Psychology Attention-Deficit/Hyperactivity Disorder (ADHD) In Adults
by
Will H. Canu, John T. Mitchell
  • LAST REVIEWED: 13 October 2016
  • LAST MODIFIED: 21 November 2012
  • DOI: 10.1093/obo/9780199828340-0070

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable, heterogeneous, and relatively common psychological disorder that originates in childhood and, for many affected individuals, continues to cause substantial functional impairment into adulthood. The prevalence of this disorder in childhood was estimated by the Centers for Disease Control and Prevention in 2009 to be approximately 8 percent in the United States, with evidence showing more consistency than divergence from this rate in other regions worldwide. Three ADHD types are currently established by the American Psychiatric Association: Predominantly Hyperactive-Impulsive, Predominantly Inattentive, and Combined (i.e., prominent symptoms of both hyperactivity-impulsivity and inattention). Extensive research in child and adolescent populations has established that the hallmark symptoms that are broadly characterized by cognitive, behavioral, and emotional disinhibition tend to be associated with impairment in school, at home, in extracurricular activities, in relationships with peers and family members, and in other important endeavors (e.g., maintaining personal safety). Adding to the heterogeneity of the disorder, comorbidity with other psychological syndromes is common in clinical populations, with disruptive behavior (e.g., oppositional defiant disorder, conduct disorder), mood, anxiety, tic, and substance use disorders most frequently co-occurring. The term “adult ADHD” has been used somewhat loosely, seeming to refer in different contexts to one or more of the three following groups: (1) those who are diagnosed with ADHD in childhood whose related symptoms continue into adulthood to such an extent that functional impairment persists; (2) individuals who are not diagnosed in childhood yet exhibited signs of the disorder from an early age and present for assessment and intervention in adulthood due to increased task demands that result in impairment; and (3) persons who only begin to evince symptoms and impairment related to ADHD in adulthood. While research has demonstrated that presentation of bona fide ADHD symptoms may occur as late as early-to-middle adolescence, the current consensus among researchers in the field seems to argue against the existence of this latter group. In other words, it is virtually always the case that clear signs of ADHD at some point in childhood are at least retrospectively apparent in cases that merit a clinical diagnosis, and where such data is not present it is likely that a given individual is suffering from another condition that mimics ADHD symptoms or is malingering. For decades, ADHD was widely considered—by professionals and the public alike—to be confined to childhood and adolescence, and only after long-term, longitudinal studies concluded in the 1980s and 1990s that functional impairment commonly persisted in ADHD probands did substantial focus turn to affected adults. Despite this decades-long delay, research on the adult manifestation of ADHD is burgeoning, and broadly indicates that many of those affected in childhood continue to suffer deleterious outcomes in educational, professional, occupational, and relational domains of life. What follows is a brief primer on the related research; the reader seeking genuine expertise regarding ADHD in adulthood is encouraged to use these resources as a springboard to other, more extensive material.

General Overviews

Several resources that provide a broad overview of issues related to adult ADHD exist. These range from fairly high-level (e.g., Manos 2010; Spencer, et al. 2007) to in-depth (e.g., Barkley, et al. 2008). Of particular note is Barkley, et al. 2008, which comprehensively incorporates the existing adult ADHD literature into the reporting of results from two important longitudinal studies conducted by the authors in Milwaukee and Massachusetts. It is worth mentioning that Davidson 2008 focuses not only on the state of knowledge regarding the manifestation of ADHD in adults but also the efficacy of treatments and assessment for this population. The perspective of Kooij, et al. 2010 is particularly informative as it is representative of the growing worldwide agreement regarding the validity and characteristics of adult ADHD.

  • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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    An all-around excellent resource examining the broad issues related to adult ADHD, including the presentation of groundbreaking longitudinal research.

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    • Davidson, M. A. 2008. ADHD in adults: A review of the literature. Journal of Attention Disorders 11:628–641.

      DOI: 10.1177/1087054707310878Save Citation »Export Citation »E-mail Citation »

      A brief review focusing on diagnostic issues, assessment methods, and treatment of ADHD in adults.

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      • Kooij, S. J. J., S. Begerot, A. Blackwell, et al. 2010. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 10:1–24.

        DOI: 10.1186/1471-244X-10-67Save Citation »Export Citation »E-mail Citation »

        A thorough review of the clinical presentation, diagnostic issues, and treatment issues related to the adult ADHD population; this perspective from outside of the United States helps demonstrate the commonalities across Western countries.

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        • Manos, M. J. 2010. Nuances of assessment and treatment of ADHD in adults: A guide for psychologists. Professional Psychology: Research and Practice 41:511–517.

          DOI: 10.1037/a0021476Save Citation »Export Citation »E-mail Citation »

          This resource aimed at mental health practitioners describes typical symptomatic differences in adults versus children, comorbidity considerations, and special approaches to treating affected adults.

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          • Spencer, T. J., J. Biederman, and E. Mick. 2007. Attention-deficit/hyperactivity disorder: Diagnosis, lifespan, comorbidities, and neurobiology. Journal of Pediatric Psychology 32:631–642.

            DOI: 10.1093/jpepsy/jsm005Save Citation »Export Citation »E-mail Citation »

            Etiology, course, comorbidity, evidence for validity of the disorder in adulthood, and the need for better, developmentally appropriate diagnostic criteria for adults are among the topics that receive attention in this brief review.

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            Historical Roots and Seminal Studies

            The phenomenon of adult ADHD, specifically, was first documented much earlier than many people imagine. Barkley and Peters 2012 nicely summarizes and comments on the recently recognized, first published report regarding this condition, that of the German physician Melchior Adam Weikard, which originally appeared in a medical textbook in 1775. Barkley, et al. 2008 provides a comprehensive overview of how, in modern times, ADHD came to be recognized as a condition that persists beyond childhood. Paul Wender is prominent among the initial investigators of adult ADHD, and he and colleagues were among the first to suggest that symptoms could persist into middle adulthood (Wood, et al. 1976). Even more convincing than their cross-sectional data were those provided by early longitudinal studies that followed hyperactive children (males, largely) across many years, establishing the trend of continued impairment. Studies published by the independent groups of Gabrielle Weiss and then Salvatore Mannuzza arguably most influenced the shift toward acceptance of the adult ADHD phenomenon, spurring efforts toward effective description, evaluation, and treatment (Mannuzza, et al. 1993; Weiss, et al. 1985).

            • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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              In addition to providing a broad overview of the current state of scientific knowledge regarding ADHD, Barkley and colleagues systematically review the history of research, assessment, and treatment regarding adult ADHD.

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              • Barkley, R. A., and H. Peters. 2012. The earliest reference to ADHD in the medical literature? Melchior Adam Weikard’s description in 1775 of “attention deficit” (Mangel del Aufmerksamkeit, Attentio Volubilis). Journal of Attention Disorders 16:623–630.

                DOI: 10.1177/1087054711432309Save Citation »Export Citation »E-mail Citation »

                Description and related commentary regarding the “discovery” of Weikard’s clinical accounting of adult ADHD, dating to the 18th century.

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                • Mannuzza, S., R. G. Klein, A. Bessler, P. Malloy, and M. LaPadula. 1993. Adult outcome of hyperactive boys: Educational achievement, occupational rank, and psychiatric status. Archives of General Psychiatry 50:565–576.

                  DOI: 10.1001/archpsyc.1993.01820190067007Save Citation »Export Citation »E-mail Citation »

                  One of the seminal longitudinal studies documenting the long-term, negative impact of ADHD originating in childhood.

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                  • Weiss, G., L. Hechtman, T. Milroy, and T. Perlman. 1985. Psychiatric status of hyperactives as adults: A controlled prospective 15-year follow-up of 63 hyperactive children. Journal of the American Academy of Child Psychiatry 24:211–220.

                    DOI: 10.1016/S0002-71380960450-7Save Citation »Export Citation »E-mail Citation »

                    The study emerging from the third five-year-follow-up interval of this Canadian research team’s longitudinal study of children diagnosed with ADHD; Weiss and colleagues document widespread impairments in the adult probands and pave the way for others to focus on ADHD in this developmental period.

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                    • Wood, D. R., F. W. Reimherr, P. H. Wender, and G. E. Johnson. 1976. Diagnosis and treatment of minimal brain dysfunction in adults: A preliminary report. Archives of General Psychiatry 33:1453–1460.

                      DOI: 10.1001/archpsyc.1976.01770120057005Save Citation »Export Citation »E-mail Citation »

                      An informative, well-constructed early study that demonstrated the efficacy of methylphenidate intervention in an adult clinical population presenting with impairing symptoms of ADHD. One thrust of the authors’ discussion is an assertion that ADHD in adulthood exists—one of the earliest in modern literature.

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                      Prevalence

                      Epidemiological studies indicate that the prevalence of ADHD in childhood is between 5.3 percent and 7.8 percent (Polanczyk and Rohde 2007; Visser, et al. 2007). Some studies report higher rates, which is likely attributable to different methodologies (Polanczyk and Jensen 2008). The estimated prevalence of ADHD in adulthood is slightly lower and ranges from 3.4 percent to 4.4 percent (Fayyad, et al. 2007; Kessler, et al. 2006). Of those meeting criteria for the disorder, just 11 percent had received treatment for their ADHD in the previous twelve months, while 25 percent had received treatment for another mental disorder in that same timeframe (Kessler, et al. 2006).

                      • Fayyad, J., R. de Graaf, R. Kessler, et al. 2007. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. British Journal of Psychiatry 190:402–409.

                        DOI: 10.1192/bjp.bp.106.034389Save Citation »Export Citation »E-mail Citation »

                        Prevalence and correlates of ADHD in adulthood are reported in this article. This study provides a thorough assessment of ADHD epidemiology in adulthood in ten countries in the Americas, Europe, and the Middle East.

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                        • Kessler, R. C., L. Adler, R. Barkley, et al. 2006. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163:716–723.

                          DOI: 10.1176/appi.ajp.163.4.716Save Citation »Export Citation »E-mail Citation »

                          This highly cited study provides prevalence estimate and correlates of adult ADHD in the United States based on the National Comorbidity Survey Replication.

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                          • Polanczyk, G., and P. Jensen. 2008. Epidemiologic considerations in attention deficit hyperactivity disorder: A review and update. Child and Adolescent Psychiatric Clinics of North America 17:245–260.

                            DOI: 10.1016/j.chc.2007.11.006Save Citation »Export Citation »E-mail Citation »

                            This review article addresses methodological aspects of prevalence studies based on a systematic review of prevalence estimates pertaining to children and adolescents with ADHD. Though this does not necessarily target adult samples, many of the points emphasized in this article are applicable to adult samples.

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                            • Polanczyk, G., and L. A. Rohde. 2007. Epidemiology of attention-deficit/hyperactivity disorder across the lifespan. Current Opinions in Psychiatry 20:386–392.

                              DOI: 10.1097/YCO.0b013e3281568d7aSave Citation »Export Citation »E-mail Citation »

                              This review addresses potential reasons for inconsistencies in prevalence estimates in ADHD and provides a summary of epidemiological studies of ADHD across the lifespan.

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                              • Visser, S. N., C. A. Lesesne, and R. Perou. 2007. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics 119 (Suppl. 1): S99–S106.

                                DOI: 10.1542/peds.2006-2089OSave Citation »Export Citation »E-mail Citation »

                                This study provides prevalence estimates of ADHD in children aged four to seventeen years in a large sample.

