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ADHD in Adults: Does Age at Diagnosis Matter?

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Title: ADHD in Adults: Does Age at Diagnosis Matter?
Language: English
Authors: Chloe Hutt Vater, Maura DiSalvo, Alyssa Ehrlich, Haley Parker, Hannah O'Connor (ORCID 0009-0002-7968-1090), Stephen V. Faraone (ORCID 0000-0002-9217-3982), Joseph Biederman
Source: Journal of Attention Disorders. 2024 28(5):614-624.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 11
Publication Date: 2024
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
Contract Number: U01AR07609201A1
1R21MH1264940
R01MH116037
1R01NS12853501
Document Type: Journal Articles
Reports - Research
Descriptors: Attention Deficit Hyperactivity Disorder, Age Differences, Clinical Diagnosis, Adults, Children, Individual Characteristics, Symptoms (Individual Disorders), Executive Function, Educational Attainment, Individual Differences, Behavior, Validity
DOI: 10.1177/10870547231218450
ISSN: 1087-0547
1557-1246
Abstract: Objective: To provide additional information about clinical features associated with adult ADHD in patients diagnosed in childhood compared to those first diagnosed in adulthood. Method: We stratified a sample of adults with ADHD into patients diagnosed in childhood versus adulthood and compared demographic and clinical characteristics. Results: We found similar clinical features in adults diagnosed in childhood and adults diagnosed in adulthood. Among those diagnosed in adulthood, 95% reported symptom onset in youth. Our results do not support the hypothesis that ADHD diagnosed in adulthood is due to misinterpreting symptoms of other disorders as ADHD. They also suggest incorporating behavioral signs of executive dysfunction into diagnostic criteria for ADHD in adults may increase diagnostic sensitivity. Conclusion: These results support the validity of ADHD diagnoses in adulthood, as these adults show similar clinical profiles to those diagnosed in youth. Our results also suggest that if adult-onset ADHD exists, it is rare.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1440579
Database: ERIC
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  Value: <anid>AN0175968770;gs001mar.24;2024Mar14.04:50;v2.2.500</anid> <title id="AN0175968770-1">ADHD in Adults: Does Age at Diagnosis Matter? </title> <p>Objective: To provide additional information about clinical features associated with adult ADHD in patients diagnosed in childhood compared to those first diagnosed in adulthood. Method: We stratified a sample of adults with ADHD into patients diagnosed in childhood versus adulthood and compared demographic and clinical characteristics. Results: We found similar clinical features in adults diagnosed in childhood and adults diagnosed in adulthood. Among those diagnosed in adulthood, 95% reported symptom onset in youth. Our results do not support the hypothesis that ADHD diagnosed in adulthood is due to misinterpreting symptoms of other disorders as ADHD. They also suggest incorporating behavioral signs of executive dysfunction into diagnostic criteria for ADHD in adults may increase diagnostic sensitivity. Conclusion: These results support the validity of ADHD diagnoses in adulthood, as these adults show similar clinical profiles to those diagnosed in youth. Our results also suggest that if adult-onset ADHD exists, it is rare.</p> <p>Keywords: ADHD; adults; diagnosis; onset</p> <hd id="AN0175968770-2">Introduction</hd> <p>Many adult patients being evaluated for ADHD have never had a diagnosis of the disorder when they were children or adolescents. This raises difficulties for the diagnostic process because the diagnostic criteria for the disorder require onset of some impairing symptoms in childhood. In the absence of a childhood diagnosis, documenting childhood onset can be challenging due to the age dependent decline in symptoms of ADHD ([<reflink idref="bib19" id="ref1">19</reflink>]), poor recall of adults with ADHD about childhood symptoms ([<reflink idref="bib32" id="ref2">32</reflink>]), lack of informants who know the patient in childhood, the possibility that patients are feigning to seek a drug of addiction ([<reflink idref="bib20" id="ref3">20</reflink>]), and the challenges of making diagnoses in primary care, where most adults must be treated and where the time allocated for diagnosis is brief ([<reflink idref="bib14" id="ref4">14</reflink>]; [<reflink idref="bib17" id="ref5">17</reflink>]; [<reflink idref="bib21" id="ref6">21</reflink>]).</p> <p>Diagnosing ADHD in adulthood has also been complicated by claims that most ADHD in adulthood is adult onset ADHD and most childhood ADHD remits in adulthood ([<reflink idref="bib18" id="ref7">18</reflink>]). Several studies show that when ADHD apparently onsets in adulthood, the patient experienced subthreshold symptoms of the disorder in youth and also had increased rates of other mental disorders in childhood ([<reflink idref="bib4" id="ref8">4</reflink>]; [<reflink idref="bib15" id="ref9">15</reflink>]; [<reflink idref="bib24" id="ref10">24</reflink>]; [<reflink idref="bib34" id="ref11">34</reflink>]; [<reflink idref="bib37" id="ref12">37</reflink>]). [<reflink idref="bib15" id="ref13">15</reflink>] studied referred adults who retrospectively reported ADHD symptoms in childhood and met criteria for ADHD in adulthood. The authors concluded that the diagnoses made in adulthood were valid based on retrospectively reported clinical features and evidence of familial transmission. One-third of the adults studied also had childhood histories of oppositional defiant disorder, conduct disorder, and school failure ([<reflink idref="bib15" id="ref14">15</reflink>]).