European Consensus Statement on Diagnosis and Treatment of Adult ADHD: The European Network Adult ADHD

Sandra JJ Kooij; Susanne Bejerot; Andrew Blackwell; Herve Caci; Miquel Casas-Brugué; Pieter J Carpentier; Dan Edvinsson; John Fayyad; Karin Foeken; Michael Fitzgerald; Veronique Gaillac; Ylva Ginsberg; Chantal Henry; Johanna Krause; Michael B Lensing; Iris Manor; Helmut Niederhofer; Carlos Nunes-Filipe; Martin D Ohlmeier; Pierre Oswald; Stefano Pallanti; Artemios Pehlivanidis; Josep A Ramos-Quiroga; Maria Rastam; Doris Ryffel-Rawak; Steven Stes; Philip Asherson

Disclosures

BMC Psychiatry. 2010;10(69) 

In This Article

Clinical Picture of ADHD in Adults

Definition of ADHD

The two most frequently used diagnostic terms to describe the condition in childhood are attention-deficit/hyperactivity disorder (ADHD) and hyperkinetic disorder (HKD). For both definitions the disorder is defined as a clinical syndrome characterised by the presence of developmentally inappropriate levels of inattention, hyperactivity and impulsivity, starting in childhood and leading to impairment. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for ADHD as defined by the American Psychiatric Association are the most widely used criteria and describe three subtypes of ADHD based on the predominant symptom pattern: inattentive type, hyperactive-impulsive type and the combined type.[112] The International Classification of Diseases (ICD-10) criteria for HKD as defined by the World Health Organisation (WHO) are more conservative and define a severe subgroup of people fulfilling the ADHD combined type diagnosis.[113] This results in a lower estimated prevalence of HKD (about 1%) compared to the prevalence estimates of 4–8% for ADHD in childhood.[114] ICD-10 criteria also exclude the presence of common co-occurring disorders including anxiety or depression[115] that are allowed under the DSM-IV definition of ADHD.

The next edition of the DSM (version 5) now in preparation is due to be published in 2013 and the revised ICD (version 11) for 2015. The revised DSMV criteria are expected to follow similar lines to the current criteria with the following expected changes http://www.dsm5.org :

  1. Symptom thresholds: For older adolescents and adults (aged 17 and above) only 4 symptoms in either the inattentive or hyperactive-impulsive domain are required.

  2. The list of hyperactive-impulsive symptoms has been increased to 13 to include 'uncomfortable doing things slowly or carefully', 'is often impatient', 'difficult to resist temptations or opportunities' and 'tends to act without thinking'.

  3. Descriptions of symptom items have been elaborated to include more specific descriptions of behaviour, some of which are more applicable to adults.

  4. The age of onset criteria has been broadened to include 'noticeable inattentive or hyperactive-impulsive symptoms by the age of 12 years'.

  5. The requirement for clear evidence of impairment from the symptoms is a key part of the diagnostic criteria, but is no longer required before the age of 12 years or younger.

  6. Autism spectrum disorder is no longer listed as an exclusion criterion.

These changes recognise that impairment from the symptoms of ADHD may develop later in life and that in some cases symptoms cannot be clearly identified until the early adolescent years. The reduction in the symptom threshold for adults as compared to children recognises the age-dependent changes in the course of the disorder, since the lower threshold in adults is still clinically significant where there is clear evidence of impairment from the symptoms of ADHD; and better reflects the characteristics and natural course of the disorder. These changes mean that many people who previously met the 'in partial remission criteria' will meet full criteria for ADHD under the revised DSM-V (see below for further discussion).