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                                Persistence from Childhood

                                Rates of persistence of ADHD into adulthood vary in longitudinal studies, though in studies that consider differing reporting sources and degree of developmental deviance, approximately 65 percent of children with the diagnosis continue to meet criteria into adulthood (Barkley, et al. 2008). Barkley, et al. 2008 provides a thorough review of seminal longitudinal studies that demonstrate that ADHD and its complications are not restricted to childhood. Significant predictors of the disorder into adulthood include severe functional impairment associated with ADHD, psychiatric comorbidity, and exposure to maternal psychopathology in childhood (Biederman, et al. 2011). In other studies assessing predictors of ADHD into adulthood, the following are also significant: childhood ADHD severity, ADHD symptom profile (primarily those exhibiting elevated levels of hyperactivity-impulsivity and inattention), lack of childhood treatment, psychiatric comorbidity, paternal anxiety mood disorder, and parental antisocial personality disorder (Kessler, et al. 2005; Lara, et al. 2009). In a study assessing expanded symptom criteria that included more developmentally age-appropriate language, adult persistence was greater for inattentive than hyperactive-impulsive symptoms (Kessler, et al. 2010). Further, in the same study, symptoms of executive functioning were more consistent and discriminating predictors of ADHD in adulthood than inattentive and hyperactive-impulsive symptoms.

                                • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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                                  A book-length overview covering a variety of current topics on ADHD in adulthood; an all-around excellent resource. The authors provide a detailed summary of seminal longitudinal studies documenting syndromatic persistence of ADHD into adulthood.

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                                  • Biederman, J., C. R. Petty, A. Clarke, A. Lomedico, and S. V. Faraone. 2011. Predictors of persistent ADHD: An 11-year follow-up study. Journal of Psychiatric Research 45:150–155.

                                    DOI: 10.1016/j.jpsychires.2010.06.009Save Citation »Export Citation »E-mail Citation »

                                    Based on a highly cited prospective study, results from this longitudinal analysis suggest that the vast majority (78 percent) of children diagnosed with ADHD continue to experience impairing symptoms of ADHD in emerging adulthood, with baseline severity of ADHD, comorbidity, and maternal psychopathology relating to persistence.

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                                    • Kessler, R. C., L. A. Adler, R. Barkley, et al. 2005. Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: Results from the National Comorbidity Survey Replication. Biological Psychiatry 57:1442–1451.

                                      DOI: 10.1016/j.biopsych.2005.04.001Save Citation »Export Citation »E-mail Citation »

                                      This study utilized data from a large sample and retrospectively assessed predictors of persistence of ADHD from childhood to adulthood; results suggest that childhood factors such as original symptom severity and active treatment better predict persistent ADHD than any more proximal factors.

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                                      • Kessler, R. C., J. G. Green, L. A. Adler, et al. 2010. Structure and diagnosis of adult attention-deficit/hyperactivity disorder: Analysis of expanded symptom criteria from the Adult ADHD Clinical Diagnostic Scale. Archives of General Psychiatry 67:1168–1178.

                                        DOI: 10.1001/archgenpsychiatry.2010.146Save Citation »Export Citation »E-mail Citation »

                                        This study evaluated ADHD symptom stability from childhood to adulthood, with findings generally confirming that inattention remains more stable than hyperactivity-impulsivity. Executive dysfunctions, however, were the best overall predictors of ADHD status persistence, suggesting that such symptoms should play a greater role in formal assessment.

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                                        • Lara, C., J. Fayyad, R. de Graaf, et al. 2009. Childhood predictors of adult attention-deficit/hyperactivity disorder: Results from the World Health Organization World Mental Health Survey Initiative. Biological Psychiatry 65:46–54.

                                          DOI: 10.1016/j.biopsych.2008.10.005Save Citation »Export Citation »E-mail Citation »

                                          This study assessed childhood predictors of persistence for adults diagnosed with ADHD in ten countries and will likely serve as a solid foundation for future studies assessing the expression of ADHD in adulthood in different countries. Generally, findings conform to the broader literature, with a majority of children with diagnosed with ADHD continuing to meet a criterion of ADHD-related impairment in adulthood, and persistence being linked to prominent inattentive symptoms and comorbidity.

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                                          Biological Differences

                                          Over the past several decades, numerous researchers have systematically established that ADHD is a disorder that primarily arises from inherent, biological differences, as opposed to environmental factors. While a few exceptions in the latter domain remain (e.g., exposure to toxins such as lead), a large body of evidence suggests ADHD to be a highly heritable disorder with a genetic and neurological basis, as reviewed in the following subsections.

                                          Genetics

                                          An important focus in the ADHD literature has been the examination of the biological underpinnings of the syndrome. Generally speaking, very few environmental factors have been shown to be associated with well-specified cases of ADHD (though there are some exceptions, such as Nigg, et al. 2010), whereas substantial evidence for biological mechanisms related to disorder-specific deficiencies has been uncovered. A highly influential Australian study (Levy, et al. 1997) examined the question of heritability using a national sample of twins and their families, and found the variance of ADHD status was most highly related to genetic relatedness or, in other words, that the heritability of ADHD is very high and on par with many other psychological disorders. The “holy grail” for biological determination of ADHD may lie in the establishment of a genetic profile for the disorder or, at least, the genetic markers of risk. This has proven to be more elusive than the establishment of heritability, with the evidence pointing to polygenetic influence. Many candidate gene polymorphisms have been examined, with just a few being determined as robust predictors of risk and even those accounting for, in sum, a small amount of variance in ADHD traits in the population (for an excellent review, see Gizer, et al. 2009). The genes in question largely relate to the functioning of the dopaminergic and seretonergic neurotransmitter systems, although others associated with noradrenergic and other systems have been shown to have some association as well. While, clearly, genetic research on children and adolescents with ADHD has direct bearing on the affected adult population (and represents the bulk of published data, to date), studies have recently emerged that examine genetic factors that relate specifically to adult-persistent ADHD; the work Ribases, et al. 2011, examining the association of the LPHN3 gene to adult ADHD, is a nice example of this nascent trend.

                                          • Gizer, I. R., C. Ficks, and I. D. Waldman. 2009. Candidate gene studies of ADHD: A meta-analytic review. Human Genetics 126:51–90.

                                            DOI: 10.1007/s00439-009-0694-xSave Citation »Export Citation »E-mail Citation »

                                            Widely regarded as one of the best, recent reviews of the burgeoning literature supporting genetic risk for ADHD.

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                                            • Levy, F., D. A. Hay, M. McStephen, C. Wood, and I. Waldman. 1997. Attention-deficit hyperactivity disorder: A category or a continuum? Genetic analysis of a large-scale twin study. Journal of the American Academy of Child & Adolescent Psychiatry 36:737–744.

                                              DOI: 10.1097/00004583-199706000-00009Save Citation »Export Citation »E-mail Citation »

                                              This highly cited study utilized a very large Australian twin and related family sample to demonstrate the heritability of ADHD, which, by their measures, can conservatively be estimated at .8.

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                                              • Nigg, J. T., M. Nikolas, G. M. Knottnerus, K. Cavanagh, and K. Friderici. 2010. Confirmation and extension of association of blood lead with attention-deficit/hyperactivity disorder (ADHD) and ADHD symptom domains at population-typical exposure levels. Journal of Child Psychology and Psychiatry 51:58–65.

                                                DOI: 10.1111/j.1469-7610.2009.02135.xSave Citation »Export Citation »E-mail Citation »

                                                One of the few environmental factors that have historically been associated with ADHD incidence is toxic lead exposure. Nigg and colleagues provide an updated analysis and confirmation of this relationship.

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                                                • Ribases, M., J. A. Ramos-Quiroga, C. Sánchez-Mora, et al. 2011. Contribution of LPHN3 to the genetic susceptibility to ADHD in adulthood: A replication study. Genes, Brain, & Behavior 10:149–157.

                                                  DOI: 10.1111/j.1601-183X.2010.00649.xSave Citation »Export Citation »E-mail Citation »

                                                  While much of the extant literature on genetic etiology of ADHD focuses on the broad expression of the syndrome in the population, Ribases and colleagues here focus on a candidate gene for risk for adult persistent ADHD.

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                                                  Neuropsychological Findings

                                                  Of course, biological differences extend well beyond evidence of genotypic variation. As technology enabling structural and functional measurement of the brain and specific regions thereof has become more refined and readily accessible, neuropsychological examination of the ADHD population and its differences from nondiagnosed counterparts has proliferated. Krain and Castellanos 2006 reviews the consistent findings regarding volumetric differences in children with ADHD—a decrement of 3–4 percent across the four major lobes—as well as the support for an irregular frontal-striatal-cerebellar circuit that may underlie the core deficits associated with the disorder. It should be noted that at the time of their review the vast majority of studies, however, had been conducted with male samples, thereby limiting the certainty of generalization to girls with ADHD. Neurocognitive assessment of clinical ADHD groups has yielded a body of work that identifies specific dysfunctions associated with ADHD in adulthood. The excellent review Woods, et al. 2002 documents evidence across neuropsychological assessment techniques for dysfunction in affected adults—apparent in relatively subtle deficits in performance on attention, executive (e.g., organizational) functioning, verbal memory, and complex information processing tasks—and suggest ways in which future research may better work toward the development of effective neurocognitive screening techniques. Hervey, et al. 2004, a meta-analysis of studies employing like assessment techniques, largely supports Woods, et al.’s conclusions, while adding behavioral inhibition as a notable impairment. The Boonstra, et al. 2005 meta-analysis, which focuses on executive functioning assessment of adults with ADHD, further supports that a broad array of cognitive dysfunctions characterize the condition, and also signals that the field must evolve toward including control tasks and clinical comparison groups in order to accurately identify dysfunction specific to adult ADHD.

                                                  • Boonstra, A. M., J. Oosterlaan, J. A. Sergeant, and J. K. Buitelaar. 2005. Executive functioning in adult ADHD: A meta-analytic review. Psychological Medicine 35:1097–1108.

                                                    DOI: 10.1017/S003329170500499XSave Citation »Export Citation »E-mail Citation »

                                                    This review paper focuses on analyzing data across the published ADHD literature on shared neuropsychological measures of executive functioning in affected adults; various consistent cognitive dysfunctions are noted, as are suggestions for design of future related research.

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                                                    • Hervey, A. S., J. N. Epstein, and J. F. Curry. 2004. Neuropsychology of adults with attention-deficit/hyperactivity disorder: A meta-analytic review. Neuropsychology 18:485–503.

                                                      DOI: 10.1037/0894-4105.18.3.485Save Citation »Export Citation »E-mail Citation »

                                                      A review of the evidence for a broad array of cognitive performance deficiencies in adults with ADHD.

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                                                      • Krain, A. L., and F. X. Castellanos. 2006. Brain development and ADHD. Clinical Psychology Review 26:433–444.

                                                        DOI: 10.1016/j.cpr.2006.01.005Save Citation »Export Citation »E-mail Citation »

                                                        This paper critically examines the published findings regarding structural (i.e., volume, symmetry, gray-versus-white-matter) differences observed in ADHD populations. The authors aptly emphasize that the cerebellum and basal ganglia are implicated because of consistent differences, regions that are often underemphasized as compared to the frontal lobe.

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                                                        • Woods, S. P., D. W. Lovejoy, and J. D. Ball. 2002. Neuropsychological characteristics of adults with ADHD: A comprehensive review of initial studies. Clinical Neuropsychologist 16:12–34.

                                                          DOI: 10.1076/clin.16.1.12.8336Save Citation »Export Citation »E-mail Citation »

                                                          A relatively early review of neuropsychological assessment evidence of differences in adults with ADHD; helped to confirm that executive dysfunction is a central facet of the disorder in adulthood.

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                                                          Assessment

                                                          Assessment of ADHD in adulthood typically relies on multiple reporting sources and a developmental perspective. Below we review the current “gold standard” methods of assessing ADHD in adulthood and diagnostic issues that require further consideration.

                                                          Methods

                                                          Best practice guidelines for assessing ADHD across the lifespan generally include thorough clinical interviews, standardized measures, self and other reporters, and past record reviews that rely on Diagnostic and Statistical Manual of Mental Disorders (4th edition text revision, DSM-IV-TR; American Psychiatric Association 2000) criteria. In adults, various standardized self- and other-report scales (Murphy and Adler 2004; Rosler, et al. 2006; Taylor, et al. 2011) and clinical interviews (Barkley and Murphy 2006, Epstein, et al. 2000) are commonly administered in ADHD assessments. The correspondence between self and other ratings of current symptoms is generally moderate to high and slightly lower for childhood functioning (Barkley, et al. 2011). Regarding the latter, a challenge in adult ADHD assessments involves retrospective reporting of childhood ADHD symptoms (McGough and Barkley 2004). Insufficient evidence supports the use of neuropsychological tests and brain imaging to diagnose ADHD (McGough and Barkley 2004).