</p> <p>[<reflink idref="bib4" id="ref15">4</reflink>] conducted a literature review of studies assessing the validity of late-onset ADHD (i.e., onset after age 12 years) based on prospective assessments of ADHD symptoms from childhood into later life. A significant proportion of adult ADHD cases did not meet full diagnostic criteria in childhood but had some ADHD symptoms or externalizing disorders, such as oppositional defiant disorder, in childhood. The authors concluded that the emergence of ADHD symptoms in later life rarely occurs in the absence of precursors ([<reflink idref="bib4" id="ref16">4</reflink>]). Moreover, most of the late-onset cases developed the disorder between 12 and 16 years of age, consistent with [<reflink idref="bib18" id="ref17">18</reflink>] hypothesis that onsets of ADHD in adulthood should be rare.</p> <p>[<reflink idref="bib24" id="ref18">24</reflink>] conducted a longitudinal population-based study and found that childhood clinical features and familial history of ADHD significantly predicted both childhood persistent ADHD and late-onset ADHD. A cohort study of 15,436 individuals found an overall ADHD prevalence of 4.29% (<emph>N</emph> = 662). Of those with ADHD, 194 (1.26%) were diagnosed before age 12 years, 394 (2.55%) were diagnosed between ages 12 to 18 years, and 74 (0.48%) were diagnosed after age 18 years ([<reflink idref="bib37" id="ref19">37</reflink>]). However, only 9 (0.12%; 6 female) of the 74 individuals diagnosed with ADHD in adulthood did not have discernible neuropsychiatric symptoms as children. Notably, 66% of those with adult ADHD symptoms and no reported childhood psychopathology were female. The majority (<emph>N</emph> = 65, 88%) of adult-onset cases presented with a milder degree of symptoms during childhood that did not warrant clinical attention. Those with adult-onset ADHD were also more likely to have been diagnosed with a different disorder as children. Those with a community diagnosis of ADHD in adulthood demonstrated an average increase in childhood ADHD symptoms roughly three times that of the control group. Adult-diagnosed ADHD was also associated with increased co-morbid symptoms, including autistic traits, motor problems, learning difficulties, tics, and oppositional behavior ([<reflink idref="bib37" id="ref20">37</reflink>]).</p> <p>Another complication when diagnosing ADHD in adults is the potential for recall bias. Adult recollection of childhood ADHD symptoms is often poor, with low predictive validity when symptoms are endorsed retrospectively ([<reflink idref="bib27" id="ref21">27</reflink>]). In a group of adult individuals where the prevalence for ADHD was 5.6%, 162 individuals endorsed childhood symptoms when only 66 were true diagnosed cases, and 356 individuals negatively endorsed childhood symptoms when in fact 221 did not meet diagnostic criteria ([<reflink idref="bib13" id="ref22">13</reflink>]). Overall, the final prevalence rate of the group included 60% of false-positive cases, a high percentage due to poor recall ([<reflink idref="bib13" id="ref23">13</reflink>]). Recall is often poor among adults with ADHD because they often have impaired memory performance and difficulty with the knowledge of events and details regarding themselves. This can lead to false-negative diagnoses ([<reflink idref="bib31" id="ref24">31</reflink>]).</p> <p>[<reflink idref="bib36" id="ref25">36</reflink>] conducted a systematic review to evaluate the diagnostic validity of adult-onset ADHD as a distinct clinical entity. Nine studies were included in their review. Findings indicate insufficient methodologies and ambiguity surrounding the nature of late-onset symptoms. Although they found sufficient evidence that ADHD symptoms occur in adulthood, the underlying factors driving symptom onset and presentation were unclear. The authors highlight three sources of diagnostic uncertainty. First, childhood symptoms may not result in clinical attention. Second, substance use, trauma, concussions, acute medical conditions, or symptoms of other psychological disorders may mimic ADHD symptoms and lead to false positive diagnoses of ADHD. Third, adult-emergent ADHD (or subsyndromal childhood ADHD reaching diagnostic criteria in adulthood) could be due to epigenetic mechanisms through which environmental moderation and personal accommodation interact with underlying neurobiological and genetic factors to influence symptom onset and presentation. That is, lower environmental demands and supportive facilitators in childhood could delay onset of ADHD symptoms ([<reflink idref="bib36" id="ref26">36</reflink>]).</p> <p>The present study sought to provide additional information about the clinical features associated with adult ADHD in patients who have been diagnosed in childhood compared to those who were first diagnosed in adulthood. We hypothesized that differences in clinical features between these groups could yield insights into the validity of the later diagnoses and might provide clinicians with information useful in clarifying these diagnoses.