literature review: adhd in adults: a review of the literature

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2008 11: 628 originally published online 19 December 2007Journal of Attention DisordersMegan A. Davidson

Literature Review: ADHD in Adults: A Review of the Literature

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628

ADHD in Adults

A Review of the LiteratureMegan A. DavidsonQueen’s University

Objective: ADHD presents significant challenges to adults. The current review’s goals are (a) to critically examine thecurrent state of knowledge regarding ADHD in adults and (b) to provide clinicians with practice-friendly informationregarding assessment, diagnosis, and treatment. Method: Searches of PsycINFO and Medline were conducted, andreference lists from articles and books were searched for additional relevant references. Results/Conclusion: A valid andreliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview,neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive andspecific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, withthe stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highestefficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting thecombination of cognitive behavioral therapy and medication. (J. of Att. Dis. 2008; 11(6) 628-641)

Keywords: attention-deficit/hyperactivity disorder; adult ADHD assessment; adult ADHD treatment; diagnostic issues

ADHD is a disorder that comprises a constellation ofsymptoms including inattention, impulsivity, and

hyperactivity. ADHD is well studied in children, butmuch less is known about the disorder in adulthood. Thepurpose of the present article is to critically examinethe current state of knowledge concerning the assess-ment and treatment of ADHD in adults, with the goal ofestablishing the best methods of assessment and treat-ment. In doing so, the present article reviews a numberof issues within the literature, including estimates ofprevalence of the disorder, diagnostic and assessmentissues, comorbidities and psychosocial functioning,validity of assessments, and treatments and their effec-tiveness. Recommendations for evidence-based approachesto adult patients in clinical practice are made. In choos-ing articles to include in the present review, we conductedsearches of PsycINFO and Medline from 1980 to 2007using ADHD and attention deficit hyperactivity disorder,combined with adult, as keywords. We also searched ref-erence lists from articles and books for additional rele-vant references. Our searches produced approximately2,500 references, of which 130 were included in thepresent review.

Prevalence

The American Psychiatric Association (APA; 2000)estimates that 3% to 7% of school-aged children haveADHD. Historically, ADHD was considered to be prin-cipally a disorder of childhood, one that was generallyoutgrown by adolescence and that was nonexistent byadulthood (Ross & Ross, 1976). There is now clear evi-dence that ADHD symptoms continue through adoles-cence and adulthood (e.g., Barkley, Fischer, Smallish, &Fletcher, 2002). The prevalence of ADHD in adults isestimated to fall between 4% and 5% (Kessler et al.,2005; Murphy & Barkley, 1996b).

Even though the persistence of ADHD beyond child-hood is established, it is difficult to determine the extentof this persistence. Only a small number of prospectivestudies have followed samples of children with ADHDinto adulthood, and of these studies, only four have

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Author’s Note: Address correspondence to Megan A. Davidson,Queen’s University, Department of Psychology, Humphrey Hall,62 Arch St., Kingston, Ontario K7L 3N6, Canada; e-mail:[email protected].

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retained 50% or more of their original sample into adult-hood (Barkley, Fischer, et al., 2002; Fischer, Barkley,Edelbrock, & Smallish, 1990; Mannuzza, Klein, Bessler,Malloy, & LaPadula, 1998; Rasmussen & Gillberg,2001; G. Weiss & Hechtman, 1993). The results ofthese four studies are mixed with respect to persistence.G. Weiss and Hechtman (1993) conducted a prospectivefollow-up study of hyperactive children. At the 15-yearfollow-up (age M = 25 years), 66% of the original sam-ple of hyperactive children reported at least one or moresymptoms of ADHD versus 7% of the control group. Inaddition, 36% of the hyperactive sample had at leastmoderate to severe levels of hyperactive, impulsive, andinattentive symptoms, compared to 2% of the controlgroup. Rasmussen and Gillberg (2001) obtained similarresults: Of probands, 49% reported marked symptoms ofADHD at age 22 years, compared to 9% of controls.

The studies by G. Weiss and Hechtman (1993) andRasmussen and Gillberg (2001) were limited by the factthat formal diagnostic criteria were not used at any ofthe outcome points in the studies. Mannuzza and col-leagues (1998) corrected this methodological flaw byfollowing two cohorts of ADHD children using criteriaof the third edition of the Diagnostic and StatisticalManual of Mental Disorders (DSM-III) to assess thedisorder. The authors found that 40% of their initialcohort and 43% of their second cohort met DSM-III cri-teria for ADHD at adolescent follow-up (age M = 18years), compared to 3% and 4% of the comparisongroups. However, at adult follow-up (age M = 26years), the rates of ADHD in the probands decreased to8% and 4%, respectively. Barkley (2006) suggested thatthese relatively low estimates of persistence are partlybecause of the study’s stringent selection criteria regard-ing aggression and antisocial behaviors. Finally, a fourthprospective study, by Barkley, Fischer, et al. (2002),evaluated hyperactive children and a control group atages 19 to 25 years using formal diagnostic criteria.Based on self-report, ADHD was rare in the both groups(5.0% and 0.0%, respectively) at follow-up. However,ADHD was substantially higher using parent reports(46.0% and 1.4%, respectively).

These four prospective studies show considerable dis-crepancy among the rates of ADHD persistence intoadulthood. These discrepancies are likely because of anumber of variables, including variations in the criteriaused for diagnosis (Riccio et al., 2005), selection criteria,sources of information, changes in source of informa-tion, and changes in diagnostic criteria (for a review, seeBarkley, 2006). Thus, because of these issues, and issueswith the current diagnostic criteria, the persistence ofADHD into adulthood is difficult to estimate.

Diagnostic Issues

Use of DSM-IV Criteria in Adults

Extensive psychometric studies have provided empir-ical support for the symptom thresholds used to diagnoseADHD in children (Lahey et al., 1994), and there is gen-eral agreement that ADHD can be reliably diagnosed inchildren through the use of these formal diagnostic crite-ria. However, the reliability of the diagnosis of ADHD inadults is much less clear (Riccio et al., 2005) and contin-ues to be an area of controversy within the literature(Faraone, Biederman, & Feighner, 2000).

