Epidemiology of attention-deficit/hyperactivity disorder across
the lifespan
Guilherme Polanczyk and Luis Augusto Rohde
Purpose of review
Prevalence estimates of the attention-deficit hyperactivity
disorder (ADHD) and the rate of persistence of symptoms
across the lifespan are heterogeneous, raising questions
about the validity of the diagnosis. This review aims to
discuss potential reasons for variability in ADHD prevalence
estimates and rates of symptom persistence, as well as to
present ADHD prevalence rates during the lifespan.
Recent findings
The best available estimates of ADHD prevalence are
around 5.29% for children and adolescents and 4.4% in
adulthood. Estimates of ADHD prevalence and rate of
symptom persistence over time seem to be highly affected
by methodological characteristics of the studies.
Summary
The review of ADHD epidemiology highlights the need for
standardizing study methodologies to make findings
comparable. Even so, epidemiological cross-national data
seem to support the validity of ADHD.
Keywords
ADHD, adults, children, course of symptoms, prevalence
Curr Opin Psychiatry 20:386–392. ß 2007 Lippincott Williams & Wilkins.
ADHD Outpatient Program, Child and Adolescent Psychiatric Division, Hospital de
Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Brazil
Correspondence to Professor Luis Augusto Rohde, Child and Adolescent
Psychiatric Division, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos,
2350 Porto Alegre, RS, Brazil
Tel: +5590035 003; fax: +55 51 3321 3946; e-mail: lrohde@terra.com.br
Current Opinion in Psychiatry 2007, 20:386–392
Abbreviations
ADHD attention-deficit/hyperactivity disorder
DSM Diagnostic and Statistical Manual of Mental Disorders
ICD International Classification of Diseases
ß 2007 Lippincott Williams & Wilkins
0951-7367
386
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of
the most common mental disorders affecting children and
adolescents. The core ADHD symptoms are pervasive and
impairing inattention, hyperactivity, or impulsivity [1,2].
Due to its significant prevalence during the lifespan and
associated impairments, the disorder is considered a major
health problem [1].
Epidemiological studies have contributed to the under-
standing of the distribution and etiology of ADHD and to
an accurate planning of services for affected children.
Disparate prevalence rates can be found around the world,
however, raising questions about the consistency of esti-
mates and a discussion about the validity of the diagnosis.
Moreover, only recently, attention of investigators shifted
to the recognition of the disorder during adulthood. In
addition, there are scarce data from longitudinal nonre-
ferred samples on the persistence rate of ADHD over time.
We reviewed the literature about the epidemiology of
ADHD aiming to answer four questions: Are the ADHD
prevalence estimates in children and adolescents diverse
around the world? What is the persistence rate of ADHD
from childhood to adulthood? What is the best available
ADHD prevalence estimate for adults? Are male to
female ratio, ethnic and socioeconomic issues relevant
for the epidemiology of ADHD?
Attention deficit/hyperactivity disorder
prevalence in childhood and adolescence
Wide variations in ADHD prevalence estimates during
childhood and adolescence can be found around the world
[3–5], from as low as 0.9% [6] to as high as 20% [7]. Similar
estimates from 5.2% [8] to 7.5% [9] are detected, however,
even in different sociocultural settings, such as Switzerland
[8], Brazil [10], Italy [11], Taiwan [9], and Congo [12].
Three systematic reviews on this subject have been pub-
lished to date [13,14,15]. A number of papers attempted to
provide a ‘true’ prevalence rate, and to explain the reasons
for the variability in results across studies [13,14,16,17].
The prevalence rate estimated by these reviews is com-
monly between 5 and 10% [13,14,16,17].
Some authors speculated that differences of estimates
would be secondary to demographic issues – with higher
rates in North America [18] – nurturing the idea that

ADHD is a product of the western culture [19]. Others
stated that differences are secondary to methodological
issues in the studies and have hypothesized that applying
similar methodologies in different countries, would result
in equivalent findings [2,13].
