Purpose of Review
The traditional definition of Attention-Deficit/Hyperactivity Disorder (ADHD), assuming onset in childhood, has been challenged by evidence from four recent birth-cohort studies that reported most adults with ADHD lacked a childhood categorical ADHD diagnosis.
Late onset of symptoms was evaluated in the long-term follow-up of the Multimodal Treatment study of ADHD (MTA). In most cases, other factors were present that discounted the late onset of ADHD symptoms and excluded the diagnosis of ADHD.
We offer two theoretical frameworks for understanding the ADHD trajectory throughout the life cycle: (1) the complex phenotype model, and (2) the restricted phenotype model. We conclude that (a) late onset (after age 12) is a valid trajectory for ADHD symptoms, (b) the percentage of these cases with onset after adolescence is yet uncertain, and (c) the percentage meeting exclusion criteria for diagnosis of ADHD is influenced by the rigor of the methodology used to obtain evidence and whether or not DSM exclusionary criteria are applied.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
APA. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.
Shaw P, Lerch J, Greenstein D, Sharp W, Clasen L, Evans A, et al. Longitudinal mapping of cortical thickness and clinical outcome in children and adolescents with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2006;63(5):540–9. https://doi.org/10.1001/archpsyc.63.5.540.
Weiss G, Hechtman L, Milroy T, Perlman T. Psychiatric status of hyperactives as adults: a controlled prospective 15-year follow-up of 63 hyperactive children. J Am Acad Child Psychiatry. 1985;24(2):211–20.
Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult psychiatric status of hyperactive boys grown up. Am J Psychiatry. 1998;155(4):493–8. https://doi.org/10.1176/ajp.155.4.493.
• Sibley MH, Mitchell JT, Becker SP. Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. The lancet Psychiatry. 2016;3(12):1157–65. https://doi.org/10.1016/S2215-0366(16)30190-0. This systematic review has documented that methods of adult diagnosis is a major factor in the variation of ADHD persistence estimates
Karam RG, Breda V, Picon FA, Rovaris DL, Victor MM, Salgado CA, et al. Persistence and remission of ADHD during adulthood: a 7-year clinical follow-up study. Psychol Med. 2015:1–12. https://doi.org/10.1017/S0033291714003183.
Breda V, Rovaris DL, Vitola ES, Mota NR, Blaya-Rocha P, Salgado CA, et al. Does collateral retrospective information about childhood attention-deficit/hyperactivity disorder symptoms assist in the diagnosis of attention-deficit/hyperactivity disorder in adults? Findings from a large clinical sample. Aust New Zealand J Psychiatry. 2016;50(6):557–65. https://doi.org/10.1177/0004867415609421.
•• Moffitt TE, Houts R, Asherson P, Belsky DW, Corcoran DL, Hammerle M, et al. Is adult ADHD a childhood-onset neurodevelopmental disorder? Evidence from a four-decade longitudinal cohort study. Am J Psychiatry. 2015;172(10):967–77. https://doi.org/10.1176/appi.ajp.2015.14101266. The first time that the late-onset ADHD was reported in an analysis of long-term outcome in a longitudinal (four-decade) birth cohort in New Zealand.
• Agnew-Blais JC, Polanczyk GV, Danese A, Wertz J, Moffitt TE, Arseneault L. Evaluation of the persistence, remission, and emergence of attention-deficit/hyperactivity disorder in young adulthood. JAMA psychiatry. 2016;73(7):713–20. https://doi.org/10.1001/jamapsychiatry.2016.0465. An UK longitudinal cohort study found similar results in regard to the late-onset ADHD and reported factors from childhood related to this trajectory.
• Caye A, Rocha TB, Anselmi L, Murray J, Menezes AM, Barros FC, et al. Attention-deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort Supporting a late-onset syndrome. JAMA psychiatry. 2016;73(7):705–12. https://doi.org/10.1001/jamapsychiatry.2016.0383. A Brazilian longitudinal cohort study found similar results in regard to the late-onset ADHD and tested for multiple confounding factors in secondary analyses.
