ADHD Atten Def Hyp Disord (2012) 4:53–62
DOI 10.1007/s12402-012-0077-3
REVIEW ARTICLE
ADHD in adults: a concept in evolution
Breno Matte • Luis Augusto Rohde •
Eugenio Horácio Grevet
Received: 27 March 2012 / Accepted: 3 May 2012 / Published online: 16 May 2012
Ó Springer-Verlag 2012
Abstract Although attention-deficit/hyperactivity disor-
der (ADHD) has been recognized as a disorder affecting
individuals across the life cycle since the end of the nine-
ties, there is still considerable debate on how to concep-
tualize the disorder in adults, and on the best way to
operationalize diagnostic criteria for this age range. In this
comprehensive non-systematic review of the literature, we
provide data about prevalence and presentation of ADHD
in adulthood as well as discuss major problems in applying
criteria developed for children in assessing adults (clinical
utility, threshold of symptoms for diagnosis, full ADHD
diagnosis in childhood, information source, and additional
dimensions for diagnosis—executive functioning impair-
ment and emotional impulsivity). In addition, we provide
some recommendations for improving ADHD diagnostic
criteria in adulthood.
Keywords ADHD
Diagnosis
Attention-deficit

Hyperactivity
DSM-5
Introduction
The first reports on attention-deficit/hyperactivity disorder
(ADHD) in adults can be traced to the middle seventies
B. Matte
L. A. Rohde (&)
E. H. Grevet
ADHD Outpatient Program, Hospital de Clinicas de Porto
Alegre, Federal University of Rio Grande do Sul, Rua Ramiro
Barcelos 2350, Porto Alegre, Rio Grande do Sul, Brazil
e-mail: lrohde@terra.com.br
L. A. Rohde
National Institute of Developmental Psychiatry for Children and
Adolescents, Porto Alegre, Brazil
(Wood et al. 1976). Since then, accumulating data have
noted that a significant proportion of children affected by
the disorder continue to present ADHD symptoms and
associated impairment during adulthood (Barkley 2009;
Mannuzza et al. 1998; Biederman et al. 2011; Mick et al.
2004; Klein et al. in press).
Despite evidence from longitudinal investigations doc-
umenting the persistence of ADHD during adulthood, there
is still much debate on the best way to conceptualize the
disorder in adults (Barkley 2009; Kooij et al. 2010). Since
ADHD is one of the few disorders in psychiatry first rec-
ognized in children, much of the research about its phe-
nomenology has derived from children and adolescents
(Rohde 2008). Moreover, questions about what are the best
means of capturing the clinical presentation of adult
ADHD have been renewed by the proximity of the
new classification systems in psychiatry—the DSM-5 and
ICD-11.
In this comprehensive non-systematic review of the
literature, we discuss several key aspects related to the
challenges of defining the ADHD clinical presentation in
adulthood and the diagnostic criteria to capture it. The
following aspects are reviewed: (a) prevalence of ADHD in
adulthood; (b) how to improve the clinical utility of the
existent criteria for adults; (c) developmental perspective in
defining the adult ADHD phenotype—the age-dependent
decline of ADHD symptoms, the best symptomatic
threshold for the diagnosis in adults, the age at onset, and
information source for ADHD and related recall problems;
(d) doubt about the need of the full syndrome in childhood
for the adult diagnosis; and (e) the presence of new con-
structs as part of the phenotype in adulthood, such as
executive deficit impairment and emotional impulsivity.
We finally present some recommendations pertinent to
these issues.
123
54
Prevalence of adult ADHD
In a comprehensive systematic review, the prevalence of
ADHD in children and adolescents was estimated to be
5.29 % worldwide (Polanczyk et al. 2007). The prevalence
of ADHD in adults is less established. Several population-
based samples in different countries have relied on self-
rating scales. In the United States, a survey in 720 adults
applying for or renewing their driver’s licenses estimated
the prevalence of DSM-IV ADHD to be 4.7 % (Murphy and
Barkley 1996). When compared to similar studies, this
paper provides slightly higher prevalence rates. This might
be related to methodological issues, such as a self-referring,
non-random sampling strategy, and a case definition that
required only symptom frequency (6/9 symptoms in at least
one of the ADHD dimensions), not considering other
diagnostic criteria (age of onset, impairment, situational
pervasiveness, etc.). In 448 university students in the United
States, Heiligenstein et al. (1998) reported a prevalence of
DSM-IV ADHD of about 4 %. In three samples of uni-
versity students, DuPaul et al. (2001) obtained prevalence
rates of adult ADHD of 1.01 % in Italy (n = 197), 2.81 %
in New Zealand (n = 213), and 3.39 % in the United States
(n = 799). In 1,813 adults in the Netherlands, the preva-
lence of ADHD was 1 % (Kooij et al. 2005). A US tele-
phone survey of 966 adults (Faraone and Biederman 2005)
found a 2.9 % prevalence of DSM-IV ADHD.
A few population studies have examined the prevalence
of ADHD in adult populations, relying on direct interviews.
A Mexican interview study of a nationally representative
urban sample of 2,362 subjects found a 1 % prevalence of
adult DSM-IV ADHD (Medina-Mora et al. 2005). A much
larger rate, 4.4 %, was reported in a US nationally repre-
sentative household survey in 3,199 adults (Kessler et al.
2006). In a recent systematic review and meta-analysis of
the above studies, Simon et al. (2009) generated a pooled
prevalence of adult ADHD of 2.5 % (95 % CI 2.1–3.1) and
reported a decline with age.
Fayyad et al. (2007) have reported a comprehensive
assessment of adult ADHD in ten different countries as part
of World Health Organization World Mental Health Sur-
vey Initiative. A total of 11,422 adults aged 18–44 years
were assessed, and a mathematical model of multiple
imputations was used to derive a pooled prevalence, based
on the assumption of cross-national calibration compara-
bility. The pooled prevalence found was 3.4 % (range
1.2–7.3 %).
Complicating estimates of the prevalence of ADHD in
adults, there is doubt about the validity of DSM-IV criteria
for diagnosing adult ADHD. It has been noted that the
DSM-IV criteria may not capture the complex presentation
of ADHD in adulthood and may underestimate its preva-
lence (Kieling and Rohde 2012).
123
B. Matte et al.
Clinical utility of DSM-IV ADHD diagnostic criteria
applied to adults
The DSM-IV clinical criteria for ADHD were never tested
in field trials with adults. They were assessed in predomi-
nantly school-age children and some adolescents (Lahey
et al. 1994).
