Approximately 4.4% of US adults have attention-deficit/hyperactivity disorder (ADHD).1 Yet, this condition remains underdiagnosed as only 10.9% of adults with ADHD receive treatment.1 To complicate diagnosis, adults with ADHD often have comorbid psychiatric disorders, which may mask the symptoms of ADHD.
ADHD Diagnostic Criteria
Although ADHD is a developmental disorder, up to 85% of children with ADHD are at risk for having the disorder as adults.1 The current diagnostic criteria2 for ADHD were developed for children, and modifications are necessary to address the progression of the disorder into adulthood.3 For example, unlike in children, gross motor hyperactivity is relatively rare in adults. Adults with ADHD more often exhibit symptoms of impulsivity, inattention, and/or executive dysregulation, such as high distractibility, impulsive decision making, poor time management, difficulty following directions, working memory problems, excessive speeding while driving, difficulty engaging quietly in leisure activities, and poor follow-through.
Assessment of Adult ADHD
When assessing adults for ADHD, the following recommendations may be helpful: (1) obtain patients’ self-report on current functioning (using only 4 of the DSM-IV-TR criteria) as well as functioning before 16 years of age, (2) obtain corroboration of symptoms and evidence of impairment in several major life activities, (3) obtain evidence of a chronic course of illness without periods of remission, (4) define impairment relative to the average person, (5) explain impairment that developed after 16 years of age, (6) use rating scales for adult ADHD, and (7) rule out a low IQ, learning disabilities, and other co-occurring disorders. Comorbid disorders are common in ADHD and can make accurate diagnosis difficult.3,4
Adult ADHD and Comorbidities
Many adults with ADHD also have co-occurring psychiatric disorders, including anxiety (47%), mood (38%), impulse control (20%), and substance use disorders (SUD, 15%).1 Symptoms of ADHD can be concealed by more robust symptoms of these co-occurring conditions. Conversely, comorbid anxiety and learning disorders can be obfuscated by more obvious ADHD symptoms.
Some comorbid disorders may be a direct reflection of the impact of ADHD symptoms; for example, poor academic achievement owing to ADHD may lead to anxiety. Additionally, other frequently co-occurring conditions, such as depression, share common environmental risk factors with ADHD.5
Comorbidities may differ in frequency between adults and children with ADHD. Adults with ADHD are more likely than children to have one or more anxiety disorders, SUD, personality disorder, and social phobia, but children are more likely to have comorbid oppositional disorder and separation anxiety.6
Adults with undiagnosed ADHD and comorbidities are likely to seek treatment because of problems associated with a co-occurring disorder, not because of ADHD symptoms. Further, the presence of comorbid psychiatric conditions can affect the presentation and course of ADHD and may require treatment independent from that of ADHD. Therefore, clinicians should screen patients with ADHD for other DSM-IV disorders as well as assess patients with other DSM-IV disorders for ADHD.
Take-Home Points
Adults with ADHD often present with different impairments than children with the disorder. Accurately assessing adults for ADHD requires using different criteria than are currently available. Additionally, comorbid psychiatric disorders may complicate the clinical presentation of ADHD. Thus, clinicians should thoroughly screen adults for ADHD as well as for mood, anxiety, substance use, personality, and impulse control disorders to begin to comprehensively address all conditions and improve patients’ overall outcomes.
Disclosure of off-label usage: Dr. Barkley has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration–approved labeling has been presented in this activity.
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Footnotes
This ACADEMIC HIGHLIGHTS Update section of The Primary Care Companion to The Journal of Clinical Psychiatry is derived from the Academic Highlights “ADHD and Comorbid Disorders in Adults” (J Clin Psychiatry 2008;69(8):1328–1335). This report was prepared by the CME Institute of Physicians Postgraduate Press, Inc., and supported by an educational grant from Eli Lilly and Company.
The faculty for the ACADEMIC HIGHLIGHTS were Russell A. Barkley, PhD, SUNY Upstate Medical University, Syracuse, NY; and Jeffrey H. Newcorn, MD, Mount Sinai School of Medicine, New York, NY.
Financial disclosure: Dr. Barkley is a consultant for Eli Lilly, Shire, and Abbott; has received grant/research support from UC-Davis and NIMH; has received honoraria from CADDRA, the Learning Disabilities-Attention Deficit Disorder Program of North Carolina, ThedaCare, NASP, MCW, NEEI, Egleston Children's Hospital, the Spanish Child Psychiatry Association, the Portugal ADHD Foundation, the Brazil ADHD Parent's Association, the Uruguay ADHD Parent's Association, and the Argentina Mental Health Conference; is a member of the speakers/advisory boards for Eli Lilly, Shire, Novartis, and Janssen; and has received other financial or material support from Guilford Publications, Compact Clinics, NEEI, and J&K Seminars. Dr. Newcorn is an advisor/consultant for Eli Lilly, McNeil, Shire, Novartis, Lupin, Sanofi-Aventis, Abbott, and Psychogenics; has received grant/research support from Eli Lilly and McNeil; and has received honoraria for speaking from Eli Lilly, Shire, and McNeil.
The opinions expressed herein are those of the faculty and do not necessarily reflect the views of the CME provider and publisher or the commercial supporter.
REFERENCES
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