In diagnosing ADHD in adults, clinicians andresearchers in North America most often use the criteriaset out by the fourth edition, text revision of DSM (DSM-IV-TR; APA, 2000). Three subtypes of ADHD are recog-nized: ADHD combined type (ADHD-C; both inattentiveand hyperactive–impulsive symptoms), ADHD predomi-nantly inattentive type (ADHD-I), and ADHD predomi-nantly hyperactive–impulsive type (ADHD-H). Amongadults with ADHD, the ADHD-I subtype is the mostcommon diagnosis (Erk, 2000).

The use of DSM-IV criteria for ADHD in adults hasbeen criticized. Barkley (1998) suggests that applyingcurrent ADHD criteria to adults is not developmentallysensitive. The DSM-IV criteria for ADHD were designedfor and selected based on studies with children (Riccioet al., 2005), and validation studies of ADHD criteria inadults have not been conducted (Belendiuk, Clarke,Chronis, & Raggi, 2007). Because of this, it has beensuggested that the symptom lists in DSM-IV may beinappropriately worded for adults and that diagnosticthresholds may be too stringent or restrictive whenapplied to adults (Heiligenstein, Conyers, Berns, &Smith, 1998). Moreover, some symptoms, such as pro-crastination, overreacting to frustration, poor motivation,insomnia, and time-management difficulties, are com-mon complaints of adults with ADHD, but they are notincluded in DSM-IV. Finally, the level of impairmentcaused by ADHD symptoms may be different betweenadults and children, and symptoms will likely affectmore domains in adults (e.g., marital, familial, occupa-tional, etc.).

Indeed, longitudinal studies demonstrate a develop-mental influence on ADHD symptoms. In general,ADHD symptoms appear to decrease as age increases:Prospectively derived data in clinical and epidemiologi-cal samples of children, adolescents, and young adultsdemonstrate an overall reduction of ADHD symptomsover time (Hart, Lahey, Loeber, Applegate, & Frick,1995; Heiligenstein et al., 1998; Levy, Hay, McStephen,

Davidson / ADHD in Adults 629




Wood, & Waldman, 1997; Millstein, Wilens, Biederman,& Spencer, 1997; National Academy for the Advancementof ADHD Care, 2003). Specifically, it appears thathyperactive–impulsive symptoms decline more withincreasing age, whereas inattentive symptoms of ADHDtend to persist (Achenbach, Howell, McConaughy, &Stranger, 1995; Hart et al., 1995). In support of this,studies of adults with ADHD suggest that the mostprominent symptoms of ADHD relate to inattention asopposed to hyperactivity and impulsivity (Murphy &Barkley, 1996a). Furthermore, Millstein et al. (1997)found that symptoms of hyperactivity and impulsivityameliorate as persons reach adulthood, but inattentionremains a prominent clinical feature in more than 90% ofclinic-referred adults.

The decrease in ADHD symptoms over time mayindicate true remission of symptoms, but it may alsoindicate a measurement problem: reduced sensitivity ofADHD symptom criteria with age. If this is true, thenusing the same symptom threshold to define deviance ateach age will reduce the number of diagnosable casesamong older individuals (Faraone et al., 2000), and itwill be more difficult for individuals with ADHD to meetcriteria for the disorder as they get older. Heiligensteinet al. (1998) addressed this issue by determining ADHDsymptom thresholds specific to college students. First,the authors determined the number of DSM-IV diagnosesof ADHD, finding that 4% met the DSM-IV criteria.ADHD was then defined as deviance from the norm:Students were identified as having ADHD if their totalsymptom score exceeded the 93rd percentile (+1.5 SD)of the sample. This redefinition increased the prevalenceof ADHD to 11%, and students who met this criterionstill demonstrated clinically significant symptoms.

In their prospective study, Barkley, Fischer, et al.(2002) defined adult ADHD by using both DSM-III cri-teria and a developmentally referenced criterion (DRC;98th percentile; +2 SD). Using DSM-III criteria, parentalinterview resulted in an ADHD rate of 42%. However,this rate rose to 66% when the DRC was employed.Compared to a control group, the DRC-diagnosed groupfared worse on a number of measures including GPA,class ranking, job performance ratings, and ADHDsymptoms at work.

Murphy and Barkley (1996b) examined the preva-lence of ADHD symptoms in adults and suggested thatthe cutoff of six of nine hyperactive–impulsive symp-toms and six of nine inattentive symptoms recommendedin DSM-IV sets a prevalence of deviance that is statisti-cally extreme for an adult population. In their sample ofadults, this cutoff fell at approximately 2.5 to 3.0 stan-dard deviations above the mean (> 99th percentile) for

most ratings of current ADHD behavior. According toMurphy and Barkley, this level of statistical deviance isfar higher than that required of children to receive a diag-nosis of ADHD and supports the use of DRC in adults.In their study, a cutoff of four of the six inattentive symp-toms and five of the six hyperactive symptoms wouldhave been sufficient to identify an adult aged 17 to 29years as deviant from the traditional 93rd percentile(+1.5 SD) used in child ADHD research. Clearly, theresults of Heiligenstein et al. (1998), Barkley, Fischer,et al. (2002), and Murphy and Barkley (1996b) all suggestthat the DSM-IV criteria threshold for ADHD may be toostringent for adult diagnosis.