The concept of clinical utility is central to the process of
reviewing the diagnostic criteria in the new classification
systems (Mullins-Sweatt and Widiger 2009). Specifically,
the clinical utility of the DSM-IV ADHD criteria in adults
has been criticized for failing to reflect developmental
variations in symptom expression through the age range,
leading to age-inappropriate descriptors for adults (e.g.,
‘‘often runs about or climbs excessively in situations in
which it is inappropriate’’).
Thus, it has been recommended that DSM-IV criteria be
reworded to improve the adequacy of the criteria to adults.
Addressing this point, the DSM-5 ADHD and Disruptive
Behavior Disorder Workgroup has made a proposal to
modify the criteria to better reflect adult symptomatic
presentation (see http://www.dsm5.org/ProposedRevision/
). However, although a step in the right direction, these
proposals have not been formally tested nor assessed to
check their linguistic consistency.
Developmental perspective in defining the adult ADHD
phenotype
Age-dependent decline of ADHD symptoms
In their self-rating study of adults applying for driving
license renewals, Murphy and Barkley (1996) reported that
significantly fewer symptoms of inattention and hyperac-
tivity were endorsed, as individuals get older. Biederman
et al. (2000) observed that age was significantly associated
with decline in ADHD symptoms in a follow-up study.
Symptoms of inattention remitted at lower rates (40 %) than
symptoms of hyperactivity (70 %) and impulsivity (70 %).
A meta-analysis by Faraone et al. (2006a, b, c), pooling
together data from 32 studies derived from 10 different
samples, estimated that 16 % of ADHD children remained
ADHD subjects at age 20 according to full DSM criteria. If
less restrictive, subthreshold criteria were used, and the
persistence rate increased to 65 %, but remained far from
100 %. The lack of developmental adequacy in DSM to
capture ADHD clinical presentation in adults, as well as an
age-dependent decline in ADHD symptoms, may contrib-
ute to this decline in ADHD prevalence with age.
More recently, Ramtekkar et al. (2010) reported that
ADHD prevalence and severity decreased with age in a
population sample. They estimated the prevalence to be
ADHD in adults
11.7 % in children, 9.7 % in adolescents, and 6.4 % in
adults. The number of symptoms also decreased with age.
Recent evidence also suggests that the ADHD symp-
tomatic decline with age might not be linear. A Swedish
follow-up study of twins (Larsson et al. 2011) did not find a
single trajectory for symptom course. On the basis of the
parent scales in childhood and self-rating scales at age 17,
at least 4 trajectories were identified: two for hyperactivity
and two for inattention. Hyperactivity followed a low-
grade, chronic trajectory, or a high level one with reduction
with age. Inattention also displayed a low-grade, chronic
pattern over time, or a high inattention trajectory that
increases in severity with age. However, the study did not
extend beyond age 17.
Best symptomatic threshold of diagnostic criteria
for diagnosing ADHD in adults
The DSM-IV criteria for ADHD stipulate that at least six
out of nine symptoms of inattention and/or six out of nine
symptoms of hyperactivity should be present with negative
impact on at least two of the three following areas: social,
academic, or occupational functioning. The threshold of
symptoms is the same for all ages (APA 1994), although
some studies support a lower threshold for ADHD diag-
nosis in adults.
Murphy and Barkley (1996), in a population-based
prevalence study of ADHD in adults, showed that the cutoff
of six out of nine symptoms represents a 2.5–3 standard
deviations above the mean ([99 percentile), which captures
only the most extreme portion of the population. Conver-
gent results are found in a study conducted by Kooij et al.
(2005), which estimated that four symptoms of inattention
or hyperactivity are enough to identify people with signif-
icant impairment in life. In a more recent study, Solanto
et al. (2011) applied a scale to measure the severity of
hyperactivity in 88 patients presenting clinical diagnosis of
ADHD (inattentive and combined subtypes). Among sub-
jects with hyperactivity scores equal to or higher than 1.5
standard deviations above the mean, only 52 % met the
cutoff of six symptoms of hyperactivity. The authors
reported that a cutoff of 4 symptoms of hyperactivity cap-
tured 81 % of the cases. However, the study analyzed only
hyperactive symptoms, since the design of the study did not
allow testing the inattention dimension due to lack of var-
iation in the scores (all patients of the combined and inat-
tentive subtypes had high inattention scores).
Although it is argued that maintaining a threshold of six
symptoms for adult ADHD diagnosis misses the diagnosis
of affected adults, lowering the threshold may increase the
number of false-positive diagnoses, identifying as ADHD
individuals who might have other mental disorders. Data
that address this point are limited.
55
Age at onset of ADHD symptoms
A maximum age at onset as a diagnostic criterion for
ADHD was first introduced in 1980 in DSM-III, based
mainly on clinical experience. In the DSM-IV-TR, this
criterion states ‘‘some hyperactive-impulsive or inattentive
symptoms that caused impairment were present before the
age of 7 years’’. Several studies have failed to document
the contribution of this age of onset criterion to the validity
of the diagnosis of ADHD as estimated by clinicians’
diagnoses (Kieling et al. 2010). In a clinical sample of 380
children in the DSM-IV field trials, Applegate et al. (1997)
found that the ADHD types had different ages at onset,
with later onset for ADHD inattentive-type than the com-
bined type. They also reported that 18 % of the children
with ADHD combined type children and 43 % of those
with inattentive type did not manifest functional impair-
ment before 7 years of age. For subjects with these types of
ADHD, requiring the age at onset criterion reduced
agreement with both clinical diagnosis and with identifi-
cation of currently impaired subjects (Applegate et al.
1997).
Several clinical studies have reported that subjects who
met clinical criteria, but not the age at onset criterion, were
not dissimilar from those with onset by age 7, with regard
to psychiatric comorbidity and functional impairment
(Faraone et al. 2006b; Rohde et al. 2000), neuropsycho-
logical profile (Faraone et al. 2006c), personality traits
(Faraone et al. 2009), substance use pattern (Faraone et al.
2007), and response to stimulant treatment (Biederman
et al. 2006; Reinhardt et al. 2007). These similarities
between early (by age 7)- and late-onset (after age 7)
ADHD subjects in terms of impairment and psychopatho-
logic features were also identified in longitudinal studies, in
which memory recall is not an important source of infor-
mation bias (Barkley et al. 1990; Todd et al. 2008). In a
recent large birth cohort study, children were prospectively
assessed at ages 7 and 12. Significant differences in esti-
mated prevalence of ADHD, clinical or cognitive features,
and risk factors were not found between the two time-point
assessments. The inclusion of subjects beginning symp-
toms after 7 years of age as cases did not significantly
increase the prevalence of ADHD (Polanczyk et al. 2010).
