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Attention Disorders

Literature Review: ADHD in Adults: A Review of the Literature

Megan A. Davidson
Journal of Attention Disorders 2008 11: 628 originally published online 19 December 2007
DOI: 10.1177/1087054707310878

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Literature Review Journal of Attention Disorders
Volume 11 Number 6
May 2008 628-641
© 2008 Sage Publications
10.1177/1087054707310878
http://jad.sagepub.com
hosted at

ADHD in Adults http://online.sagepub.com

A Review of the Literature

Megan A. Davidson
Queen’s University

Objective: ADHD presents significant challenges to adults. The current review’s goals are (a) to critically examine the
current state of knowledge regarding ADHD in adults and (b) to provide clinicians with practice-friendly information
regarding assessment, diagnosis, and treatment. Method: Searches of PsycINFO and Medline were conducted, and
reference lists from articles and books were searched for additional relevant references. Results/Conclusion: A valid and
reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview,
neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and
specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with
the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest
efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the
combination of cognitive behavioral therapy and medication. (J. of Att. Dis. 2008; 11(6) 628-641)

Keywords: attention-deficit/hyperactivity disorder; adult ADHD assessment; adult ADHD treatment; diagnostic issues

A DHD is a disorder that comprises a constellation of

symptoms including inattention, impulsivity, and
hyperactivity. ADHD is well studied in children, but
Prevalence

The American Psychiatric Association (APA; 2000)

much less is known about the disorder in adulthood. The
purpose of the present article is to critically examine
the current state of knowledge concerning the assess-
ment and treatment of ADHD in adults, with the goal of
establishing the best methods of assessment and treat-
ment. In doing so, the present article reviews a number
of issues within the literature, including estimates of
prevalence of the disorder, diagnostic and assessment
issues, comorbidities and psychosocial functioning,
validity of assessments, and treatments and their effec-
tiveness. Recommendations for evidence-based approaches
to adult patients in clinical practice are made. In choos-
ing articles to include in the present review, we conducted
searches of PsycINFO and Medline from 1980 to 2007
using ADHD and attention deficit hyperactivity disorder,
combined with adult, as keywords. We also searched ref-
erence lists from articles and books for additional rele-
vant references. Our searches produced approximately
2,500 references, of which 130 were included in the
present review.
estimates that 3% to 7% of school-aged children have
ADHD. Historically, ADHD was considered to be prin-
cipally a disorder of childhood, one that was generally
outgrown by adolescence and that was nonexistent by
adulthood (Ross & Ross, 1976). There is now clear evi-
dence that ADHD symptoms continue through adoles-
cence and adulthood (e.g., Barkley, Fischer, Smallish, &
Fletcher, 2002). The prevalence of ADHD in adults is
estimated to fall between 4% and 5% (Kessler et al.,
2005; Murphy & Barkley, 1996b).
Even though the persistence of ADHD beyond child-
hood is established, it is difficult to determine the extent
of this persistence. Only a small number of prospective
studies have followed samples of children with ADHD
into adulthood, and of these studies, only four have
Author’s Note: Address correspondence to Megan A. Davidson,
Queen’s University, Department of Psychology, Humphrey Hall,
62 Arch St., Kingston, Ontario K7L 3N6, Canada; e-mail:
9md9@queensu.ca.