</p> <hd id="AN0175968770-3">Methods</hd> <p></p> <hd id="AN0175968770-4">Sample</hd> <p>The sample comprised 134 adults who were 18 to 55 years of age of both sexes and clinically referred to the MGH Adult ADHD clinic for the evaluation and treatment of ADHD between June 2016 and April 2022. Included were patients who self-reported a previous diagnosis of ADHD during their clinic intake assessment. We confirmed ADHD diagnosis and age at which the patient was diagnosed using electronic medical records. Those with an unconfirmed diagnosis or missing age at diagnosis were excluded. There was no selection bias based on social class or insurance restrictions. We received institutional review board approval to review, analyze, and report anonymously on these subjects.</p> <hd id="AN0175968770-5">Assessment Procedures</hd> <p>Patients completed a battery of rating scales before their initial evaluation to assess common areas of difficulties in adults with ADHD. The assessment battery included the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A; [<reflink idref="bib30" id="ref27">30</reflink>]), the Adult Self Report (ASR; [<reflink idref="bib1" id="ref28">1</reflink>]), the Adult ADHD Self Report Scale (ASRS; [<reflink idref="bib22" id="ref29">22</reflink>], [<reflink idref="bib23" id="ref30">23</reflink>]), the Barkley Emotional Dysregulation Scale ([<reflink idref="bib5" id="ref31">5</reflink>], [<reflink idref="bib6" id="ref32">6</reflink>]), the Mind Wandering Questionnaire (MWQ; [<reflink idref="bib26" id="ref33">26</reflink>]), and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; [<reflink idref="bib16" id="ref34">16</reflink>]).</p> <p>The BRIEF-A is a 75-item patient-rated questionnaire to assess behavioral concomitants of EFDs within the past month ([<reflink idref="bib30" id="ref35">30</reflink>]). Raw scores are calculated and used to generate <emph>T</emph>-scores for nine scales, two summary index scales, and one total scale reflecting overall functioning. A <emph>T</emph>-score ≥65 (≥1.5 <emph>SD</emph>s) is used as the clinical cutoff in each domain.</p> <p>The ASR is a 126-item self-rated assessment of adult psychopathology, social competence, and substance use ([<reflink idref="bib1" id="ref36">1</reflink>]). Raw scores are calculated and used to generate <emph>T</emph>-scores for eight clinical scales, two composite scales, one total scale, six adaptive functioning scales, and three substance use scales. The clinical cutoffs are defined as <emph>T</emph>-scores ≥70 for the clinical scales and substance use scales, <emph>T</emph>-scores ≥64 for the composite and total scales, and <emph>T</emph>-scores ≤30 for the adaptive functioning scales.</p> <p>The ASRS is an 18-item patient-rated questionnaire to determine severity of ADHD symptoms ([<reflink idref="bib22" id="ref37">22</reflink>], [<reflink idref="bib23" id="ref38">23</reflink>]). Subdomain scores (Inattentive and Hyperactive/Impulsive) can range from 0 to 36, and patients with a score of ≥24 are highly likely to have ADHD.</p> <p>Because of emerging data documenting that a sizeable proportion of individuals with ADHD suffer from emotional dysregulation and, when present, it represents a source of added morbidity ([<reflink idref="bib7" id="ref39">7</reflink>]), we incorporated an assessment of emotional dysregulation using Barkley's Emotional Dysregulation Scale, a subset of eight questions from the Current Behavior Scale (CBS; [<reflink idref="bib5" id="ref40">5</reflink>], [<reflink idref="bib6" id="ref41">6</reflink>]). Total scores range from 0 to 24 and scores ≥8 are categorized as high-level emotional dysregulation ([<reflink idref="bib7" id="ref42">7</reflink>]).</p> <p>Likewise, because of the increasing recognition of mind wandering as another source of unique morbidity in ADHD ([<reflink idref="bib8" id="ref43">8</reflink>]), we assessed mind wandering using the MWQ, a 5-item scale that assesses mind wandering traits ([<reflink idref="bib26" id="ref44">26</reflink>]). Total scores range from 5 to 30 and scores ≥24 are categorized as high-level mind wandering ([<reflink idref="bib8" id="ref45">8</reflink>]).</p> <p>The assessment of quality of life relied on the Q-LES-Q, a self-rated 16-item rating scale to assess enjoyment and satisfaction levels in various areas of daily life ([<reflink idref="bib16" id="ref46">16</reflink>]). The total score is calculated by summing the first 14 items and scores can range from 14 to 70.</p> <p>In addition to the rating scales, patients completed forms regarding demographic characteristics, current treatments for ADHD and other psychiatric disorders, and previous psychiatric diagnoses.</p> <hd id="AN0175968770-6">Statistical Methods</hd> <p>We stratified the sample into patients who were diagnosed with ADHD in childhood (<18 years of age) versus adulthood (≥18 years of age). We compared demographic characteristics of these two groups using <emph>t</emph>-tests and Pearson's chi-square tests. Rates of clinical impairment on each rating scale and psychiatric medications were analyzed using logistic, exact logistic, or Firth logistic regression models. The total score on the Q-LES-Q was analyzed using a truncated Poisson regression model with a lower limit of 14 and an upper limit of 70 for truncation. Individual items on the Q-LES-Q were analyzed using ordinal logistic regression models. The number of impaired scales on the BRIEF and ASR were also analyzed using truncated Poisson regression models with upper limits for truncation of 9 and 