Finally, a systematic review about the age at onset criterion
for ADHD failed to find any study providing significant
findings differentiating children with onset of ADHD
before and after 7 years of age (Kieling et al. 2010).
This discussion is relevant to the diagnosis of ADHD in
adults insofar as the diagnosis relies on retrospective recall
of early childhood dysfunction. Problems with recall have
been noted in several studies. In a longitudinal study, Todd
et al. (2008) found that of ADHD subjects who continued
to meet clinical criteria for ADHD, 46 % failed to recall
123
56
accurately the age of onset criterion 5 years later. Thus, the
reliability of the ADHD age of onset criteria seems poor
over a relatively short interval. In adulthood, the time gap
between age 7 and the age at evaluation is much longer,
and reliability and accuracy are likely to decrease even
further. Although the recall bias may operate bidirection-
ally, as a tendency to either under- or overreport childhood
ADHD symptoms, previous evidence has suggested a bias
toward informing older ages for onset ADHD symptoms
(Todd et al. 2008).
In a large adult population survey in the United States,
99 % of individuals with clinical features of ADHD ret-
rospectively recalled an onset before age 16, 95 % before
age 12, and only 50 % before age 7 (Kessler et al. 2005).
The lack of empirical support for the 7 years as ADHD
age at onset and the growing recognition of ADHD as a
valid diagnosis for adults suggest that an extension of the
age at onset criterion to the transition from childhood to
adolescence should be considered. Thus, although still an
arbitrary cutoff, an age of onset of 12 years old would
probably be more adequate. This older age of onset would
cause less false negative assessments, specially for teen-
agers and adults (Kieling et al. 2010).
Information source: does the diagnostic process
for ADHD in adults require collateral reports?
It is well recognized that agreement between parents and
teachers is low for ADHD symptoms in children and
adolescents and that ADHD diagnosis based only on self-
report is not adequate in early life, increasing chances of
false negatives (Rohde 2008). Although we still do not
know which the best way to combine information from
parents and teachers is (see Valo and Tannock 2010),
there is consensus that both information sources are
important for diagnosing ADHD in children. However,
little data exist to guide clinicians on the need of collat-
eral information on ADHD symptoms in adulthood. We
still do not know whether information from significant
others is important to capture current and past symptoms
in adults. In this regard, Murphy and Schachar (2000)
described a significant agreement between self-report and
other report of ADHD current and past symptoms,
although this study was based on scales and the subjects
were not ADHD cases. Dias et al. (2008) assessed the
agreement between parent and self-report on childhood
symptoms of ADHD in a clinical sample of patients with
the disorder documenting a moderate agreement rate
(67.6 % agreement; 23.5 % only self-report ADHD
childhood symptoms; 8.9 % only parental ADHD child-
hood symptoms).
Mannuzza et al. (2002) verified that the self-report on
retrospective diagnosis of childhood ADHD may not be
123
B. Matte et al.
valid in low-prevalence settings, such as epidemiological
samples, but it may be more reliable in settings with a high
prevalence of ADHD, such as outpatient clinics. In the
same study, the authors described a set of symptoms with a
higher discriminating power for retrospective diagnosis of
childhood ADHD (distractibility, concentration difficulties,
complaints of inattention, acting before thinking, being on
the go, and fidgeting/squirming). A more recent follow-up
study demonstrated that both adolescents and their parents
reported inaccurate childhood ADHD symptoms (Miller
et al. 2010). However, parents and patients with current
symptoms were more accurate in describing childhood
symptoms than those without current symptoms, suggest-
ing that self and other recall on childhood ADHD symp-
toms might be more reliable if the subject still has present
ADHD symptoms.
Despite the low rates of agreement demonstrated
between parents and patients in terms of current and past
symptoms, informant report may be useful to comple-
ment information on symptoms and impairment. On the
other hand, considering collateral report as a necessary
condition for the adult ADHD diagnosis would enhance
the clinical complexity of the diagnostic process. No
other DSM diagnostic criteria require information from
others as part of the diagnostic process. This would be
only justified should there be robust evidence supporting
the value of informant reports for the diagnosis of ADHD
in adults.
Is there a need of a full syndrome in childhood
for ADHD diagnosis in adults?
There is a general consensus that ADHD is a neurodevel-
opmental disorder. The DSM-5 draft, for instance, included
ADHD as part of this class of disorders (see http://www.
dsm5.org/ProposedRevision/). In both the DSM-IV and the
DSM-5 proposal, ADHD in adulthood does not require the
full ADHD disorder in childhood or adolescence. The
DSM-IV only requires: ‘‘some hyperactive-impulsive or
inattentive symptoms that caused impairment were present
before the age of 7 years’’, and DSM-5 proposal demands:
‘‘Several noticeable inattentive or hyperactive-impulsive
symptoms were present by age 12’’.
Since adult ADHD has progressively became a valid
clinical entity, it would be important to study whether the
adult diagnosis remains valid in a context of an incomplete
(subthreshold) diagnosis during childhood. Unfortunately,
few studies address this issue. Faraone et al. report on a
series of studies about the validity of late-onset (age at
onset after age 7) and subthreshold (ADHD symptoms
never fulfilling full DSM criteria) ADHD diagnosis
(Faraone et al. 2006a, b, c, 2007, 2009). These studies used
ADHD in adults
self-report retrospective evaluation of childhood ADHD,
which may be problematic due to inaccurate recall. Find-
ings suggest that subthreshold subjects have patterns of
comorbidity and functional impairment (Faraone et al.
2006a, b, c), neuropsychological tests profile (Faraone
et al. 2006c), personality traits (Faraone et al. 2009), and
substance use patterns (Faraone et al. 2007) that are dif-
ferent from full ADHD and late-onset ADHD cases, and
closer to subjects without ADHD. These results, suggesting
that the subthreshold group shares more features with the
non-ADHD group than with the late-onset and full ADHD
groups, raise questions about the validity of subthreshold
ADHD. However, the study reports on ever subthreshold
cases, and the relevant issue in adults is whether a previous
childhood history of subthreshold ADHD suffices for
diagnosing ADHD in adults.
The follow-up studies usually include subjects who
fulfill full DSM ADHD criteria at baseline (see Mannuzza
et al. 1998). However, one study with adolescents has
focused on subthreshold cases as potential predictors of
full ADHD in adulthood. Shankman et al. (2009) followed
a large group of adolescents until age 30. In this study,
which is not affected by recall bias, subthreshold ADHD
in adolescence was an independent predictor of substance
use disorders and antisocial personality disorder, but no
other mental disorder, including the full adult ADHD
syndrome; however, the study may have been under-
powered for this outcome. In contrast, full ADHD in
adolescence predicted full ADHD and substance use dis-
orders in adulthood. These results suggest that adolescent
subthreshold ADHD may be associated with impairing
comorbidity in adulthood and may share the prediction of
substance use later in life with adolescent full ADHD.