628

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retained 50% or more of their original sample into adult-
hood (Barkley, Fischer, et al., 2002; Fischer, Barkley,
Edelbrock, & Smallish, 1990; Mannuzza, Klein, Bessler,
Malloy, & LaPadula, 1998; Rasmussen & Gillberg,
2001; G. Weiss & Hechtman, 1993). The results of
these four studies are mixed with respect to persistence.
G. Weiss and Hechtman (1993) conducted a prospective
follow-up study of hyperactive children. At the 15-year
follow-up (age M = 25 years), 66% of the original sam-
ple of hyperactive children reported at least one or more
symptoms of ADHD versus 7% of the control group. In
addition, 36% of the hyperactive sample had at least
moderate to severe levels of hyperactive, impulsive, and
inattentive symptoms, compared to 2% of the control
group. Rasmussen and Gillberg (2001) obtained similar
results: Of probands, 49% reported marked symptoms of
ADHD at age 22 years, compared to 9% of controls.
The studies by G. Weiss and Hechtman (1993) and
Rasmussen and Gillberg (2001) were limited by the fact
that formal diagnostic criteria were not used at any of
the outcome points in the studies. Mannuzza and col-
leagues (1998) corrected this methodological flaw by
following two cohorts of ADHD children using criteria
of the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) to assess the
disorder. The authors found that 40% of their initial
cohort and 43% of their second cohort met DSM-III cri-
teria for ADHD at adolescent follow-up (age M = 18
years), compared to 3% and 4% of the comparison
groups. However, at adult follow-up (age M = 26
years), the rates of ADHD in the probands decreased to
8% and 4%, respectively. Barkley (2006) suggested that
these relatively low estimates of persistence are partly
because of the study’s stringent selection criteria regard-
ing aggression and antisocial behaviors. Finally, a fourth
prospective study, by Barkley, Fischer, et al. (2002),
evaluated hyperactive children and a control group at
ages 19 to 25 years using formal diagnostic criteria.
Based on self-report, ADHD was rare in the both groups
(5.0% and 0.0%, respectively) at follow-up. However,
ADHD was substantially higher using parent reports
(46.0% and 1.4%, respectively).
These four prospective studies show considerable dis-
crepancy among the rates of ADHD persistence into
adulthood. These discrepancies are likely because of a
number of variables, including variations in the criteria
used for diagnosis (Riccio et al., 2005), selection criteria,
sources of information, changes in source of informa-
tion, and changes in diagnostic criteria (for a review, see
Barkley, 2006). Thus, because of these issues, and issues
with the current diagnostic criteria, the persistence of
ADHD into adulthood is difficult to estimate.
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Davidson / ADHD in Adults 629
Diagnostic Issues
Use of DSM-IV Criteria in Adults
Extensive psychometric studies have provided empir-
ical support for the symptom thresholds used to diagnose
ADHD in children (Lahey et al., 1994), and there is gen-
eral agreement that ADHD can be reliably diagnosed in
children through the use of these formal diagnostic crite-
ria. However, the reliability of the diagnosis of ADHD in
adults is much less clear (Riccio et al., 2005) and contin-
ues to be an area of controversy within the literature
(Faraone, Biederman, & Feighner, 2000).
In diagnosing ADHD in adults, clinicians and
researchers in North America most often use the criteria
set out by the fourth edition, text revision of DSM (DSM-
IV-TR; APA, 2000). Three subtypes of ADHD are recog-
nized: ADHD combined type (ADHD-C; both inattentive
and hyperactive–impulsive symptoms), ADHD predomi-
nantly inattentive type (ADHD-I), and ADHD predomi-
nantly hyperactive–impulsive type (ADHD-H). Among
adults with ADHD, the ADHD-I subtype is the most
common diagnosis (Erk, 2000).
The use of DSM-IV criteria for ADHD in adults has
been criticized. Barkley (1998) suggests that applying
current ADHD criteria to adults is not developmentally
sensitive. The DSM-IV criteria for ADHD were designed
for and selected based on studies with children (Riccio
et al., 2005), and validation studies of ADHD criteria in
adults have not been conducted (Belendiuk, Clarke,
Chronis, & Raggi, 2007). Because of this, it has been
suggested that the symptom lists in DSM-IV may be
inappropriately worded for adults and that diagnostic
thresholds may be too stringent or restrictive when
applied to adults (Heiligenstein, Conyers, Berns, &
Smith, 1998). Moreover, some symptoms, such as pro-
crastination, overreacting to frustration, poor motivation,
insomnia, and time-management difficulties, are com-
mon complaints of adults with ADHD, but they are not
included in DSM-IV. Finally, the level of impairment
caused by ADHD symptoms may be different between
adults and children, and symptoms will likely affect
more domains in adults (e.g., marital, familial, occupa-
tional, etc.).
Indeed, longitudinal studies demonstrate a develop-
mental influence on ADHD symptoms. In general,
ADHD symptoms appear to decrease as age increases:
Prospectively derived data in clinical and epidemiologi-
cal samples of children, adolescents, and young adults