Given the criticisms of the diagnostic criteria forADHD in adults and the recent research findings demon-strating the utility of DRC, it may be useful to recastADHD as a norm-referenced rather than a criterion-referenced diagnosis (Barkley, 2006; Faraone et al.,2000). Although a norm-referenced diagnosis may be avalid method of diagnosis, more research is necessary.Such a change in the diagnostic process would result insignificant implications for clinical practice; thus, it isimperative that extensive empirical research supportsuch a change.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consider-ation of differential diagnoses, as it can be difficult to dif-ferentiate ADHD from a number of other psychiatricconditions (Pary et al., 2002), including major depression,bipolar disorder, generalized anxiety, obsessive–compulsivedisorder (OCD), substance abuse or dependence, person-ality disorders (borderline and antisocial), and learningdisabilities (Searight, Burke, & Rottnek, 2000). Forexample, differential diagnosis of ADHD from mood andconduct disorders may be difficult because of commonfeatures such a mood swings, inability to concentrate,memory impairments, restlessness, and irritability (Adler,2004). Differential diagnosis of learning disabilitiescan also prove difficult because of the interrelated func-tional aspects of the disorders that have the common out-come of poor academic functioning (Adler, 2004; Jackson& Farrugia, 1997).

Comorbidities and PsychosocialFunctioning

Comorbid Psychiatric Disorders

Comorbid disorders are common in children withADHD. In school-aged children with ADHD, as many as

630 Journal of Attention Disorders





two thirds may have another Axis I disorder (Biederman,Newcorn, & Sprich, 1991). Common comorbidities inchildren with ADHD include oppositional defiant disor-der (ODD), conduct disorder (CD), mood and anxietydisorders, and learning disabilities (Greenhill, 1998).High rates of comorbidities are also seen in adults withADHD, with the majority having at least one additionalpsychiatric disorder. In fact, in clinical populations ofadults with ADHD, as many as three in four patientshave one or more comorbid psychiatric disorders(Faraone & Biederman, 1998).

Outcome studies have demonstrated that individualsdiagnosed with ADHD in childhood are at risk for devel-oping comorbid conditions (Barkley, 2006; G. Weiss &Hechtman, 1993), some of which are likely secondary toADHD-related frustration and failure. Biederman andcolleagues (1993) found a relatively high incidence oflifetime diagnoses of anxiety disorders (43% to 52%),major depressive disorder (31%), ODD (29%), CD(20%), antisocial personality disorder (12%), and alco-hol and drug dependencies (27% and 18%, respectively)in their sample of clinic-referred adults with ADHD.Comparable rates were found in a second sample of non-referred adults with ADHD. Murphy and Barkley(1996a) found similar high rates of comorbid disordersin their sample of clinic-referred adults with ADHD.

With respect to ADHD subtypes in adults, Millsteinet al. (1997) found higher rates of ODD, bipolar disorder,and substance use disorders in patients with ADHD-Cthan in those with other subtypes and higher rates ofODD, OCD, and PTSD in patients with ADHD-H thanin those with ADHD-I. In their study, Sprafkin, Gadow,Weiss, Schneider, and Nolan (2007) found that all threesubtypes reported more severe comorbid symptoms thandid a control group, with the ADHD-C group obtainingthe highest ratings of comorbid symptom severity.Comparable rates of comorbidities have been found inmen and women with ADHD, with the exception of menhaving higher rates of antisocial personality disorder(Biederman et al., 1994).

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adultswith ADHD often complain of psychosocial difficulties.Indeed, Biederman et al. (1993) found a much higherrate of separation and divorce among adults with ADHDthan among controls, and their sample of adults withADHD had lower socioeconomic status, poorer past andcurrent global functioning estimates, and higher occur-rence of prior academic problems relative to the controlgroup. Likewise, Murphy and Barkley (1996a) documented

high rates of educational, employment, and marital prob-lems in adults with ADHD. Multiple marriages weremore common in the adult ADHD group, and signifi-cantly more adults with ADHD had performed poorly,quit, or been fired from a job and had a history of poorereducational performance and more frequent school dis-ciplinary actions against them than did adults withoutADHD. Low self-concept and low self-esteem are com-mon secondary characteristics of adults with ADHD,often resulting from problematic educational experi-ences and interpersonal difficulties (Jackson & Farrugia,1997). Adults with ADHD often have strong feelings ofincompetence, insecurity, and ineffectiveness, and manyof these individuals live with a chronic sense of under-achievement and frustration (Murphy, 1995).

Assessment of Adult ADHD

The diagnosis of adult ADHD is a clinical decision-making process (Faraone & Biederman, 1998). A diag-nosis is established through the use of a comprehensiveexamination assessing psychopathology, functionalimpairments, pervasiveness of the disorder, age of onset,and absence of other disorders that could better explainthe symptoms (Rosler et al., 2006). Given the difficultieswith the formal diagnostic criteria for ADHD, determin-ing the diagnosis of ADHD in adults presents differentchallenges than determining the diagnosis in children(Riccio et al., 2005). There is no single neurobiological orneuropsychological test that can determine a diagnosisof ADHD on an individual basis (Rosler et al., 2006).Instead, diagnosticians often rely on a combination ofclinical interviews, behavioral rating scales, familyhistory, and neuropsychological evaluation. The use ofreports from multiple informants is considered best prac-tice, as evidence from multiple studies suggests thatadults with ADHD underreport their ADHD symptomsand the severity of those symptoms (Barkley, Fischer,et al., 2002; Fischer, 1997; Wender, 1995).

Clinical Interview

A comprehensive clinical interview is one of the mosteffective methods through which one can identifyADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy& Adler, 2004; Wilens, Faraone, & Biederman, 2004).Here, open-ended questions about childhood and adultbehaviors can be used to elicit information necessary todiagnose ADHD. Interviews also include questionsregarding developmental and medical history, school andwork history, psychiatric history, and family history ofADHD and other psychiatric disorders (Barkley, 2006).





Although many clinicians use unstructured interviews toassess adult ADHD, semistructured interviews do exist.

Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID). The CAADID (Epstein, Johnson, &Conners, 2000) is a semistructured interview designed togather information necessary to make a diagnosis ofADHD. The CAADID assesses for the presence ofDSM-IV ADHD symptoms and collects informationrelated to history, developmental course, ADHD risk fac-tors, and comorbid psychopathology. Test–retest reliabil-ity has been demonstrated for both individual symptomsof inattention and hyperactivity–impulsivity and foroverall diagnosis (κ = .40 to .91). Concurrent validity hasalso been demonstrated for adult hyperactive–impulsiveand child inattentive symptoms (Epstein & Kollins,2006).

Schedule for Affective Disorders and Schizophrenia(K-SADS). The K-SADS (Chambers et al., 1985; Puig-Antich & Chambers, 1978) was originally developed foruse in school-aged children and adolescents, but it hasbeen used to assess past and present symptoms of ADHDin adults (Belendiuk et al., 2007; Magnússon et al.,2006). The K-SADS has been demonstrated to havegood interrater reliability and strong criterion and con-struct validity (Ambrosini, 2000; Magnússon et al.,2006).

Structured Clinical Interview for DSM-IV Criteriafor DSM Axis I (SCID-I). The SCID-I (First, Spitzer,Gibbon, & Williams, 2002) can be used to diagnoseADHD and to assess comorbidity in adults. It is also use-ful in ruling out other disorders as being the cause ofADHD symptomatology. The SCID-I has demonstratedreliability and validity (e.g., Steiner, Tebes, Sledge, &Walker, 1995; Zanarini et al., 2000).

ADHD Rating Scales

Self-report behavioral checklists are commonly usedin the assessment of ADHD (Woods, Lovejoy, & Ball,2002). In addition to self-report behavioral rating scales,rating scales completed by an individual’s spouse orsignificant other can provide useful information indetermining the individual’s overall life functioning.Parents can also complete such rating scales to provideinformation regarding current and childhood functioning(Barkley, 2006).

Conners’s Adult ADHD Rating Scales (CAARS). TheCAARS (Conners, Erhart, & Sparrow, 1999) assessesADHD symptoms in adults and comprises short, long,and screening self-report and observer rating scaleforms. The CAARS produces eight scales, includingscales based on DSM-IV criteria and an overall ADHD

index. Internal consistency is good, with Cronbach’salpha across age, scales, and forms ranging from .49 to.92 (Conners et al., 1999; Erhardt, Epstein, Connors,Parker, & Sitarenios, 1999). Test–retest reliability(1 month) estimates are high, ranging from .85 to .95(Conners et al., 1999; Erhardt et al., 1999). The ADHDindex produces an overall correct classification rate of85%, and the sensitivity of the ADHD index has beenestimated at 71% and the specificity at 75% (Connerset al., 1999).

Brown Attention-Deficit Disorder Rating Scale forAdults (Brown ADD-RS). The Brown ADD-RS (Brown,1996; Brown & Gammon, 1991) assesses symptoms ofADHD in adults. It was developed before the DSM-IVconcept of ADHD was published and focuses more onsymptoms of inattention rather than hyperactivity andimpulsivity. The scale shows high internal consistency(α = .96) and satisfactory validity (M. Weiss, Hechtman,& Weiss, 1999).

Wender Utah Rating Scale (WURS). The WURS(Ward, Wender, & Reimherr, 1993) is an assessment toolused to retrospectively diagnose ADHD. The measure isbased on items from the monograph Minimal BrainDysfunction in Children (Wender, 1971) that are moredetailed than the 18 items in the DSM-IV criteria(Murphy & Adler, 2004). The measure demonstrates sat-isfactory internal consistency, as demonstrated by split-half reliability coefficients (r = .90; Ward et al., 1993),and satisfactory test–retest reliability (r = .68). Correlationsbetween the WURS and a parent-report retrospectiverating scale of childhood ADHD (r = .41 to .49) supportthe validity of the scale.

Current Symptoms Scale. The Current SymptomsScale (Barkley & Murphy, 1998) is an 18-item self-report scale with both a patient version and an informantversion. It contains the 18 items from the diagnostic cri-teria in DSM-IV. Validity has been demonstrated throughpast findings of significant group differences betweenADHD and control adults (Barkley, Murphy, DuPaul, &Bush, 2002). An earlier DSM-III version of the scale cor-related significantly with the same scale completed by aparent (r = .75) and by a spouse or intimate partner of theADHD adult (r = .65; Murphy & Barkley, 1996a).

ADHD Rating Scale–IV. The ADHD Rating Scale–IV(DuPaul, Power, Anastopoulos, & Reid, 1998) is a norm-referenced checklist that assesses the symptoms ofADHD according to DSM-IV. The measure wasdesigned for use with children; however, it can be modi-fied and administered to adults (Murphy & Adler, 2004).The ADHD Rating Scale–IV is not self-report; it isdesigned to be completed by a parent or a teacher. Eachitem corresponds to one of the symptoms in DSM-IV.Internal consistency estimates are good for each of its





three scales (inattention α = .86 to .96; hyperactivity–impulsivity α = .88; total score α = .92 to .94). Test–retestreliability (4 weeks) is also high (r = .85 to .90; DuPaulet al., 1998).

Adult ADHD Self-Report Scale–version 1.1 (ASRS-v1.1). The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003)is an 18-item measure based on the DSM-IV-TR criteriafor ADHD that produces three scale scores. Questionsare designed to suit an adult rather than a child (e.g., ref-erences to “play” and “schoolwork” are deleted), and thelanguage provides a context for symptoms that adultscan relate to (Murphy & Schachar, 2000). Internal con-sistency estimates are high (α = .88), and the ASRS-v1.1has been shown to have high concurrent validity (Adleret al., 2006). Adler and his colleagues (2006) comparedthe clinician-administered version of the scale to a pilotversion of the ASRS-v1.1 and found a high intraclasscorrelation coefficient for total ADHD symptoms (α =.84). There was acceptable agreement for individualitems (% agreement = 43% to 72%) and significantkappa coefficients for all items.

