The State of Adult ADHD Today

April 20, 2024

The diagnostic criteria for ADHD are largely based on studies of young white boys. The symptoms spelled out in the DSM-5 — i.e., Is often “on the go” acting as if “driven by a motor” — do not reflect the lived experiences of many adults with the condition. This gap between clinical guidance and real-life symptoms has contributed to a decades-long problem with misdiagnosis, missed diagnoses, and inadequate treatment for individuals who slipped under the ADHD radar in childhood.

ADHD persists into adulthood for up to 90% of children with the condition. Symptoms evolve and change, but they do not magically disappear. In fact, the Centers for Disease Control and Prevention calls ADHD a “public health concern” with long-term repercussions. The longevity of ADHD is confirmed by scientific research, as is the fact that three boys are diagnosed with ADHD for every one girl with the condition. As a result, we now have a surging population of adults seeking a first-time diagnosis for lifelong symptoms of ADHD that may have become more debilitating, or at least distressing, with age.

“It’s not that ADHD symptoms necessarily get worse with age,” said David Goodman, M.D., assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine, during an ADDitude webinar in April 2024. “But when you are younger, ADHD symptoms are disruptive and inconvenient to others; as you age, ADHD symptoms become disruptive and inconvenient to you.”

Pent-up demand for ADHD evaluations among adult patients continues to grow, yet clinicians today have no reliable, standardized metrics for evaluating those symptoms. The DSM-5 contains some guidance for diagnosing adults, but it is controversial and largely considered inadequate. In addition, only 33% of pediatricians, 30% of family practitioners, 25% of nurse practitioners, and 22% of internists said that they received adequate training on ADHD in medical school, according to data presented by the American Professional Society of ADHD and Related Disorders (APSARD) at its 2024 conference.

“ADHD is the second most common psychiatric disorder in adults, but it is rarely focused on” by health care providers, Goodman said during the ADDitude webinar, titled “ADHD in Older Adults: Clinical Guidance and Implications.” “Older patients should not be easily discounted as having age-related cognitive decline and dismissed.”

First-Ever Adult ADHD Guidelines

APSARD is working to remedy this huge obstacle to care. In 2023, it established a 27-member task force that is devising clinical practice guidelines for the diagnosis and treatment of ADHD in adults. According to Goodman, who is leading the medical subcommittee for the task force, the adult ADHD guidelines have the greatest chance at widespread adoption if they are research based, clinically informed, and patient focused.

However, few research studies exist on adults over the age of 50, women, people of color, and minority populations, such as autistic adults with ADHD. If the APSARD guidelines are built on a framework of scientific research, and little, if any, unbiased scientific research exists on huge populations of patients, how thorough or helpful can those guidelines be?

“I wouldn’t say that we are going to write ‘good’ guidelines,” Goodman said during a presentation at the annual APSARD conference in January 2024, “because ‘good’ is defined in the present as what is supported by evidence. We are setting a basic standard of care… these guidelines will evolve as we learn more.”

Even so, APSARD’s clinical practice guidelines for ADHD in adults stand to impact far more than diagnosis and treatment rates. Some experts believe that formal guidelines based on high-quality scientific evidence will compel insurance companies to fully cover the medical treatment of ADHD in adults, which is seldom the case now. Others believe the guidelines could influence nationwide quotas for Schedule II controlled substances set by the Drug Enforcement Administration (DEA), opening the door for greater availability of stimulant medications used to treat ADHD. And many advocates are hopeful that adult ADHD guidelines will contribute to greater public awareness, better medical training, less stigma, and improved mental health outcomes for patients.

The adult guidelines, which are slated for release in late 2024 or early 2025, will take into consideration many of ADHD’s major comorbid conditions, according to committee member Frances Levin, M.D., of the Columbia University Irving Medical Center. Levin confirmed that her subcommittee is meeting with subject-matter experts on substance abuse, depression, and bipolar disorder, among other ADHD-related conditions.

