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The validity and accuracy of ADHD as a diagnosis is still questioned by some groups as they dispute the current evidence supporting ADHD diagnosis 3 , One feature of ADHD diagnosis at issue is that it may be easily biased and lacks standardization 21 , which is in part due to the subjectivity in evaluating children with ADHD Also, the decision about the threshold of symptoms at which to seek medical attention or at which impairment occurs may largely be open to interpretation.

Research is lacking on objective ways to validate the diagnosis 3. However, challenges for clinical diagnosticians can be addressed by some methods.


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Detailed prenatal, family, and educational histories are of significant value in aiding the diagnosis of ADHD Standardized tools of assessment could go far to bolstering the accuracy of diagnosis as well as the acceptance by families and others of the clinical diagnosis procedure. Children in the US spend a significant portion of their time in school making teachers and the school structure extremely influential for typical development and for the diagnosis of ADHD.

However, teacher ratings of ADHD symptoms in students may have limitations.

For example, a discrepancy has been shown in the level of reports of ADHD symptoms in African American students versus same age non-black peers 2. Because of the reliance on accurate teacher ratings of child behavior, the mental health community makes a significant impact when it provides training and support for educationally based professionals in the recognition and management of children with ADHD.

The attitude of schools toward ADHD and their incorporation of early intervention efforts can have a significant impact on children and parents Many parents express feeling unheard by teachers and school administration when concerns were raised about symptoms prior to ADHD diagnosis Numerous factors intrinsic to a child or youth can affect their diagnosis of ADHD including, gender, age, race, socioeconomic status, and severity of symptoms 11 , While the true rate of ADHD in boys is higher than in girls, it is also true that detection rates, and therefore formal diagnosis, may differ by gender.

Clinicians are also more likely to give the diagnosis of ADHD to boys when compared to girls due to a higher degree of externalizing symptoms in males 10 , Girls are frequently underdiagnosed as they more likely to present with internalizing symptoms 23 , which can be less apparent, such as forgetfulness and difficulty sustaining attention At times somatic, physical, or syndromic features can overshadow ADHD symptoms 9 , However, the presence of comorbidities and their severity can also increase the likelihood of service use which may be associated with increased rates of accurate diagnosis Children with different backgrounds or exposures can present with disruptive symptoms that resemble ADHD but have a different origin such as trauma from exposure to war or a language barrier from recent immigration Children living in a household where English is the primary language were four times more likely to be diagnosed with ADHD than those in which English is not the primary language 6.

The psychosocial histories of children and factors contributing to behavioral phenotypes may vary considerably, and so determining etiology of behaviors associated with the diagnosis of ADHD may be complex There is an apparent discrepancy between the lack of objective methods for the clinical diagnosis of ADHD and recent advancements in genetic, neuroimaging, and other biological assessment methods Reliable biomarkers would significantly reduce some difficulties of diagnosing ADHD but findings thus far have not demonstrated distinctive biomarkers that have high sensitivity and specificity for ADHD diagnosis.

Strong genetic contributions have been reported for ADHD 7 , 21 , It is documented that genetic influences have also been shown to mediate the continuity of ADHD between early and middle childhood 2. Studies in model systems also suggest that genetic variations may cause dysregulation of dopamine signaling and paucity of dopamine release in response to stimuli result in hyperactivity and forgetfulness similar to the symptoms ADHD Despite these important discoveries about genetic risk factors, no specific genetic finding has been identified that can aid in diagnosis.

EEG and brain imaging have been investigated as a way to support and enhance the diagnosis of ADHD and choices about treatment. However, the number of subjects was small and the findings not specific for these biomarkers as well as many others that have been investigated. The behaviors associated with ADHD clearly have biological correlates which theoretically could be demonstrated through differences in functional neuroimaging While research studies have demonstrated group differences in neuroimaging outcomes between ADHD patients and controls: Some studies have examined the role of environmental factors that may predispose an individual to ADHD and thus could be helpful as diagnostic factors or indicators of risk.

For example, exposure to nicotine during human prenatal development has been linked with ADHD 38 , perhaps mediated through disrupted hippocampal and overall brain development as shown in animal models Smoking has also been suggested to have effects across multiple generations through maternal passage of risk for ADHD to offspring Family smoking history may thus take on a larger role in ADHD diagnosis as more research elucidates these risks. Another factor sometimes considered in the diagnostic process is iron deficiency.

Iron plays a substantial role in the development of the central nervous system, including the dopamine, norepinephrine, and serotonin neurotransmitter systems Iron-deficiency in model systems results in changes in dopaminergic signaling In children, studies have also suggested that iron deficiency anemia alter monoamine neurotransmitters and CNS myelination, which may be related to ADHD Serum ferritin levels have been found to be low in children with ADHD Lastly, food additives have been examined for possible roles in ADHD.