However, there is no consistency in the trajectory from
subthreshold ADHD in adolescence and full syndrome
ADHD in adulthood. To our knowledge, there are no
other follow-up studies on the longitudinal course of
subthreshold ADHD.
Due to the lack of more robust empirical data, deciding
whether there is a need of a full syndrome in childhood for
the diagnosis of adult ADHD is difficult. Considering the
full syndrome in childhood as a necessary condition for
adult ADHD enhances the risk of recall bias and false-
negative results, which could classify impaired subjects as
non-cases and make their access to treatment more diffi-
cult. On the other hand, considering partial symptoms in
childhood as sufficient for adult ADHD diagnosis enhances
the risk of false-positive results, which could artificially
enhance the prevalence of ADHD among adults. The
ADHD and Disruptive Behavior Disorder Workgroup took
an intermediate position on this dilemma, demanding a bit
more from the phenotype in childhood than the DSM-IV,
but not the full syndrome.
57
New constructs as potential parts of the phenotype
in adulthood
Executive deficit impairment
There is little consensus about what the concept of exec-
utive function (EF) refers to and its borders. A broad def-
inition would be that EF encompasses brain functions
related to the organization of behavior to achieve future
goals, mainly a prefrontal cortex function (Fuster 1997), or
the capacity of maintenance of problem-solving sets
toward those goals (Welsh and Pennington 1988).
Regardless of the nature of the concept, there is a strong
body of evidence showing that symptoms of poor executive
functioning (EF) are associated with ADHD in children and
adults, leading some authors to consider EF as the main
explanatory neuropsychological domain for ADHD. Bark-
ley has advanced a theoretical model that suggests that
ADHD comprises a deficit in behavior inhibition, which is
related to executive functions such as working memory,
self-regulation of affect-motivation-arousal, internalization
of speech, and reconstitution (analysis and synthesis of the
behavior) (Barkley 1997).
The majority of studies testing this model have com-
pared the performance on tests of EF of subjects with
ADHD and normal controls. In general, subjects with the
disorder consistently show worse performance on EF tests.
In children and adolescents, a meta-analysis including 26
studies suggested that children with ADHD may have
deficits in multiple components of working memory pro-
cesses, independently of comorbidity with language/
learning disorder (Martinussen et al. 2005). The effect size
for deficits in nonverbal working memory tended to be
bigger than the one for verbal working memory. A different
meta-analysis addressed the magnitude of the deficit in
overall cognitive ability by comparing cases with ADHD
and controls (not restricted by age-group) in terms of IQ
(Frazier et al. 2004). The authors also compared effect
sizes for other neuropsychological tests in this setting. The
effect size for the difference in overall intellectual ability
(Full Scale IQ—FSIQ) between ADHD and healthy par-
ticipants was significant. Effect sizes for FSIQ were sig-
nificantly smaller than those for spelling and arithmetic
achievement tests and only marginally significantly smaller
than those for continuous performance tests. Effect sizes
for FSIQ were comparable to effect sizes for all other
measures (mean reaction time; Stop Signal Task; Wis-
consin Card Sorting Test; Matching Familiar Figures Test;
Wide Range Achievement Test). These findings suggest
that EF-related, theoretically more specific neuropsycho-
logical tests for ADHD might not be much better than
general IQ measures in separating ADHD cases and con-
trols. Another meta-analysis included 83 studies that
123
58
compared EF measures in groups with and without ADHD
(Willcutt et al. 2005). In general, groups with ADHD
showed significant impairment in all EF tasks. The stron-
gest effects were obtained on measures of response inhi-
bition, vigilance, working memory, and planning. The
effect sizes fell in the medium range for all measures, and
there was no universality of EF deficits among individuals
with ADHD, leading the author to suggest that EF deficit is
one important (but not the single) component of the neu-
ropsychology of ADHD.
In adults, a meta-analysis with findings from 33 studies
(most of them comparing ADHD cases with non-clinical
controls) showed that deficits associated with ADHD in
multiple domains of executive functioning, such as atten-
tion, behavioral inhibition, and working memory (Hervey
et al. 2004). Another meta-analysis included 14 studies that
compared the performance in EF tests between DSM-
defined ADHD adults and normal controls (Boonstra et al.
2005). The authors found medium effect sizes in both EF
domains (such as verbal fluency, inhibition, set shifting)
and non-EF areas (such as response consistency, word
reading, and color naming). These findings suggest that
neuropsychological deficits in adult ADHD may not be
restricted to EF and also raise questions about the speci-
ficity of poor EF in adult ADHD.
In general, the available evidence is very consistent
documenting an association between ADHD and EF defi-
cits. However, the specificity of this association is still to be
better understood, since the vast majority of studies com-
pared ADHD cases to non-clinical controls, and there are
some studies on other common psychiatric disorders, such
as schizophrenia (Groom et al. 2008), post-traumatic stress
disorder (Polak et al. 2012), bipolar disorder (Torralva et al.
2011), and Asperger disorder (Happé et al. 2006), reporting
EF-deficit patterns that are not robustly different from those
found in ADHD. In addition, a significant proportion of
patients with clinically diagnosable ADHD across the life
cycle do not have EF deficits, at least in the neuropsycho-
logical tests available for assessing this brain function.
Regarding this last issue, the psychometric properties of
the EF tests are also a matter of concern, since few of them
were properly evaluated in terms of reliability (Willcutt
et al. 2005). More problematically, the available EF tests
are sometimes complex, involving multiple cognitive pro-
cesses that might not adequately capture the intended
construct of EF (Anderson 2002), and might have low
ecological validity when compared to EF performance in
natural settings. Biederman et al. (2008) reported only a
modest overlap between self-report and psychometric
definitions of EF deficits in an ADHD case–control study.
In this study, EF tests identified specially subjects with
lower IQ and achievement testing, whereas behavioral
questions about EF deficits identified subjects with higher
123
B. Matte et al.
levels of ADHD, comorbidities, and interpersonal deficits.
Such results led some authors to suggest that EF ratings,
rather than EF tests, could capture better the construct of
EF and have a better correlation with daily life impairment
(Barkley and Murphy 2010).