Validity of Measures Used to Diagnose ADHD

Rating scales can be used to assess current symptomsand functioning as well as childhood symptoms andfunctioning. However, they may be subject to reportingbiases and errors in memory (Wadsworth & Harper,2007). Murphy and Schachar (2000) examined the valid-ity of self-reported ratings of current and childhoodADHD symptoms by adults. In one study, participants’ratings of their childhood ADHD symptoms were com-pared to their parents’ ratings of childhood symptoms. Ina second study, participants’ ratings of their currentADHD symptoms were compared to a significant other’srating of current symptoms. All correlations betweenself-ratings and parent ratings were significant for inat-tentive, hyperactive–impulsive, and total ADHD symp-toms (r = .69 to .79), as were correlations betweenself-ratings and significant other ratings (r = .59 to .70).Belendiuk et al. (2007) examined the concordance ofdiagnostic measures for ADHD, including self-ratingsand collateral versions of both rating scales and semi-structured interviews. Results supported the findings ofMurphy and Schachar, showing high correlationsbetween self-reports and collateral reports of inattentiveand hyperactive–impulsive symptoms. Results alsodemonstrated high correlations between self-report rat-ing scales and diagnostic interviews.

Taken together, this review of rating scales and diag-nostic interviews used in the assessment of adult ADHDindicates that a number of reliable and valid measuresexist. Research has demonstrated that rating scales can

accurately reflect the frequency and intensity of symp-toms (Wadsworth & Harper, 2007) and, when used ret-rospectively, are valid indicators of symptomatology(Murphy & Schachar, 2000). Research also suggests thatsemistructured clinical interviews can reliably and accu-rately be used for determining a diagnosis of ADHD inadults (Epstein & Kollins, 2006). However, this literatureis quite young, and more research is needed to corrobo-rate these findings.

Neuropsychological Testing

Neuropsychological testing plays a meaningful role inthe assessment of ADHD. However, Barkley (2006)urges caution in interpreting such data, as there is no sin-gle test or battery of tests that has adequate predictivevalidity or specificity to make a reliable diagnosis ofADHD. In adult ADHD, neuropsychological testing ismost beneficial when the results are used to support con-clusions based on history, rating scales, and analysis ofcurrent functioning.

Woods and his colleagues (2002) reviewed the role ofneuropsychological evaluation in the diagnosis of adultswith ADHD. In their review of 35 studies, the authorsfound that the majority of the studies demonstrated sig-nificant discrepancies between adults with ADHD andnormal control participants on at least one measure ofexecutive function (i.e., the ability to assess a task situa-tion, plan a strategy to meet the needs of the situation,implement the plan, make adjustments, and successfullycomplete the task; Riccio et al., 2005) or attention.Moreover, Woods et al. found that the most prominentand reliable executive function and attention measuresthat differentiated adults with ADHD were Stroop tasks(Stroop, 1935) and continuous performance tests (CPTs).Stroop tasks are complex word- and color-naming pro-cedures that require visual attention and response inhibi-tion, whereas CPTs are computer-based tasks that assessattentional lapses, vigilance, and impulsivity (Spreen &Strauss, 1998). In addition, Woods et al. found that ver-bal letter fluency tasks (i.e., generating words beginningwith a specific letter or words belonging to a specific cat-egory) and auditory–verbal list learning tasks (e.g.,California Verbal Learning test; Delis, Kramer, Kaplan,& Ober, 1987) were also able to discriminate betweenadults with ADHD and controls. However, the authorscaution that the validity of these findings is somewhathindered by limitations of the studies reviewed, includ-ing methodological and sample variability, a restrictedrange of interpretive techniques, and uncertain discrimi-nant validity of the neuropsychological assessment pro-cedures in distinguishing ADHD from other psychiatricor neurological conditions.




Schoechlin and Engel (2005) also attempted to deter-mine neuropsychological test performance differences inadults with ADHD. The authors performed a meta-analysisintegrating 24 empirical studies reporting results of atleast 1 of 50 neuropsychological tests comparing adultswith ADHD to controls. The authors categorized each ofthe tests into 1 of 10 functional domains: verbal intelli-gence, visual–figural problem solving, abstract verbalproblem solving with working memory, executive func-tion, fluency, simple attention, sustained attention,focused attention, verbal memory, and figural memory.For each of the 10 domains, a pooled effect size (d) wascalculated. Adults with ADHD showed significant per-formance deficits in 8 of the 10 domains. Small effectsizes (d between .18 and .26) were found for the domainsof visual memory, visual problem solving, and executivefunction. The highest effect sizes (d between .50 and .60)were found for verbal memory, focused attention, sus-tained attention, fluency, and abstract verbal problemsolving with working memory. In these domains, ADHDpatients scored approximately one half of an SD lowerthan did the control participants.

The findings of Schoechlin and Engel (2005) aresomewhat inconsistent with those of Woods et al. (2002).Although both studies noted differences between adultswith ADHD and controls on tasks of verbal memory andfluency, Schoechlin and Engel did not find that perfor-mance on executive function tasks was a strong predictorof the distinction between adults with ADHD and con-trols. This nonsignificant finding may have occurred fora few reasons. The authors also note that there is nocommonly accepted definition of executive function.Schoechlin and Engel chose to separate more basicaspects of executive function such as working memoryand inhibition from higher-level functioning. If ADHDaffects some aspects of executive function more thanothers, their decision to not include all measures that arediscussed as executive functions may have decreasedtheir effect size.

Woods et al. (2002) concluded that although a generalprofile of attentional and executive function impairmentis evident in adults with ADHD, expansive impairmentsin these domains (i.e., impairments on all attention andexecutive function tasks) is not common. Their reviewdemonstrated inconsistencies in specific instrumentsacross studies, indicating that adults with ADHD maynot perform poorly on all attentional measures all thetime. This finding is not surprising given the fact thatadults with ADHD often demonstrate sporadic or incon-sistent attention, which can be difficult to identify giventhe structure provided by the one-on-one testing envi-ronment (Barkley, 1998). In light of this, researchers

agree that a neuropsychological assessment will be mostsensitive to ADHD when the assessment incorporatesmultiple, overlapping procedures measuring a broadarray of attentional and executive functions (Alexander& Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woodset al., 2002).