The individual and combined statistical significance of
each methodological characteristic of the studies on the
variability of results, however, had not been evaluated
until a recent study by our group [15]. We conducted a
comprehensive systematic review on ADHD prevalence
during childhood and adolescence providing an esti-
mated pooled prevalence for the disorder. In addition,
we applied meta-regression analyses to evaluate the
role of methodological characteristics on the variability
of results. After a broad review and a rigorous analysis of
papers, we included 102 studies comprising 171 756
subjects from all world regions. The aggregated preva-
lence of ADHD based on all studies was 5.29% (95% CI,
5.01–5.56). The pooled prevalence for children and
adolescents were respectively 6.48% (4.62–8.35) and
2.74% (2.04–3.45) [15].
Furthermore, adjusting for methodological issues, esti-
mates from North America and Europe were not signifi-
cantly different. Differences between studies regarding
the diagnostic criteria used [Diagnostic and Statistical
Manual of Mental Disorders (DSM)-III, DSM-III-R,
DSM-IV or International Classification of Diseases
(ICD)-10], source of information (best-estimate pro-
cedure, parents, ‘and rule’, ‘or rule’, teachers, or subjects),
and requirement or not of impairment for the diagnosis
were associated with significant variability of results [15].
In this way, it is fundamental to understand the evolved
aspects of ADHD diagnosis in epidemiological studies
and its impact on results [20].
The ADHD was operationally described in DSM-III [21]
in 1980. After that, two other versions of the DSM have
been published, with different conceptualization of the
disorder. In the first classification, inattention and hyper-
activity were represented in two separated domains and it
was possible to derive an ADHD diagnosis based on the
presence of enough symptoms in only one dimension.
DSM-III-R [22] grouped these symptoms in a unique
domain, along with impulsivity. DSM-IV [23] listed
inattentive and hyperactivity–impulsivity symptoms
in separate domains. It is possible to derive a diagnosis
of ADHD according to DSM-IV based on the presence
of symptoms in one or both domains, resulting in three
possible subtypes. The symptoms must be associated
with functional impairment in at least two settings,
and some symptoms associated with functional impair-
ment must have been present before the age of 7 years.
The list of symptoms and the evaluated constructs are
very similar between DSM-IV [23] and ICD-10 [24];
Attention-deficit/hyperactivity disorder Polanczyk and Rohde 387
differences are more related to the way the diagnosis is
constructed. The ICD-10 requires both a minimum
number of symptoms in all three dimensions (inattention,
overactivity, and impulsivity), and presence of each
symptom in at least two different settings. Furthermore,
the ICD-10 has mood, anxiety and developmental dis-
orders as exclusion diagnoses. DSM-IV and DSM-III-R
allow the establishment of ADHD diagnosis in the pre-
sence of mood and anxiety disorders, but not of pervasive
developmental disorders. Thus, when ADHD is evalu-
ated through the same diagnostic interview and the
diagnosis is generated according to both DSM-IV and
ICD-10, higher rates are found with the DSM-IV diag-
nostic criteria in community and clinical samples [25].
In epidemiological studies, the judgment of the abnormal
nature of the behavior is frequently based on an inde-
pendent informant rather than on a clinical evaluation
[26]. The more appropriate way to define a diagnosis
seems to be collecting information from different sources,
evaluating the information and judging it according to the
clinical expertise [27,28]. Other possibilities are the
requirement of positive information about a symptom
from more than one source (‘and rule’) [29] or from just
one among different sources (‘or rule’) [30]. The estab-
lishment of the diagnosis based on only one informant has
some caveats. Children and adolescents have poor abil-
ities to provide reliable information about their behavior
[16]. Parents and teacher are the most common sources,
but they are not always congruent [29]. This may happen
because the occurrence of each symptom is dependent
on the setting or because parents and teacher have
tendencies to value or to overlook different symptoms.