Concerned about the lack of validity of DSM ADHD
criteria in adults, Faraone et al. (2010) compared adult
cases with ADHD and controls on 99 potential ADHD
items. They compared the diagnostic efficiency of three
algorithms on predicting DSM-IV-defined ADHD: Barkley
et al.’s 9-item scale (Barkley et al. 2008), the best 9-item
scale, and the best 18-item scales among the tested items.
The three algorithms had similar efficiency in predicting
adult ADHD (areas under the curve, around 0.82–0.86).
Interestingly, many of the most efficient items in this study
could be considered as behavioral measures of EF deficits
(such as difficulty persisting, remembering, organizing
thoughts, and doing things in order).
With similar objectives, Kessler et al. (2010) evaluated
the structure and the symptoms more predictive of DSM-IV
adult ADHD in a sample of 345 subjects who responded to
the Adult ADHD Clinical Diagnostic Scale. In a factorial
analysis of the data, a three-factor structure of adult symp-
toms emerged including EF, inattention hyperactivity, and
impulsivity. Among the four items that best predicted
ADHD, three can be considered as behavior measures of EF
(difficult prioritizing work, cannot complete tasks in allotted
time, make careless mistakes). Having two of these 4 items
predicted DSM-IV ADHD with good diagnostic efficiency
(sensitivity = 96.7 %; specificity = 98.5 %; positive pre-
dictive value = 84.5 %; negative predictive value =
99.7 %; area under the curve = 0.98). None of these items
increased the predictions of any other DSM-IV diagnoses
beyond of what expected by the total ADHD score.
EF relations with ADHD and other psychiatric disorders
still need to be better clarified. Overall, it seems that the
use of EF tests as a diagnostic tool for ADHD is far from
the clinical reality, due to the lack of specificity, largely
unknown psychometric properties, and questionable ability
to capture the construct of EF. On the other hand, the
inclusion of items about EF behavioral correlates as part of
the diagnostic criteria of ADHD for adults, which may be
easier to assess and may have a stronger ecological valid-
ity, might increase the validity and clinical utility of the
diagnosis. However, this alternative should be more
extensively tested and replicated for its diagnostic effi-
ciency in different settings and in population samples
before incorporation in future classificatory systems.
Emotional impulsivity
ADHD has been described as comprising developmentally
inadequate symptoms in two dimensions of
ADHD in adults
neuropsychological functioning: inattention and hyperactivity
impulsivity in the last three decades, since the third version of
the DSM (APA 1980). The current ADHD definition excludes
from the disorder an important feature involving emotional
impulsivity (EI) and deficits in emotional inhibition and self-
regulation (DESR). This emotional impulsivity domain,
related to a deficiency in the effortful, executive, or cognitive
control of emotions, in general, and those related to frustra-
tion, impatience, and anger, in particular, was once considered
as part of the disorder in the first conceptualizations of ADHD
in children (Barkley 2010). In the seventies, the classic
descriptions of ADHD in adults, by Wood et al. (1976) and
Wender et al. (1981), and the following Wender-Utah Rating
Scale (Ward et al. 1993) also included items of emotional
impulsivity. In spite of this historical concept of EI-DESR as
one central construct in ADHD, this dimension has been
treated as a separate entity that may be associated with some
cases of ADHD due to low sensitivity and specificity to predict
ADHD diagnosis. So, it has been largely neglected in the
ADHD literature. Nonetheless, symptoms of EI-DESR were
used to conceptualize a new disorder in DSM-III, opposite-
defiant disorder (ODD) (APA 1980). Thus, it is not surprising
that recent investigations have found extremely high preva-
lence rates of comorbidity between ADHD and ODD in both
children and adolescents either in clinical or in non-referred
samples (see Souza et al. 2004; Garcia et al. 2010).
Recent studies suggest that this separation between ADHD
and EI-DESR might be reconsidered. Besides the historical
proximity, the executive function-based theory of ADHD
considers self-regulation of emotion, motivation, and arousal
using working memory systems as one of the central execu-
tive functions related to ADHD at least in part of the affected
individuals (Barkley 2010). Neuroanatomical networks
related to ADHD may also support EI-DESR as a central
feature of ADHD, since the frontolimbic networks that are
believed to be responsible for hyperactivity, inattentive, and
impulsive behavior in ADHD may be similar to those
responsible for the cognitive, effortful control of emotion.
Neuroimaging studies suggest that lateral prefrontal cortex
and anterior cingulated cortex may be areas that are related
both to ADHD and to the conscious regulation of emotion
(Bush et al. 2005; Ochsner and Gross 2005). In adults, there
are also evidences for a clinical coexistence of symptoms
assessing emotional regulation and symptoms of impulsive-
ness, which loaded on the same factor in the study conducted
by Conners et al. (1998). More recent research showed that
ADHD adults manifest problems with EI-DESR symptoms
and that the symptoms were as common for this population as
DSM-IV symptoms of inattention, and even more frequent
than those of hyperactivity impulsivity (Barkley et al. 2008).
Considering EI-DESR as a core component of ADHD could
also contribute to understanding the high level of social
59
impairment in ADHD and the high comorbidity between
ADHD and ODD.
Overall, it seems clear that EI-DESR is a dimension that is
closely associated with ADHD. Recent growing interest in
this construct has motivated investigations suggesting that it
may even be a central component of the disorder mainly in
adults (Mannuzza et al., unpublished manuscript). More data
are needed in order to clarify whether EI-DESR has a specific
association with ADHD and whether EI-DESR symptoms
could have any diagnostic utility for ADHD in the future. In
this sense, the ADHD and Disruptive Behavior Working
Group for DSM-5 already proposed 4 potential new impul-
sivity items to be tested in field trials for inclusion as part of
the ADHD symptom list in the DSM-5 (see http://www.
dsm5.org/ProposedRevision/). Up to this moment, these
items were tested only in a sample of Iranian children using
exploratory and confirmatory factor analyses (Ghanizadeh
2012).
Recommendations
Although we are approaching the launching of the DSM-5
in the beginning of 2013, there is still much work to
improve the concept and the operational definitions of
ADHD in adults. We clearly need much more investiga-
tions, and these studies are not doable up to the deadline
available at least for DSM-5 (ICD-11 is expected for 2015).
In this review, we focused on the most prominent issues
for adults. Other issues relevant to ADHD but pertinent
across the entire life cycle are addressed in other reviews
(see, e.g., Rohde 2008). One example of a non-assessed
issue pertinent to ADHD across the life cycle is the dif-
ferential power/weight of individual symptoms to capture
the ADHD latent construct, an issue never adequately
tested in the ADHD field.