                                                          • American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association.

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                                                            This manual, referred to as the DSM-IV-TR, lists the diagnostic criteria for ADHD and other mental health disorders.

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                                                            • Barkley, R. A., L. E. Knouse, and K. R. Murphy. 2011. Correspondence and disparity in the self- and other ratings of current and childhood ADHD symptoms and impairment in adults with ADHD. Psychological Assessment 23:437–446.

                                                              DOI: 10.1037/a0022172Save Citation »Export Citation »E-mail Citation »

                                                              This study examined the degree to which self-report and other-report ratings of ADHD symptoms and impairment correspond in a sample of adults thoroughly assessed for ADHD.

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                                                              • Barkley, R. A., and K. R. Murphy. 2006. Attention-deficit/hyperactivity disorder: A clinical workbook. Vol. 3. New York: Guilford.

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                                                                This is a user-friendly workbook that provides forms and interviews for use in clinical practice to thoroughly assess ADHD in adulthood.

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                                                                • Epstein, J. N., D. Johnson, and C. K. Conners. 2000. Conners’ adult ADHD diagnostic interview for DSM-IV. North Tonawanda, NY: Multi-Health Systems.

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                                                                  This measure is another user-friendly interview for use in clinical settings that fully assesses DSM-IV-TR-defined ADHD in adulthood.

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                                                                  • McGough, J. J., and R. A. Barkley. 2004. Diagnostic controversies in adult attention deficit hyperactivity disorder. American Journal of Psychiatry 161:1948–1956.

                                                                    DOI: 10.1176/appi.ajp.161.11.1948Save Citation »Export Citation »E-mail Citation »

                                                                    Highlighting contemporary issues relevant to diagnosis in adulthood, this review provides a thorough summary of diagnostic issues specific to ADHD in adulthood that includes differing assessment approaches and diagnostic controversies.

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                                                                    • Murphy, K. R., and L. A. Adler. 2004. Assessing attention-deficit/hyperactivity disorder in adults: Focus on rating scales. Journal of Clinical Psychiatry 65 (Suppl. 3): 12–17.

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                                                                      This review provides a thorough overview of different adult ADHD rating scales commonly used in clinical practice and research settings. This article, along with Rosler, et al. 2006 and Taylor et al. 2011, ——provides excellent information particularly for those learning how to interpret and properly administer these measures.

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                                                                      • Rosler, M., W. Retz, J. Thome, M. Schneider, R. D. Stieglitz, and P. Falkai. 2006. Psychopathological rating scales for diagnostic use in adults with attention-deficit/hyperactivity disorder (ADHD). European Archives of Psychiatry and Clinical Neuroscience 256 (Suppl. 1): i3–i11.

                                                                        DOI: 10.1007/s00406-006-1001-7Save Citation »Export Citation »E-mail Citation »

                                                                        This review also provides a thorough overview of different rating scales commonly used in clinical practice and research for ADHD in adults.

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                                                                        • Taylor, A., S. Deb, and G. Unwin. 2011. Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): A systematic review. Research in Developmental Disabilities 32:924–938.

                                                                          DOI: 10.1016/j.ridd.2010.12.036Save Citation »Export Citation »E-mail Citation »

                                                                          This review discusses the development, psychometrics, scoring, and clinical utility of current adult ADHD rating scales.

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                                                                          Future Directions in Assessment

                                                                          Diagnostic criteria for ADHD were developed with child samples. As a result, a number of DSM-IV-TR shortcomings have been identified when assessing ADHD in adulthood and are areas that deserve further consideration. For instance, DSM-IV-TR guidelines for assessing ADHD in adulthood include developmentally inappropriate symptoms (e.g., excessive climbing) and symptom thresholds (i.e., endorsing six of nine inattentive or hyperactive-impulsive symptoms; McGough and Barkley 2004). Regarding the former, alternative symptom sets focusing on age-appropriateness have been suggested for emerging (e.g., Fedele, et al. 2010) and young-to-middle adulthood (e.g., Barkley, et al. 2008). In addition, there is a lack of evidence for the current DSM-IV-TR age-of-onset criterion (i.e., age seven). That is, ADHD adults with an age of onset after age seven do not differ from those who are able to demonstrate symptom onset prior to age seven (e.g., Faraone, et al. 2009) and extending this age-of-onset criterion to age twelve would not affect prevalence estimates or correlates and risk factors of ADHD (Polanczyk, et al. 2010). An additional area that has received consideration in assessing ADHD in adults involves executive functioning symptoms. In comparison to inattentive and hyperactive-impulsive symptoms, executive functioning symptoms are more specific predictors of ADHD in adulthood (Kessler, et al. 2010). Extending symptom content to also incorporate emotional dysregulation difficulties as a core component of the disorder in adults, adolescents, and children has also been proposed (Barkley 2010). ADHD diagnostic changes for DSM-5 are currently under consideration (American Psychiatric Association 2011), including modified symptom thresholds for older adolescents and adults (i.e., four of nine inattentive symptoms and four of thirteen hyperactive-impulsive symptoms), and age-of-onset by age twelve.

                                                                          • American Psychiatric Association. 2011. DSM-5 Development: A 06 Attention Deficit/Hyperactivity Disorder.

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                                                                            The American Psychiatric Association has published this website of current DSM-5 diagnostic changes being considered for ADHD in adulthood by workgroups. A number of changes for ADHD and other psychiatric disorders are being considered and are easily available for the general public to view and make comments.

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                                                                            • Barkley, R. A. 2010. Deficient emotional self-regulation is a core component of attention-deficit/hyperactivity disorder. Journal of ADHD & Related Disorders 1:5–37.

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                                                                              This article provides a summary of research demonstrating that deficient emotion regulation is common in ADHD and argues that emotion dysregulation be considered as a core feature currently neglected in the ADHD literature.

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                                                                              • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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                                                                                A book-length overview covering a variety of current topics on ADHD in adulthood. An all-around excellent resource. The authors provide a detailed summary addressing the age-appropriateness of current and proposed adult ADHD symptoms.

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                                                                                • Faraone, S. V., A. Kunwar, J. Adamson, and J. Biederman. 2009. Personality traits among ADHD adults: Implications of late-onset and subthreshold diagnoses. Psychological Medicine 39:685–693.

                                                                                  DOI: 10.1017/S0033291708003917Save Citation »Export Citation »E-mail Citation »

                                                                                  This study built on previous studies demonstrating the validity of ADHD in adults when age of onset criterion is not satisfied. Demonstrated that personality profiles did not differ between adults who meet full DSM-IV-TR criteria for ADHD and those who meet all but the age-of-onset criterion.

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                                                                                  • Fedele, D. A., C. M. Hartung, W. H. Canu, and B. M. Wilkowski. 2010. Potential symptoms of ADHD for emerging adults. Journal of Psychopathology and Behavioral Assessment 32: 385–396.

                                                                                    DOI: 10.1007/s10862-009-9173-xSave Citation »Export Citation »E-mail Citation »

                                                                                    This study identified potential symptoms for ADHD in young adults, including two new factors not currently included in the DSM-IV-TR: cognitive inflexibility and disinhibition. Such studies demonstrate that future diagnostic considerations should consider symptoms beyond inattention and hyperactivity-impulsivity.

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                                                                                    • Kessler, R. C., J. G. Green, L. A. Adler, et al. 2010. Structure and diagnosis of adult attention-deficit/hyperactivity disorder: Analysis of expanded symptom criteria from the Adult ADHD Clinical Diagnostic Scale. Archives of General Psychiatry 67:1168–1178.

                                                                                      DOI: 10.1001/archgenpsychiatry.2010.146Save Citation »Export Citation »E-mail Citation »

                                                                                      This study evaluated ADHD symptom stability from childhood to adulthood, ADHD symptom structure in adults with the disorder, and ADHD symptoms that were the most consistent and most discriminating predictors of current ADHD. They proposed including executive functioning symptoms not currently included in the DSM-IV-TR.

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                                                                                      • McGough, J. J., and R. A. Barkley. 2004. Diagnostic controversies in adult attention deficit hyperactivity disorder. American Journal of Psychiatry 161:1948–1956.

                                                                                        DOI: 10.1176/appi.ajp.161.11.1948Save Citation »Export Citation »E-mail Citation »

                                                                                        This review provides an excellent summary of diagnostic issues specific to ADHD in adulthood, including differing assessment approaches and diagnostic controversies.

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                                                                                        • Polanczyk, G., A. Caspi, R. Houts, S. H. Kollins, L. A. Rohde, and T. E. Moffitt. 2010. Implications of extending the ADHD age-of-onset criterion to age 12: Results from a prospectively studied birth cohort. Journal of the American Academy of Child and Adolescent Psychiatry 49:210–216.

                                                                                          DOI: 10.1016/j.jaac.2009.12.014Save Citation »Export Citation »E-mail Citation »

                                                                                          The aim of this study was to assess whether modifying the age-of-onset criterion for ADHD would (a) impact prevalence of the disorder and (b) affect clinical and cognitive features, impairment profile, and risk factors for ADHD. This article provides strong support for revising this current DSM-IV-TR criterion.

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                                                                                          Treatment

                                                                                          Treatments for ADHD in adulthood include pharmacological and psychosocial options. Aspects of both treatment options are efficacious in reducing ADHD symptoms and related functional concerns, although this is likely an area of research that will receive increasing focus in years to come, as this is a relatively less-developed research literature in comparison to ADHD in childhood.

                                                                                          Pharmacological

                                                                                          Evidence for the efficacy of pharmacological intervention for childhood ADHD, and particularly psychostimulants such as methylphenidate, emerged in the 1970s and 1980s, and in 1990s research that included affected adults largely indicated that such older individuals tend to benefit as well. Indeed, many contend that a well-controlled titration of medication to address ADHD symptoms should be the first line of intervention, given its widespread efficacy at addressing core symptoms of the disorder. Differences can be noted, however, between recommendations for the pharmacological treatment of children (Pliszka and AACAP Work Group on Quality Issues 2007), adolescents (Hazell 2007), and adults (Hammerness, et al. 2008). Several publications have offered guidance for efficacious and responsible management of pharmacological treatment for ADHD (Graham, et al. 2011; Newcorn 2011; Wigal 2009). Regarding cardiac safety, a recent and largest population-based cohort study indicated no elevated risk of serious cardiac problems being associated with stimulant treatment (Habel, et al. 2011). McCarthy, et al. 2009 provides evidence from the United Kingdom that practitioners may under-prescribe to teens and young adults.

                                                                                          • Graham, J., T. Banaschewski, J. Buitelaar, et al. 2011. European guidelines on managing adverse effects of medication for ADHD. European Child & Adolescent Psychiatry 20:17–37.

                                                                                            DOI: 10.1007/s00787-010-0140-6Save Citation »Export Citation »E-mail Citation »

                                                                                            An excellent summary of both severe and common side effects related to stimulant medication use—cardiac adverse events, suicide, stunted growth, sleep disturbance, tics, medication diversion and misuse, seizures, and psychotic symptoms—and advice regarding the management of such risks. Not explicitly focused on adults.

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                                                                                            • Habel, L. A., W. O. Cooper, C. M. Sox, et al. 2011. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. Journal of the American Medical Association 24:2673–2683.

                                                                                              DOI: 10.1001/jama.2011.1830Save Citation »Export Citation »E-mail Citation »

                                                                                              Responding to the disturbing adverse cardiac complications (and mortality) that occurred in individuals with ADHD taking psychostimulant medications in the early-to-mid 2000s, Habel and colleagues conducted this large retrospective, population-based cohort study and concluded that ADHD medications are not associated with an increased risk of serious cardiovascular events.

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                                                                                              • Hammerness, P., C. Surman, and K. Miller. 2008. Update on adult attention-deficit/hyperactivity disorder. Current Neurology and Neuroscience Reports 8:484–489.

