symptoms of attention-deficit/hyperactivity disorder: genetic effects, family risk and associated psychopathology
J Child Psychol Psychiatry
Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type
Am J Psychiatry
The separation of ADHD inattention and hyperactivity-impulsivity symptoms: pathways from genetic effects to cognitive impairments and symptoms
J Abnorm Child Psychol
A gradient of childhood self-control predicts health, wealth, and public safety
Proc Natl Acad Sci USA
The heritability of clinically diagnosed attention deficit hyperactivity disorder across the lifespan
Psychol Med
Childhood attention-deficit hyperactivity disorder as an extreme of a continuous trait: a quantitative genetic study of 8 500 twin pairs
J Child Psychol Psychiatry
Separation of cognitive impairments in attention-deficit/hyperactivity disorder into 2 familial factors
Arch Gen Psychiatry
Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults
Psychol Med
Attention-deficit/hypereactivity disorder
Nature Rev Dis Primers
European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD
BMC Psychiatry
Cognitive and neurophysiological markers of ADHD persistence and remission
Br J Psychiatry
Different heritabilities but shared etiological influences for parent, teacher and self-ratings of ADHD symptoms: an adolescent twin study
Psychol Med
Measuring adult Attention Deficit Hyperactivity Disorder using the Quantified Behavior Test Plus
PsyCh journal
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