8, respectively. We examined the moderating effects of age, gender, and medication status on the relationships between time of ADHD diagnosis (childhood vs. adulthood) and our functional outcomes by individually adding interaction terms (time of ADHD diagnosis-by-age, time of ADHD diagnosis-by-gender, and time of ADHD diagnosis-by-medication status) to each regression model. All analyses controlled for age at referral and gender given the significant differences between those diagnosed with ADHD in childhood versus adulthood. We also performed a sensitivity analysis restricting the group of patients with ADHD diagnosed in childhood to only those diagnosed ≤12 years of age and comparing them to all patients with ADHD diagnosed in adulthood (≥18). All tests were two-tailed and performed using Stata (Version 17.0; [<reflink idref="bib35" id="ref47">35</reflink>]). Tests were performed at the.05 alpha level for the primary analyses and at the.01 alpha level for analyses examining moderating effects of age, gender, race, and medication status. Descriptive statistics are presented as means ± standard deviations or counts and percentages.</p> <hd id="AN0175968770-7">Results</hd> <p>Of the 134 adults with ADHD, 56 (42%) were diagnosed in childhood (<18 years of age) and 78 (58%) were diagnosed in adulthood (≥18 years of age). Those with a childhood diagnosis had an average age of 11.3 ± 3.7 at ADHD diagnosis, while those with a diagnosis in adulthood had an average age of 25.8 ± 8.3 at ADHD diagnosis (<emph>p</emph> <.001). Information about onset of ADHD symptoms was available for 26 patients diagnosed in childhood and 54 patients diagnosed in adulthood. There was no significant difference between the two groups in onset of ADHD symptoms (<emph>p</emph> =.86), with most patients experiencing symptom onset between pre-school and middle school (Table 1).</p> <p>Graph</p> <p>Table 1. Demographic and ADHD Diagnosis Characteristics of Adult Patients Who Were Diagnosed With ADHD in Childhood Versus Adulthood.</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center">ADHD diagnosed in childhood <italic>N</italic> = 56</th><th align="center">ADHD diagnosed in adulthood <italic>N</italic> = 78</th><th align="center" rowspan="2"><italic>p</italic>-value</th></tr><tr><th /><th align="center"><italic>M</italic> ± <italic>SD</italic></th><th align="center"><italic>M</italic> ± <italic>SD</italic></th></tr></thead><tbody><tr><td>Age at referral</td><td>27.4 ± 7.1</td><td>32.2 ± 10.1</td><td>.003</td></tr><tr><td>Age at ADHD diagnosis</td><td>11.2 ± 3.7</td><td>26.4 ± 8.8</td><td><.001</td></tr><tr><td /><td>N (%)</td><td>N (%)</td><td /></tr><tr><td colspan="3">Age at ADHD diagnosis</td><td>n/a</td></tr><tr><td> ≤12</td><td>36 (64)</td><td>n/a</td><td /></tr><tr><td> 13–17</td><td>20 (36)</td><td>n/a</td><td /></tr><tr><td> ≥18</td><td>n/a</td><td>78 (100)</td><td /></tr><tr><td colspan="3">Onset of ADHD symptoms<xref ref-type="table-fn" rid="tfn1">‡</xref></td><td>.86</td></tr><tr><td> Pre-school</td><td>3 (12)</td><td>2 (4)</td><td /></tr><tr><td> Elementary school</td><td>8 (31)</td><td>14 (26)</td><td /></tr><tr><td> Early childhood</td><td>5 (19)</td><td>8 (15)</td><td /></tr><tr><td> Middle school</td><td>3 (12)</td><td>8 (15)</td><td /></tr><tr><td> Childhood</td><td>4 (15)</td><td>12 (22)</td><td /></tr><tr><td> High school</td><td>3 (12)</td><td>7 (13)</td><td /></tr><tr><td> College</td><td>0 (0)</td><td>2 (4)</td><td /></tr><tr><td> After college</td><td>0 (0)</td><td>1 (2)</td><td /></tr><tr><td>Male</td><td>27 (48)</td><td>24 (31)</td><td>.04</td></tr><tr><td colspan="3">Race</td><td>.66<xref ref-type="table-fn" rid="tfn2">†</xref></td></tr><tr><td> Asian; Native Hawaiian/Other Pacific Islander</td><td>0 (0)</td><td>7 (9)</td><td /></tr><tr><td> Black/African American</td><td>0 (0)</td><td>5 (6)</td><td /></tr><tr><td> Hispanic/Latino</td><td>3 (5)</td><td>4 (5)</td><td /></tr><tr><td> White/Caucasian</td><td>43 (77)</td><td>55 (71)</td><td /></tr><tr><td> More than one race</td><td>9 (16)</td><td>6 (8)</td><td /></tr><tr><td> Unknown/not reported</td><td>1 (2)</td><td>1 (1)</td><td /></tr></tbody></table> </ephtml> </p> <p>1 ADHD diagnosed in childhood: <emph>N</emph> = 26, ADHD diagnosed in adulthood: <emph>N</emph> = 54.</p> <p>2 Statistical test comparing distribution of three categories. Race: white/Caucasian versus not white/Caucasian versus unknown/not reported.</p> <hd id="AN0175968770-8">Demographic Characteristics</hd> <p>As expected, those with an ADHD diagnosis in childhood were significantly younger at referral compared to those with an ADHD diagnosis in adulthood (Table 1). Additionally, a significantly greater proportion of patients with an ADHD diagnosis in childhood were male compared to those with a diagnosis in adulthood (Table 1). There was no significant difference between the two groups in race distribution. All subsequent analyses control for age at referral and gender.