                                                                                                DOI: 10.1007/s11910-008-0077-zSave Citation »Export Citation »E-mail Citation »

                                                                                                A brief primer on current medications for adult ADHD, treatment effects and toxicity related to dosage, treating comorbid ADHD, and abbreviated material to cardiac risk.

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                                                                                                • Hazell, P. 2007. Pharmacological management of attention-deficit hyperactivity disorder in adolescents: Special considerations. CNS Drugs 21:37–46.

                                                                                                  DOI: 10.2165/00023210-200721010-00004Save Citation »Export Citation »E-mail Citation »

                                                                                                  Along with other useful information, this resource provides advice regarding the use of extended-release versus standard-release medications to provide symptom reduction throughout the day, and also reviews the efficacy of common prescriptions for ADHD.

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                                                                                                  • McCarthy, S., P. Asherson, D. Coghill, et al. 2009. Attention-deficit hyperactivity disorder: Treatment discontinuation in adolescents and young adults. British Journal of Psychiatry 194:273–277.

                                                                                                    DOI: 10.1192/bjp.bp.107.045245Save Citation »Export Citation »E-mail Citation »

                                                                                                    Using a national general medical practice database, the authors demonstrate that the rate that prescriptions for ADHD are discontinued by physicians and associated professionals outpaces the developmental reduction of ADHD symptoms that has been consistently documented in other research.

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                                                                                                    • Newcorn, J. H. 2011. Risks and benefits of available treatments for adult ADHD. Journal of Clinical Psychiatry 72:e12.

                                                                                                      DOI: 10.4088/JCP.9066tx2cSave Citation »Export Citation »E-mail Citation »

                                                                                                      An up-to-date primer on adult ADHD medication; useful for medical and mental health practitioners as well as affected individuals interested in taking an active role in their health care.

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                                                                                                      • Pliszka, S., and AACAP Work Group on Quality Issues. 2007. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46:894–921.

                                                                                                        DOI: 10.1097/chi.0b013e318054e724Save Citation »Export Citation »E-mail Citation »

                                                                                                        The product of a workgroup of this national professional association for child and adolescent psychiatry, these parameters provide expert guidance regarding assessment and treatment in clinical settings.

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                                                                                                        • Wigal, S. B. 2009. Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults. CNS Drugs 23 (Suppl. 1): 21–31.

                                                                                                          DOI: 10.2165/00023210-200923000-00004Save Citation »Export Citation »E-mail Citation »

                                                                                                          This article focuses on recent evidence for efficacy and safety of stimulant and nonstimulant medications approved for use with ADHD clients. Brief discussion of comorbidities and combination pharmacotherapies is included.

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                                                                                                          Psychosocial

                                                                                                          Cognitive-behavioral therapy (CBT) is a psychosocial treatment approach for adults with ADHD. Though CBT has not received strong support as a treatment for ADHD in childhood (Antshel and Barkley 2008), this brief, structured, and short-term intervention has demonstrated moderate to large effect sizes in adult ADHD samples (Weiss, et al. 2008). CBT has garnered greater interest as a component of multimodal treatment because, although stimulant medications are effective for adult ADHD, many patients treated with medication alone are not sufficiently treated for various reasons (e.g., medication side effects or failure to respond to medication). In recent years, a series of randomized controlled trials have demonstrated treatment efficacy in both group therapy and individual therapy settings following a CBT-based format (e.g., Safren, et al. 2010; Solanto, et al. 2010)—see Knouse and Safren 2010 for a review. One important aspect of future research involves clarifying mechanisms of change in CBT for adults for ADHD to inform how CBT works for this population. There are various proposed mechanisms (Ramsay 2010), though little research has been conducted to date. Also, expanding CBT to incorporate additional treatments, either as complementary components to CBT or as stand-alone treatments, is emerging. For example, mindfulness training has a strong rationale to suggest that it would be an efficacious treatment for adults with ADHD since it involves training in attentional functioning in a population that is deficient in this area. Though it has been incorporated into largely CBT-based approaches (e.g., Hirvikoski, et al. 2011) and as a stand-alone treatment (Zylowska, et al. 2008), the efficacy of such an approach is currently an area that requires more well-designed studies before widespread dissemination in clinical practice.

                                                                                                          • Antshel, K. M., and R. Barkley. 2008. Psychosocial interventions in attention deficit hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America 17:421–437.

                                                                                                            DOI: 10.1016/j.chc.2007.11.005Save Citation »Export Citation »E-mail Citation »

                                                                                                            This review provides a brief summary of the history of ADHD psychosocial treatments for ADHD in children.

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                                                                                                            • Hirvikoski, T., E. Waaler, J. Alfredsson, et al. 2011. Reduced ADHD symptoms in adults with ADHD after structured skills training group: Results from a randomized controlled trial. Behaviour Research and Therapy 49:175–185.

                                                                                                              DOI: 10.1016/j.brat.2011.01.001Save Citation »Export Citation »E-mail Citation »

                                                                                                              This randomized controlled trial assessed the feasibility, acceptability, and efficacy of dialectical behavior therapy skills group for adults with ADHD, which includes training in mindfulness.

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                                                                                                              • Knouse, L. E., and S. A. Safren. 2010. Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder. Psychiatric Clinics of North America 33:497–509.

                                                                                                                DOI: 10.1016/j.psc.2010.04.001Save Citation »Export Citation »E-mail Citation »

                                                                                                                This review provides an overview of psychosocial treatment efficacy studies for adults with ADHD and proposes a conceptual model addressing how cognitive-behavioral therapy may be effective for this population.

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                                                                                                                • Ramsay, J. R. 2010. CBT for adult ADHD: Adaptations and hypothesized mechanisms of change. Journal of Cognitive Psychotherapy: An International Quarterly 24:37–45.

                                                                                                                  DOI: 10.1891/0889-8391.24.1.37Save Citation »Export Citation »E-mail Citation »

                                                                                                                  In an area of adult ADHD research that is in its infancy and is likely a topic that will be rapidly growing in years to come, this article addresses how cognitive-behavioral therapy has been applied to adults with ADHD and proposes potential mechanisms of change that may lead to therapeutic improvement.

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                                                                                                                  • Safren, S. A., S. Sprich, M. J. Mimiaga, et al. 2010. Cognitive behavioral therapy vs. relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. Journal of the American Medical Association 304:875–880.

                                                                                                                    DOI: 10.1001/jama.2010.1192Save Citation »Export Citation »E-mail Citation »

                                                                                                                    This study is a recent randomized controlled trial demonstrating the efficacy of a manualized cognitive-behavioral therapy for adults with ADHD against an active treatment condition.

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                                                                                                                    • Solanto, M. V., D. J. Marks, J. Wasserstein, et al. 2010. Efficacy of meta-cognitive therapy for adult ADHD. American Journal of Psychiatry 167:958–968.

                                                                                                                      DOI: 10.1176/appi.ajp.2009.09081123Save Citation »Export Citation »E-mail Citation »

                                                                                                                      This study is another recent randomized controlled trial demonstrating the efficacy of a manualized cognitive-behavioral therapy for adults with ADHD in a group format targeting time management, organization, and planning behaviors. This treatment extends a cognitive-behavior therapy approach to incorporate executive self-management skills deficient in ADHD as well.

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                                                                                                                      • Weiss, M., S. A. Safren, M. V. Solanto, et al. 2008. Research forum on psychological treatment of adults with ADHD. Journal of Attention Disorders 11:642–651.

                                                                                                                        DOI: 10.1177/1087054708315063Save Citation »Export Citation »E-mail Citation »

                                                                                                                        This article provides an expert review of the current status of the psychosocial treatment outcome literature for adults with ADHD and provides a summary of methodological challenges for future research.

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                                                                                                                        • Zylowska, L., D. L. Ackerman, M. H. Yang, et al. 2008. Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders 11: 737–746.

                                                                                                                          DOI: 10.1177/1087054707308502Save Citation »Export Citation »E-mail Citation »

                                                                                                                          This preliminary study assessed the feasibility of a group-based mindfulness training program for a group of adults and adolescents with ADHD. Though these results are promising, future treatment outcome research is required.

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                                                                                                                          Sex Differences

                                                                                                                          Prevalence estimates across the genders have varied substantially over time and developmental level, with early sex ratio estimates for clinical diagnoses in the 4 male: 1 female to 10:1 range, in childhood, and more recent estimates coming closer to 2:1. Epidemiological research in the general adult population, in the United States, has suggested a sex ratio under 2:1 (Kessler, et al. 2006). While the occurrence of ADHD that persists into adulthood, therefore, may be relatively evenly distributed between the sexes, the coverage in the existent literature regarding long-term outcomes is heavily biased toward male samples. Studies that have focused on women point to both similarities and differences in the adult manifestation of the ADHD across the sexes. Longitudinal research shows that, like males, females diagnosed in childhood tend to continue experiencing deleterious outcomes as adults (Babinski, et al. 2011), and other research has shown that comorbidity, cognitive, and other problems are experienced similarly in men and women diagnosed with ADHD (Biederman, et al. 2004; Biederman, et al. 1994). Further, the neuropsychological profile of affected men and women has been shown to include similar dysfunctions (Seidman, et al. 2005). However, recent research such as Fedele, et al. 2012 suggests that the manifestation of ADHD in women in their late teens to mid-twenties may be more severe than in male counterparts. Further research is clearly needed to better document the impact of ADHD on women; in the meantime, Quinn 2005 makes a logical case for particular care to be taken in the assessment and treatment of young women with ADHD, given that their most-common symptoms (i.e., inattention, versus hyperactivity-impulsivity) may lead to a significant lag time to accurate diagnosis and that mislabeling and misunderstandings earlier in life can exact a significant emotional toll.

                                                                                                                          • Babinski, D. E., W. E. Pelham Jr., B. S. G. Molina, et al. 2011. Late adolescent and young adult outcomes of girls diagnosed with ADHD in childhood: An exploratory investigation. Journal of Attention Disorders 15:204–214.

                                                                                                                            DOI: 10.1177/1087054710361586Save Citation »Export Citation »E-mail Citation »

                                                                                                                            Impairments associated with ADHD in this relatively small-scale longitudinal study of young women include more conflict with mothers, less involvement in romantic relationships, and more extensive depressive symptoms. Data from self- and parent-reports were included.

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                                                                                                                            • Biederman, J., S. V. Faraone, M. C. Monuteaux, M. Bober, and E. Cadogen. 2004. Gender effects on attention-deficit/hyperactivity disorder in adults, revisited. Biological Psychiatry 55:692–700.

                                                                                                                              DOI: 10.1016/j.biopsych.2003.12.003Save Citation »Export Citation »E-mail Citation »

                                                                                                                              The follow-up study to Biederman, et al. 1994, with very similar results, effectively replicating that there is little notable difference in functional impairments between male and female adults with ADHD.

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                                                                                                                              • Biederman, J., S. V. Faraone, T. Spencer, T. Wilens, E. Mick, and K. A. Lapey. 1994. Gender differences in a sample of adults with attention deficit hyperactivity disorder. Psychiatry Research 53:13–29.

                                                                                                                                DOI: 10.1016/0165-17819490092-2Save Citation »Export Citation »E-mail Citation »

                                                                                                                                A relatively early comparison of outcome differences between men and women with ADHD. The take-home finding: there are relatively few differences in long-term outcome between the sexes, but those with ADHD clearly differ—in the negative direction—from those without the diagnosis.

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                                                                                                                                • Fedele, D. A., E. K. Lefler, C. M. Hartung, and W. H. Canu. 2012. Sex differences in the manifestation of ADHD in emerging adults. Journal of Attention Disorders 16:109–117.

                                                                                                                                  DOI: 10.1177/1087054710374596Save Citation »Export Citation »E-mail Citation »

                                                                                                                                  This study of a large, multi-site college sample found that women in this developmental group report higher ADHD symptoms in both cardinal clusters, and that those with ADHD report higher degrees of impairment, as compared to their respective male counterparts.