demonstrate an overall reduction of ADHD symptoms
over time (Hart, Lahey, Loeber, Applegate, & Frick,
1995; Heiligenstein et al., 1998; Levy, Hay, McStephen,
630 Journal of Attention Disorders
Wood, & Waldman, 1997; Millstein, Wilens, Biederman,
& Spencer, 1997; National Academy for the Advancement
of ADHD Care, 2003). Specifically, it appears that
hyperactive–impulsive symptoms decline more with
increasing age, whereas inattentive symptoms of ADHD
tend to persist (Achenbach, Howell, McConaughy, &
Stranger, 1995; Hart et al., 1995). In support of this,
studies of adults with ADHD suggest that the most
prominent symptoms of ADHD relate to inattention as
opposed to hyperactivity and impulsivity (Murphy &
Barkley, 1996a). Furthermore, Millstein et al. (1997)
found that symptoms of hyperactivity and impulsivity
ameliorate as persons reach adulthood, but inattention
remains a prominent clinical feature in more than 90% of
clinic-referred adults.
The decrease in ADHD symptoms over time may
indicate true remission of symptoms, but it may also
indicate a measurement problem: reduced sensitivity of
ADHD symptom criteria with age. If this is true, then
using the same symptom threshold to define deviance at
each age will reduce the number of diagnosable cases
among older individuals (Faraone et al., 2000), and it
will be more difficult for individuals with ADHD to meet
criteria for the disorder as they get older. Heiligenstein
et al. (1998) addressed this issue by determining ADHD
symptom thresholds specific to college students. First,
the authors determined the number of DSM-IV diagnoses
of ADHD, finding that 4% met the DSM-IV criteria.
ADHD was then defined as deviance from the norm:
Students were identified as having ADHD if their total
symptom score exceeded the 93rd percentile (+1.5 SD)
of the sample. This redefinition increased the prevalence
of ADHD to 11%, and students who met this criterion
still demonstrated clinically significant symptoms.
In their prospective study, Barkley, Fischer, et al.
(2002) defined adult ADHD by using both DSM-III cri-
teria and a developmentally referenced criterion (DRC;
98th percentile; +2 SD). Using DSM-III criteria, parental
interview resulted in an ADHD rate of 42%. However,
this rate rose to 66% when the DRC was employed.
Compared to a control group, the DRC-diagnosed group
fared worse on a number of measures including GPA,
class ranking, job performance ratings, and ADHD
symptoms at work.
Murphy and Barkley (1996b) examined the preva-
lence of ADHD symptoms in adults and suggested that
the cutoff of six of nine hyperactive–impulsive symp-
toms and six of nine inattentive symptoms recommended
in DSM-IV sets a prevalence of deviance that is statisti-
cally extreme for an adult population. In their sample of
adults, this cutoff fell at approximately 2.5 to 3.0 stan-
dard deviations above the mean (> 99th percentile) for
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most ratings of current ADHD behavior. According to
Murphy and Barkley, this level of statistical deviance is
far higher than that required of children to receive a diag-
nosis of ADHD and supports the use of DRC in adults.
In their study, a cutoff of four of the six inattentive symp-
toms and five of the six hyperactive symptoms would
have been sufficient to identify an adult aged 17 to 29
years as deviant from the traditional 93rd percentile
(+1.5 SD) used in child ADHD research. Clearly, the
results of Heiligenstein et al. (1998), Barkley, Fischer,
et al. (2002), and Murphy and Barkley (1996b) all suggest
that the DSM-IV criteria threshold for ADHD may be too
stringent for adult diagnosis.
Given the criticisms of the diagnostic criteria for
ADHD in adults and the recent research findings demon-
strating the utility of DRC, it may be useful to recast
ADHD as a norm-referenced rather than a criterion-
referenced diagnosis (Barkley, 2006; Faraone et al.,
2000). Although a norm-referenced diagnosis may be a
valid method of diagnosis, more research is necessary.
Such a change in the diagnostic process would result in
significant implications for clinical practice; thus, it is
imperative that extensive empirical research support
such a change.
Differential Diagnosis
Diagnosing ADHD in adults requires careful consider-
ation of differential diagnoses, as it can be difficult to dif-
ferentiate ADHD from a number of other psychiatric
conditions (Pary et al., 2002), including major depression,
bipolar disorder, generalized anxiety, obsessive–compulsive
disorder (OCD), substance abuse or dependence, person-
ality disorders (borderline and antisocial), and learning
disabilities (Searight, Burke, & Rottnek, 2000). For
example, differential diagnosis of ADHD from mood and
conduct disorders may be difficult because of common
features such a mood swings, inability to concentrate,
memory impairments, restlessness, and irritability (Adler,
2004). Differential diagnosis of learning disabilities
can also prove difficult because of the interrelated func-
tional aspects of the disorders that have the common out-
come of poor academic functioning (Adler, 2004; Jackson
& Farrugia, 1997).
Comorbidities and Psychosocial
Functioning
Comorbid Psychiatric Disorders
Comorbid disorders are common in children with
ADHD. In school-aged children with ADHD, as many as