For each psychiatric comorbidity diagnosed alongside ADHD, a patient’s risk of premature death rises exponentially, according to Goodman. The risk of premature death is 1.56 times higher for an adult with ADHD compared to one without ADHD, and it is 29.29 times higher for an adult with ADHD and four comorbid conditions, he said, citing a 2019 study published in JAMA Psychiatry.¹

The Concept of Subthreshold ADHD

The notion of “subthreshold” ADHD was introduced by task force members at the APSARD conference as well. Subthreshold ADHD may not meet the necessary DSM-5 criteria for a diagnosis in childhood, but mild symptoms may become severe due to the stress of parenthood or the hormonal swings that accompany menopause, said Maggie Sibley, Ph.D., head of the diagnosis and assessment subcommittee. People with subthreshold ADHD may not exhibit impairing symptoms before age 12, as required in the current DSM-5 for a diagnosis. However, these undiagnosed, untreated adults may experience significant distress later in life and face an elevated risk for substance abuse, burnout, and professional and personal problems as a result, Sibley argued during a presentation at the 2024 APSARD conference.

“People with subthreshold ADHD may be massively impaired even though they don’t quite meet the criteria for a diagnosis,” said Stephen Faraone, Ph.D., a distinguished professor in the Departments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University, during the APSARD presentation.

Citing 2022 research showing that 63.8% of people with ADHD experienced symptom fluctuations throughout their lives, Sibley said, “We need to recognize that ADHD symptoms are not stable; they wax and wane over the lifespan.”²

Removing or adjusting the DSM requirement that ADHD symptoms must be present before age 12 is one way to improve diagnosis and treatment. Another approach may be to expand the symptom criteria for adult ADHD to include emotional dysregulation, a common and impairing ADHD trait not currently included in the DSM-5. Some experts like Anthony Rostain, M.D., point out that “other DSM disorders allow ‘suffering’ or ‘distress’” due to persistent symptoms as justification for a diagnosis, “but an ADHD diagnosis requires impairment. Can we use impairment or distress instead?”

Implications for Treatment and Care

Though the APSARD task force is squarely focused on developing clinical practice guidelines for the diagnosis and treatment of ADHD in adults, it will also likely “address the issue of prescriptions for older adults with ADHD,” Goodman said. A primary concern is the safety of stimulant medication use among older adults, and the risk for introducing or exacerbating cardiovascular problems. In 2023, JAMA published a meta-analysis of 19 observational studies, involving 3.9 million participants, that found ADHD medications — both stimulants and non-stimulants — do not place patients of any age at greater risk for cardiovascular events, including heart failure and hypertension. The study found that there was no statistically significant association between ADHD medications and cardiovascular disease (CVD), even among middle-aged and older adults.³ Still, some prescribers hesitate or refuse to prescribe ADHD medications to patients older than age 50.

Perhaps surprisingly, the average duration of treatment for adults with ADHD is currently just seven months, said APSARD Past President Ann Childress, M.D., during a presentation on the topic of treatment barriers for adults with ADHD. More than half of adults stop taking their ADHD medication due to “suboptimal management of ADHD symptoms,” she said, citing a 2022 study published in BMC Psychiatry.⁴ 

To reverse this trend, Childress suggested greater clinician education regarding the benefits of long-acting stimulant medication for patients who would benefit from symptom control in professional and personal settings. Currently, 48% of adult ADHD patients are taking a short-acting stimulant, said APSARD President Greg Mattingly, M.D., an associate clinical professor at Washington University School of Medicine. Mattingly reported during an APSARD presentation that long-acting stimulants, sometimes in combination with a non-stimulant medication, are more effective for many of his patients.

APSARD is partnering with Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) to develop clinical tools based on the forthcoming adult ADHD guidelines that clinicians can use to aid the evaluation process, Goodman said.

Mattingly added that ADHD screenings should become a routine part of annual doctors’ visits.

“Five years ago, 20% of pediatricians were screening for depression, and now it is a ubiquitous quality measure,” he said. “ADHD screening has a higher rate of reliability, and it can be a quality measure, too.”

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