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                                                                                                                                  • Kessler, R. C., L. Adler, R. O. Barkley, J. Biederman, C. K. Connors, and O. Demler. 2006. The prevalence and correlates of ADHD in the United States: Results from the National Comorbidity Survey Replication (NCS-R). American Journal of Psychiatry 163:716–723.

                                                                                                                                    DOI: 10.1176/appi.ajp.163.4.716Save Citation »Export Citation »E-mail Citation »

                                                                                                                                    Perhaps the current gold standard in terms of prevalence for ADHD in the general United States population, given the representative epidemiological sampling. Estimated prevalence of ADHD in adults is 4.4 percent––above 3 in women and above 5 percent in men.

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                                                                                                                                    • Quinn, P. O. 2005. Treating adolescent girls and women with ADHD: Gender-specific issues. Journal of Clinical Psychology: In Session 61:579–587.

                                                                                                                                      DOI: 10.1002/jclp.20121Save Citation »Export Citation »E-mail Citation »

                                                                                                                                      A review of potential pitfalls of sex-blind treatment of adults with ADHD, including consideration of hormonal fluctuation, differential comorbidities, and a detailed case study.

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                                                                                                                                      • Seidman, L. J., J. Biederman, M. C. Monuteaux, E. Valera, A. E. Doyle, and S. V. Faraone. 2005. Impact of gender and age on executive functioning: Do girls and boys with attention deficit hyperactivity disorder differ neuropsychologically in preteen and teenage years? Developmental Neuropsychology 27:79–105.

                                                                                                                                        DOI: 10.1207/s15326942dn2701_4Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        This study of neuropsychological performance in a clinical ADHD and nondiagnosed comparison group suggests, as with general impairment data (e.g., Biederman, et al. 2004), that there are few differences across sexes in adulthood.

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                                                                                                                                        Ethnicity and Culture

                                                                                                                                        The role of ethnicity and culture in the prevalence and presentation of ADHD, in both adults and children, has received relatively little attention in the published literature. However, recent years have seen an upsurge in related studies, particularly with a focus on deriving accurate, worldwide prevalence estimates of the disorder. Much of this work, however, has focused on child populations, and that which has focused on adulthood seems predominantly based on college student samples. An informative and representative example within that line of research, suggesting that culture indeed merits consideration in relation to the prevalence and even the construct of adult ADHD, is DuPaul, et al. 2001. In that study, across undergraduates from New Zealand, Italy, and the United States, there were marked differences in inattentive and hyperactive-impulsive factor structures and prevalence rates. However, Rohde, et al. 2005, a review of research conducted in Brazil, argues against a cultural construction of ADHD, citing evidence for prevalence, factor structure, familial transmission, and other facets of the disorder in the Brazilian population that parallel the trend in Western countries. Affected college students of even very different cultures, however, may be similarly impacted in their educational pursuits; Norvilitis, et al. 2009, for instance, shows inattention to be the core ADHD dysfunction that differentially predicts academic, social, and pre-professional impairment, across Chinese and American undergraduates. Ethnicity—and related minority status—within the general adult population of the United States may still be very important to take into consideration in clinical intervention, as detailed case studies of an African American (Waite and Ivey 2009) and a Hispanic woman (Waite and Ramsey 2010) aptly illustrate. Finally, when age-adjusted diagnostic criteria were employed, one investigation showed the combination of self- and parent-report of ADHD symptoms yielded similar overall prevalence in African-American and Caucasian undergraduates, but that the former was overrepresented in the Inattentive type and the latter in the Hyperactive-Impulsive type (despite parent-only ratings of opposite bias; Lee, et al. 2008).

                                                                                                                                        • DuPaul, G. J., E. A. Schaughency, L. L. Weyandt, et al. 2001. Self-report of ADHD symptoms in university students: Cross-gender and cross-national prevalence. Journal of Learning Disabilities 34:370–379.

                                                                                                                                          DOI: 10.1177/002221940103400412Save Citation »Export Citation »E-mail Citation »

                                                                                                                                          Examined factor structure and prevalence of ADHD across representative universities in Italy, the United States, and New Zealand, using standard DSM-IV-TR criteria and age-appropriate criteria, as well. Highest full-criteria prevalence was noted in men in New Zealand (8.1 percent), and the lowest in Italian women (0 percent).

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                                                                                                                                          • Lee, D. H., T. Oakland, G. Jackson, and J. Glutting. 2008. Estimated prevalence of attention deficit/hyperactivity disorder among college freshmen: Gender, race, and rater effects. Journal of Learning Disabilities 41:371–384.

                                                                                                                                            DOI: 10.1177/0022219407311748Save Citation »Export Citation »E-mail Citation »

                                                                                                                                            Related to this section, Lee and colleagues examine differences and similarities in prevalence between African American and Caucasian students; while overall there were no differences on ADHD symptomatology, a significantly higher proportion of African American students reported above-clinical-threshold symptoms.

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                                                                                                                                            • Norvilitis, J. M., L. Sun, and J. Zhang. 2009. ADHD symptomatology and adjustment to college in China and the United States. Journal of Learning Disabilities 43:86–94.

                                                                                                                                              DOI: 10.1177/0022219409345012Save Citation »Export Citation »E-mail Citation »

                                                                                                                                              This study investigated whether ADHD symptoms differentially affected the adjustment of undergraduates in China and the United States; the general findings were that ADHD in both cultures was associated with broad impairment in the college setting, and that inattentive symptoms were particularly predictive of difficulties.

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                                                                                                                                              • Rohde, L. A., C. Szobot, G. Polanczyk, M. Schmitz, S. Martins, and S. Tramontina. 2005. Attention-deficit/hyperactivity disorder in a diverse culture: Do research and clinical findings support the notion of a cultural construct for the disorder? Biological Psychiatry 57:1436–1441.

                                                                                                                                                DOI: 10.1016/j.biopsych.2005.01.042Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                The authors systematically examine whether the reports on prevalence, etiology, construct, or treatment of ADHD vary between the Brazilian ADHD literature and that of “developed” countries. Overall, no notable differences emerged, contradicting the theory that ADHD is a cultural construct of economically advantaged countries.

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                                                                                                                                                • Waite, R., and N. Ivey. 2009. Unveiling the mystery about adult ADHD: One woman’s journey. Issues in Mental Health Nursing 30: 547–553.

                                                                                                                                                  DOI: 10.1080/01612840902741989Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                  A provocative developmental, biographical account of the pre- and post-diagnosis experience of an African American woman. Particularly informative regarding impact of late diagnosis of ADHD on adjustment throughout life.

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                                                                                                                                                  • Waite, R., and J. R. Ramsey. 2010. Cultural proficiency: A Hispanic woman with ADHD—A case example. Journal of Attention Disorders 13:424–432.

                                                                                                                                                    DOI: 10.1177/1087054709332393Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                    In a call for development of cultural competence in practice and research, the authors present the case of a young Hispanic woman with ADHD. Family of origin and varying ethnicity, delay in diagnosis and related functional and emotional challenges, and developmental stages of competence in therapy are among issues covered.

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                                                                                                                                                    Comorbidity

                                                                                                                                                    Comorbidity, including internalizing disorders, externalizing disorders, personality disorders, and substance use disorders, is common in adult ADHD (Kessler, et al. 2006; Miller, et al. 2007). Among adults diagnosed with the disorder, comorbidity is more of the norm than the exception with 65 percent to 89 percent qualifying for one or more additional psychiatric diagnoses (Fischer, et al. 2007; McGough, et al. 2005; Sobanski 2006). In addition to higher rates of comorbidity, ADHD in adulthood is associated with earlier onset of major depression, dysthymia, oppositional defiant disorder, and conduct disorder (McGough, et al. 2005). One notable finding is that childhood ADHD is predictive of suicide attempts later on in life. In particular, female sex, maternal depression, and concurrent symptoms at four to six years of age predicted which children with ADHD were at greatest risk (Chronis-Tuscano, et al. 2010). Chapter- and book-length reviews, such as Barkley, et al. 2008 and Brown 2009, report on specific patterns of comorbidity.

                                                                                                                                                    • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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                                                                                                                                                      A book-length overview covering a variety of current topics on ADHD in adulthood; an all-around excellent resource. The authors provide a detailed summary of comorbidity among adults with ADHD.

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                                                                                                                                                      • Brown, T. E. 2009. ADHD comorbidities: Handbook for ADHD complications in children and adults. Washington, DC: American Psychiatric Press.

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                                                                                                                                                        This reference provides a comprehensive and authoritative review of comorbid conditions in ADHD across the lifespan.

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                                                                                                                                                        • Chronis-Tuscano, A., B. S. Molina, W. E. Pelham, et al. 2010. Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Archives of General Psychiatry 67:1044–1051.

                                                                                                                                                          DOI: 10.1001/archgenpsychiatry.2010.127Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                          This longitudinal study assessed the outcome of young children with ADHD with a particular focus on suicidal behavior at multiple developmental time points.

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                                                                                                                                                          • Fischer, A. G., C. H. Bau, E. H. Grevet, et al. 2007. The role of comorbid major depressive disorder in the clinical presentation of adult ADHD. Journal of Psychiatric Research 41.12: 991–996.

                                                                                                                                                            DOI: 10.1016/j.jpsychires.2006.09.008Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                            This study evaluated patterns of major depressive disorder in adults with ADHD and clinical features of this comorbid subgroup.

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                                                                                                                                                            • Kessler, R. C., L. Adler, R. Barkley, et al. 2006. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163:716–723.

                                                                                                                                                              DOI: 10.1176/appi.ajp.163.4.716Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                              This study provides prevalence estimates and correlates of adult ADHD in the United States based on the National Comorbidity Survey Replication data, including patterns of comorbidity.

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                                                                                                                                                              • McGough, J. J., S. L. Smalley, J. T. McCracken, et al. 2005. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: Findings from multiplex families. American Journal of Psychiatry 162:1621–1627.

                                                                                                                                                                DOI: 10.1176/appi.ajp.162.9.1621Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                This large-scale study, utilizing a pool of diagnosed and nondiagnosed parents of children with ADHD; the most salient finding was that fully 87 percent of those parents with ADHD had at least one psychiatric comorbidity.

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                                                                                                                                                                • Miller, T. W., J. T. Nigg, and S. V. Faraone. 2007. Axis I and II comorbidity in adults with ADHD. Journal of Abnormal Psychology 116:519–528.

                                                                                                                                                                  DOI: 10.1037/0021-843X.116.3.519Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                  This study assessed patterns of psychiatric comorbidity in adults with ADHD, including Axis I and Axis II disorders, including patterns of comorbidity in different ADHD subtypes. Incorporating a thorough analysis of Axis II disorders is novel and provides clear evidence that this domain is worthy of future inquiry.

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                                                                                                                                                                  • Sobanski, E. 2006. Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD). European Archives of Psychiatry and Clinical Neuroscience 256 (Suppl. 1): i26–31.

                                                                                                                                                                    DOI: 10.1007/s00406-006-1004-4Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                    This article provides a concise overview of psychiatric comorbidity patterns in ADHD across the lifespan, including a discussion of clinical implications.

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                                                                                                                                                                    Psychiatric Disorders

                                                                                                                                                                    Mood disorders such as major depressive disorder and dysthymia are comorbid in approximately 16 percent to 31 percent of adult ADHD samples (reviewed in Barkley, et al. 2008). Anxiety disorders are comorbid in up to 47 percent of adults diagnosed with ADHD (Kessler, et al. 2006). Though there is some association between both disorders, other studies have not found any significant patterns of comorbidity (Murphy, et al. 2002; Roy-Byrne, et al. 1997). Rates of conduct disorder (17 percent to 25 percent) and oppositional defiant disorder (24 percent to 35 percent) are higher in clinic-referred adults diagnosed with ADHD either currently or over the course of development. Among hyperactive children followed longitudinally who meet criteria for ADHD in adulthood, these rates are doubled or tripled (reviewed in Barkley, et al. 2008). Higher rates of Cluster B (particularly borderline and antisocial personality disorders) and Cluster C (particularly avoidant personality disorder) personality disorders are typically indicated in adult ADHD samples (Miller, et al. 2008; Miller, et al. 2007).