two thirds may have another Axis I disorder (Biederman,
Newcorn, & Sprich, 1991). Common comorbidities in
children with ADHD include oppositional defiant disor-
der (ODD), conduct disorder (CD), mood and anxiety
disorders, and learning disabilities (Greenhill, 1998).
High rates of comorbidities are also seen in adults with
ADHD, with the majority having at least one additional
psychiatric disorder. In fact, in clinical populations of
adults with ADHD, as many as three in four patients
have one or more comorbid psychiatric disorders
(Faraone & Biederman, 1998).
Outcome studies have demonstrated that individuals
diagnosed with ADHD in childhood are at risk for devel-
oping comorbid conditions (Barkley, 2006; G. Weiss &
Hechtman, 1993), some of which are likely secondary to
ADHD-related frustration and failure. Biederman and
colleagues (1993) found a relatively high incidence of
lifetime diagnoses of anxiety disorders (43% to 52%),
major depressive disorder (31%), ODD (29%), CD
(20%), antisocial personality disorder (12%), and alco-
hol and drug dependencies (27% and 18%, respectively)
in their sample of clinic-referred adults with ADHD.
Comparable rates were found in a second sample of non-
referred adults with ADHD. Murphy and Barkley
(1996a) found similar high rates of comorbid disorders
in their sample of clinic-referred adults with ADHD.
With respect to ADHD subtypes in adults, Millstein
et al. (1997) found higher rates of ODD, bipolar disorder,
and substance use disorders in patients with ADHD-C
than in those with other subtypes and higher rates of
ODD, OCD, and PTSD in patients with ADHD-H than
in those with ADHD-I. In their study, Sprafkin, Gadow,
Weiss, Schneider, and Nolan (2007) found that all three
subtypes reported more severe comorbid symptoms than
did a control group, with the ADHD-C group obtaining
the highest ratings of comorbid symptom severity.
Comparable rates of comorbidities have been found in
men and women with ADHD, with the exception of men
having higher rates of antisocial personality disorder
(Biederman et al., 1994).
Psychosocial Functioning
In addition to comorbid psychiatric disorders, adults
with ADHD often complain of psychosocial difficulties.
Indeed, Biederman et al. (1993) found a much higher
rate of separation and divorce among adults with ADHD
than among controls, and their sample of adults with
ADHD had lower socioeconomic status, poorer past and
current global functioning estimates, and higher occur-
rence of prior academic problems relative to the control
group. Likewise, Murphy and Barkley (1996a) documented
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Davidson / ADHD in Adults 631
high rates of educational, employment, and marital prob-
lems in adults with ADHD. Multiple marriages were
more common in the adult ADHD group, and signifi-
cantly more adults with ADHD had performed poorly,
quit, or been fired from a job and had a history of poorer
educational performance and more frequent school dis-
ciplinary actions against them than did adults without
ADHD. Low self-concept and low self-esteem are com-
mon secondary characteristics of adults with ADHD,
often resulting from problematic educational experi-
ences and interpersonal difficulties (Jackson & Farrugia,
1997). Adults with ADHD often have strong feelings of
incompetence, insecurity, and ineffectiveness, and many
of these individuals live with a chronic sense of under-
achievement and frustration (Murphy, 1995).
Assessment of Adult ADHD
The diagnosis of adult ADHD is a clinical decision-
making process (Faraone & Biederman, 1998). A diag-
nosis is established through the use of a comprehensive
examination assessing psychopathology, functional
impairments, pervasiveness of the disorder, age of onset,
and absence of other disorders that could better explain
the symptoms (Rosler et al., 2006). Given the difficulties
with the formal diagnostic criteria for ADHD, determin-
ing the diagnosis of ADHD in adults presents different
challenges than determining the diagnosis in children
(Riccio et al., 2005). There is no single neurobiological or
neuropsychological test that can determine a diagnosis
of ADHD on an individual basis (Rosler et al., 2006).
Instead, diagnosticians often rely on a combination of
clinical interviews, behavioral rating scales, family
history, and neuropsychological evaluation. The use of
reports from multiple informants is considered best prac-
tice, as evidence from multiple studies suggests that
adults with ADHD underreport their ADHD symptoms
and the severity of those symptoms (Barkley, Fischer,
et al., 2002; Fischer, 1997; Wender, 1995).
Clinical Interview
A comprehensive clinical interview is one of the most
effective methods through which one can identify
ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy
& Adler, 2004; Wilens, Faraone, & Biederman, 2004).
Here, open-ended questions about childhood and adult
behaviors can be used to elicit information necessary to
diagnose ADHD. Interviews also include questions
regarding developmental and medical history, school and
work history, psychiatric history, and family history of
ADHD and other psychiatric disorders (Barkley, 2006).
632 Journal of Attention Disorders
Although many clinicians use unstructured interviews to
assess adult ADHD, semistructured interviews do exist.
Conners Adult ADHD Diagnostic Interview for DSM-
IV (CAADID). The CAADID (Epstein, Johnson, &
Conners, 2000) is a semistructured interview designed to
gather information necessary to make a diagnosis of
ADHD. The CAADID assesses for the presence of
DSM-IV ADHD symptoms and collects information
related to history, developmental course, ADHD risk fac-
tors, and comorbid psychopathology. Test–retest reliabil-
ity has been demonstrated for both individual symptoms
of inattention and hyperactivity–impulsivity and for
overall diagnosis (κ = .40 to .91). Concurrent validity has
also been demonstrated for adult hyperactive–impulsive
and child inattentive symptoms (Epstein & Kollins,
2006).
Schedule for Affective Disorders and Schizophrenia
(K-SADS). The K-SADS (Chambers et al., 1985; Puig-
Antich & Chambers, 1978) was originally developed for
use in school-aged children and adolescents, but it has
been used to assess past and present symptoms of ADHD
in adults (Belendiuk et al., 2007; Magnússon et al.,
2006). The K-SADS has been demonstrated to have
good interrater reliability and strong criterion and con-
struct validity (Ambrosini, 2000; Magnússon et al.,
2006).
Structured Clinical Interview for DSM-IV Criteria
for DSM Axis I (SCID-I). The SCID-I (First, Spitzer,
Gibbon, & Williams, 2002) can be used to diagnose
ADHD and to assess comorbidity in adults. It is also use-
ful in ruling out other disorders as being the cause of
ADHD symptomatology. The SCID-I has demonstrated
reliability and validity (e.g., Steiner, Tebes, Sledge, &
Walker, 1995; Zanarini et al., 2000).
ADHD Rating Scales
Self-report behavioral checklists are commonly used
in the assessment of ADHD (Woods, Lovejoy, & Ball,
2002). In addition to self-report behavioral rating scales,
rating scales completed by an individual’s spouse or
significant other can provide useful information in
determining the individual’s overall life functioning.
Parents can also complete such rating scales to provide
information regarding current and childhood functioning
(Barkley, 2006).
Conners’s Adult ADHD Rating Scales (CAARS). The
CAARS (Conners, Erhart, & Sparrow, 1999) assesses
ADHD symptoms in adults and comprises short, long,
and screening self-report and observer rating scale
forms. The CAARS produces eight scales, including
scales based on DSM-IV criteria and an overall ADHD
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index. Internal consistency is good, with Cronbach’s
alpha across age, scales, and forms ranging from .49 to
.92 (Conners et al., 1999; Erhardt, Epstein, Connors,
Parker, & Sitarenios, 1999). Test–retest reliability
(1 month) estimates are high, ranging from .85 to .95
(Conners et al., 1999; Erhardt et al., 1999). The ADHD
index produces an overall correct classification rate of
85%, and the sensitivity of the ADHD index has been
estimated at 71% and the specificity at 75% (Conners
et al., 1999).
Brown Attention-Deficit Disorder Rating Scale for
Adults (Brown ADD-RS). The Brown ADD-RS (Brown,
1996; Brown & Gammon, 1991) assesses symptoms of
ADHD in adults. It was developed before the DSM-IV
concept of ADHD was published and focuses more on
symptoms of inattention rather than hyperactivity and
impulsivity. The scale shows high internal consistency
(α = .96) and satisfactory validity (M. Weiss, Hechtman,
& Weiss, 1999).
Wender Utah Rating Scale (WURS). The WURS
(Ward, Wender, & Reimherr, 1993) is an assessment tool
used to retrospectively diagnose ADHD. The measure is
based on items from the monograph Minimal Brain
Dysfunction in Children (Wender, 1971) that are more
detailed than the 18 items in the DSM-IV criteria
(Murphy & Adler, 2004). The measure demonstrates sat-
isfactory internal consistency, as demonstrated by split-
half reliability coefficients (r = .90; Ward et al., 1993),
and satisfactory test–retest reliability (r = .68). Correlations
between the WURS and a parent-report retrospective
rating scale of childhood ADHD (r = .41 to .49) support
the validity of the scale.
Current Symptoms Scale. The Current Symptoms
Scale (Barkley & Murphy, 1998) is an 18-item self-
report scale with both a patient version and an informant
version. It contains the 18 items from the diagnostic cri-
teria in DSM-IV. Validity has been demonstrated through
past findings of significant group differences between
ADHD and control adults (Barkley, Murphy, DuPaul, &
Bush, 2002). An earlier DSM-III version of the scale cor-
related significantly with the same scale completed by a
parent (r = .75) and by a spouse or intimate partner of the
ADHD adult (r = .65; Murphy & Barkley, 1996a).
ADHD Rating Scale–IV. The ADHD Rating Scale–IV
(DuPaul, Power, Anastopoulos, & Reid, 1998) is a norm-
referenced checklist that assesses the symptoms of
ADHD according to DSM-IV. The measure was
designed for use with children; however, it can be modi-
fied and administered to adults (Murphy & Adler, 2004).
The ADHD Rating Scale–IV is not self-report; it is
designed to be completed by a parent or a teacher. Each
item corresponds to one of the symptoms in DSM-IV.
Internal consistency estimates are good for each of its