Parents have the advantage to have a good knowledge
about their child’s behavior and to have followed his/her
development over time. Teachers are expected to observe
children more objectively and they are in a position where
it is possible to compare children in the same develop-
mental stage [16,26]. For instance, in a representative
sample of 2400 Canadian children, the DSM-III-R ADHD
diagnosis was estimated as 3.3% according to children’s
report, 8.9% according to teachers’ and 5% according to
parents’ report.
Considering that motor activity and attention span are
expressed in a continuum in the population and there
is no clear cutoff point to categorize behavior into normal
or abnormal [31], some adjunctive criteria are used.
DSM-IV [23] requires that symptoms must be devel-
opmentally inappropriate and occur frequently, but does
not define this term objectively. Clinical impairment is
another frequent indicator of abnormality, but this is also
dependent of environmental demands and life circum-
stances of the individual. Some investigations report
ADHD estimates using a definition of impairment
(although not always the same across studies) while
388 Services research and outcomes
others report on ADHD symptoms without any defi-
nition of impairment. Canino et al. [32] evaluated the
DSM-IV ADHD prevalence without the requirement of
impairment for the diagnosis and according to three
different definitions of impairment. The proportion of
children meeting ADHD criteria varied from 3.7 to 8.9%,
with lower rates associated with more rigorous impairment
criterion.
Course of symptoms
The ADHD was first conceptualized as a disorder
restricted to childhood and adolescence. Longitudinal
studies showed that although there is a clear decline of
symptoms with age, they tend to persist in a variable
proportion of people [33] who are more frequently
impaired than controls in several major life activities
[34]. Longitudinal studies available are limited by the
relatively short period of follow-up (only one study eval-
uated subjects in their early thirties) and by the historical
changes in classificatory systems [35]. Similarly to
prevalence estimates of the disorder in childhood, the
estimation of persistence of the diagnosis vary substan-
tially across studies, from 4 to 80% [36]. This is probably
due to methodological artifacts, such as the definition
chosen for persistence in adult life (syndromatic versus
symptomatic), and age of individuals at follow-up [35].
In this regard, Biederman et al. [37] demonstrated the
influence of the definition of remission used on persist-
ence rates. In a clinical sample of 128 boys followed
during 4 years, the rate of full diagnosis persistence at
18–20 years was 40%, while 90% of the subjects remained
functionally impaired. Faraone et al. [35] conducted a
systematic review and a meta-analysis of longitudinal
studies of ADHD. They found a 15% persistence rate
when full diagnosis was defined and 40–60% when cases
of ADHD in partial remission were included. These
findings fuelled the debate over whether the symptom
threshold should be lower in adults. Thus, individuals
whose symptoms have partially remitted but who are
clinically impaired would be identified [38]. Focusing on
this issue, Faraone et al. [39] compared adults with full
ADHD diagnosis, late-onset ADHD (all criteria meet
except the age-of-onset criterion), subthreshold ADHD
(three or more but less than six inattentive or hyperactive-
impulsive symptoms), and controls regarding psycho-
pathology, several measures of impairment and familial
risk of ADHD. Subjects with subthreshold ADHD pre-
sented less psychopathology and impairment than subjects
with late-onset and full ADHD diagnosis. Although the
subthreshold group was significantly impaired, results
provided weak support for the validity of subthreshold
ADHD diagnosis.
Biederman et al. [40] assessed a clinical sample of
individuals 10 years after the initial diagnosis of ADHD,
by a mean age of 21 years. At this time interval, 58%
presented a full or subthreshold (four or five symptoms)
current ADHD diagnosis. Individuals with initial diag-
nosis of ADHD presented a significant higher lifetime
risk of major depression, bipolar disorder, separation
anxiety, oppositional-defiant disorder, conduct disorder,
antisocial personality disorder, tics/Tourette disorder,
and nicotine dependence than controls.