</p> <hd id="AN0175968770-9">Current Medication Characteristics</hd> <p>There were no significant differences between those with an ADHD diagnosis in childhood and adulthood in rates of earlier ADHD treatment (Figure 1a). Among those who were previously treated, the average age at which ADHD treatment began was 11.4 ± 4.1 years for patients with a childhood diagnosis and 26.0 ± 9.0 years for patients with a diagnosis in adulthood (<emph>p</emph> <.001). Additionally, as shown in Figure 1b, there were no significant differences between those with an ADHD diagnosis in childhood and adulthood in rates of past antianxiety, mood stabilizer, or antipsychotic medications. While the rate of past antidepressant medications was lower in those with an ADHD diagnosis in childhood versus adulthood (13% vs. 28%), there was no statistically significant difference between the two groups (<emph>p</emph> =.1; Figure 1b). There were no significant differences between the two groups in rates of current psychiatric medications (Figure 1c).</p> <p>Graph: Figure 1. Past and current psychiatric medications of patients with ADHD diagnoses made in childhood and adulthood: (a) previous ADHD treatment, (b) other past psychiatric medications, and (c) current psychiatric medications.</p> <hd id="AN0175968770-10">Clinical Correlates</hd> <p>There were no significant differences between patients with an ADHD diagnosis in childhood and those with an ADHD diagnosis in adulthood in highest level of education (Figure 2a); rate of employment (Figure 2b); ADHD symptoms as measured by the ASRS (Figure 3a); psychopathology, social competence, and substance use as measured by the ASR (Figures 3b, c, and 4a); executive functioning as measured by the BRIEF (Figure 3d); rates of high-level mind wandering (Figure 4b); rates of high-level emotional dysregulation (Figure 4c); or in quality of life (Figure 4d).</p> <p>Graph: Figure 2. Education and employment in patients with ADHD diagnoses made in childhood and adulthood: (a) highest level of education and (b) employment status.</p> <p>Graph: Figure 3. Psychopathology and executive functioning in patients with ADHD diagnoses made in childhood and adulthood: (a) impairment on the ASRS,† (b) impairment on the ASR clinical and composite scales,† (c) impairment on the ASR substance use scales,† and (d) impairment on the BRIEF scales.† Note. A. ADHD Diagnosed in Childhood: N = 53, ADHD Diagnosed in Adulthood: N = 77; B. ADHD Diagnosed in Childhood: N = 52; C. ADHD Diagnosed in Childhood: N = 51–52, ADHD Diagnosed in Adulthood: N = 77–78; D. ADHD Diagnosed in Childhood: N = 53.†Smaller sample sizes.</p> <p>Graph: Figure 4. Adaptive functioning, mind wandering, emotional dysregulation, and quality of life in patients with ADHD diagnoses made in childhood and adulthood: (a) impairment on the ASR adaptive functioning scales,† (b) high-level mind wandering,† (c) high-level emotional dysregulation,† and (d) quality of life.† Note. A. ADHD diagnosed in childhood: N = 20–52; ADHD diagnosed in adulthood: N = 26–78; B. ADHD diagnosed in childhood: N = 53; ADHD diagnosed in adulthood: N = 77; C. ADHD diagnosed in childhood: N = 52; ADHD diagnosed in adulthood: N = 77.†Smaller sample sizes.</p> <hd id="AN0175968770-11">Moderating Effects of Age, Gender, Race, and Current Psychiatric Medications</hd> <p>The only significant interactions identified were between age at referral and time of ADHD diagnosis when examining the number of impaired ASR scales (<emph>p</emph> =.003) and the number of impaired BRIEF scales (<emph>p</emph> =.004). Among those with an ADHD diagnosis made in childhood, the number of impaired ASR and BRIEF scales significantly increased as age at intake increased (both <emph>p</emph> =.001). However, among those with an ADHD diagnosis made in adulthood, there were no significant changes in the number of impaired ASR or BRIEF scales as age at intake increased (both <emph>p</emph> >.05). There were no significant moderating effects of gender or current medication status on the relationship between time of ADHD diagnosis and the functional outcomes.</p> <hd id="AN0175968770-12">Sensitivity Analysis</hd> <p>Results remained the same when we restricted patients with an ADHD diagnosis in childhood to those diagnosed ≤12 years of age (<emph>N</emph> = 36) and compared them to all patients with ADHD diagnosed in adulthood (≥18; <emph>N</emph> = 78).</p> <hd id="AN0175968770-13">Discussion</hd> <p>In this study of clinically referred adults with ADHD, we found very similar clinical features in adults who had been diagnosed in childhood and adults diagnosed in adulthood. Perhaps our most important finding is that, among the adults first diagnosed in adulthood, 95% reported onset of symptoms of ADHD in their youth. This is consistent with [<reflink idref="bib18" id="ref48">18</reflink>] arguments debunking the idea put forth from epidemiologic studies that most childhood ADHD remits in adulthood and most adult ADHD is adult-onset ADHD.</p> <p>Some have also questioned the validity of adult-onset ADHD, as it has been associated with high rates of co-morbid disorders in adulthood. In the MTA study, [<reflink idref="bib33" id="ref49">33</reflink>]found that clinically impairing ADHD symptoms in adolescence and young adulthood were attributed to other disorders, predominantly substance use disorder, rather than ADHD. However, our results do not support this hypothesis that ADHD diagnosed in adulthood is due to incorrectly interpreting symptoms of other disorders as symptoms of ADHD. If this were true, we would have expected higher rates of psychopathology in the later diagnosed group. That was not the case. None of the differences in psychopathology were statistically significant (Figure 3) and some of the ASR clinical scales were non-significantly worse in the younger diagnosed group (e.g., anxious/depressed; intrusive, use of drugs and alcohol). This supports prior work showing that the diagnosis of comorbidity in ADHD cannot be accounted for by overlapping symptoms with other disorders ([<reflink idref="bib25" id="ref50">25</reflink>]).