three scales (inattention α = .86 to .96; hyperactivity–
impulsivity α = .88; total score α = .92 to .94). Test–retest
reliability (4 weeks) is also high (r = .85 to .90; DuPaul
et al., 1998).
Adult ADHD Self-Report Scale–version 1.1 (ASRS-
v1.1). The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003)
is an 18-item measure based on the DSM-IV-TR criteria
for ADHD that produces three scale scores. Questions
are designed to suit an adult rather than a child (e.g., ref-
erences to “play” and “schoolwork” are deleted), and the
language provides a context for symptoms that adults
can relate to (Murphy & Schachar, 2000). Internal con-
sistency estimates are high (α = .88), and the ASRS-v1.1
has been shown to have high concurrent validity (Adler
et al., 2006). Adler and his colleagues (2006) compared
the clinician-administered version of the scale to a pilot
version of the ASRS-v1.1 and found a high intraclass
correlation coefficient for total ADHD symptoms (α =
.84). There was acceptable agreement for individual
items (% agreement = 43% to 72%) and significant
kappa coefficients for all items.
Validity of Measures Used to Diagnose ADHD
Rating scales can be used to assess current symptoms
and functioning as well as childhood symptoms and
functioning. However, they may be subject to reporting
biases and errors in memory (Wadsworth & Harper,
2007). Murphy and Schachar (2000) examined the valid-
ity of self-reported ratings of current and childhood
ADHD symptoms by adults. In one study, participants’
ratings of their childhood ADHD symptoms were com-
pared to their parents’ ratings of childhood symptoms. In
a second study, participants’ ratings of their current
ADHD symptoms were compared to a significant other’s
rating of current symptoms. All correlations between
self-ratings and parent ratings were significant for inat-
tentive, hyperactive–impulsive, and total ADHD symp-
toms (r = .69 to .79), as were correlations between
self-ratings and significant other ratings (r = .59 to .70).
Belendiuk et al. (2007) examined the concordance of
diagnostic measures for ADHD, including self-ratings
and collateral versions of both rating scales and semi-
structured interviews. Results supported the findings of
Murphy and Schachar, showing high correlations
between self-reports and collateral reports of inattentive
and hyperactive–impulsive symptoms. Results also
demonstrated high correlations between self-report rat-
ing scales and diagnostic interviews.
Taken together, this review of rating scales and diag-
nostic interviews used in the assessment of adult ADHD
indicates that a number of reliable and valid measures
exist. Research has demonstrated that rating scales can
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Davidson / ADHD in Adults 633
accurately reflect the frequency and intensity of symp-
toms (Wadsworth & Harper, 2007) and, when used ret-
rospectively, are valid indicators of symptomatology
(Murphy & Schachar, 2000). Research also suggests that
semistructured clinical interviews can reliably and accu-
rately be used for determining a diagnosis of ADHD in
adults (Epstein & Kollins, 2006). However, this literature
is quite young, and more research is needed to corrobo-
rate these findings.
Neuropsychological Testing
Neuropsychological testing plays a meaningful role in
the assessment of ADHD. However, Barkley (2006)
urges caution in interpreting such data, as there is no sin-
gle test or battery of tests that has adequate predictive
validity or specificity to make a reliable diagnosis of
ADHD. In adult ADHD, neuropsychological testing is
most beneficial when the results are used to support con-
clusions based on history, rating scales, and analysis of
current functioning.
Woods and his colleagues (2002) reviewed the role of
neuropsychological evaluation in the diagnosis of adults
with ADHD. In their review of 35 studies, the authors
found that the majority of the studies demonstrated sig-
nificant discrepancies between adults with ADHD and
normal control participants on at least one measure of
executive function (i.e., the ability to assess a task situa-
tion, plan a strategy to meet the needs of the situation,
implement the plan, make adjustments, and successfully
complete the task; Riccio et al., 2005) or attention.
Moreover, Woods et al. found that the most prominent
and reliable executive function and attention measures
that differentiated adults with ADHD were Stroop tasks
(Stroop, 1935) and continuous performance tests (CPTs).
Stroop tasks are complex word- and color-naming pro-
cedures that require visual attention and response inhibi-
tion, whereas CPTs are computer-based tasks that assess
attentional lapses, vigilance, and impulsivity (Spreen &
Strauss, 1998). In addition, Woods et al. found that ver-
bal letter fluency tasks (i.e., generating words beginning
with a specific letter or words belonging to a specific cat-
egory) and auditory–verbal list learning tasks (e.g.,
California Verbal Learning test; Delis, Kramer, Kaplan,
& Ober, 1987) were also able to discriminate between
adults with ADHD and controls. However, the authors
caution that the validity of these findings is somewhat
hindered by limitations of the studies reviewed, includ-
ing methodological and sample variability, a restricted
range of interpretive techniques, and uncertain discrimi-
nant validity of the neuropsychological assessment pro-
cedures in distinguishing ADHD from other psychiatric
or neurological conditions.
634 Journal of Attention Disorders
Schoechlin and Engel (2005) also attempted to deter-
mine neuropsychological test performance differences in
adults with ADHD. The authors performed a meta-analysis
integrating 24 empirical studies reporting results of at
least 1 of 50 neuropsychological tests comparing adults
with ADHD to controls. The authors categorized each of
the tests into 1 of 10 functional domains: verbal intelli-
gence, visual–figural problem solving, abstract verbal
problem solving with working memory, executive func-
tion, fluency, simple attention, sustained attention,
focused attention, verbal memory, and figural memory.
For each of the 10 domains, a pooled effect size (d) was
calculated. Adults with ADHD showed significant per-
formance deficits in 8 of the 10 domains. Small effect
sizes (d between .18 and .26) were found for the domains
of visual memory, visual problem solving, and executive
function. The highest effect sizes (d between .50 and .60)
were found for verbal memory, focused attention, sus-
tained attention, fluency, and abstract verbal problem
solving with working memory. In these domains, ADHD
patients scored approximately one half of an SD lower
than did the control participants.
The findings of Schoechlin and Engel (2005) are
somewhat inconsistent with those of Woods et al. (2002).
Although both studies noted differences between adults
with ADHD and controls on tasks of verbal memory and
fluency, Schoechlin and Engel did not find that perfor-
mance on executive function tasks was a strong predictor
of the distinction between adults with ADHD and con-
trols. This nonsignificant finding may have occurred for
a few reasons. The authors also note that there is no
commonly accepted definition of executive function.
Schoechlin and Engel chose to separate more basic
aspects of executive function such as working memory
and inhibition from higher-level functioning. If ADHD
affects some aspects of executive function more than
others, their decision to not include all measures that are
discussed as executive functions may have decreased
their effect size.
Woods et al. (2002) concluded that although a general
profile of attentional and executive function impairment
is evident in adults with ADHD, expansive impairments
in these domains (i.e., impairments on all attention and
executive function tasks) is not common. Their review
demonstrated inconsistencies in specific instruments
across studies, indicating that adults with ADHD may
not perform poorly on all attentional measures all the
time. This finding is not surprising given the fact that
adults with ADHD often demonstrate sporadic or incon-
sistent attention, which can be difficult to identify given
the structure provided by the one-on-one testing envi-
ronment (Barkley, 1998). In light of this, researchers
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agree that a neuropsychological assessment will be most
sensitive to ADHD when the assessment incorporates
multiple, overlapping procedures measuring a broad
array of attentional and executive functions (Alexander
& Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods
et al., 2002).
Although the studies by Woods et al. (2002) and
Schoechlin and Engel (2005) indicate demonstrated dif-
ferences between adults with ADHD and control partici-
pants on measures of cognitive functioning, these
measures have limited predictive value in distinguishing
ADHD from other psychiatric or neurological conditions
that are associated with similar cognitive impairments
(Wadsworth & Harper, 2007). Cognitive assessments are
useful, however, in that they can (a) improve the validity
of an ADHD assessment and (b) be used in assessing the
efficacy of pharmacological and/or psychological inter-
ventions (Epstein et al., 2003).
Malingering
Malingering is an important issue in ADHD diagnosis
and is defined as the conscious fabrication or exaggera-
tion of physical or psychological symptoms in the pur-
suit of a recognizable goal (APA, 1994). A diagnosis of
ADHD can provide an individual with a number of ben-
efits, including stimulant medication, disability benefits,
tax benefits, and academic accommodations, and such
benefits may motivate adults undergoing diagnostic eval-
uations for ADHD to exaggerate symptomatology on
self-report measures and tests of neurocognitive func-
tioning (Harrison, Edwards, & Parker, 2007; Sullivan,
May, & Galbally, 2007). Detection of faking can prove
difficult with adults in particular, as clinicians may not
have access to a parent or sibling who can attest to prior
history of ADHD symptoms. Moreover, adults often lack
developmental documentation such as report cards,
teacher evaluations, or prior psychological testing
reports (Quinn, 2003). Sullivan et al. (2007) examined
archived assessment cases of ADHD at a university
campus–based clinic and found that almost 50% of cases
failed one or more effort measures on the Word Memory
Test (Green, 2003; Green, Allen, & Astner, 1996; Green
& Astner, 1995), a symptom validity test designed to
detect suboptimal effort in the context of neuropsycho-
logical evaluations. In examining the performance of
university students feigning ADHD and comparing it to
the performance of non-ADHD and genuine ADHD
students, Harrison et al. (2007) demonstrated that the
symptoms of ADHD could easily be fabricated and that
simulators could be indistinguishable from those with
the disorder. Moreover, the authors found that students