                                                                                                                                                                    • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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                                                                                                                                                                      A book-length overview covering a variety of current topics on ADHD in adulthood; an all-around excellent resource. The authors provide a detailed summary of psychiatric comorbidity among adults with ADHD.

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                                                                                                                                                                      • Kessler, R. C., L. Adler, R. Barkley, et al. 2006. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163:716–723.

                                                                                                                                                                        DOI: 10.1176/appi.ajp.163.4.716Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                        This study provides prevalence estimates and correlates of adult ADHD in the United States based on the National Comorbidity Survey Replication, including patterns of comorbidity.

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                                                                                                                                                                        • Miller, C. J., J. D. Flory, S. R. Miller, S. C. Harty, J. H. Newcorn, and J. M. Halperin. 2008. Childhood attention-deficit/hyperactivity disorder and the emergence of personality disorders in adolescence: A prospective follow-up study. Journal of Clinical Psychiatry 69:1477–1484.

                                                                                                                                                                          DOI: 10.4088/JCP.v69n0916Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                          This longitudinal study demonstrated the early emergence of Axis II personality disorder comorbidity in participants between sixteen and twenty-six years old with ADHD diagnosed in childhood.

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                                                                                                                                                                          • Miller, T. W., J. T. Nigg, and S. V. Faraone. 2007. Axis I and II comorbidity in adults with ADHD. Journal of Abnormal Psychology 116:519–528.

                                                                                                                                                                            DOI: 10.1037/0021-843X.116.3.519Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                            This study assessed patterns of psychiatric comorbidity in adults with ADHD, including Axis I and Axis II disorders, including patterns of comorbidity in different ADHD subtypes.

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                                                                                                                                                                            • Murphy, K. R., R. A. Barkley, and T. Bush. 2002. Young adults with ADHD: Subtype differences in comorbidity, educational, and clinical history. Journal of Nervous and Mental Disease 190:147–157.

                                                                                                                                                                              DOI: 10.1097/00005053-200203000-00003Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                              This study assessed comorbidity patterns among young adults with ADHD and addressed ADHD subtyping differences.

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                                                                                                                                                                              • Roy-Byrne, P., L. Scheele, J. Brinkley, et al. 1997. Adult attention-deficit hyperactivity disorder: Assessment guidelines based on clinical presentation to a specialty clinic. Comprehensive Psychiatry 38:133–140.

                                                                                                                                                                                DOI: 10.1016/S0010-440X(97)90065-1Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                This study assessed patterns of psychiatric comorbidity in adults diagnosed with ADHD against a subclinical ADHD group and control group. Additional analyses assessed the clinical utility of rating scales, laboratory measures, and lifetime history characteristics that differentiate adults with and without ADHD.

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                                                                                                                                                                                Substance Use Disorders

                                                                                                                                                                                Substance use disorder (SUD) comorbidity is common among adults with ADHD with odds ratio rates ranging from 1.5 to 7.9 (Kessler, et al. 2006). Both longitudinal (Biederman, et al. 2006; Molina and Pelham 2003) and cross-sectional studies (Szobot, et al. 2007) support that SUD comorbidity is frequent in ADHD. In a recent meta-analytic review, children with ADHD were more likely to develop disorders of abuse/dependence for nicotine, alcohol, marijuana, cocaine, and other substances (Lee, et al. 2011). Several reviews provide a thorough overview of the relationship between ADHD in childhood and the development of substance use (e.g., Molina 2011). The comorbidity between ADHD and cigarette smoking is a particularly robust relationship (Glass and Flory 2010, McClernon and Kollins 2008).

                                                                                                                                                                                • Biederman, J., M. C. Monuteaux, E. Mick, et al. 2006. Young adult outcome of attention deficit hyperactivity disorder: A controlled 10-year follow-up study. Psychological Medicine 36:167–179.

                                                                                                                                                                                  DOI: 10.1017/S0033291705006410Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                  This seminal longitudinal study assessed patterns of comorbidity in an ADHD sample, including substance use outcomes.

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                                                                                                                                                                                  • Glass, K., and K. Flory. 2010. Why does ADHD confer risk for cigarette smoking? A review of psychosocial mechanisms. Clinical Child and Family Psychology Review 13:291–313.

                                                                                                                                                                                    DOI: 10.1007/s10567-010-0070-3Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                    This review provides an overview of patterns of comorbidity between ADHD and cigarette smoking, including potential psychosocial mechanisms that account for this relationship.

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                                                                                                                                                                                    • Kessler, R. C., L. Adler, R. Barkley, et al. 2006. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163:716–723.

                                                                                                                                                                                      DOI: 10.1176/appi.ajp.163.4.716Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                      This study provides prevalence estimate and correlates of adult ADHD in the United States based on the National Comorbidity Survey Replication, including patterns of substance use.

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                                                                                                                                                                                      • Lee, S. S., K. L. Humphreys, K. Flory, R. Liu, and K. Glass. 2011. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review. Clinical Psychology Review 31:328–341.

                                                                                                                                                                                        DOI: 10.1016/j.cpr.2011.01.006Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                        This paper examines substance use outcomes. It also meta-analyzes longitudinal studies also examining this association.

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                                                                                                                                                                                        • McClernon, F. J., and S. H. Kollins. 2008. ADHD and smoking: From genes to brain to behavior. Annals of the New York Academy of Sciences 1141:131–147.

                                                                                                                                                                                          DOI: 10.1196/annals.1441.016Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                          This review provides an overview of the relationship between ADHD and smoking, including an emphasis on underlying neuropharmacological mechanisms that account for this comorbidity.

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                                                                                                                                                                                          • Molina, B. S. 2011. Delinquency and substance use in ADHD: Adolescent and young adult outcomes in developmental context. In Treating attention deficit hyperactivity disorder: Assessment and intervention in developmental context. Edited by S. W. Evans and B. Hoza. New York: Civic Research Institute.

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                                                                                                                                                                                            This book chapter provides an overview of the history and synthesizes current findings concerning the relationship between ADHD and patterns of substance use.

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                                                                                                                                                                                            • Molina, B. S., and W. E. Pelham Jr. 2003. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. Journal of Abnormal Psychology 112:497–507.

                                                                                                                                                                                              DOI: 10.1037/0021-843X.112.3.497Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                              This seminal and highly cited longitudinal study prospectively evaluated risk for substance use in children with and without ADHD while considering the role of externalizing disorder comorbidity.

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                                                                                                                                                                                              • Szobot, C. M., L. A. Rohde, O. Bukstein, et al. 2007. Is attention-deficit/hyperactivity disorder associated with illicit substance use disorders in male adolescents? A community-based case-control study. Addiction 102:1122–1130.

                                                                                                                                                                                                DOI: 10.1111/j.1360-0443.2007.01850.xSave Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                One primary aim of this study was to assess for confounding variables that could account for elevated odds ratios for illicit substance use in adolescents and young adults with ADHD, including the role of conduct disorder, and demonstrated that its relationship with ADHD is quite robust.

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                                                                                                                                                                                                Outcomes

                                                                                                                                                                                                A general criterion for ADHD diagnosis is that impairment due to its associated symptoms must be present in at least two domains of life functioning. As such, it is no surprise that adults with ADHD often experience a broad array of difficulties in their day-to-day activities. The negative impact of adult ADHD is perhaps most salient in the social, vocational, educational, and personal safety domains, as outlined below.

                                                                                                                                                                                                Social

                                                                                                                                                                                                Social maladjustment is a common problem for children diagnosed with ADHD, and research has increasingly documented that this trend continues into adulthood. Studies have shown that individuals with adult-persistent ADHD were substantially more likely to have experienced divorce and also to be dissatisfied with their social lives (Biederman, et al. 2006), to report deficient social skills (Shaw-Zirt, et al. 2005), and, among young women, to have more conflict in familial relations and fewer overall romantic partners (Babinski, et al. 2011). Interestingly, some evidence suggests that for young men, unlike in childhood, being of the Inattentive ADHD type may be more deleterious than having elevated hyperactivity-impulsivity, especially in the development and initiation of heterosexual romantic relationships (Canu and Carlson 2003, Canu and Carlson 2007). Of emerging concern is the risk for interpersonal violence in couples with an ADHD partner; particularly in the presence of comorbid conduct disorder, ADHD has been shown to elevate the odds for physically and emotionally aggressive acts in the context of romantic relationships (Fang, et al. 2010).

                                                                                                                                                                                                • Babinski, D. E., W. E. Pelham Jr., B. S. G. Molina, et al. 2011. Late adolescent and young adult outcomes of girls diagnosed with ADHD in childhood: An exploratory investigation. Journal of Attention Disorders 15:204–214.

                                                                                                                                                                                                  DOI: 10.1177/1087054710361586Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                  Social dysfunction was prominent in the young women followed in this longitudinal study, including conflict with mothers and less involvement in romantic relationships. Data from self- and parent-reports were included.

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                                                                                                                                                                                                  • Biederman, J., S. V. Faraone, T. J. Spencer, E. Mick, M. C. Monuteaux, and M. Aleardi. 2006. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1,001 adults in the community. Journal of Clinical Psychiatry 67:524–540.

                                                                                                                                                                                                    DOI: 10.4088/JCP.v67n0403Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                    A large-scale cross-sectional study of a random sample of adults in the United States. Regarding social dysfunction, a majority of adults with ADHD reported some measure of dissatisfaction with family life, romantic relationships, and general social life, which was not the case in nondiagnosed peers.

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                                                                                                                                                                                                    • Canu, W. H., and C. L. Carlson. 2003. Differences in heterosocial behavior and outcomes of ADHD-symptomatic subtypes in a college sample. Journal of Attention Disorders 6:123–133.

                                                                                                                                                                                                      DOI: 10.1177/108705470300600304Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                      A relatively small-scale study of college males conforming to the Inattentive and Combined ADHD types (and nonsymptomatic peers), focusing on romantic behaviors and outcomes. Of particular note are results from an interaction with confederate females and utilized third-party raters, who consistently perceived the participants with ADHD Inattentive type most negatively.

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                                                                                                                                                                                                      • Canu, W. H., and C. L. Carlson. 2007. Rejection sensitivity and social outcomes of young men with ADHD. Journal of Attention Disorders 10:261–275.

                                                                                                                                                                                                        DOI: 10.1177/1087054706288106Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                        Utilizes a sample of university and community college students; contrary to expectations, men with ADHD do not report higher rejection sensitivity, possibly due to positive illusory bias. Of interest are differences between the ADHD types; those of Inattentive type appear more maladjusted, yet those with Combined type have lowest self-esteem.

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                                                                                                                                                                                                        • Fang, X., G. M. Massetti, L. Ouyang, S. D. Grosse, and J. A. Mercy. 2010. Attention-deficit/hyperactivity disorder, conduct disorder, and young adult intimate partner violence. Archives of General Psychiatry 67:1179–1186.

                                                                                                                                                                                                          DOI: 10.1001/archgenpsychiatry.2010.137Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                          National Longitudinal Study of Adolescent Health data is used to examine the association between ADHD and conduct disorder (CD) and the perpetration of interpersonal violence (IPV). CD predicted two types of IPV—resulting and not resulting in injury to one’s partner—whereas ADHD was associated only with IPV with injury.

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                                                                                                                                                                                                          • Shaw-Zirt, B., L. Popali-Lehane, W. Chaplin, and A. Bergman. 2005. Adjustment, social skills, and self-esteem in college students with symptoms of ADHD. Journal of Attention Disorders 8:109–120.

                                                                                                                                                                                                            DOI: 10.1177/1087054705277775Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                            Two small, matched samples of undergraduates with and without significant ADHD symptoms are compared; those with ADHD reported lower self-esteem and comparatively weak social skills.