Clinical Presentation in Adults

Whereas the core symptoms of hyperactivity, impulsivity and inattention, are well characterised in children, these symptoms may have different and more subtle expressions in adult life. Comparison with the normal behaviour of age, gender and cognitive ability matched groups must be taken into account. For instance, where children with ADHD may run and climb excessively, or have difficulty in playing or engaging quietly in leisure activities, adults with ADHD are more likely to experience inner restlessness, inability to relax, or over talkativeness. Hyperactivity may also be expressed as excessive fidgeting, the inability to sit still for long in situations when sitting is expected (at the table, in the movie, in church or at symposia), or being on the go all the time. Impulsivity may be expressed as impatience, acting without thinking, spending impulsively, starting new jobs and relationships on impulse, and sensation seeking behaviours. Inattention often presents as distractibility, disorganization, being late, being bored, need for variation, difficulty making decisions, lack of overview, and sensitivity to stress. In addition, many adults with ADHD experience lifetime mood lability with frequent highs and lows, and short-fuse temper outburst.[35,37,116–118] Typically, adults with ADHD will not settle after the age of 30 but continue to change and/or lose jobs and relationships, either through boredom or being fired. They are usually underachievers with an estimated annual twenty two days of excess lost role performance.[119–122] As a consequence relationships and jobs are often short lived. Relationships that last are often impaired due to the inability to listen with concentration to the spouse, not finishing or procrastinating tasks, often being on a 'short fuse' and interrupting conversations.[123] Driving accidents are increased in young adults with ADHD as a result of being distracted, impulsive and having an increased need for stimulation.[124–127] ADHD patients are also more likely to be subjected to other accidents like dog-bites and burns, and display an unhealthy lifestyle: smoking, alcohol and drug abuse, riskier sexual lifestyle, a delayed rhythm due to chronic sleep problems, lack of structure and inappropriate healthcare.[128–132] Criminality in adulthood is predicted by ADHD and comorbid conduct disorder in childhood, especially with substance abuse and antisocial personality disorder in adulthood. Among male prisoners, ADHD was found to be strongly related to the number of critical incidents involving aggression and poorly controlled behaviour even after controlling for the presence of antisocial personality disorder.[133] ADHD patients are significantly more arrested, convicted, and incarcerated compared to normal controls, and ADHD is increasingly diagnosed in adults in forensic psychiatry.[134–137]

An additional burden on family life may be the presence of one or more children with ADHD, which happens frequently due to the high familial risks of the disorder. Adults with ADHD are at risk for poorer parent-child relationships.[138] Inattention problems often lead to inability to complete independent academic work, resulting in underachievement at school, during study and in the workplace compared to their peer group with equivalent cognitive ability. Therefore many have lower financial resources.[17,18,139–141] Many feel isolated and lonely due to social handicaps and shame about failures. They may have less success with personal growth, lower ability to present themselves in a socially appropriate fashion and lower mental and physical well-being, even in the presence of a high IQ.[8,121,142–144]

The clinical picture of ADHD is also coloured by frequent co-morbidity. In childhood, as many as 65% of children with ADHD have one or more co-morbid conditions, including oppositional defiant and conduct disorder, anxiety and mood disorders, tics or Tourette syndrome, learning disorders and pervasive developmental disorders (e.g. autism).[145–147] Similarly in adults, co-morbidity is the rule, with 75% of clinical patients having at least one other disorder, and the mean number of psychiatric comorbidities being three.[41,148] Mood, anxiety, sleep, personality and substance use disorders are found, as well as learning and other neurodevelopmental disorders.[22,37,41,121,144,148–152] ADHD has also been associated with earlier onset of substance abuse.[153] In adults with ADHD, gambling and other addictions are very common.[27,154–158]

Gender Issues

As boys dominate clinical samples of ADHD in childhood, female manifestations and gender differences have been relatively neglected in research as well as clinical practice.[159–162] In childhood ADHD is identified far more frequently in boys than girls with around a one in five ratio in most studies. However, the differences in prevalence and diagnostic rates according to gender become far less skewed with age, as more females are identified and become diagnosed in adulthood;[17,161,163,164] and in some adult clinical series female cases may predominate.

Several factors may explain these observations. In childhood, girls may have less externalizing problems than boys: they suffer more from internalizing problems, chronic fatigue and inattention while boys may be more hyperactive and more aggressive.[165,166] Girls show lower rates of hyperactivity and comorbid conduct disorder than males, and more frequently have the inattentive subtype of ADHD, with a later onset of impairment.[162,167] For these reasons, general practitioners and health care professionals are less aware of ADHD in girls and they are thus less likely to be referred for treatment.[168] In adulthood, the higher prevalence of anxiety and depressive disorders in women may conceal underlying ADHD and influence diagnosis and treatment. As more women seek help from psychiatrists than men, the change in referral pattern may also contribute to the change in gender ratio within clinical populations.[169]

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