feigning ADHD could easily perform poorly on tests of
reading and processing speed, which could allow them
access to academic accommodations. Quinn (2003)
examined the issue of malingering by comparing the sus-
ceptibility of a self-report ADHD rating scale and a CPT
to faking in an undergraduate sample of individuals with
and without a diagnosis of ADHD. Results indicated that
the CPT showed greater sensitivity to malingering than
did the self-report scale and that a CPT can successfully
discriminate malingerers from those with a valid diagno-
sis of ADHD. Given the potential benefits associated
with an ADHD diagnosis, clinicians should include a
symptom validity measure in their assessment battery. At
present, however, there is no demonstrated best practice
for this.
Treatment of Adult ADHD
Treatment of adult ADHD often includes pharmaco-
logical interventions and psychological interventions. In
fact, a combination of treatments is usually recom-
mended for adults with ADHD (Barkley, 2006). Formal
guidelines for the treatment of ADHD in school-aged
children exist (American Academy of Pediatrics, 2001);
however, there is a lack of such guidelines for the treat-
ment of ADHD in adults. Such guidelines are needed.
Moreover, treatments for ADHD in adults remain under-
studied (Rostain & Ramsay, 2006). Within the adult
literature, no single treatment strategy has emerged as
being the most efficacious (Montano, 2004; M. Weiss
et al., 1999). However, treatment is generally aimed at
symptom reduction and minimizing the negative effects
of the disorder to improve one’s overall quality of life.
Pharmacological Treatment
Pharmacotherapy is the principal form of treatment
for patients with ADHD (Pary et al., 2002), and its use in
adults is increasing. Castle, Aubert, Verbrugge, Khalid,
and Epstein (2007) examined trends in the use of med-
ication to treat ADHD and found that 0.8% of adults use
medications to treat ADHD. Furthermore, treatment
prevalence for adults increased rapidly during the 5-year
study period (2000 to 2005), with an annual treatment
prevalence growth rate of 15.3%. The usefulness of phar-
macotherapy is well established in children with ADHD
but not in adults with ADHD (Wilens, 2003). Wilens
(2003) reviewed the literature on the use of pharma-
cotherapy in adult ADHD and identified 15 studies
examining the efficacy of stimulants and 28 studies
examining the efficacy of nonstimulants.
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Davidson / ADHD in Adults 635
Stimulants. Stimulants are the treatment of first choice
in ADHD (Spencer et al., 1996). The mechanism of
action for stimulants is thought to result from a release of
norepinephrine and dopamine (Pary et al., 2002).
Controlled studies in adults with ADHD have demon-
strated response rates ranging from 25% to 78% for
methylphenidate (Biederman et al., 2006; Mattes,
Boswell, & Oliver, 1984; Spencer et al., 1995; Spencer
et al., 2005) and response rates ranging from 54% to
70% for amphetamine (Horrigan & Barnhill, 2000;
Paterson, Douglas, Hallmayer, Hagan, & Zyron, 1999;
Spencer et al., 2001). Response rates with placebo for
adults with ADHD were reported to be 10%.
Although stimulants are effective in adult ADHD, it is
estimated that at least 30% of individuals do not ade-
quately respond to, or are not able to tolerate, stimulants
(Barkley, 1977; Gittleman, 1980; Spencer et al., 1996).
In addition, stimulants are associated with a number of
shortcomings. First, they are controlled substances,
which may increase both the potential for abuse and the
barriers to treatment. In addition, mood disorders that are
often comorbid with ADHD may have an adverse impact
on responsivity to stimulant drugs (Barkley, 2006). In
particular, stimulants have demonstrated poor response
rates with comorbid manic symptomatology and may in
fact cause a worsening of mood instability (Biederman
et al., 1999). Thus, in many cases, physicians must turn
to other drug classes in treating the disorder.
Antidepressants. Antidepressants have been demon-
strated to be an effective therapy for adult ADHD.
Most of this research has examined the efficacy of the
noradrenergic compounds bupropion, venlafaxine,
desipramine, and atomoxetine. Bupropion is an atypical
antidepressant from the aminoketone class of antidepres-
sants and is thought to possess both indirect dopamine
agonist and noradrenergic effects (Barkley, 2006).
Venlafaxine is also an atypical antidepressant and is
thought to have both serotonergic and noradrenergic
effects. Desipramine is a tricyclic antidepressant, which
is assumed to act on norepinephrine and dopamine
reuptake (Barkley, 2006). Finally, atomoxetine is one
of a newer class of compounds, known as specific nor-
epinephrine reuptake inhibitors.
Maidment (2003) reviewed the literature examining
the efficacy of antidepressants in the treatment of adult
ADHD. Of those agents that have undergone controlled
trials, he concluded that there is the most evidence sup-
porting the use of desipramine, followed by atomoxetine.
Desipramine has been shown to produce clinically and
statistically significant improvement in ADHD symp-
toms (Wilens, Biederman, Mick, & Spencer, 1995;
Wilens et al., 1996), as has atomoxetine (Adler, Spencer,
636 Journal of Attention Disorders
Milton, Moore, & Michelson, 2005; Michelson et al.,
2003; Spencer et al., 1998). Studies investigating bupro-