Although the studies by Woods et al. (2002) andSchoechlin and Engel (2005) indicate demonstrated dif-ferences between adults with ADHD and control partici-pants on measures of cognitive functioning, thesemeasures have limited predictive value in distinguishingADHD from other psychiatric or neurological conditionsthat are associated with similar cognitive impairments(Wadsworth & Harper, 2007). Cognitive assessments areuseful, however, in that they can (a) improve the validityof an ADHD assessment and (b) be used in assessing theefficacy of pharmacological and/or psychological inter-ventions (Epstein et al., 2003).

Malingering

Malingering is an important issue in ADHD diagnosisand is defined as the conscious fabrication or exaggera-tion of physical or psychological symptoms in the pur-suit of a recognizable goal (APA, 1994). A diagnosis ofADHD can provide an individual with a number of ben-efits, including stimulant medication, disability benefits,tax benefits, and academic accommodations, and suchbenefits may motivate adults undergoing diagnostic eval-uations for ADHD to exaggerate symptomatology onself-report measures and tests of neurocognitive func-tioning (Harrison, Edwards, & Parker, 2007; Sullivan,May, & Galbally, 2007). Detection of faking can provedifficult with adults in particular, as clinicians may nothave access to a parent or sibling who can attest to priorhistory of ADHD symptoms. Moreover, adults often lackdevelopmental documentation such as report cards,teacher evaluations, or prior psychological testingreports (Quinn, 2003). Sullivan et al. (2007) examinedarchived assessment cases of ADHD at a universitycampus–based clinic and found that almost 50% of casesfailed one or more effort measures on the Word MemoryTest (Green, 2003; Green, Allen, & Astner, 1996; Green& Astner, 1995), a symptom validity test designed todetect suboptimal effort in the context of neuropsycho-logical evaluations. In examining the performance ofuniversity students feigning ADHD and comparing it tothe performance of non-ADHD and genuine ADHDstudents, Harrison et al. (2007) demonstrated that thesymptoms of ADHD could easily be fabricated and thatsimulators could be indistinguishable from those withthe disorder. Moreover, the authors found that students






feigning ADHD could easily perform poorly on tests ofreading and processing speed, which could allow themaccess to academic accommodations. Quinn (2003)examined the issue of malingering by comparing the sus-ceptibility of a self-report ADHD rating scale and a CPTto faking in an undergraduate sample of individuals withand without a diagnosis of ADHD. Results indicated thatthe CPT showed greater sensitivity to malingering thandid the self-report scale and that a CPT can successfullydiscriminate malingerers from those with a valid diagno-sis of ADHD. Given the potential benefits associatedwith an ADHD diagnosis, clinicians should include asymptom validity measure in their assessment battery. Atpresent, however, there is no demonstrated best practicefor this.

Treatment of Adult ADHD

Treatment of adult ADHD often includes pharmaco-logical interventions and psychological interventions. Infact, a combination of treatments is usually recom-mended for adults with ADHD (Barkley, 2006). Formalguidelines for the treatment of ADHD in school-agedchildren exist (American Academy of Pediatrics, 2001);however, there is a lack of such guidelines for the treat-ment of ADHD in adults. Such guidelines are needed.Moreover, treatments for ADHD in adults remain under-studied (Rostain & Ramsay, 2006). Within the adultliterature, no single treatment strategy has emerged asbeing the most efficacious (Montano, 2004; M. Weisset al., 1999). However, treatment is generally aimed atsymptom reduction and minimizing the negative effectsof the disorder to improve one’s overall quality of life.

Pharmacological Treatment

Pharmacotherapy is the principal form of treatmentfor patients with ADHD (Pary et al., 2002), and its use inadults is increasing. Castle, Aubert, Verbrugge, Khalid,and Epstein (2007) examined trends in the use of med-ication to treat ADHD and found that 0.8% of adults usemedications to treat ADHD. Furthermore, treatmentprevalence for adults increased rapidly during the 5-yearstudy period (2000 to 2005), with an annual treatmentprevalence growth rate of 15.3%. The usefulness of phar-macotherapy is well established in children with ADHDbut not in adults with ADHD (Wilens, 2003). Wilens(2003) reviewed the literature on the use of pharma-cotherapy in adult ADHD and identified 15 studiesexamining the efficacy of stimulants and 28 studiesexamining the efficacy of nonstimulants.

Stimulants. Stimulants are the treatment of first choicein ADHD (Spencer et al., 1996). The mechanism ofaction for stimulants is thought to result from a release ofnorepinephrine and dopamine (Pary et al., 2002).Controlled studies in adults with ADHD have demon-strated response rates ranging from 25% to 78% formethylphenidate (Biederman et al., 2006; Mattes,Boswell, & Oliver, 1984; Spencer et al., 1995; Spenceret al., 2005) and response rates ranging from 54% to70% for amphetamine (Horrigan & Barnhill, 2000;Paterson, Douglas, Hallmayer, Hagan, & Zyron, 1999;Spencer et al., 2001). Response rates with placebo foradults with ADHD were reported to be 10%.

Although stimulants are effective in adult ADHD, it isestimated that at least 30% of individuals do not ade-quately respond to, or are not able to tolerate, stimulants(Barkley, 1977; Gittleman, 1980; Spencer et al., 1996).In addition, stimulants are associated with a number ofshortcomings. First, they are controlled substances,which may increase both the potential for abuse and thebarriers to treatment. In addition, mood disorders that areoften comorbid with ADHD may have an adverse impacton responsivity to stimulant drugs (Barkley, 2006). Inparticular, stimulants have demonstrated poor responserates with comorbid manic symptomatology and may infact cause a worsening of mood instability (Biedermanet al., 1999). Thus, in many cases, physicians must turnto other drug classes in treating the disorder.

