Head To Head

Is ADHD a valid diagnosis in adults? Yes

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c549 (Published 26 March 2010) Cite this as: BMJ 2010;340:c549
  1. Philip Asherson, professor of molecular psychiatry and honorary consultant psychiatrist1,
  2. Marios Adamou, consultant psychiatrist2,
  3. Blanca Bolea, consultant psychiatrist and honorary lecturer3,
  4. Ulrich Muller, university lecturer and honorary consultant psychiatrist4,
  5. Susan Dunn Morua, founder and chairwoman adult attention deficit disorder UK (AADD-UK)5,
  6. Mark Pitts, clinical nurse specialist6,
  7. Johannes Thome, professor of psychiatry7,
  8. Susan Young, senior lecturer in clinical forensic psychology and consultant clinical and forensic psychologist8
  1. 1MRC Social Genetic and Developmental Psychiatry, Institute of Psychiatry, King’s College London SE5 8AF
  2. 2Service for adults with ADHD, Manygates Clinic, South West Yorkshire Partnership NHS Foundation Trust, Yorkshire WF1 5PN
  3. 3University of Bristol, Bristol Adult ADHD Clinic, Avon and Wiltshire Partnership Mental Health Trust, Bristol BS2 8HW
  4. 4Adult ADHD Research Clinic, Department of Psychiatry, University of Cambridge/Cambridgeshire and Peterborough NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge CB2 2QQ
  5. 5Adult Attention Deficit Disorder UK (AADD-UK), London SW15 6NP and Bristol BS40 7RT
  6. 6Adult ADHD Service, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London SE5 8AZ
  7. 7Swansea Medical School, University of Wales, Swansea SA2 0GH
  8. 8Department of Forensic Mental Health Science, Institute of Psychiatry, King’s College London, London SE5 8AF
  1. Correspondence to: P J Asherson philip.asherson{at}kcl.ac.uk

    Philip Asherson and colleagues argue that the concept of ADHD in adults is valid but Joanna Moncrieff and Sami Timimi (doi:10.1136/bmj.c547) believe that it is supported by little more than aggressive marketing

    Attention deficit hyperactivity disorder (ADHD) is well established in childhood, with 3.6% of children in the United Kingdom being affected.1 Most regions have child and adolescent mental health or paediatric services for ADHD. Follow-up studies of children with ADHD find that 15% still have the full diagnosis at 25 years, and a further 50% are in partial remission, with some symptoms associated with clinical and psychosocial impairments persisting.2

    ADHD is a clinical syndrome defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, by high levels of hyperactive, impulsive, and inattentive behaviours in early childhood that persist over time, pervade across situations, and lead to notable impairments. ADHD is thought to result from complex interactions between genetic and environmental factors.3

    Proof of validity

    Using the Washington University diagnostic criteria, the National Institute for Health and Clinical Excellence (NICE) reviewed the validity of the system used to diagnose ADHD in children and adults.4 5

    Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are found to cluster together in both clinical and population samples. Studies in such samples also separate ADHD symptoms from conduct problems and neurodevelopmental traits. Twin studies show a distinct pattern of genetic and environmental influences on ADHD compared with conduct problems,6 and overlapping genetic influences between ADHD and neurodevelopmental disorders such as autism and specific reading difficulties.7 8 Disorders that commonly, but not invariably, occur in adults with ADHD include antisocial personality, substance misuse, and depression.4

    Symptoms of ADHD are continuously distributed throughout the population.9 As with anxiety and depression, most people have symptoms of ADHD at some time. The disorder is diagnosed by the severity and persistence of symptoms, which are associated with high levels of impairment and risk for developing co-occurring disorders. ADHD should not be diagnosed to justify the use of stimulant drugs to enhance performance in the absence of a wider range of impairments indicating a mental health disorder.4

    ADHD symptoms have been tracked from childhood through adolescence into adult life. They are relatively stable over time with a variable outcome in which around two thirds show persistence of symptoms associated with impairments.2 10 11 Current evidence defines the syndrome as being associated with academic difficulties, impaired family relationships, social difficulties, and conduct problems. Cross sectional and longitudinal follow-up studies of adults with ADHD have reported increased rates of antisocial behaviour, drug misuse, mood and anxiety disorders, unemployment, poor work performance, lower educational performance, traffic violations, crashes, and criminal convictions.4

    Several genetic,12 environmental,13 and neurobiological variables distinguish ADHD from non-ADHD cases at group level, but are not sufficiently sensitive or specific to diagnose the syndrome. A family history of ADHD is the strongest predictor—parents of children with ADHD and offspring of adults with ADHD are at higher risk for the disorder. Heritability is around 76%,12 and genetic associations have been identified.14 Consistently reported associations include structural15 and functional brain changes,15 16 17 18 19 and environmental factors (such as maternal stress20 during pregnancy and severe early deprivation21).

    The effects of stimulants and atomoxetine on ADHD symptoms in adults are similar to those seen in children.4 22 23 Improvements in ADHD symptoms and measures of global function are greater in most studies than are reported in drug trials of depression. The longest controlled trial of stimulants in adults showed improvements in these response measures over six months.24 Stimulants may enhance cognitive ability in some people who do not have ADHD, although we are not aware of any placebo controlled trials of the effects of stimulants on work or study related performance in healthy populations. This should not, however, detract from their specific use to reduce symptoms and associated impairments in adults with ADHD.25

    Psychological treatments in the form of psychoeducation, cognitive behavioural therapy, supportive coaching, or help with organising daily activities are thought to be effective.26 Further research is needed because the evidence base is not strong enough to recommend the routine use of these treatments in clinical practice.

    Conclusions

    ADHD is an established childhood syndrome that often (in around 65% of cases) persists into adult life. NICE guidelines are a milestone in the development of effective clinical services for adults with ADHD. Recognition of ADHD in primary care and referral to secondary or tertiary care specialists will reduce the psychiatric and psychosocial morbidity associated with ADHD in adults.4

    Notes

    Cite this as: BMJ 2010;340:c549

    Footnotes

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf and declare (1) No financial support for the submitted work; (2) PA, MA, BB, UM, JT, SY were consultants for Janssen-Cilag. PA, SY, and JT were consultants for Eli-Lilly. PA and SY were consultants for Shire. PA was a consultant for Flynn Pharma, PA has received grants from Shire, Wellcome Trust, US National Institute of Mental Health, National Institute of Health Research, and Janssen-Cilag. UM has received grants from Janssen-Cilag, Medical Research Council, and Wellcome Trust. PA developed educational programmes for Janssen-Cilag and Shire. PA and SY gave educational talks at meetings sponsored by Janssen-Cilag, Shire, and Flynn-Pharma. UM gave educational talks at meetings sponsored by Bristol-Myers Squibb, Eli-Lilly, Janssen-Cilag, Pharmacia Upjohn, and UCB Pharma. JT has given educational talks at meetings sponsored by Janssen-Cilag and Eli-Lilly. SDM received travel expenses from Janssen-Cilag. PA and SY were members of the NICE guideline development group for ADHD. PA, SY, JT, UM, BB, MA, and MP are board members of the UK Adult ADHD Network (UKAAN), a non-profit organisation providing support and training for UK clinicians in the delivery of clinical services to adults with ADHD. SDM acts in an advisory capacity to UKAAN and is a user representative who runs a local and national support group. All authors declare that they have no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References

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