pion have generally demonstrated improved ADHD
symptoms (Kuperman et al., 2001; Wender & Reimherr,
1990; Wilens et al., 2001), although its efficacy is
unclear (Maidment, 2003). Finally, initial data on ven-
lafaxine suggest that the antidepressant is associated
with high response rates (Adler, Resnick, Kunz, &
Devinsky, 1995; Findling, Schwartz, Flannery, & Manos,
1998; Hedges, Reimherr, Rogers, Strong, & Wender,
1995; Reimherr, Hedges, & Strong, 1995). However,
these data are from open-label studies, and controlled
studies are needed to confirm this finding.
Antihypertensive agents. Antihypertensive agents
such as clonidine and guanfacine have been investigated
in the treatment of children with ADHD; however, there
is little research examining the efficacy of these beta-
adrenoceptor agonists in adults. These drugs are thought
to inhibit the release of norepinephrine, increasing
dopamine turnover and reducing blood serotonin levels
(Barkley, 2004). One controlled study examined the
effect of guanfacine on ADHD in adults and found that
the drug significantly reduced ADHD symptoms relative
to a placebo (Taylor & Russo, 2001). Beta-adrenoceptor
antagonists such as propanolol have also been investi-
gated, and preliminary data suggested that they may also
be useful in the treatment of adults with ADHD (Mattes,
1986; Ratey, Greenberg, & Linden, 1991). However,
more research is necessary before any firm conclusions
can be drawn.
Medication adherence. In children, varied medication
adherence rates have been noted, with rates ranging from
35% to 100% (Hack & Chow, 2001). Research examin-
ing adherence in adults with ADHD has suggested that
adults are compliant with their medication for a brief
period (i.e., 2 months) but that compliance rates tend to
decrease after this brief period (Perwien, Hall, Swensen,
& Swindle, 2004). Other researchers (Safren, Duran,
Yovel, Perlman, & Sprich, 2007) have found that ADHD
medication adherence is significantly and positively
correlated with ADHD symptom severity.
Psychosocial Intervention
Because of the severity and pervasiveness of the
symptoms of ADHD, pharmacotherapy alone is an insuf-
ficient treatment of adult ADHD in upward of 50% of
cases (Wilens, Spencer, & Biederman, 2000). In addi-
tion, even though medications may offer improvements
on measures of core symptoms, these changes may not
always translate into satisfactory functional improve-
ments (e.g., time management, organization, planning,
self-esteem; M. Weiss et al., 1999). For these reasons,
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many adults with ADHD seek additional help in the form
of psychosocial treatment (Ramsay & Rostain, 2007).
Psychosocial interventions can include cognitive behav-
ioral therapy (CBT), self-management skills training,
environmental restructuring, psychoeducation, individ-
ual psychotherapy, family therapy, marital or couple
therapy, vocational counseling, and ADHD coaching.
However, it must be emphasized that for almost all of
these interventions, little to no controlled research has
been conducted. Despite an abundance of popular books
describing numerous psychosocial approaches for the
management of ADHD, there is still almost no empirical
evidence to support their efficacy (Barkley, 2006). Thus,
it is too early to draw conclusions regarding the effec-
tiveness of most psychosocial treatments. Descriptions
of these treatments, and any empirical studies evaluating
their effectiveness, are presented below.
CBT. CBT has emerged as a potential psychosocial
treatment for adult ADHD (Rostain & Ramsay, 2006). Its
use in children and adolescents with ADHD has also
been investigated, but the results have generally demon-
strated little utility in this population (e.g., Baer &
Neitzel, 1991; Bloomquist, August, & Ostrander, 1991;
Dush, Hirt, & Schroeder, 1989). CBT was originally
developed as a treatment for depression but has recently
been modified for the treatment of adult ADHD (e.g.,
McDermott, 2000; Ramsay & Rostain, 2003; Rostain &
Ramsay, 2006; Safren, Perlman, Sprich, & Otto, 2005).
In general, the focus of CBT is on modifying problem-
atic thoughts and beliefs to create changes in emotions
and behaviors. This focus is well suited for adults with
ADHD, as many have developed negative beliefs about
the self and about the world. CBT is also useful for treat-
ing the cormorbid diagnoses (e.g., anxiety, depression)
and functional problems (e.g., procrastination, poor time
management) that are often encountered when working
with adult ADHD (Rostain & Ramsay, 2006). Overall, a
therapeutic model focusing on training in methods of
time management, organizational skills, communication
skills, decision making, self-monitoring and reward,
chunking large tasks into smaller steps, and changing
faulty cognitions and beliefs is thought to be useful for
adults with ADHD (Barkley, 2006).
The use of CBT for ADHD in adults is fairly recent,
and thus little research has examined its efficacy. There
is preliminary evidence for its efficacy when used in
combination with medication. Wilens et al. (1999) eval-
uated the potential benefit of cognitive therapy—used in
conjunction with medications—in adults with ADHD.
Treatment was associated with significant improvements
in symptoms of ADHD and improvements in overall
functioning and in anxiety and depressive symptoms.
Safren, Otto, et al. (2005) showed similar results in their

