Adult ADHD

The adult ADHD diagnosis

As noted in the childhood ADHD summary,  the diagnosis of Attention Deficit Hyperactivity Disorder is typically made when a person has marked inattention, or distractibility, along with “executive dysfunction”, or disorganization.  In adults, there is usually not an inability to sit still in classrooms (mistakenly labeled “hyperactivity”)  since most adults are no longer in school; rather the executive dysfunction is typically the primary complaint. 

Most adults receive amphetamines as symptomatic treatments for inattention. Symptom-oriented treatment, although very popular, breaks the Hippocratic tradition in medicine, and causes more harm than good.  

The mood and anxiety factor

In the National Comorbidity Study (NCS), an epidemiological analysis of prevalence of all mental conditions in the US, 3% of the US population was diagnosable with adult Attention Deficit and Hyperactivity Disorder  (meaning meeting standard criteria as adults and, retrospectively, in childhood).  Of these patients, over 40% also were diagnosable with bipolar illness, and over 40% were diagnosable with “major depressive disorder” (MDD).  In sum, 84% were diagnosable with mood illnesses.  Using the concept of a diagnostic hierarchy, described here,  poor attention is a symptom of depression and mania (and anxiety); thus the occurrence of inattention while a patient has depressive or manic symptoms or episodes does not mean that the person has both an attention “disorder” and a mood “disorder”. This would be like saying every person with pneumonia also has a fever “disorder.”  It is very rare to find adult ADHD in a person who does not have other illnesses, mood and anxiety conditions, which cause the symptom of inattention. This has also been shown in a 33 year prospective follow up study of children with ADHD into adulthood, and in another NCS analysis which found that the inattention of adult with such diagnosis occurred only with concurrent anxiety disorders. 

Explanations

There are two possible explanations of the fact that “adult ADHD” almost always happens with mood and anxiety conditions in adults.  Either the mood and anxiety conditions cause the poor concentration, which is our view, or the adult ADHD causes the mood and anxiety symptoms, which is view of those who prefer to diagnose adult ADHD.  In the latter case, the claim would be that every time someone has such diagnosis, they get very depressed and anxious about having it. This may be plausible colloquially, but there is no scientific research to support it. On the other hand, there are about two centuries of research studies that state that depressive, manic, and anxiety conditions cause poor concentration, and that the inattention of those states improves once the mood and anxiety conditions improve. 

A separate condition?

Based on these considerations, our view is that the diagnosis of adult Attention Deficit Hyperactivity Disorder is not a scientifically valid condition.  It is not an illness or disease.  Children may be diagnosable with Attention Deficit Hyperactivity Disorder, but their symptoms are either due to mood or anxiety illnesses, or due to a developmental delay in attention which normalizes by adolescence in most cases and certainly by adulthood.  Older studies found that 90% of children did not meet ADHD criteria by age 20, as reviewed here

Not worth the risks

It is relevant that the diagnosis of adult ADHD coincides with marketing by the pharmaceutical industry, when Eli Lilly got the first FDA indication for this label with atomoxetine (Strattera) in 1996.  Since that date many academics, often paid by the industry, have been promoting the concept of the adult diagnosis . This is a good example of “disease-mongering” when a condition that has never been observed in centuries of medical research by very competent experts is suddenly made popular in association with a new treatment being offered for it, and profits to the companies that market that new treatment. 

Summary

PL does not recommend making the diagnosis of adult Attention Deficit Hyperactivity Disorder, given the considerations  about its scientific invalidity here.  Treatment with amphetamines is also not recommended since the diagnosis is questionably valid. Risks with amphetamines, including sudden death in adults, make such treatment even more questionable, and are discussed in more detail here. 

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