Thus, the following issues would benefit from more
research in representative adult population samples:
(a) Should the inclusion of new dimensions—EF deficits
and EI—increase the validity and clinical utility of the
diagnosis of ADHD in adults? If included, do they
modify the bidimensional construct proposed by DSM-
IV for ADHD?
(b) What is the best threshold of symptoms to capture
ADHD construct in adults? This question can only be
answered after defining the adequacy of inclusion of
new dimensions.
(c) Is there ADHD in adults without ADHD in children?
How prevalent is the trajectory from subthreshold
ADHD in children to full syndrome ADHD in adults
in the population? Is this phenotype associated with
different clinical correlates and outcomes than those
123
60
found in persistent full syndrome ADHD? At least the
first question would need data coming from longitu-
dinal studies to avoid recall bias.
Some issues might be tested in population samples but
will also need some assessment in clinical samples. For
instance, how relevant information from others is in the
ADHD diagnostic process in adults? Is there any decrease
in false negatives? Is it feasible to ask for information from
others in clinical settings?
There are some issues that might benefit more from
qualitative studies than quantitative ones. Does rewording
of the DSM-IV ADHD symptoms descriptors (criteria A)
to improve developmental utility for adults keep semantic
consistency? Do adults with ADHD understand the modi-
fications properly?
Finally, we will need to face an important conceptual
dilemma if data from future investigations would suggest
that several modifications should be implemented in the
operational criteria for adult ADHD: Is the field ready to
have different phenotypic criteria for ADHD across the life
cycle? What would be the impact in clinical settings of
different phenotypic descriptors for ADHD in adults and
children? Would be this an opportunity for really having
developmental psychopathology as part of the new classi-
fication systems in Psychiatry moving them away from
developmental static definitions (an old aspiration from
child mental health professionals)?
We are anticipating an exciting new era in the research
arena of ADHD in adults for the next few years with many
clinically relevant research questions to be answered.
Acknowledgments This review is part of the formative phase for a
research project financed by the Brazilian National Council of
Technological and Scientific Development—CNPq (159782/2011-2).
Dr. Grevet receives a postdoc scholarship from the CNPq, Brazil. The
authors thank Dr. Rachel Klein for her expertise and for her kind help
in reviewing this paper.
Conflict of interest Dr. Luis Augusto Rohde was on the speakers’
bureau and/or acted as consultant for Eli-Lilly, Janssen-Cilag, Nov-
artis, and Shire in the last 3 years (less than U$ 10,000 per year and
reflecting less than 5 % of his gross income per year). He also
received travel awards (air tickets and hotel) to take part of two Child
Psychiatric Meetings from Janssen-Cilag and Novartis in 2010. The
ADHD and Juvenile Bipolar Disorder Outpatient Programs chaired by
him received unrestricted educational and research support from the
following pharmaceutical companies in the last 3 years: Eli-Lilly,
Janssen-Cilag, Novartis, and Shire. Dr. Matte and Dr. Grevet have no
conflicts of interest.
References
American Psychiatric Association (1980) Diagnostic and statistical
manual of mental disorders, 3rd edn. American Psychiatric
Association, Washington, DC
123
B. Matte et al.
American Psychiatric Association (APA) (1994) Diagnostic and
statistical manual of mental disorders, 4 edn. Washington, DC:
American Psychiatric Press
Anderson P (2002) Assessment and development of executive
function (EF) during childhood. Child Neuropsychol 8(2):71–82
Applegate B, Lahey BB, Hart EL, Biederman J, Hynd GW, Barkley
RA, Ollendick T, Frick PJ, Greenhill L, McBurnett K, Newcorn
JH, Kerdyk L, Garfinkel B, Waldman I, Shaffer D (1997)
Validity of the age-of-onset criterion for ADHD: a report from
the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry
36(9):1211–1221
Barkley RA (1997) Behavioral inhibition, sustained attention, and
executive functions: constructing a unifying theory of ADHD.
Psychol Bull 121(1):65–94
Barkley RA (2009) Challenges in diagnosing adults with ADHD.
J Clin Psychiatry 69(12):e36
Barkley RA (2010) Deficient emotional self-regulation: a core
component of attention-deficit/hyperactivity disorder. J ADHD
Relat Disord 1(2):5–37
Barkley RA, Murphy KR (2010) Impairment in occupational
functioning and adult ADHD: the predictive utility of executive
function (EF) ratings versus EF tests. Arch Clin Neuropsychol
5(3):157–173
Barkley R, Fischer M, Edelbrock C, Smallish L (1990) The
adolescent outcome of hyperactive children diagnosed by
research criteria, I: an 8-year prospective follow-up study.
J Am Acad Child Adolesc Psychiatry 29:546–557
Barkley RA, Murphy KR, Fischer M (2008) ADHD in adults: what
the science says. Guilford Press, New York, NY
Biederman J, Mick E, Faraone SV (2000) Age-dependent decline of
symptoms of attention deficit hyperactivity disorder: impact of
remission definition and symptom type. Am J Psychiatry
157(5):816–818
Biederman J, Mick E, Spencer T, Surman C, Hammerness P, Doyle R,
Dougherty M, Aleardi M, Schweitzer K (2006) An open-label
trial of OROS methylphenidate in adults with late-onset ADHD.
CNS Spectr 11:390–396
Biederman J, Petty CR, Fried R, Black S, Faneuil A, Doyle AE,
Seidman LJ, Faraone SV (2008) Discordance between psycho-
metric testing and questionnaire-based definitions of executive
function deficits in individuals with ADHD. J Atten Disord
12(1):92–102
Biederman J, Petty CR, Clarke A, Lomedico A, Faraone SV (2011)
Predictors of persistent ADHD: an 11-year follow-up study.
J Psychiatr Res 45(2):150–155
Boonstra AM, Oosterlaan J, Sergeant JA, Buitelaar JK (2005)
Executive functioning in adult ADHD: a meta-analytic review.
Psychol Med 35(8):1097–1108
Bush G, Valera EM, Seidman LJ (2005) Functional neuroimaging of
attention-deficit/hyperactivity disorder: a review and suggested
future directions. Biol Psychiatry 57(11):1273–1284
Conners CK, Erhardt D, Sparrow E (1998) Conners adults ADHD
rating scale. Multi-Health System, Inc, North Tonawanda
Dias G, Mattos P, Coutinho G, Segenreich D, Saboya E, Ayrão V
(2008) Agreement rates between parent and self-report on past
ADHD symptoms in an adult clinical sample. J Atten Disord
12(1):70–75
DuPaul GJ, Schaughency EA, Weyandt LL, Tripp G, Kiesner J, Ota
K, Stanish H (2001) Self-report of ADHD symptoms in
university students: cross-gender and cross-national prevalence.