Some studies have found positive associations but no causal link between hyperactivity and dietary artificial food coloring and sodium benzoate preservative However, other studies have suggested no relationship between food additives and ADHD Further advances in these areas of research may be relevant for both the diagnosis and treatment of ADHD.

Attention Deficit Hyperactivity disorder likely arises from multiple changes in biological, psychological, and social domains from which many etiologies of small effect, both environmental and genetic, interact and result in symptoms This process likely gives rise to ADHD differently in multiple kinds of vulnerable people 27 , which may continue to pose challenges to diagnosis.

There is need for more research in child psychiatry at the basic biological level, focusing on early human brain development, to help better understand the pathophysiology of ADHD and child psychiatric illnesses in general Adolescents and youth face challenges during transition to adulthood which can limit their abilities to obtain medical services 9 , 23 , During adolescence and young adulthood, only There are multiple factors that contribute to this decline in ADHD treatment that accompanies adulthood. Physician may rely more on adolescents reporting their own symptoms at this age, as they have less supervision by their parents; however, adolescents may minimize their behavioral problems, which can lower the probability of receiving an accurate diagnosis of ADHD 9.

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In addition, it is very common for adolescents who received a diagnosis in childhood to discontinue medical care over time 9. Physicians should obtain previous records of adolescents to review prior ADHD symptomology and to evaluate for comorbidities including substance use disorders SUD , depression, and anxiety The worldwide prevalence of ADHD in adults is estimated to be 4—5.

One study showed that using DSM IV criteria for diagnosing adults, which mandates six hyperactive-impulsive symptoms excluded almost half of adults who were at least 1. DSM-5 has a lower threshold for adult diagnosis, mandating four symptoms for diagnosis, which could be a more sensitive threshold for detecting individuals with functional impairment 26 , Diagnosis with ADHD matters, in part, because it is often accompanied by recommendations for treatment. Treatment of ADHD has been a source of controversy, especially in relation to the use of psychostimulants like methylphenidate Ritalin and mixed amphetamine salts Adderall and non-stimulants, such as atomoxetine, clonidine, and guanfacine for children, each of which has its own limitations 28 , 53 , More extensive reviews exist that discuss the thresholds for use and limitations of stimulant treatment for children with ADHD 55 , only some of which will be discussed here.

Methylphenidate blocks dopamine and norepinephrine re-uptake transporters 58 and has been used for the treatment of ADHD for many decades. Despite this long history of use, the precise prefrontal cortical and subcortical mechanisms of action are poorly understood 56 for both methylphenidate and mixed amphetamine salts, which may partially contribute to ongoing controversies about their use. Evidence suggests there has been an increased use of stimulants in US 6 , 59 , The prevalence of stimulant use in the United States estimated to be 4.

This is attributable to multiple factors including physician prescribing practices as well as parental and child attitudes about ADHD diagnosis and treatment 6 , 11 , More clinically related variables that effect adherence to recommended stimulant treatment include how the mechanism of action of stimulants is explained and how medication routines are simplified 18 , In the popular press, the increased call for early diagnosis and treatment of ADHD has been attributed at times to profit-seeking actions of pharmaceutical companies Others have argued that increased treatment of children with severe ADHD has led to benefits including decreased number of hospitalizations and decreased crime rates Studies suggest that African American and Hispanic children in particular have lower prescription filling rates than Caucasian children 2 , This may be a result of lower percentage of diagnosis in these populations or variations in attitudes about the treatment of ADHD.

The adverse side effects of stimulant use contribute to the ambivalence some patients and families have about treatment initiation and compliance Some patients may benefit from their clinicians becoming more educated about optimizing stimulant use by titrating the medication until achieving the maximum benefits 9. The development of novel treatments with different side effect profiles may also provide some resolution to concerns about adverse effects. Regardless, treatment options for ADHD will always inform perceptions of the disorder itself and its diagnosis.

Other treatment modalities in addition to pharmacotherapy include: While the evidence base for each of these differs, multiple different approaches are used widely in the treatment of ADHD. All approaches elicit a variety of individual and community opinions that in turn influence whether individuals receive an ADHD diagnosis. One of the major consequences of ADHD not being diagnosed is a lack of treatment.

How to Recognize Adult ADHD Symptoms

Untreated ADHD can pose a tremendous amount of psychological, financial, academic, and social burden to the individual and the community, which reflects the importance of diagnosing and treating the disorder 23 , Untreated ADHD during childhood is a risk factor for later adult mental health issues, which extend beyond impairment in academics A lack of treatment for ADHD also impairs social and occupational functioning and increases the likelihood of developing comorbid disorders like anxiety, depression, personality disorders, antisocial behaviors, and SUD 66 , Many mechanisms may be at work linking undiagnosed ADHD to vulnerabilities The consequences of untreated ADHD has been shown in many different domains of functioning.