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                                                                                                                                                                                                            Vocational

                                                                                                                                                                                                            Adult ADHD is unfortunately also associated with maladjustment in the vocational domain. Professionally, individuals with ADHD reported less success at work tasks, greater unemployment and frequency of job transitions, and fell into the lowest income bracket with twice the frequency of nondiagnosed peers in one community sample (in 2003, $25,000; Biederman, et al. 2006). Kessler, et al. 2008 estimated in one large manufacturing firm that the human capital costs associated with ADHD—in terms of compromised efficiency and sick days due to the syndrome—was upward of $4,000 per affected worker. While these and other studies implicitly suggest that professional choice and workplace fit may be of significantly greater importance to individuals with ADHD, as compared to nondiagnosed peers, there is little evidence to suggest that adults with ADHD are effectively selective in related decision making. For instance, an exploratory study in college students indicated that young men with ADHD Inattentive type discount the importance of safety in making choices about career direction, which seems to run directly into a specific vulnerability of the disorder (see Safety; Canu 2007). Limited guidelines exist for the career counseling of adults with ADHD; the reader with this particular interest is encouraged to consult Nadeau 2005 and Ramsay 2010. Of course, some adults’ vocation is child rearing, and, unfortunately, research to date suggests that individuals with ADHD face particular challenges in this role as well. For instance, mothers with ADHD have been shown to be less consistent in their disciplinary behavior, employ poorer-monitoring of child behavior, and may generate poorer-quality solutions to child-oriented problems, as compared to unaffected mothers (Murray and Johnston 2006). Further, both maternal and paternal ADHD tend to be associated with lower structure and order within the home, which plays an exacerbating role in ineffective parenting practices (Mokrova, et al. 2010). Finally, a recent review outlines how deficits in ADHD may lead to impairment in the common vocation of parenting (e.g., effective behavioral control and emotional responsiveness), which in turn negatively impacts the outcomes of offspring (Johnston, et al. 2012).

                                                                                                                                                                                                            • Biederman, J., S. V. Faraone, T. J. Spencer, E. Mick, M. C. Monuteaux, and M. Aleardi. 2006. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1,001 adults in the community. Journal of Clinical Psychiatry 67:524–540.

                                                                                                                                                                                                              DOI: 10.4088/JCP.v67n0403Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                              A large-scale cross-sectional study of a random sample of adults in the United States. Regarding vocational dysfunction, adults with ADHD reported higher unemployment, underemployment (i.e., part-time only), and job turnover, as compared to nondiagnosed peers. The ADHD adults also often endorsed leaving at least one job due to their symptoms.

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                                                                                                                                                                                                              • Canu, W. H. 2007. Vocational safety preference of college males with and without attention-deficit/hyperactivity disorder: An exploratory study. Journal of College Counseling 10:54–63.

                                                                                                                                                                                                                DOI: 10.1002/j.2161-1882.2007.tb00006.xSave Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                An exploratory study of undergraduate students with symptoms of ADHD conforming to the Combined and Inattentive types and a nonsignificantly symptomatic group. The primary finding was that those in the Inattentive type placed less importance on safety considerations in career planning.

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                                                                                                                                                                                                                • Johnston, C., E. J. Mash, N. Miller, and J. E. Ninowski. 2012. Parenting in adults with attention-deficit/hyperactivity disorder (ADHD). Clinical Psychology Review 32:215–228.

                                                                                                                                                                                                                  DOI: 10.1016/j.cpr.2012.01.007Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                  This article provides a review of the literature regarding parenting in adults with ADHD and proposes a model of linking core deficits in parent ADHD, parental impairments, and child outcomes while also considering the role of potential moderators.

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                                                                                                                                                                                                                  • Kessler, R. C., M. Lane, P. E. Stang, and D. L. Van Brunt. 2008. The prevalence and workplace costs of adult attention deficit hyperactivity disorder in a large manufacturing firm. Psychological Medicine 39:137–147.

                                                                                                                                                                                                                    DOI: 10.1017/S0033291708003309Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                    In a large sample of employed adults, ADHD is shown to be associated with a 4 to 5 percent reduction in work efficiency and double the chance of “sick absence” and accidents on the job. Such trends are monetized in analyses, with an annual estimated cost of ADHD reaching higher than $4,000 per affected worker.

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                                                                                                                                                                                                                    • Mokrova, I., M. O’Brien, S. Calkins, and S. Keane. 2010. Parental ADHD symptomatology and ineffective parenting: The connecting link of home chaos. Parenting: Science and Practice 10:119–135.

                                                                                                                                                                                                                      DOI: 10.1080/15295190903212844Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                      An interesting study, demonstrating that for both mothers and fathers with ADHD it may be home chaos (e.g., lack of consistent structure and order) that mediates associated poor parenting (e.g., nonsupportive responses toward children).

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                                                                                                                                                                                                                      • Murray, C., and C. Johnston. 2006. Parenting in mothers with and without attention-deficit/hyperactivity disorder. Journal of Abnormal Psychology 115:52–61.

                                                                                                                                                                                                                        DOI: 10.1037/0021-843X.115.1.52Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                        The study documents negative parenting in mothers with ADHD, as compared to nondiagnosed mothers. The former were less consistent in their discipline, monitoring the behavior of their children, and engaging in effective child-related problem solving.

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                                                                                                                                                                                                                        • Nadeau, K. G. 2005. Career choices and workplace challenges for individuals with ADHD. Journal of Clinical Psychology: In Session 61:549–563.

                                                                                                                                                                                                                          DOI: 10.1002/jclp.20119Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                          Offers practical guidance for the practitioner who works with adults with ADHD, specifically relating to assessment and intervention for vocational concerns.

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                                                                                                                                                                                                                          • Ramsay, R. 2010. Career counseling and workplace support. In Nonmedication treatments for adult ADHD: Evaluating impact on daily functioning and well-being. Edited by J. Ramsay, 77–90. Washington, DC: American Psychological Association.

                                                                                                                                                                                                                            DOI: 10.1037/12056-004Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                            This chapter reviews the difficulties that face individuals with ADHD in work settings, examines existent research in this domain, and provides related suggestions for intervention to maximize success.

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                                                                                                                                                                                                                            Educational

                                                                                                                                                                                                                            One of the driving factors for much of the vocational underachievement that is often associated with ADHD (described in Outcomes: Vocational) may be ongoing difficulty in educational pursuits. In large samples in the United States and France, individuals with ADHD in young-to-middle adulthood report worse academic performance across subjects, more frequent grade retention, and lesser overall educational attainment (e.g., completion of secondary or higher learning degrees), among other negative outcomes as compared to nondiagnosed peers (Biederman, et al. 2006; Galera, et al. 2009). Academic concerns in college appear to be more related to current degree of inattention than other ADHD-related symptomatology (Rabiner, et al. 2008), as does impairment related to effective study skills (Norwalk, et al. 2009), although it is of note that no set of concerns or skill deficiencies in this domain appear to specifically differentiate students with ADHD from those without (Lewandowski, et al. 2008). However, even when compared to students with other learning disabilities, the study Reaser, et al. 2007 suggests that college students with ADHD have deficits in time management, attending to task (i.e., selecting main ideas from reading content and general concentration), and effective test-taking strategies. Some data exists to suggest that low academic self-esteem may play a mediating role in poor adjustment in the college setting (Shaw-Zirt, et al. 2005), and it seems possible that the negative bias that college students hold toward peers with ADHD (Canu, et al. 2008) may lead to even further self-handicapping in that setting. Further research regarding the specific academic deficits related to ADHD in adulthood and related efficacious interventions is indicated.

                                                                                                                                                                                                                            • Biederman, J., S. V. Faraone, T. J. Spencer, E. Mick, M. C. Monuteaux, and M. Aleardi. 2006. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1,001 adults in the community. Journal of Clinical Psychiatry 67:524–540.

                                                                                                                                                                                                                              DOI: 10.4088/JCP.v67n0403Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                              A large-scale cross-sectional study of a random sample of adults in the United States. Regarding educational outcomes, adults with ADHD reported more frequently failing to finish high school, less frequently obtaining a college degree, receiving generally lower grades, and endorsing lower academic self-esteem, as compared to nondiagnosed counterparts.

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                                                                                                                                                                                                                              • Canu, W. H., M. L. Newman, T. L. Morrow, and D. L. W. Pope. 2008. Social appraisal of adults with ADHD: Stigma and influences of the beholder’s big five personality traits. Journal of Attention Disorders 11:700–710.

                                                                                                                                                                                                                                DOI: 10.1177/1087054707305090Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                This study utilizes vignettes of fictional peers as prompts for evaluating others with ADHD, minor medical concerns, and no discernible weaknesses; college students more negatively evaluate those described as having ADHD across a range of possible relationships.

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                                                                                                                                                                                                                                • Galera, C., M. Melchior, J. F. Chastang, M. P. Bouvard, and E. Fombonne. 2009. Childhood and adolescent hyperactivity-inattention symptoms and academic achievement 8 years later: The GAZEL Youth study. Psychological Medicine 39:1895–1906.

                                                                                                                                                                                                                                  DOI: 10.1017/S0033291709005510Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                  A large-scale longitudinal study, ongoing in France; overall, young adults with ADHD were shown to have very much increased odds of negative academic outcomes, including grade retention, failure to graduate from secondary school, obtaining lower-status diplomas, and generally lower grades.

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                                                                                                                                                                                                                                  • Lewandowski, L. J., B. J. Lovett, R. S. Codding, and M. Gordon. 2008. Symptoms of ADHD and academic concerns in college students with and without ADHD diagnoses. Journal of Attention Disorders 12:156–161.

                                                                                                                                                                                                                                    DOI: 10.1177/10870547073110882Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                    Specifically examines the association between ADHD symptoms and academic complaints in college; those undergraduates with ADHD diagnoses reported decidedly more academic difficulties than nondiagnosed peers, but such reports did not conform to a consistent pattern of dysfunction that could be diagnostic of ADHD.

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                                                                                                                                                                                                                                    • Norwalk, K., J. M. Norvilitis, and M. G. MacLean. 2009. ADHD symptomatology and its relationship to factors associated with college adjustment. Journal of Attention Disorders 13:251–258.

                                                                                                                                                                                                                                      DOI: 10.1177/1087054708320441Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                      In a college sample, higher levels of ADHD symptomatology were shown to be associated with poorer academic adjustment, and lower self-efficacy regarding career choice and study skills, over and above the influence of co-existing symptoms of depression. Notably, it was inattentive symptoms that drove these associations.

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                                                                                                                                                                                                                                      • Rabiner, D. L., A. D. Anastopoulos, J. Costello, R. H. Hoyle, and H. S. Swartzwelder. 2008. Adjustment to college in students with ADHD. Journal of Attention Disorders 11:689–699.

                                                                                                                                                                                                                                        DOI: 10.1177/1087054707305106Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                        When comparing an ADHD-diagnosed group to nondiagnosed peers drawn from a large multi-site sample of undergraduates, inattentive symptoms in the ADHD group were associated with poorer academic adjustment, an effect that was not moderated by medication status.

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                                                                                                                                                                                                                                        • Reaser, A., F. Prevatt, Y. Petscher, and B. Proctor. 2007. The learning and study strategies of college students with ADHD. Psychology in the Schools 44:627–638.

                                                                                                                                                                                                                                          DOI: 10.1002/pits.20252Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                          An interesting cross-sectional study, particularly given the inclusion of a clinical comparison group (students with learning disabilities). Group comparisons show those with ADHD to have particular difficulty with time management, attending to academic tasks, and employing effective test-taking strategies.

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                                                                                                                                                                                                                                          • Shaw-Zirt, B., L. Popali-Lehane, W. Chaplin, and A. Bergman. 2005. Adjustment, social skills, and self-esteem in college students with symptoms of ADHD. Journal of Attention Disorders 8:109–120.

                                                                                                                                                                                                                                            DOI: 10.1177/1087054705277775Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                            Two small, matched samples of undergraduates with and without significant ADHD symptoms are compared; of particular interest here is data supporting the suggestion that low self-esteem may be a moderating or mediating variable to consider in future research examining ADHD-related academic dysfunction in adults.