</p> <p>The findings about behavioral signs of executive dysfunction also show no significant differences between groups, but in contrast to the psychopathology results, most of the executive dysfunction measures were non-significantly worse among the later diagnosed patients. Not only is this consistent with much prior work about executive dysfunction in ADHD ([<reflink idref="bib3" id="ref51">3</reflink>]; [<reflink idref="bib9" id="ref52">9</reflink>]; [<reflink idref="bib11" id="ref53">11</reflink>]; [<reflink idref="bib12" id="ref54">12</reflink>]), it suggests that incorporating behavioral signs of executive dysfunction into diagnostic criteria for ADHD in adults may help increase the sensitivity of diagnosis. This idea does not apply to neuropsychological tests of executive dysfunction as they are only weakly associated with behavioral measures of executive dysfunction ([<reflink idref="bib10" id="ref55">10</reflink>]).</p> <p>Although we found no significant group differences in adaptive functioning (Figure 4a), the later onset group was more impaired in all areas (friends, spouse/partner, family, job, and education) compared with the earlier diagnosed group. This finding suggests that the early identification of ADHD in youth may reduce adverse outcomes in adulthood. Despite these differences in adaptive functioning, the later onset ADHD group was non-significantly more likely to have graduated a four-year college and to have completed a graduate or professional degree compared with the earlier diagnosed group of adults. High achievement in the presence of problems with adaptive functioning suggests that the later diagnosed adults with ADHD had compensatory resources that allowed them to cope with their ADHD in youth. Although some may question the validity of diagnosing ADHD in the presence of high achievement, the validity of doing so has been well documented ([<reflink idref="bib2" id="ref56">2</reflink>]; [<reflink idref="bib29" id="ref57">29</reflink>], [<reflink idref="bib28" id="ref58">28</reflink>]).</p> <p>Our work should be viewed in the context of some limitations. Most importantly, our sample was likely not large enough to detect some significant effects. Our findings point to measures that should be useful for future studies of this topic. Our sample was clinically referred. Although this is the group of most concern to clinicians, the results may not generalize to studies of ADHD in the community.</p> <p>Despite these limitations, our results provide further support for the validity of diagnoses of ADHD that are made in adulthood as these adults show a profile of clinical features that is very similar to those seen in adults diagnosed with ADHD in their youth. Our results also suggest that, if adult-onset ADHD exists, it is rare.</p> <ref id="AN0175968770-14"> <title> References </title> <blist> <bibl id="bib1" idref="ref28" type="bt">1</bibl> <bibtext> Achenbach T. M., Rescorla L. A. (2003). Manual for ASEBA adult forms & profiles. 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Cancer and its treatment had weakened him physically, but they did not limit his bubbling creativity, intellectual drive and deep knowledge of the field. We had published a lot about "late onset" ADHD and done our bit to explain that "adult onset" ADHD was not a new disorder distinct from childhood onset ADHD. Joe's clinical experience taught him that most apparent onsets of ADHD in adulthood were delayed onsets due to missed diagnoses in childhood or social, intellectual, and emotional scaffolding that presented full-threshold ADHD to emerge. This paper, which was 100% his idea, asks a simple, yet clinically important question: do the features of ADHD differ between those diagnosed in childhood and those diagnosed in adulthood. The short answer: they do not. And the data we present further support the idea that if adult-onset ADHD exists, it is rare.</bibtext> </blist> <blist> <bibtext> The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors' declarations of interest in the past 36 months are as follows: Chloe Hutt Vater, Maura DiSalvo, Dr. Alyssa Ehrlich, Haley Parker, and Hannah O'Connor have no conflicts of interest relevant to this article to disclose. In the past year, Dr. Faraone received income, potential income, travel expenses continuing education support and/or research support from Aardvark, Aardwolf, AIMH, Tris, Otsuka, Ironshore, Kanjo, Johnson & Johnson/Kenvue, KemPharm/Corium, Akili, Supernus, Atentiv, Noven, Sky Therapeutics, Axsome, and Genomind. With his institution, he has US patent US20130217707 A1 for the use of sodium-hydrogen exchange inhibitors in the treatment of ADHD. He also receives royalties from books published by Guilford Press: <emph>Straight Talk about Your Child's Mental Health</emph>, Oxford University Press: <emph>Schizophrenia: The Facts</emph> and Elsevier: ADHD: <emph>Non-Pharmacologic Interventions.