A longitudinal study that examined the impact of stimulant treatment in ADHD to academic outcome during late adolescence found that children treated with stimulants showed academic gains on several measures relative to children who did not receive treatment Symptoms of hyperactivity that would typically be addressed by treatment are linked, when untreated, to long-term social and peer problems Poor listening skills and poor frustration tolerance that persist in untreated ADHD can lead to tension at work and home, decreased intimate relationships, internalizing problems, and low self-esteem in adulthood When ADHD persists in parenthood, there is an increased risk of family conflict and negative parent—child interactions; this may be related to parents with ADHD being easily frustrated and unable to control their emotions and impulses when untreated A study based on a clinical sample also found a connection between childhood ADHD and intimate partner violence IPV in adulthood in association with conduct disorder CD and when controlling for CD as a comorbidity An increase in risk for substance use, nicotine addiction, and alcohol abuse was conferred by even a single symptom of hyperactivity or inattention While many individuals treated for ADHD continue to have persistent symptoms, this study also suggests that the initiation of substance use was more likely with more uncontrolled symptoms.

Having ADHD is associated with an earlier onset of psychoactive substance abuse across the life course For adolescent boys and girls, increased levels of hyperactivity and impulsivity symptoms had a statistically significant prediction for all substance abuse, nicotine dependence and cannabis abuse, even when controlling for conduct disorder as a comorbidity Adults with SUD have been shown to have a higher rate of ADHD than the general population and, in this population, ADHD contributes to increased rates of comorbid disorders, previous criminal convictions and suicide attempts Substance using individuals with ADHD compared to those with only SUD had higher self-rated impairment across several domains of daily life and higher rate of substance abuse and alcohol consumption, suicide attempts, and depression.

These findings highlight the negative impact of ADHD on individuals and the increased burden they place on the mental healthcare system Attention Deficit Hyperactivity disorder, especially when untreated, can lead to financial and employment difficulties 8 , 33 , Studies suggest that uncontrolled ADHD can negatively affect work efficiency leading to longer hours of work, job instability, lack of insight into future goals, and lower annual personal incomes 23 , Even if some adults are able to maintain appearances, overcoming impairments that are not treated may be a struggle that can interfere with general life satisfaction 23 , Procrastination, distractibility, frequent lost workdays, and disability have high economic burden with greater utilization of medical services 23 , Untreated ADHD is associated with higher rates of criminality, imprisonment, speeding, traffic violation, and motor vehicle accidents 23 , 75 , Longitudinal research that followed hyperactive children for 10 years has suggested that hyperactivity is a risk factor for increases in other psychiatric diagnosis However, aggressive behavior which occurs in some children with ADHD, particularly without treatment, is highly predictive of whether juvenile offenders will reoffend Mortality rate in a recent study of an ADHD population was 5.

Interestingly, the highest rate of mortality was found in people diagnosed in adulthood For diagnosis between ages 6 and 17, the MRR increased to 4.

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This emphasizes the importance of early diagnosis and treatment in ADHD. Children with ADHD, adolescents in particular, have a significantly higher suicide rate at three times higher than the national average. While there are significant data detailing the consequences of ADHD not being treated, fewer studies have been performed to understand whether diagnosis matters independently.

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ADHD diagnosis and its associated opportunity for psychoeducation and prognostic information may have important effects on development. The few studies that have been done suggest that there are consequences in a variety of domains. First, evidence suggests lower levels of educational attainment in individuals with ADHD who are undiagnosed compared to those diagnosed 8 , 33 , The prevalence of undiagnosed ADHD within a substance treatment population was approximately fivefold higher than the general population 66 suggesting that undiagnosed ADHD may have substance abuse requiring treatment as a consequence.

The relative underdiagnosis of ADHD in girls may lead to more women gaining an ADHD or other diagnosis in adulthood, with high rates of inattentive or impulsive symptoms at times diagnosed as depression and borderline personality disorder Undiagnosed ADHD subjects are less likely to report that a first-degree family member had been diagnosed with ADHD; missed diagnosis in parents or sibling can result in missed or delay diagnosis in other members of the family Also, as reviewed previously, the MRRs of individuals with delayed diagnosis of ADHD has been shown to be significantly higher than those diagnosed earlier, suggesting that a lack of diagnosis may accumulate risks to mortality Several studies have focused on examining the experience described by individuals with ADHD.