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                                                                                                                                                                                                                                            Safety

                                                                                                                                                                                                                                            The extant literature suggests that adults with ADHD, as in children with the disorder, engage in unsafe behaviors and experience personal harm due to the same at higher rates than nondiagnosed counterparts. Research has documented this trend via driving, sexual relations, and accidental injury data. Adult drivers with ADHD tend to report and demonstrate (in driving simulator tasks) less safe-driving behaviors (Knouse, et al. 2005). Not surprisingly, then, they have been shown to have significantly higher rates of traffic violations, vehicular crashes of substantial severity (as indexed by repair cost >$4,000 in 2001), road rage, and license suspensions as compared to nondiagnosed peers; disinhibition may be a specific mediator of accident frequency in the ADHD group (Barkley and Cox 2007). Further, stimulant medication may potentially improve driving performance (Barkley and Cox 2007). Evidence points to the hyperactivity-impulsivity symptom cluster being most influential in predicting traffic tickets and vehicular accidents (Thompson, et al. 2007). In terms of risky sexual behavior, results from the Pittsburgh Area Longitudinal Study indicate that ADHD, in young men, at least, is associated with higher odds ratios for increased casual sex, infrequent condom use, and more than four sexual partners, in the absence of comorbid externalizing disorders (the presence of which added risk for unplanned pregnancies; Flory, et al. 2006). In another longitudinal study assessing persistence of ADHD into adolescence and adulthood, ADHD was associated with a ten-fold increased risk for teenage pregnancy and four-fold risk for sexually transmitted diseases (Barkley, et al. 2008). Diminished ability to assess risk of injury was similarly demonstrated in another study of adolescents with ADHD and nondiagnosed peers engaging in a virtual-reality road-crossing task (Clancy, et al. 2006). Finally, analysis of corporate health filings suggest that adults with ADHD are more than twice as likely as those without to present for accidental injury treatment, and that their injuries tend to be more severe (as indicated by higher cost of intervention; Swensen, et al. 2004).

                                                                                                                                                                                                                                            • Barkley, R. A., and D. Cox. 2007. A review of driving risks and impairments associated with attention-deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. Journal of Safety Research 38:113–128.

                                                                                                                                                                                                                                              DOI: 10.1016/j.jsr.2006.09.004Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                              This article provides a thorough review of the literature pertaining to driving performance in ADHD and how stimulant medication may minimize driving risks with the disorder.

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                                                                                                                                                                                                                                              • Barkley, R. A., K. R. Murphy, and M. Fischer. 2008. ADHD in adults: What the science says. New York: Guilford.

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                                                                                                                                                                                                                                                A book-length overview covering a variety of current topics on ADHD in adulthood; an all-around excellent resource. The authors provide a detailed summary of seminal longitudinal studies assessing persistence of ADHD in adulthood.

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                                                                                                                                                                                                                                                • Clancy, T. A., J. J. Rucklidge, and D. Owen. 2006. Road-crossing safety in virtual reality: A comparison of adolescents with and without ADHD. Journal of Clinical Child and Adolescent Psychology 35:203–215.

                                                                                                                                                                                                                                                  DOI: 10.1207/s15374424jccp3502_4Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                  The authors creatively employed virtual reality (VR) technology to examine risk-taking in older adolescents with ADHD, here measured via VR road-crossing behavior. ADHD participants, all off medication at the time of the experiment, displayed several indices of less safe behavior and decision making in this context.

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                                                                                                                                                                                                                                                  • Flory, K., B. G. Molina, W. Pelham Jr., E. Gnagy, and B. Smith. 2006. Childhood ADHD predicts risky sexual behavior in young adulthood. Journal of Clinical Child and Adolescent Psychology 35:571–577.

                                                                                                                                                                                                                                                    DOI: 10.1207/s15374424jccp3504_8Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                    Drawing from Pittsburgh ADHD Longitudinal Study data, the authors demonstrate that young men with ADHD tend to initiate sexual activity earlier in life and within relationships, engage in sex with more partners, engage in more casual (i.e., uncommitted) sex and without condoms, and have more partner pregnancies.

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                                                                                                                                                                                                                                                    • Knouse, L. E., C. L. Bagwell, R. A. Barkley, and K. R. Murphy. 2005. Accuracy of self-evaluation in adults with ADHD evidence from a driving study. Journal of Attention Disorders 8:221–234.

                                                                                                                                                                                                                                                      DOI: 10.1177/1087054705280159Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                      Using naturalistic, VR, and self-report drivers, this study shows adult ADHD drivers not only perform poorly relative to nondiagnosed peers, but that they consistently overestimate their driving performance, which may be construed as evidence for the developmental continuity of the positive illusory bias noted in child ADHD research.

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                                                                                                                                                                                                                                                      • Swensen, A. R., H. G. Birnbaum, R. Ben Hamedi, P. Greenberg, P. Y. Cremieux, and K. Secnik. 2004. Incidence and costs of accidents among attention-deficit/hyperactivity disorder patients. Journal of Adolescent Health 35:346e1–346e9.

                                                                                                                                                                                                                                                        DOI: 10.1016/j.jadohealth.2003.12.003Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                        In an analysis of medical claims for a Fortune 100 company in the United States, the authors parse adults from children and show that those with ADHD are more than twice as likely as those without to present for accidental injury treatment, and that their injuries tend to be more severe.

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                                                                                                                                                                                                                                                        • Thompson, A. L., B. G. Molina, W. Pelham Jr., and E. M. Gnagy. 2007. Risky driving in adolescents and young adults with childhood ADHD. Journal of Pediatric Psychology 32:745–759.

                                                                                                                                                                                                                                                          DOI: 10.1093/jpepsy/jsm002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                          Over three hundred participants from the Pittsburgh ADHD Longitudinal Study were surveyed regarding their driving behaviors and outcomes; hyperactivity-impulsivity was shown to predict higher rates of tickets and accidents in the group of adults with ADHD, as compared to nondiagnosed peers.

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                                                                                                                                                                                                                                                          Clinical Resources and Materials

                                                                                                                                                                                                                                                          Various manuals (Ramsay and Rostain 2008; Safren, et al. 2005; Solanto 2011) and descriptions of these treatments (Murphy 2005; Sprich, et al. 2010) are available for clinicians. The works included here follow cognitive-behavioral guidelines and are either based on specific protocols assessed in randomized controlled designs or emerged from a similar approach. Though this is not an exhaustive list, it provides a general overview for clinicians.

                                                                                                                                                                                                                                                          • Murphy, K. 2005. Psychosocial treatments for ADHD in teens and adults: A practice-friendly review. Journal of Clinical Psychology 61:607–619.

                                                                                                                                                                                                                                                            DOI: 10.1002/jclp.20123Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                            This article describes aspects of psychosocial treatment approaches that commonly comprise cognitive-behaviorally based therapy, from a pioneer in adult ADHD research.

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                                                                                                                                                                                                                                                            • Ramsay, J. R., and A. L. Rostain. 2008. Cognitive-behavioral therapy for adult ADHD: An integrative psychosocial and medical approach. New York: Routledge.

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                                                                                                                                                                                                                                                              This text provides an overview of assessing ADHD and thorough description of cognitive-behavioral therapy that can be followed in treatment. Clinical vignettes are included to illustrate certain aspects of cognitive-behavioral therapy.

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                                                                                                                                                                                                                                                              • Safren, S. A., C. A. Perlman, S. Sprich, and M. W. Otto. 2005. Mastering your adult ADHD: A cognitive-behavioral treatment program therapist guide. New York: Oxford Univ. Press.

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                                                                                                                                                                                                                                                                Based on a cognitive-behavioral therapy developed by Safren et al. and which has now been assessed in two randomized controlled trials, this clinical resource is a gold standard manual to guide therapists when treating an adult with ADHD.

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                                                                                                                                                                                                                                                                • Solanto, M. V. 2011. Cognitive-behavioral therapy for adult ADHD: Targeting executive dysfunction. New York: Guilford.

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                                                                                                                                                                                                                                                                  Solanto’s text is a gold standard group therapy resource based on a cognitive-behavioral therapy treatment model assessed in a group format that has demonstrated treatment efficacy in a randomized trial. Though this has been tested in group settings, it can also be applied for individual therapy cases.

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                                                                                                                                                                                                                                                                  • Sprich, S. E., L. E. Knouse, C. Cooper-Vince, J. Burbridge, and S. A. Safren. 2010. Description and demonstration of CBT for ADHD in Adults. Cognitive and Behavioral Practice 17:9–15.

                                                                                                                                                                                                                                                                    DOI: 10.1016/j.cbpra.2009.09.002Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                                                    This practical, how-to resource following the cognitive-behavioral therapy model summarized in Safren, et al. 2005 provides practical instructions for clinicians to deliver this treatment. Citations are also provided in this article for online demonstrations of therapeutic techniques.

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                                                                                                                                                                                                                                                                    Psychoeducation for Patients

                                                                                                                                                                                                                                                                    Numerous materials are available for members of the public to learn about ADHD in adulthood—this section is only a sampling and is far from exhaustive. Various books contain general information about behavioral coping and cognitive restructuring strategies (Barkley 2010; Hallowell and Ratey 1995; Safren, et al. 2005; Kelly and Ramundo 2006; Nadeau 2006), how loved ones can help (Pera 2008), and the nature of ADHD in adulthood itself (Barkley 2006). There are also many resources available via the internet that are evidence-based, particularly the National Resource Center on ADHD.

                                                                                                                                                                                                                                                                    • Barkley, R. A. 2006. Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford.

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                                                                                                                                                                                                                                                                      This text provides a thorough account of the nature of ADHD across the lifespan, including history of the disorder, prevalence rates, developmental outcomes, and treatment options. This book provides an in-depth reference addressing contemporary issues in ADHD for researchers, clinicians, and patients.

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                                                                                                                                                                                                                                                                      • Barkley, R. A. 2010. Taking charge of adult ADHD. New York: Guilford.

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                                                                                                                                                                                                                                                                        This informative and user-friendly book provides behavioral strategies that adults with ADHD can use to improve their daily functioning, and is likely to become a classic resource.

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                                                                                                                                                                                                                                                                        • Hallowell, E. M., and J. J. Ratey. 1995. Driven to distraction: Recognizing and coping with attention deficit disorder from childhood through adulthood. New York: Touchstone.

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                                                                                                                                                                                                                                                                          This is an often-cited, classic resource for patients with ADHD that includes practical coping strategies.

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                                                                                                                                                                                                                                                                          • Kelly, K., and P. Ramundo. 2006. You mean I’m not lazy, stupid or crazy?! The classic self-help book for adults with attention deficit disorder. New York: Scribner.

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                                                                                                                                                                                                                                                                            This is another classic resource for patients with ADHD in a self-help format that covers a wide array of domains frequently impaired among adults with ADHD.

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                                                                                                                                                                                                                                                                            • National Resource Center on ADHD.

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                                                                                                                                                                                                                                                                              Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) provides excellent empirically based information relevant to ADHD across the lifespan and also important information about support groups across the United States. See also the CHADD homepage.

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                                                                                                                                                                                                                                                                              • Nadeau, K. G. 2006. Survival guide for college students with ADHD or LD. Washington, DC: Magination.

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                                                                                                                                                                                                                                                                                This self-help booklet targets behaviors commonly impaired among adults with ADHD who are attending college and provides practical strategies to cope with this disorder in this domain that can easily elicit symptoms of ADHD.

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                                                                                                                                                                                                                                                                                • Pera, G. 2008. Is it you, me, or adult A.D.D.? Stopping the roller coaster when someone you love has attention deficit disorder. San Francisco: 1201 Alarm Press.

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                                                                                                                                                                                                                                                                                  Focusing on an often-neglected group, this book provides strategies for significant others of those meeting criteria for ADHD. This text can also be used in a couples format.

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                                                                                                                                                                                                                                                                                  • Safren, S. A., S. Sprich, C. A. Perlman, and M. W. Otto. 2005. Mastering your adult ADHD: A cognitive-behavioral treatment program client workbook. New York: Oxford Univ. Press.

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                                                                                                                                                                                                                                                                                    As opposed to self-help resources, this text is for patients engaged in cognitive-behavioral therapy and is a manualized client-version of a particularly efficacious cognitive-behavioral therapy that has been subjected to two randomized controlled trials.

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