Antidepressants. Antidepressants have been demon-strated to be an effective therapy for adult ADHD.Most of this research has examined the efficacy of thenoradrenergic compounds bupropion, venlafaxine,desipramine, and atomoxetine. Bupropion is an atypicalantidepressant from the aminoketone class of antidepres-sants and is thought to possess both indirect dopamineagonist and noradrenergic effects (Barkley, 2006).Venlafaxine is also an atypical antidepressant and isthought to have both serotonergic and noradrenergiceffects. Desipramine is a tricyclic antidepressant, whichis assumed to act on norepinephrine and dopaminereuptake (Barkley, 2006). Finally, atomoxetine is oneof a newer class of compounds, known as specific nor-epinephrine reuptake inhibitors.

Maidment (2003) reviewed the literature examiningthe efficacy of antidepressants in the treatment of adultADHD. Of those agents that have undergone controlledtrials, he concluded that there is the most evidence sup-porting the use of desipramine, followed by atomoxetine.Desipramine has been shown to produce clinically andstatistically significant improvement in ADHD symp-toms (Wilens, Biederman, Mick, & Spencer, 1995;Wilens et al., 1996), as has atomoxetine (Adler, Spencer,




Milton, Moore, & Michelson, 2005; Michelson et al.,2003; Spencer et al., 1998). Studies investigating bupro-pion have generally demonstrated improved ADHDsymptoms (Kuperman et al., 2001; Wender & Reimherr,1990; Wilens et al., 2001), although its efficacy isunclear (Maidment, 2003). Finally, initial data on ven-lafaxine suggest that the antidepressant is associatedwith high response rates (Adler, Resnick, Kunz, &Devinsky, 1995; Findling, Schwartz, Flannery, & Manos,1998; Hedges, Reimherr, Rogers, Strong, & Wender,1995; Reimherr, Hedges, & Strong, 1995). However,these data are from open-label studies, and controlledstudies are needed to confirm this finding.

Antihypertensive agents. Antihypertensive agentssuch as clonidine and guanfacine have been investigatedin the treatment of children with ADHD; however, thereis little research examining the efficacy of these beta-adrenoceptor agonists in adults. These drugs are thoughtto inhibit the release of norepinephrine, increasingdopamine turnover and reducing blood serotonin levels(Barkley, 2004). One controlled study examined theeffect of guanfacine on ADHD in adults and found thatthe drug significantly reduced ADHD symptoms relativeto a placebo (Taylor & Russo, 2001). Beta-adrenoceptorantagonists such as propanolol have also been investi-gated, and preliminary data suggested that they may alsobe useful in the treatment of adults with ADHD (Mattes,1986; Ratey, Greenberg, & Linden, 1991). However,more research is necessary before any firm conclusionscan be drawn.

Medication adherence. In children, varied medicationadherence rates have been noted, with rates ranging from35% to 100% (Hack & Chow, 2001). Research examin-ing adherence in adults with ADHD has suggested thatadults are compliant with their medication for a briefperiod (i.e., 2 months) but that compliance rates tend todecrease after this brief period (Perwien, Hall, Swensen,& Swindle, 2004). Other researchers (Safren, Duran,Yovel, Perlman, & Sprich, 2007) have found that ADHDmedication adherence is significantly and positivelycorrelated with ADHD symptom severity.

Psychosocial Intervention

Because of the severity and pervasiveness of thesymptoms of ADHD, pharmacotherapy alone is an insuf-ficient treatment of adult ADHD in upward of 50% ofcases (Wilens, Spencer, & Biederman, 2000). In addi-tion, even though medications may offer improvementson measures of core symptoms, these changes may notalways translate into satisfactory functional improve-ments (e.g., time management, organization, planning,self-esteem; M. Weiss et al., 1999). For these reasons,

many adults with ADHD seek additional help in the formof psychosocial treatment (Ramsay & Rostain, 2007).Psychosocial interventions can include cognitive behav-ioral therapy (CBT), self-management skills training,environmental restructuring, psychoeducation, individ-ual psychotherapy, family therapy, marital or coupletherapy, vocational counseling, and ADHD coaching.However, it must be emphasized that for almost all ofthese interventions, little to no controlled research hasbeen conducted. Despite an abundance of popular booksdescribing numerous psychosocial approaches for themanagement of ADHD, there is still almost no empiricalevidence to support their efficacy (Barkley, 2006). Thus,it is too early to draw conclusions regarding the effec-tiveness of most psychosocial treatments. Descriptionsof these treatments, and any empirical studies evaluatingtheir effectiveness, are presented below.

CBT. CBT has emerged as a potential psychosocialtreatment for adult ADHD (Rostain & Ramsay, 2006). Itsuse in children and adolescents with ADHD has alsobeen investigated, but the results have generally demon-strated little utility in this population (e.g., Baer &Neitzel, 1991; Bloomquist, August, & Ostrander, 1991;Dush, Hirt, & Schroeder, 1989). CBT was originallydeveloped as a treatment for depression but has recentlybeen modified for the treatment of adult ADHD (e.g.,McDermott, 2000; Ramsay & Rostain, 2003; Rostain &Ramsay, 2006; Safren, Perlman, Sprich, & Otto, 2005).In general, the focus of CBT is on modifying problem-atic thoughts and beliefs to create changes in emotionsand behaviors. This focus is well suited for adults withADHD, as many have developed negative beliefs aboutthe self and about the world. CBT is also useful for treat-ing the cormorbid diagnoses (e.g., anxiety, depression)and functional problems (e.g., procrastination, poor timemanagement) that are often encountered when workingwith adult ADHD (Rostain & Ramsay, 2006). Overall, atherapeutic model focusing on training in methods oftime management, organizational skills, communicationskills, decision making, self-monitoring and reward,chunking large tasks into smaller steps, and changingfaulty cognitions and beliefs is thought to be useful foradults with ADHD (Barkley, 2006).