• Riglin L, Collishaw S, Thapar AK, Dalsgaard S, Langley K, Smith GD, et al. Association of genetic risk variants with attention-deficit/hyperactivity disorder trajectories in the general population. JAMA psychiatry. 2016;73(12):1285–92. https://doi.org/10.1001/jamapsychiatry.2016.2817. Another UK longitudinal population-based cohort study reporting the existence of late-onset ADHD.
Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, Lapey KA, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(12):1792–8. https://doi.org/10.1176/ajp.150.12.1792.
Kieling C, Kieling RR, Rohde LA, Frick PJ, Moffitt T, Nigg JT, et al. The age at onset of attention deficit hyperactivity disorder. Am J Psychiatry. 2010;167(1):14–6. https://doi.org/10.1176/appi.ajp.2009.09060796.
Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE. 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. 2010;49(3):210–6.
Russel A, Barkley MFADHD. In adults: what the science says. New York: Guilford Press; 2007.
Hallowell E, Ratey J. Driven to distraction. Pantheon Books; 1994.
Castellanos FXI, Adult-Onset ADHD. A distinct entity? Am J Psychiatry. 2015;172(10):929–31. https://doi.org/10.1176/appi.ajp.2015.15070988.
Faraone SV, Biederman J. Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA psychiatry. 2016;73(7):655–6. https://doi.org/10.1001/jamapsychiatry.2016.0400.
Mannuzza S, Klein RG, Klein DF, Bessler A, Shrout P. Accuracy of adult recall of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 2002;159(11):1882–8. https://doi.org/10.1176/appi.ajp.159.11.1882.
Sibley MH, Pelham WE, Molina BS, Gnagy EM, Waxmonsky JG, Waschbusch DA, et al. When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment. J Consult Clin Psychol. 2012;80(6):1052–61. https://doi.org/10.1037/a0029098.
•• Sibley MH, Rohde LA, Swanson JM, Hechtman L, Molina BS, Mitchell JT et al. Late-onset ADHD reconsidered with comprehensive repeated assessments between ages 10 and 25,. Am J Psychiatry.In press. This analysis of the LNCG group of the MTA suggested that diagnosis of most cases with late-onset ADHD symptoms observed in their sample were excluded due to alternative probable causes of the symptoms.
Sibley MH, Swanson JM, Arnold LE, Hechtman LT, Owens EB, Stehli A, et al. Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity. J Child Psychol Psychiatry Allied Disciplines. 2017;58(6):655–62. https://doi.org/10.1111/jcpp.12620.
Larson K, Russ SA, Kahn RS, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics. 2011;127(3):462–70. https://doi.org/10.1542/peds.2010-0165.
Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–23. https://doi.org/10.1176/ajp.2006.163.4.716.
Jensen CM, Steinhausen HC. Comorbid mental disorders in children and adolescents with attention-deficit/hyperactivity disorder in a large nationwide study. Atten Deficit hyperactiv Dis. 2015;7(1):27–38. https://doi.org/10.1007/s12402-014-0142-1.
Du Fort GG, Newman SC, Bland RC. Psychiatry comorbidity and treatment seeking: sources of selection bias in the study of clinical populations. J Nerv Ment Dis. 1993;181(8):467–74.
Sackett DL. Bias in analytic research. J Chronic Dis. 1979;32(1–2):51–63.
Lopez R, Micoulaud-Franchi JA, Galera C, Dauvilliers Y. Is adult-onset attention deficit/hyperactivity disorder frequent in clinical practice? Psychiatry Res. 2017;257:238–41. https://doi.org/10.1016/j.psychres.2017.07.080.
Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnorm Psychol. 2002;111(2):279–89.
Swanson JM, Arnold LE, Molina BSG, Sibley MH, Hechtman LT, Hinshaw SP, et al. Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry Allied Disciplines. 2017;58(6):663–78. https://doi.org/10.1111/jcpp.12684.
Bousquet J, Jorgensen C, Dauzat M, Cesario A, Camuzat T, Bourret R, et al. Systems medicine approaches for the definition of complex phenotypes in chronic diseases and ageing. From concept to implementation and policies. Curr Pharm Des. 2014;20(38):5928–44.