Having ADHD has been shown in multiple studies to be a source of stress, with some individuals recalling a constellation of feelings of loneliness, isolation, low self-esteem, and struggle to get along with their parents and peers at school 32 , 79 , Despite struggles related to ADHD symptoms, receiving the diagnosis does not always reduce stress for an individual. Some individuals have described perceiving a certain degree of stigma attached to being diagnosed with ADHD, influencing their willingness to disclose their diagnosis to other people.

Some perceived their identity was challenged by a diagnosis of ADHD and also felt less in-control of their lives, especially when faced with the prospect of taking medication for life Still other individuals report having the diagnosis of ADHD lead them to feel as though they were different and isolated On the other hand, some individuals have described that the extra attention from their teachers or parents that accompanied the diagnosis of ADHD helped affirm and build confidence 79 , A qualitative study in which participants described their experience in their own words classified the psychological impact of receiving the diagnosis of ADHD into different emotional stages of psychological acceptance including both positive and negative aspects: Individuals diagnosed late reported low self-esteem and underachievement due to repetitive experiences of failure during childhood Clearly, ADHD diagnosis during childhood or adolescence has mixed consequences psychologically for young people.

We have reviewed many of the complexities that lead to and arise from the diagnosis of ADHD.

Frontiers | Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters | Psychiatry

One of the key conclusions from this body of literature is that receiving the diagnosis of ADHD may benefit individuals by creating the possibility for treatment. A significant body of research has demonstrated that treatment is strongly associated with improved outcomes. Outcomes after receiving an ADHD diagnosis independent of treatment are not well understood; however, significant psychological effects of receiving a diagnosis have been described.

These latter findings are in line with the complex experience clinicians have as they partner with children, youth and families coping with behavioral problems. It is precisely this partnership that then takes on greater significance when faced with such a double-edged sword in diagnosing and treating ADHD. This may be accomplished through psychoeducation, greater communication between clinicians, parents, and educators, and more research on biomarkers. Although barriers exist, clinicians who truly partner with their patients also understand that individuals receiving an ADHD diagnosis may experience immediate and complex emotions as well as challenges to their identity.

The process of diagnosing ADHD is not unlike the diagnosis of other chronic and serious medical conditions and thus can benefit positively from the medical perspective. This perspective has the potential to positively impact the entire life course of individuals with ADHD as well as their families. The partnership between clinician and patient is one of the most important ways in which this benefit can arise. AH and HS conceived, designed, acquired background material, and drafted this work; AH, AK, and HS interpreted the background material, critically revised, and approved the final version of and agreed to be accountable for this work.

The authors declare that this work was completed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. J Child Psychol Psychiatry Schonwald A, Lechner E. Curr Opin Pediatr Cochrane Database Syst Rev Centers for Disease Control and Prevention. J Psychiatr Pract The worldwide prevalence of ADHD: World Psychiatry 2: PubMed Abstract Google Scholar.

The diagnosis less traveled: J Am Assoc Nurse Pract Help seeking for emotional and behavioural problems in children and adolescents: Eur Child Adolesc Psychiatry Parental explanatory models of ADHD: Soc Psychiatry Psychiatr Epidemiol The role of parental burden in child mental health service use: J Natl Med Assoc Curr Med Res Opin Parental agreement on ADHD symptom-specific and broadband externalizing ratings of child behavior.

J Emot Behav Disord Arch Gen Psychiatry Attitudes toward attention-deficit hyperactivity disorder ADHD treatment: The reasons for this are unclear, since most psychiatrists working with children and adolescents are aware that ADHD commonly persists into adult life and they also see the disorder affecting parents of children with ADHD. Issues of transition from the care of child to adult psychiatry and the need to refer adult relatives of children with ADHD to suitable psychiatric services are a major concern.

Furthermore, many cases of adult ADHD go unrecognized or are seen by mental health teams that are not familiar with the subtleties of the adult presentation. As a result, misdiagnosis and treatment for conditions such as atypical depression, mixed affective disorder, cyclothymia, and borderline and unstable emotional personality disorders is not uncommon. There is therefore a requirement for further training in this area.

Assessing Attention-Deficit/Hyperactivity Disorder (Topics in Social Psychiatry)

This review will describe the common clinical presentation and provide guidelines for the diagnosis and treatment of ADHD in adults. Any psychiatrically trained physician using standard psychiatric assessment procedures can perform clinical evaluations for adult ADHD. As with other psychiatric disorders in adulthood, ADHD has its own characteristic onset, course and psychopathology. Symptoms of ADHD are trait-like, being stable characteristics from early childhood, and commonly co-occur with affective instability. Psychotherapeutic interventions also have an important role.

These guidelines will assist psychiatrists and other adult mental health workers in identifying and treating individuals with adult ADHD.