study of CBT of adults with ADHD. Participants were
adults with ADHD who had been stabilized on medica-
tion but still showed clinically significant symptoms.
Those who received CBT plus continued pharmacology
had significantly lower symptoms of ADHD, anxiety,
and depression and higher ratings of overall functioning
than did those who continued pharmacology alone.
Finally, Rostain and Ramsay (2006) examined the effi-
cacy of a combined treatment approach for adults with
ADHD using a 6-month course of concurrent pharma-
cotherapy and CBT. Results demonstrated significant
improvements in symptoms of ADHD, anxiety, depres-
sion, and overall functioning. These studies provide pre-
liminary evidence for the use of CBT with adult ADHD,
but control trials are required to examine the effects of
CBT relative to appropriate control conditions.
Self-management skills training or environmental
restructuring. Skill-building training can also play an
important role in reducing ADHD symptoms and in rein-
forcing gains in adults (M. D. Weiss & Weiss, 2004). The
development of self-management skills and the use of
environmental restructuring can help incorporate more
structure, routine, and organization into daily living
(Murphy, 2005). Hesslinger et al. (2002) conducted a
group skill-based training program for adults with
ADHD and found that treatment was associated with sig-
nificant improvements in ADHD symptoms, depressive
symptoms, and ratings of personal health.
Psychoeducation. Psychoeducation is an integral part
of treatment, and bibliotherapy in particular can be use-
ful in answering questions from patients and their
families (M. D. Weiss & Weiss, 2004). In fact, after
receiving a diagnosis, education about the effects of
ADHD is almost universally agreed on as a starting point
for ADHD psychosocial treatment (Ramsay & Rostain,
2007). Adults with ADHD can learn more about the dis-
order and how it affects them specifically, which can aid
in their ability to cope with the disorder and the devel-
opment of individualized treatment plans (Murphy,
2005).
Psychotherapy. Individual psychotherapy generally
comprises a number of components, including psychoe-
ducation, the setting of treatment goals and establish-
ment of strategies to meet those goals, problem solving,
and dealing with the comorbid problems that often
accompany ADHD (Barkley, 2006; Murphy, 2005).
Family and marital or couples therapy from an ADHD
perspective can help others gain an understanding of
ADHD behaviors, as the disorder can be quite disruptive
to the routine tasks of daily living and can be damaging
to couple and family functioning. Such a focus may also
help others understand that the ADHD adult’s behavior
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Davidson / ADHD in Adults 637
may not stem from willful wrongdoing and lack of car-
ing (Barkley, 2006; Murphy, 2005).
Vocational counseling. Symptoms of ADHD can sig-
nificantly impair workplace performance. Impulsivity,
inattention, disorganization, careless mistakes, poor time
management, and inconsistency can all lead to employ-
ment difficulties. Vocational counseling can help allevi-
ate occupational difficulties by identifying strengths and
limitations and by matching adults to jobs that are well
suited for them (Barkley, 2006; M. D. Weiss & Weiss,
2004).
ADHD coaching. A personal ADHD coach aids the
patient in identifying goals and strategies to meet these
goals. Coaching is different from traditional therapy in
several ways, most notably in its focus on implementa-
tion of the client’s goals. Therapy can focus on insight
and understanding, but coaching is more about action
and getting things done (Favorite, 1995).
Conclusion
ADHD is a lifelong neurobiological disorder that pre-
sents significant challenges to adults. Two important
clinical diagnostic issues have been highlighted in this
review. First, there are important differences between the
child and adult presentation of the disorder. As children
with ADHD grow into adolescence and adulthood, there
is generally an overall reduction of ADHD symptoms in
which hyperactive–impulsive symptoms decline and
inattentive symptoms persist. Second, the DSM-IV crite-
ria for ADHD must be cautiously used in adults, as these
criteria were designed for and selected based on studies
with school-aged children.
The assessment of ADHD in adults is often challenging
and complex, particularly given the fact that no litmus test
for diagnosing the disorder exists. Thus, to increase diag-
nostic accuracy, an assessment should be comprehensive
and include the use of symptom rating scales, interviews,
and neuropsychological testing and the corroboration of
patient reports with at least one other source who knows
the individual well (Barkley, 2006; M. D. Weiss & Weiss,
2004; Wilens et al., 2004). Although the diagnosis of
ADHD in adults can be both reliable and valid, there is a
strong need for the development of specific diagnostic cri-
teria that are more sensitive and specific to adult function-
ing than are the existing criteria.
There exists a range of treatment options—both phar-
macological and psychosocial—for adults with ADHD.
In terms of pharmacological interventions, the stimulants
methylphenidate and amphetamine and the antidepres-
sants desipramine and atomoxetine appear to have the
638 Journal of Attention Disorders
strongest empirical support in the treatment of adult ADHD.
Further controlled investigations of pharmacological
agents in adults with ADHD are necessary. With respect
to psychosocial interventions, there is preliminary evi-
dence supporting the combination of CBT and medication.
However, studies utilizing more rigorous methodology are
needed to corroborate their positive results. Aside from
these studies, there is virtually no research on psychoso-
cial treatments for ADHD. Researchers must begin to
systematically examine the utility and effectiveness of
such treatments. Finally, formal guidelines—similar to
those set out for children—for the treatment of ADHD in
adults are needed.
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Megan A. Davidson, MA, is a doctoral candidate in the
Clinical Psychology Program at Queen’s University. Her clin-
ical interests focus on health psychology, and her research
interests include assessment and treatment of adult ADHD,
perceptions of health risk, and assessment of chronic pain.