Attention-deficit/hyperactivity disorder
prevalence in adults
Considering that longitudinal community-based studies
are scarce, prevalence studies provide an indirect data
about the course of ADHD symptoms across lifespan.
The World Mental Health (WMH) Survey Initiative
[41] studied the prevalence of DSM-IV mental disorders
in 60 463 adults from 14 countries. ADHD was included
into the category of impulse-control disorders (bulimia,
intermittent explosive disorder, and reported persist-
ence in the past 12 months of symptoms of three
child–adolescent disorders, ADHD, conduct disorder,
and oppositional-defiant disorder). In the nine countries
where ADHD was evaluated, the prevalence of the
impulse-control disorders ranged from 0.3% in Italy
and Germany to 6.8% in the United States. Unfortu-
nately, the individual prevalence of ADHD is not
available.
Kessler et al. [42] included the evaluation of ADHD in a
sub-sample of the National Comorbidity Survey Replica-
tion (NCS-R), a nationally representative survey of adults
in the USA. From the initial screening sample of 9282
individuals, 5692 were selected either because they met
the required criteria for at least one disorder or because
they were part of a random selected sub-sample. Since
only respondents between 18 and 44 years of age
were selected, ADHD was assessed in 3199 subjects.
The respondents were divided into four groups based
on the presence of symptoms during childhood and
adulthood: those who denied ever having symptoms of
ADHD, those who reported symptoms during childhood
but did not meet full criteria, those with childhood
ADHD who denied adult symptoms, and those with
childhood ADHD who reported adult symptoms. Finally,
30 subjects from each of the first three groups and 60 from
the fourth group were contacted, and 154 subjects
were clinically evaluated for adult ADHD. Based on
the prevalence of the disorder on each of the four groups
and on multiple imputation to assign predicted diagnoses
to respondents who did not participate in the reappraisal
interviews, the estimated prevalence of current adult
(18–44 years) ADHD was 4.4%. It is important to note
that only a small portion of the sample (154 subjects)
was clinically evaluated and the prevalence rate is the
estimation of the disorder in the sample. The authors
made it clear that the sample study was weighted to

be nationally representative and the imputation equation
was statistically strong. Considering this peculiarity, this
is the best available estimate of adult ADHD prevalence
to date. In subsequent analyses of the NCS-R sample, the
persistence rate of ADHD from childhood to adulthood
was estimated in 36.3% [43].
Kooij et al. [44] evaluated the presence of ADHD symp-
toms in a sample of 1813 primary care adult patients
from The Netherlands. Inattentive and hyperactivity
symptoms were significantly associated with psychosocial
impairment. Subjects with four or more inattentive or
hyperactive–impulsive symptoms were significantly
more impaired than subjects with two, one and without
symptoms. The prevalence of ADHD was 1.0% (95%
confidence interval (CI), 0.6–1.6) for a cutoff of six
symptoms and 2.5% (95% CI, 1.9–3.4) for a cutoff of
four symptoms, with the requirement of the presence of
all three core symptoms during childhood.
Faraone and Biederman [45] evaluated the presence of
ADHD symptoms during childhood and adulthood in a
telephone screening survey with 966 adults from the
community. Two criteria were used: a broad diagnosis,
symptom was considered positive if occurred sometimes
or often; and a narrow one, symptom was only counted as
positive if the participant reported that it occurred often.
Results revealed a prevalence rate of 16.4 and 2.9% for
the broad and narrow diagnoses. Two main methodologi-
cal issues were key limitations for this study: diagnoses
were obtained only based on rating scales, and the
attrition rate was 80%, which raises important question
about the generalizability of data, as discussed by
the authors.