J Learn Disabil 34:370–379
Faraone SV, Biederman J (2005) What is the prevalence of adult
ADHD? Results of a population screen of 966 adults. J Atten
Disord 9:384–391
Faraone S, Biederman J, Doyle A, Murray K, Petty C, Adamson JJ,
Seidman L (2006) Neuropsychological studies of late onset and
ADHD in adults
subthreshold diagnoses of adult attention-deficit/hyperactivity
disorder. Biol Psychiatry 60:1081–1087
Faraone S, Biederman J, Spencer T, Mick E, Murray K, Petty C,
Adamson JJ, Monuteaux MC (2006) Diagnosing adult attention
deficit hyperactivity disorder: are late onset and subthreshold
diagnoses valid? Am J Psychiatry 163:1720–1729
Faraone SV, Biederman J, Mick E (2006c) The age-dependent decline
of attention deficit hyperactivity disorder: a meta-analysis of
follow-up studies. Psychol Med 36(2):159–165
Faraone S, Wilens T, Petty C, Antshel K, Spencer T, Biederman J
(2007) Substance use among ADHD adults: implications of late
onset and subthreshold diagnoses. Am J Addict 16(Suppl
1):24–32
Faraone S, Kunwar A, Adamson J, Biederman J (2009) Personality
traits among ADHD adults: implications of late-onset and
subthreshold diagnoses. Psychol Med 39:685–693
Faraone SV, Biederman J, Spencer T (2010) Diagnostic efficiency of
symptoms for identifying adult attention-deficit/hyperactivity
disorder. J ADHD Relat Disord 1(2): 38–48
Fayyad J, De Graaf R, Kessler RC, Alonso J, Angermeyer M,
Demyttenaere K, De Girolamo G, Haro JM, Karam EG, Lara C,
Lepine JP, Ormel J, Posada-Villa J, Zaslavsky AM, Jin R (2007)
Cross-national prevalence and correlates of adult attention-
deficit hyperactivity disorder. Br J Psychiatry 190:402–409
Frazier TW, Demaree HA, Youngstrom EA (2004) Meta-analysis of
intellectual and neuropsychological test performance in attention-
deficit/hyperactivity disorder. Neuropsychology 18(3):543–555
Fuster JM (1997) The prefrontal cortex. Raven, New York
Garcia CR, Bau CH, Silva KL, Callegari-Jacques SM, Salgado CA,
Fischer AG, Victor MM, Sousa NO, Karam RG, Rohde LA,
Belmonte-de-Abreu P, Grevet EH (2010) The burdened life of
adults with ADHD: impairment beyond comorbidity. Eur
Psychiatry. http://dx.doi.org/10.1016/j.eurpsy.2010.08.002
Ghanizadeh A (2012) Psychometric analysis of the new ADHD DSM-
IV derived symptoms. BMC Psychiatry 12(1):21
Groom MJ, Jackson GM, Calton TG, Andrews HK, Bates AT, Liddle
PF, Hollis C (2008) Cognitive deficits in early-onset schizo-
phrenia spectrum patients and their non-psychotic siblings: a
comparison with ADHD. Schizophr Res 99(1–3):85–95
Happé F, Booth R, Charlton R, Hughes C (2006) Executive function
deficits in autism spectrum disorders and attention-deficit/
hyperactivity disorder: examining profiles across domains and
ages. Brain Cogn 61(1):25–39
Heiligenstein E, Conyers LM, Berns AR, Smith MA (1998)
Preliminary normative data on DSM–IV attention deficit hyper-
activity disorder in college students. J Am Coll Health
46:185–188
Hervey AS, Epstein JN, Curry JF (2004) Neuropsychology of adults
with attention-deficit/hyperactivity disorder: a meta-analytic
review. Neuropsychology 18(3):485–503
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters
EE (2005) Lifetime prevalence and age-of-onset distributions of
DSM-IV disorders in the National Comorbidity Survey Repli-
cation. Arch Gen Psychiatry 62(6):593–602
Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler
O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T,
Üstün TB, Walters EE, Zaslavsky AM (2006) The prevalence
and correlates of adult ADHD in the United States: results from
the National Comorbidity Survey Replication. Am J Psychiatry
163:716–723
Kessler RC, Green JG, Adler LA, Barkley RA, Chatterji S, Faraone
SV, Finkelman M, Greenhill LL, Gruber MJ, Jewell M, Russo
LJ, Sampson NA, Van Brunt DL (2010) Structure and diagnosis
of adult attention-deficit/hyperactivity disorder: analysis of
expanded symptom criteria from the Adult ADHD Clinical
Diagnostic Scale. Arch Gen Psychiatry 67(11):1168–1178
61
Kieling R, Rohde LA (2012) ADHD in children and adults: diagnosis
and prognosis. Curr Top Behav Neurosci 9:1–16
Kieling C, Kieling RR, Rohde LA, Frick PJ, Moffitt T, Nigg JT,
Tannock R, Castellanos FX (2010) The age at onset of attention
deficit hyperactivity disorder. Am J Psychiatry 167(1):14–16
Klein R, Mannuzza S, Olazagasti MAR, Roizen MS, Hutchison BA,
Lashua EC, Castellanos FX. Clinical and functional outcome of
childhood ADHD 33 years later. Arch Gen Psychiatry (in press)
Kooij JJ, Buitelaar JK, van den Oord EJ, Furer JW, Rijnders CA,
Hodiamont PP (2005) Internal and external validity of attention-
deficit hyperactivity disorder in a population-based sample of
adults. Psychol Med 35:817–827
Kooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugué M,
Carpentier PJ, Edvinsson D, Fayyad J, Foeken K, Fitzgerald
M, Gaillac V, Ginsberg Y, Henry C, Krause J, Lensing MB,
Manor I, Niederhofer H, Nunes-Filipe C, Ohlmeier MD, Oswald
P, Pallanti S, Pehlivanidis A, Ramos-Quiroga JA, Rastam M,
Ryffel-Rawak D, Stes S, Asherson P (2010) European consensus
statement on diagnosis and treatment of adult ADHD: the
European Network Adult ADHD. BMC Psychiatry 10:67
Lahey BB, Applegate B, McBurnett K, Biederman J, Greenhill L, Hynd
GW, Barkley RA, Newcorn J, Jensen P, Richters J et al (1994)
DSM-IV field trials for attention deficit hyperactivity disorder in
children and adolescents. Am J Psychiatry 151(11):1673–1685
Larsson H, Dilshad R, Lichtenstein P, Barker ED (2011) Develop-
mental trajectories of DSM-IV symptoms of attention-deficit/
hyperactivity disorder: genetic effects, family risk and associated
psychopathology. J Child Psychol Psychiatry 52(9):954–963
Mannuzza S, Klein R, Bessler A, Malloy P, LaPadula M (1998) Adult
psychiatric status of hyperactive boys grown up. Am J Psychi-
atry 155:493–498
Mannuzza S, Klein RG, Klein DF, Bessler A, Shrout P (2002)
Accuracy of adult recall of childhood attention deficit hyperac-
tivity disorder. Am J Psychiatry 159(11):1882–1888
Martinussen R, Hayden J, Hogg-Johnson S, Tannock R (2005) A
meta-analysis of working memory impairments in children with
attention-deficit/hyperactivity disorder. J Am Acad Child Ado-
lesc Psychiatry 44(4):377–384
Medina-Mora ME, Borges G, Lara C, Benjet C, Blanco J, Fleiz C,
Villatoro J, Rojas E, Zambrano J (2005) Prevalence, service use,
and demographic correlates of 12-month DSM–IV psychiatric
disorders in Mexico: results from the Mexican National Comor-
bidity Survey. Psychol Med 35:1773–1783
Mick E, Faraone SV, Biederman J (2004) Age-dependent expression
of attention-deficit/hyperactivity disorder symptoms. Psychiatr
Clin North Am 27(2):215–224
Miller CJ, Newcorn JH, Halperin JM (2010) Fading memories:
retrospective recall inaccuracies in ADHD. J Atten Disord
14(1):7–14
Mullins-Sweatt SN, Widiger TA (2009) Clinical utility and DSM-V.