</emph> He is Program Director of <ulink href="http://www.ADHDEvidence.org">http://www.ADHDEvidence.org</ulink> and <ulink href="http://www.ADHDinAdults.com">http://www.ADHDinAdults.com</ulink>. In previous years 2 and 3, he received support from: Alcobra, Arbor, Aveksham, Enzymotec, Ondosis, Lundbeck/Takeda, Shire/Takeda, Medice, Neurovance, Rhodes, Sunovion, and Vallon. Dr. Faraone is supported by the European Union's Horizon 2020 research and innovation programme under grant agreement No 965381; NIMH grants U01AR076092-01A1, 1R21MH1264940, R01MH116037; 1R01NS128535—01; Oregon Health and Science University, Otsuka Pharmaceuticals, Noven Pharmaceuticals Incorporated, and Supernus Pharmaceutical Company. In 2023, Dr. Joseph Biederman received research support from the following sources: AACAP, Feinstein Institute for Medical Research, Genentech, Headspace Inc., NIDA, Pfizer Pharmaceuticals, Roche TCRC Inc., Sunovion Pharmaceuticals Inc., Takeda/Shire Pharmaceuticals Inc., Tris, and NIH. Dr. Biederman and his program received royalties from a copyrighted rating scale used for ADHD diagnoses, paid by Biomarin, Bracket Global, Cogstate, Ingenix, Medavent Prophase, Shire/Takeda, Sunovion, and Theravance; these royalties were paid to the Department of Psychiatry at MGH. Through Partners Healthcare Innovation, Dr. Biederman had a partnership with MEMOTEXT to commercialize a digital health intervention to improve adherence in ADHD. Through MGH corporate licensing, Dr. Biederman held a US Patent (#14/027,676) for a non-stimulant treatment for ADHD, a US Patent (#10,245,271 B2) on a treatment of impaired cognitive flexibility, and a patent pending (#61/233,686) on a method to prevent stimulant abuse. In 2022: Dr. Biederman received honoraria from UC Davis for Grand Rounds and the MGH Psychiatry Academy for tuition-funded CME courses. In 2021: Dr. Biederman received an honorarium for a scientific presentation from Multi-Health Systems, and a one-time consultation for Cowen Healthcare Investments. He received honoraria from AACAP, the American Psychiatric Nurses Association, BIAL—Portela & Cª. S.A. (Portugal), Medscape Education, and MGH Psychiatry Academy for tuition-funded CME courses. In 2020: Dr. Biederman received an honorarium for a scientific presentation from Tris and from the Institute of Integrated Sciences—INI (Brazil), and research support from the Food & Drug Administration. He received honoraria from Medlearning Inc, NYU, and MGH Psychiatry Academy for tuition-funded CME courses.</bibtext> </blist> <blist> <bibtext> The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Over the past 3 years, Dr. Faraone received income, potential income, travel expenses continuing education support and/or research support from Aardvark, Aardwolf, AIMH, Tris, Otsuka, Ironshore, Kanjo, Johnson & Johnson/Kenvue, KemPharm/Corium, Akili, Supernus, Atentiv, Noven, Sky Therapeutics, Axsome, Genomind, Shire/Takeda, Arbor, Medice, Ondosis, Rhodes, and Vallon. With his institution, he has US patent US20130217707 A1 for the use of sodium-hydrogen exchange inhibitors in the treatment of ADHD. He also receives royalties from books published by Guilford Press: <emph>Straight Talk about Your Child's Mental Health</emph>; Oxford University Press: <emph>Schizophrenia: The Facts</emph>; and <emph>Elsevier: ADHD: Non-Pharmacologic Interventions</emph>. He is Program Director of <ulink href="http://www.ADHDEvidence.org">http://www.ADHDEvidence.org</ulink> and <ulink href="http://www.ADHDinAdults.com">http://www.ADHDinAdults.com</ulink>. Dr. Faraone is supported by the European Union's Horizon 2020 research and innovation programme under grant agreement No 965381; NIMH grants U01AR076092-01A1, 1R21MH1264940, R01MH116037; 1R01NS128535 –01; Oregon Health and Science University, Otsuka Pharmaceuticals, Noven Pharmaceuticals Incorporated, and Supernus Pharmaceutical Company.</bibtext> </blist> <blist> <bibtext> Hannah O'Connor</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0009-0002-7968-1090 Stephen V. Faraone</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0002-9217-3982</bibtext> </blist> </ref> <aug> <p>By Chloe Hutt Vater; Maura DiSalvo; Alyssa Ehrlich; Haley Parker; Hannah O'Connor; Stephen V. Faraone and Joseph Biederman</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>Chloe Hutt Vater is a Clinical Research Coordinator for the Bressler Clinical and Research Program for Autism Spectrum Disorder and for the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital.</p> <p>Maura DiSalvo is the Senior Biostatistician for the Bressler Clinical and Research Program for Autism Spectrum Disorder and for the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital.</p> <p>Alyssa Ehrlich is a fourth-year Resident Physician in the Brigham and Women's Hospital/Harvard Medical School Psychiatry Residency Training Program.</p> <p>Haley Parker was a Clinical Research Coordinator for the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital.</p> <p>Hannah O'Connor is a Clinical Research Coordinator for the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital.</p> <p>Stephen V. Faraone is a Distinguished Professor and Vice Chair for Research at the Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University. He is the president of the World Federation of ADHD and a leading expert in ADHD research.</p> <p>Joseph Biederman was Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital, Director of the Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorders at MGH, and the MGH Trustees Endowed Chair in Pediatric Psychopharmacology. He was a professor of Psychiatry at Harvard Medical School.