Attention deficit/hyperactivity disorder
prevalence and socio-demographic
characteristics
Studies in children consistently suggest that the ADHD
prevalence is higher in boys than in girls. The male
to female ratio varies from 3 : 1 to 9 : 1, depending on
the origin of the sample ascertainment [46]. In our
systematic review and meta-regression [15], the pooled
ADHD prevalence for boys was 2.45 times higher
than the one detected for girls (only nonreferred
samples were included). The prevalence among girls
seems to be higher in community samples than in
clinical samples, probably because there is a barrier
to diagnosis and treatment referral for females [46].
A school-based study conducted by Angold et al. [30]
evidenced that the impact of the child’s problem on
the family was strongly associated with the probability
of receiving care. This might be related to the lower
prevalence of girls in clinical samples, since there
are evidences that they have less behavioral symptoms
than boys [46].
Attention-deficit/hyperactivity disorder Polanczyk and Rohde 389
The impact of ethnic and socio-economic issues on
the prevalence rates of ADHD has been much less
investigated. In our study [15], significantly different
pooled ADHD prevalence estimate was detected for
both African and Middle-Eastern studies when com-
pared to either North-American or European estimates.
This finding, however, might be related to the small
number of studies conducted in the first two world
regions making their estimates less reliable. In the study
by Angold et al. [30] mentioned above, authors did not
detected significantly different ADHD prevalence rates
in African–American (2.1%) and white (3.2%) youths.
Regarding the impact of poverty on the prevalence of
ADHD in this sample, no significant difference was
found between African–Americans and white rural chil-
dren categorized by income [47]. Mullick and Goodman
[48] compared the prevalence of psychiatric disorders in
a sample of 922 5–10-year-old children from rural, urban
and slum areas in Bangladesh. No significant difference
between these three areas was found regarding the
prevalence of ADHD. In southeast of Brazil, Fleitlich-
Bilyk [49] did not find significant different prevalence
rates of ADHD in groups of children ascertained from
private, rural, and urban schools. We understand that the
influence of social, ethnic and economic factors on
the prevalence of ADHD should be further evaluated
by studies designed to assess these factors.
Regarding adult samples, Kessler et al. [42] found a
higher prevalence in males (1.6 male–female ratio),
and in non-Hispanic white subjects in comparison to
Hispanics and non-Hispanic blacks. Kessler et al. [43]
retrospectively assessed sociodemographic and childhood
clinical factors evaluating their association with persist-
ence of ADHD in adulthood. Subjects with childhood
combined symptoms of inattention and hyperactivity-
impulsivity had significantly elevated odds ratios of
persistence in comparison to those with pure symptoms
in either domain. Similar findings were detected for
retrospectively assessed pervasiveness of childhood role
impairment and childhood treatment of ADHD. Gender,
race-ethnicity, comorbidity profile, childhood adversities,
and childhood trauma exposure were not associated
with persistence into adulthood [43]. It is important
to note that the understanding of risk factors for per-
sistence of symptoms has an important role on patient
and family education, as well as on treatment strategies.
Nevertheless, these results are limited by the retrospective
nature of reports.
Conclusion
As summarized in Table 1, recent findings on the epi-
demiology of ADHD have better elicited the disorder.