The use of CBT for ADHD in adults is fairly recent,and thus little research has examined its efficacy. Thereis preliminary evidence for its efficacy when used incombination with medication. Wilens et al. (1999) eval-uated the potential benefit of cognitive therapy—used inconjunction with medications—in adults with ADHD.Treatment was associated with significant improvementsin symptoms of ADHD and improvements in overallfunctioning and in anxiety and depressive symptoms.Safren, Otto, et al. (2005) showed similar results in their





study of CBT of adults with ADHD. Participants wereadults with ADHD who had been stabilized on medica-tion but still showed clinically significant symptoms.Those who received CBT plus continued pharmacologyhad significantly lower symptoms of ADHD, anxiety,and depression and higher ratings of overall functioningthan did those who continued pharmacology alone.Finally, Rostain and Ramsay (2006) examined the effi-cacy of a combined treatment approach for adults withADHD using a 6-month course of concurrent pharma-cotherapy and CBT. Results demonstrated significantimprovements in symptoms of ADHD, anxiety, depres-sion, and overall functioning. These studies provide pre-liminary evidence for the use of CBT with adult ADHD,but control trials are required to examine the effects ofCBT relative to appropriate control conditions.

Self-management skills training or environmentalrestructuring. Skill-building training can also play animportant role in reducing ADHD symptoms and in rein-forcing gains in adults (M. D. Weiss & Weiss, 2004). Thedevelopment of self-management skills and the use ofenvironmental restructuring can help incorporate morestructure, routine, and organization into daily living(Murphy, 2005). Hesslinger et al. (2002) conducted agroup skill-based training program for adults withADHD and found that treatment was associated with sig-nificant improvements in ADHD symptoms, depressivesymptoms, and ratings of personal health.

Psychoeducation. Psychoeducation is an integral partof treatment, and bibliotherapy in particular can be use-ful in answering questions from patients and theirfamilies (M. D. Weiss & Weiss, 2004). In fact, afterreceiving a diagnosis, education about the effects ofADHD is almost universally agreed on as a starting pointfor ADHD psychosocial treatment (Ramsay & Rostain,2007). Adults with ADHD can learn more about the dis-order and how it affects them specifically, which can aidin their ability to cope with the disorder and the devel-opment of individualized treatment plans (Murphy,2005).

Psychotherapy. Individual psychotherapy generallycomprises a number of components, including psychoe-ducation, the setting of treatment goals and establish-ment of strategies to meet those goals, problem solving,and dealing with the comorbid problems that oftenaccompany ADHD (Barkley, 2006; Murphy, 2005).Family and marital or couples therapy from an ADHDperspective can help others gain an understanding ofADHD behaviors, as the disorder can be quite disruptiveto the routine tasks of daily living and can be damagingto couple and family functioning. Such a focus may alsohelp others understand that the ADHD adult’s behavior

may not stem from willful wrongdoing and lack of car-ing (Barkley, 2006; Murphy, 2005).

Vocational counseling. Symptoms of ADHD can sig-nificantly impair workplace performance. Impulsivity,inattention, disorganization, careless mistakes, poor timemanagement, and inconsistency can all lead to employ-ment difficulties. Vocational counseling can help allevi-ate occupational difficulties by identifying strengths andlimitations and by matching adults to jobs that are wellsuited for them (Barkley, 2006; M. D. Weiss & Weiss,2004).

ADHD coaching. A personal ADHD coach aids thepatient in identifying goals and strategies to meet thesegoals. Coaching is different from traditional therapy inseveral ways, most notably in its focus on implementa-tion of the client’s goals. Therapy can focus on insightand understanding, but coaching is more about actionand getting things done (Favorite, 1995).

Conclusion

ADHD is a lifelong neurobiological disorder that pre-sents significant challenges to adults. Two importantclinical diagnostic issues have been highlighted in thisreview. First, there are important differences between thechild and adult presentation of the disorder. As childrenwith ADHD grow into adolescence and adulthood, thereis generally an overall reduction of ADHD symptoms inwhich hyperactive–impulsive symptoms decline andinattentive symptoms persist. Second, the DSM-IV crite-ria for ADHD must be cautiously used in adults, as thesecriteria were designed for and selected based on studieswith school-aged children.

The assessment of ADHD in adults is often challengingand complex, particularly given the fact that no litmus testfor diagnosing the disorder exists. Thus, to increase diag-nostic accuracy, an assessment should be comprehensiveand include the use of symptom rating scales, interviews,and neuropsychological testing and the corroboration ofpatient reports with at least one other source who knowsthe individual well (Barkley, 2006; M. D. Weiss & Weiss,2004; Wilens et al., 2004). Although the diagnosis ofADHD in adults can be both reliable and valid, there is astrong need for the development of specific diagnostic cri-teria that are more sensitive and specific to adult function-ing than are the existing criteria.

There exists a range of treatment options—both phar-macological and psychosocial—for adults with ADHD.In terms of pharmacological interventions, the stimulantsmethylphenidate and amphetamine and the antidepres-sants desipramine and atomoxetine appear to have the






strongest empirical support in the treatment of adult ADHD.Further controlled investigations of pharmacologicalagents in adults with ADHD are necessary. With respectto psychosocial interventions, there is preliminary evi-dence supporting the combination of CBT and medication.However, studies utilizing more rigorous methodology areneeded to corroborate their positive results. Aside fromthese studies, there is virtually no research on psychoso-cial treatments for ADHD. Researchers must begin tosystematically examine the utility and effectiveness ofsuch treatments. Finally, formal guidelines—similar tothose set out for children—for the treatment of ADHD inadults are needed.

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Megan A. Davidson, MA, is a doctoral candidate in theClinical Psychology Program at Queen’s University. Her clin-ical interests focus on health psychology, and her researchinterests include assessment and treatment of adult ADHD,perceptions of health risk, and assessment of chronic pain.




literature review: adhd in adults: a review of the literature

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