</p> </aug> <nolink nlid="nl1" bibid="bib19" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib32" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib20" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib14" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib17" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib21" firstref="ref6"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref7"></nolink> <nolink nlid="nl8" bibid="bib15" firstref="ref9"></nolink> <nolink nlid="nl9" bibid="bib24" firstref="ref10"></nolink> <nolink nlid="nl10" bibid="bib34" firstref="ref11"></nolink> <nolink nlid="nl11" bibid="bib37" firstref="ref12"></nolink> <nolink nlid="nl12" bibid="bib27" firstref="ref21"></nolink> <nolink nlid="nl13" bibid="bib13" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib31" firstref="ref24"></nolink> <nolink nlid="nl15" bibid="bib36" firstref="ref25"></nolink> <nolink nlid="nl16" bibid="bib30" firstref="ref27"></nolink> <nolink nlid="nl17" bibid="bib22" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib23" firstref="ref30"></nolink> <nolink nlid="nl19" bibid="bib26" firstref="ref33"></nolink> <nolink nlid="nl20" bibid="bib16" firstref="ref34"></nolink> <nolink nlid="nl21" bibid="bib35" firstref="ref47"></nolink> <nolink nlid="nl22" bibid="bib33" firstref="ref49"></nolink> <nolink nlid="nl23" bibid="bib25" firstref="ref50"></nolink> <nolink nlid="nl24" bibid="bib11" firstref="ref53"></nolink> <nolink nlid="nl25" bibid="bib12" firstref="ref54"></nolink> <nolink nlid="nl26" bibid="bib10" firstref="ref55"></nolink> <nolink nlid="nl27" bibid="bib29" firstref="ref57"></nolink> <nolink nlid="nl28" bibid="bib28" firstref="ref58"></nolink>
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  Group: NumCntrct
  Data: U01AR07609201A1<br />1R21MH1264940<br />R01MH116037<br />1R01NS12853501
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Age+Differences%22">Age Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Characteristics%22">Individual Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Executive+Function%22">Executive Function</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Attainment%22">Educational Attainment</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Differences%22">Individual Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior%22">Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Validity%22">Validity</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10870547231218450
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547<br />1557-1246
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: To provide additional information about clinical features associated with adult ADHD in patients diagnosed in childhood compared to those first diagnosed in adulthood. Method: We stratified a sample of adults with ADHD into patients diagnosed in childhood versus adulthood and compared demographic and clinical characteristics. Results: We found similar clinical features in adults diagnosed in childhood and adults diagnosed in adulthood. Among those diagnosed in adulthood, 95% reported symptom onset in youth. Our results do not support the hypothesis that ADHD diagnosed in adulthood is due to misinterpreting symptoms of other disorders as ADHD. They also suggest incorporating behavioral signs of executive dysfunction into diagnostic criteria for ADHD in adults may increase diagnostic sensitivity. Conclusion: These results support the validity of ADHD diagnoses in adulthood, as these adults show similar clinical profiles to those diagnosed in youth. Our results also suggest that if adult-onset ADHD exists, it is rare.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1440579
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1440579
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/10870547231218450
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 11
        StartPage: 614
    Subjects:
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Age Differences
        Type: general
      – SubjectFull: Clinical Diagnosis
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Individual Characteristics
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Executive Function
        Type: general
      – SubjectFull: Educational Attainment
        Type: general
      – SubjectFull: Individual Differences
        Type: general
      – SubjectFull: Behavior
        Type: general
      – SubjectFull: Validity
        Type: general
    Titles:
      – TitleFull: ADHD in Adults: Does Age at Diagnosis Matter?
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Chloe Hutt Vater
      – PersonEntity:
          Name:
            NameFull: Maura DiSalvo
      – PersonEntity:
          Name:
            NameFull: Alyssa Ehrlich
      – PersonEntity:
          Name:
            NameFull: Haley Parker
      – PersonEntity:
          Name:
            NameFull: Hannah O'Connor
      – PersonEntity:
          Name:
            NameFull: Stephen V. Faraone
      – PersonEntity:
          Name:
            NameFull: Joseph Biederman
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 03
              Type: published
              Y: 2024
          Identifiers:
            – Type: issn-print
              Value: 1087-0547
            – Type: issn-electronic
              Value: 1557-1246
          Numbering:
            – Type: volume
              Value: 28
            – Type: issue
              Value: 5
          Titles:
            – TitleFull: Journal of Attention Disorders
              Type: main
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