Psychol Assess 21(3):302–312
Murphy K, Barkley RA (1996) Prevalence of DSM-IV symptoms of
ADHD in adult licensed drivers: implications for clinical
diagnosis. J Atten Disord 1(3):147–161
Murphy P, Schachar R (2000) Use of self-ratings in the assessment of
symptoms of attention deficit hyperactivity disorder in adults.
Am J Psychiatry 157(7):1156–1159
Ochsner KN, Gross JJ (2005) The cognitive control of emotion.
Trends Cogn Sci 9(5):242–249
Polak AR, Witteveen AB, Reitsma JB, Olff M (2012) The role of
executive function in posttraumatic stress disorder: a systematic
review. J Affect Disord. http://dx.doi.org/10.1016/j.jad.
2012.01.001
Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (2007)
The worldwide prevalence of ADHD: a systematic review and
metaregression analysis. Am J Psychiatry 164(6):942–948
123
62
Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE
(2010) Implications of extending the ADHD age-of-onset
criterion to age 12: results from a prospectively studied birth
cohort. J Am Acad Child Adolesc Psychiatry 49(3):210–216
Ramtekkar UP, Reiersen AM, Todorov AA, Todd RD (2010) Sex and
age differences in attention-deficit/hyperactivity disorder symp-
toms and diagnoses: implications for DSM-V and ICD-11. J Am
Acad Child Adolesc Psychiatry 49(3):217–28.e1-3
Reinhardt M, Benetti L, Victor M, Grevet E, Belmonte-de-Abreu P,
Faraone SV, Rohde LA (2007) Is age-at-onset criterion relevant
for the response to methylphenidate in attention-deficit/hyper-
activity disorder? J Clin Psychiatry 68:1109–1116
Rohde LA (2008) Is there a need to reformulate attention deficit
hyperactivity disorder criteria in future nosologic classifications?
Child Adolesc Psychiatr Clin N Am 17(2):405–420
Rohde LA, Biederman J, Zimmermann H, Schmitz M, Martins S,
Tramontina S (2000) Exploring age-of-onset criterion in Brazil-
ian adolescents. Eur Child Adolesc Psychiatry 9:212–218
Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR,
Altman SE (2009) Subthreshold conditions as precursors for full
syndrome disorders: a 15-year longitudinal study of multiple
diagnostic classes. J Child Psychol Psychiatry 50(12):1485–1494
Simon V, Czobor P, Bálint S, Mészáros A, Bitter I (2009) Prevalence
and correlates of adult attention-deficit hyperactivity disorder:
meta-analysis. Br J Psychiatry 194(3):204–211
Solanto MV, Marks DJ, Wasserstein J, Mitchell KJ (2011) Diagnosis
of ADHD in adults: what Is the appropriate DSM-5 symptom
threshold for hyperactivity-impulsivity? J Atten Disord. doi:
10.1177/1087054711416910
Souza I, Pinheiro MA, Denardin D, Mattos P, Rohde LA (2004)
Attention-deficit/hyperactivity disorder and comorbidity in
123
B. Matte et al.
Brazil: comparison between two referred samples. Eur Child
Adolesc Psychiatry 13:243–248
Todd R, Huang H, Henderson C (2008) Poor utility of the age of onset
criterion for DSM-IV attention deficit/hyperactivity disorder:
recommendations for DSM-V and ICD-11. J Child Psychol
Psychiatry 49:942–949
Torralva T, Gleichgerrcht E, Torrente F, Roca M, Strejilevich SA,
Cetkovich M, Lischinsky A, Manes F (2011) Neuropsycholog-
ical functioning in adult bipolar disorder and ADHD patients: a
comparative study. Psychiatry Res 186(2–3):261–266
Valo S, Tannock R (2010) Diagnostic instability of DSM-IV ADHD
subtypes: effects of informant source, instrumentation, and
methods for combining symptom reports. J Clin Child Adolesc
Psychol 39(6):749–760
Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah Rating
Scale: an aid in the retrospective diagnosis of childhood attention
deficit hyperactivity disorder. Am J Psychiatry 150(8):1280
Welsh MC, Pennington BF (1988) Assessing frontal lobe functioning
in children: views from developmental psychology. Dev Neu-
ropsychol 4:199–230
Wender PH, Reimherr FW, Wood DR (1981) Attention deficit
disorder (‘minimal brain dysfunction’) in adults. A replication
study of diagnosis and drug treatment. Arch Gen Psychiatry
38(4):449–456
Willcutt EG, Doyle AE, Nigg JT, Faraone SV, Pennington BF (2005)
Validity of the executive function theory of attention-deficit/
hyperactivity disorder: a meta-analytic review. Biol Psychiatry
57(11):1336–1346
Wood DR, Reimherr FW, Wender PH, Johnson GE (1976) Diagnosis
and treatment of minimal brain dysfunction in adults: a
preliminary report. Arch Gen Psychiatry 33(12):1453–1460