The understanding of distinctive features involved in
ADHD diagnosis is fundamental to a critical appraisal
of epidemiological studies. Different methodological
390 Services research and outcomes

Table 1 Recent original studies that evaluated epidemiological issues of attention-deficit/hyperactivity disorder
First author, year Site Design Age Sample size Main result

Bener, 2006 [3] Qatar Prevalence study 6–12 years 1541 subjects ADHD prevalence: 9.4%
Cardo, 2007 [4] Island of Prevalence study 6–11 years 1509 subjects ADHD prevalence: 4.6%
Majorca
Skounti, 2006 [5] Greece Prevalence study 7 years 1285 subjects ADHD prevalence: 6.5%
Mugnaini, Italy Prevalence study 6–7 years 1891 subjects ADHD prevalence: 7.1%
2006 [11]
Polanczyk, in Systematic review of Up to 18-years 102 studies The ADHD worldwide pooled
press [15] prevalence studies old prevalence: 5.29%
and meta-regression (95% CI 5.01–5.56)
analyses of results Geographic location plays a
limited role in the explanation
of the large variability of
ADHD/HD prevalence
estimates worldwide
which seems to be explained
primarily by methodological
characteristics of studies
Kessler, USA Prevalence study 18–44 years 3199 screens ADHD prevalence: 4.4%
2006 [42] 154 diagnostic
assessment
Zuddas, Italy Evaluation of the validity 6–12 years 1575 subjects DSM-IV constructs of ADHD,
2006 [29] of the DSM-IV constructs ODD, and CD were validated
of disruptive behaviors
disorders
Barkley, USA Follow-up study of 19–25 years 149 cases Adults with hyperactivity in
2006 [34] hyperactive children 72 controls childhood had significantly
lower educational performance
and attainment, had fewer close
friends, more trouble keeping
friends, had become parents
and had been treated for
sexually transmitted disease
more frequently than controls
Biederman, USA Follow-up study of mean 22 112 cases The lifetime prevalence for all
2006 [40] ADHD children 105 controls categories of psychopathology
was significantly greater in
ADHD young adults in
comparison to controls
Faraone, USA Clinical and demographic 18–55 years 41 subthreshold Adults with late-onset and full
2006 [39] comparison of three 79 late-onset ADHD had similar patterns
clinical groups of adult 127 full of psychiatric comorbidity,
ADHD patients (divided ADHD functional impairment, and
according to age of onset 123 controls familial transmission
and number of symptoms) Subthreshold ADHD was milder
and controls and showed a different pattern
of familial transmission than
the other forms of ADHD
Faraone, 2006 [35] Systematic review of 10–30 years 32 studies When persistent ADHD is defined
follow-up studies and as meeting full criteria for ADHD,
meta-analysis of the rate of persistence is 15%
results at age 25 years; when cases
consistent with the DSM-IV
definition of ADHD in partial
remission are included, the rate
of persistence is 65%
Estimates of ADHD persistence
rely heavily on how one defines
persistence
Analyses show evidence that
ADHD lessens with age
ADHD, attention-deficit/hyperactivity disorder; CD, conduct disorder; CI, confidence interval; HD, hyperkinetic disorder; ODD, oppositional-defiant
disorder.

strategies adopted in studies explain the huge variability
in prevalence estimates found. Cross-national data on
ADHD prevalence estimates do not significantly differ
when findings were adjusted for methodological vari-
ables. The data discussed above support the consistency
of ADHD prevalence across continents, especially
between North America and Europe.
Studies conducted up to now report a variable proportion
of individuals who remain with ADHD symptoms across

the lifespan. Moreover, older subjects have not been
systematically included in the samples. In order to define
the rate of ADHD persistence over time and to estimate
the number of adults in need of treatment, methodologi-
cal and conceptual issues – such as age and gender
appropriate diagnostic criteria and the validity of subthres-
hold diagnosis – need to be extensively investigated.
Acknowledgements
Potential conflict of interests: The ADHD Outpatient Program receives
research support from the following pharmaceutical companies: Bristol-
Myers Squibb, Eli-Lilly, Janssen-Cilag, and Novartis. Prof Rohde is on
the speakers’ bureau or is a consultant for the same companies and is
on the advisory board for Eli Lilly & Company. Dr Polanczyk does not
have any potential conflict of interest.
Funding sources: This work was partially supported by research grants
from Conselho Nacional de Desenvolvimento Cientı́fico e Tecnológico
(CNPq, Brazil) (Grant MCT/CNPq 02/2006 – Universal), Hospital de
Clinicas de Porto Alegre. Dr Polanczyk holds a doctoral felloowship,
Coordenação de Aperfeiçoamento de Pessoal de Nı́vel Superior
(CAPES), Ministry of Education, Brazil.
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