Alonso-Magdalena P, Quesada I, Nadal A. Endocrine disruptors in the etiology of type 2 diabetes mellitus. Nat Rev Endocrinol. 2011;7(6):346–53. https://doi.org/10.1038/nrendo.2011.56.
Asherson P, Trzaskowski M. Attention-deficit/hyperactivity disorder is the extreme and impairing tail of a continuum. J Am Acad Child Adolesc Psychiatry. 2015;54(4):249–50. https://doi.org/10.1016/j.jaac.2015.01.014.
Larsson H, Anckarsater H, Rastam M, Chang Z, Lichtenstein P. Childhood attention-deficit hyperactivity disorder as an extreme of a continuous trait: a quantitative genetic study of 8,500 twin pairs. J Child Psychol Psychiatry Allied Disciplines. 2012;53(1):73–80. https://doi.org/10.1111/j.1469-7610.2011.02467.x.
Coghill D, Sonuga-Barke EJ. Annual research review: categories versus dimensions in the classification and conceptualisation of child and adolescent mental disorders--implications of recent empirical study. J Child Psychol Psychiatry Allied Disciplines. 2012;53(5):469–89. https://doi.org/10.1111/j.1469-7610.2011.02511.x.
Shaw P, Gilliam M, Liverpool M, Weddle C, Malek M, Sharp W, et al. Cortical development in typically developing children with symptoms of hyperactivity and impulsivity: support for a dimensional view of attention deficit hyperactivity disorder. Am J Psychiatry. 2011;168(2):143–51. https://doi.org/10.1176/appi.ajp.2010.10030385.
van Ewijk H, Heslenfeld DJ, Zwiers MP, Faraone SV, Luman M, Hartman CA et al. Different mechanisms of white matter abnormalities in attention-deficit/hyperactivity disorder: a diffusion tensor imaging study. J Am Acad Child Adolesc Psychiatry 2014;53(7):790–799 e3. doi:https://doi.org/10.1016/j.jaac.2014.05.001.
Adeyemo BO, Biederman J, Zafonte R, Kagan E, Spencer TJ, Uchida M, et al. Mild traumatic brain injury and ADHD: a systematic review of the literature and meta-analysis. J Atten Disord. 2014;18(7):576–84. https://doi.org/10.1177/1087054714543371.
Nguyen-Louie TT, Castro N, Matt GE, Squeglia LM, Brumback T, Tapert SF. Effects of emerging alcohol and marijuana use behaviors on adolescents’ neuropsychological functioning over four years. J Stud Alcohol Drugs. 2015;76(5):738–48.
Squeglia LM, Gray KM. Alcohol and drug use and the developing brain. Curr Psychiatry Rep. 2016;18(5):46. https://doi.org/10.1007/s11920-016-0689-y.
Iglay K, Hannachi H, Joseph Howie P, Xu J, Li X, Engel SS, et al. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin. 2016;32(7):1243–52. https://doi.org/10.1185/03007995.2016.1168291.
Simon V, Czobor P, Balint S, Meszaros A, Bitter I. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Brit J Psychiatry. 2009;194(3):204–11. https://doi.org/10.1192/bjp.bp.107.048827.
Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurother. 2012;9(3):490–9. https://doi.org/10.1007/s13311-012-0135-8.
Conflict of Interest
Arthur Caye and Margaret H. Sibley each declare no potential conflicts of interest.
James M. Swanson was a member of the advisory board and/or acted as a consultant for Medice and NLS Pharma in 2017.
Luis Augusto Rohde has been a member of the speakers’ bureau/advisory board and/or acted as a consultant for Eli-Lilly, Janssen-Cilag, Medice, Novartis, and Shire in the last 3 years. He receives authorship royalties from Oxford Press and ArtMed. 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. He also received travel awards from Novartis and Shire to attend the 2015 WFADHD and the 2016 AACAP meetings.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Attention-Deficit Disorder
About this article
Cite this article
Caye, A., Sibley, M.H., Swanson, J.M. et al. Late-Onset ADHD: Understanding the Evidence and Building Theoretical Frameworks. Curr Psychiatry Rep 19, 106 (2017). https://doi.org/10.1007/s11920-017-0858-7