Adult ADHD Is Real — and Still Heavily Stigmatized

Last month, Psychiatric Times published a controversial and off-putting opinion piece titled, “The Making of Adult ADHD,”¹ which calls ADHD in adulthood one of psychiatry’s “fads” in “theory, diagnosis, and treatment.” It argues, quite weakly, that adult ADHD is not a scientifically valid diagnosis; the authors instead attribute persistent symptoms to the effects of mood temperaments, which is conveniently a topic of research interest for at least one of them.

The Persistence of ADHD Into Adulthood

The essay’s authors, psychiatrist Nassir Ghaemi, M.D. (Tufts University School of Medicine), and Mark L. Ruffalo, MSW, DPsa (University of Central Florida College of Medicine), cite slim evidence, specifically two prospective follow-up studies of children with ADHD tracked to adulthood. These studies, they claim, show that only 20% of subjects with childhood ADHD still have it by adulthood.

The truth is that one of those cited studies, and its limitations, gave expert commentators pause when it first appeared seven years ago.² For one, the adult sample included 18- and 19-year-old subjects, a razor-thin slice of young adulthood. Moreover, the study’s authors used only self-reports in structured interviews to establish the existence of adult ADHD. Yet, we know self-reports to be unreliable until subjects reach their late 20s and 30s.³ By contrast, the study established childhood ADHD diagnoses using parent reports and structured interviews. Therefore, using self-reports risks under-identifying ADHD persistence into young adulthood.

A more recent study of ADHD persistence followed children originally diagnosed between ages 7 and 10.⁴ Researchers administered eight thorough re-evaluations from ages 10 to 25, on average. The results showed that most children went through an up-and-down pattern of remission. That is, results sometimes fell below full DSM diagnostic criteria but at other times fulfilled criteria. Only 10% of children with ADHD achieved full, sustained remission at young adulthood. That left 90% with persistent residual symptoms of ADHD into adulthood.

The waxing and waning of symptoms likely reflects treatment effects as well as the nature of ADHD being overly sensitive to environmental factors affecting symptom expression. Factors might include supportive teachers or bosses, or, on the other hand, the stress of starting middle school or college. Hormonal changes may also play a role in ADHD symptom severity.

[Read: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.]

Adult ADHD Is Not New or Novel, but Psychiatry Has Not Yet Caught Up

Let’s flip the script here: The diagnosis of ADHD (then called hyperkinetic reaction of childhood or adolescence) first appeared in the DSM-II.⁵ That same year saw a published study of minimal brain dysfunction (another early name for ADHD) in young adult patients, some having persistent symptoms since adolescence.⁶ In other words, adult ADHD is not a diagnosis du jour, as Ghaemi and Ruffalo assert, but part and parcel of ADHD from the start. That said, a different issue could be considered: Why has diagnostic criteria for adult ADHD lingered so far behind the work already done in the field for 55 years?

For example, a decade ago the age-of-onset criterion for an ADHD diagnosis was finally raised from 7 to 12 years old. Still, even the older cutoff misses the adolescent phase, which brings increased demands for attention, impulse control, organization, and overall self-regulation. ADHD-related difficulties often become more apparent during middle school, following years of challenges going masked and unrecognized. Indeed, we find evidence that 16 is a better age threshold for symptom emergence.⁷

At the same time, clinicians are still evaluating adults using ADHD symptom criteria developed for children, which under-represent indicators of executive dysfunction. Even the term ADHD obscures the consensus that the condition is better understood as a neurodevelopmental syndrome of self-dysregulation. ADHD is a chronic delay in the onset and efficient employment of self-regulation capacities and skills. Empirically based reviews of adult ADHD specific symptoms have addressed this issue.⁸ Yet, the absence of adult-specific criteria constrains adult diagnoses and thereby access to evidence-based treatments.

[Read: ADHD Symptoms Checklist – Signs of Hyperactive, Inattentive, Combined Subtypes]

The Effects of Biases Against ADHD

Finally, the framing and wording used in “The Making of Adult ADHD” repeats the stigma and biases many adults with ADHD (diagnosed or not) encounter in daily life. Every day, they endure skeptical comments by loved ones and the public, on social media and via other outlets. This “denialism” can and does wield a profound negative effect. Research on the effects of stigmatization and dismissal of ADHD-related concerns)^9,10 has shown that unconstructive criticisms cause individuals to experience withdrawal from others and heightened sensitivity, hindering their coping skills and preventing them from reaching out for professional support.

In fact, a psychiatrist-in-training published his experience with recognizing his own adult ADHD after harboring misconceptions about it.¹¹ He observed first-hand the bias against the diagnosis (and against mental health issues generally) within healthcare and within his own specialty, which stoked his fears of disclosure. He courageously recounts his coming to terms, seeking help, and benefitting from specialized treatment.

To this psychiatrist and to other adults with ADHD, the diagnosis is well-established,¹² even as behavioral health fields are still catching up. There is more work to do, no doubt. A heartening development underway is the first set of U.S. empirically based guidelines for the assessment and treatment of adult ADHD and corresponding practice tools tailored to support these patients. I am hopeful that these guidelines (used alongside many existing international ones) will offer a helpful hand to those who are working to support adults with ADHD.

Adult ADHD Symptoms Are Real: Next Steps

• Read: How the DSM-5 Fails People with ADHD — and a Better Way to Diagnose
• Read: ADHD Is a Whole-Life Experience. The DSM Needs to Reflect That.
• Learn: What do I need to understand about ADHD that is not fully represented in the DSM?

Disclosure: Dr. Ramsay is on the scientific advisory board of ADDitude magazine. He has no conflicts of interest relevant to the content of this commentary.

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