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ADHD in adults

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ADHD in adults

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ADHD does not, as was assumed until the end of the last millennium,1 automatically end with adulthood.

ADHD persists into adulthood in around two thirds of people with ADHD. Many show altered symptoms, while others may experience complete remission or remission with fluctuating phases. Up to 90% of persons with ADHD still have residual symptoms or significant limitations in young adulthood compared to people without ADHD. Various reasons for the persistence of ADHD into adulthood are discussed, such as low socio-economic background, high stress levels in childhood or late traumas. One theory assumes that ADHD already exists in childhood, but is masked by coping mechanisms and becomes visible in adulthood. Late-onset ADHD, i.e. a first appearance (or at least becoming recognizable) in adulthood, is possible and can occur in up to 10% of ADHD cases, especially in women.
The symptoms of ADHD change in adults compared to children, with hyperactivity decreasing and inner restlessness, inattention and organizational problems coming to the fore.

Treatment of ADHD in adults often requires lower doses of stimulants compared to children.

1. Prevalence of the persistence of ADHD into adulthood

5 % of all children have ADHD (a further 5 % are suspected of having ADHD). In the USA, around 4.4 % of all adults are affected by ADHD.23 Further studies can be found at Krause.4

65%5 to 90%6 to 100%7 of people with ADHD show at least residual symptoms or significant limitations in terms of educational and professional success into young adulthood compared to non-affected people.
63.8% showed fluctuating phases of remission and recurrence during childhood and young adulthood 89
In adulthood, people with ADHD - with altered symptoms - persist throughout their lives with - depending on the study -

  • 22 %10
  • 35 %89
  • 50 %11
  • around 66 % (which is likely to be the most resilient)1213 11
    Complete remission in adulthood is found in around 30% of children with ADHD.611

One study observed in adults whose previous ADHD remitted that only the symptom groups

  • Executive problems
  • Behavioral problems

were remitted, while

  • Hyperactivity/restlessness behavior
  • Planning/organizational deficits

persisted.14

A large international study even found a higher prevalence of ADHD in adults (2.8%) than in children (2.2%).15 This could be consistent with the fact that the heritability of adult ADHD is possibly lower than that of child ADHD, i.e. that the proportion of environmental influences on the development of ADHD could be higher in adults than in children.16

2. Possible reasons for the persistence of ADHD into adulthood

It is not possible to predict in which persons with ADHD ADHD will disappear in adulthood. Whether persons with ADHD lose their ADHD by the age of 27 is independent of

  • The severity of the Disorder17
  • The age at first onset of ADHD17
  • The IQ of childhood17
  • Behavioral problems in childhood17
  • The severity of ADHD-HI, ODD or CD17
  • The duration of stimulant treatment after adolescence17

There are various theories as to why childhood ADHD disappears in some adults and persists in others.

  • Children with ADHD from a low socio-economic background benefited more from special school support than children from higher socio-economic backgrounds.18 In our view, this indicates that families with a low socio-economic status are less able to compensate for their children’s deficits.
  • A study of stress exposure in children with ADHD found that severe stress exposure in childhood and adolescence was associated with severe ADHD-HI or ADHD-I progression into adulthood, while children with low stress exposure often showed remitting ADHD (all subtypes).19 A large cohort study in Sweden confirms this20
  • Another study found an up to 11.8-fold increase in trauma in late-onset ADHD. Neurophysiologically, late-onset ADHD did not differ from ADHD in people with ADHD who had had it since childhood. However, the effects were significantly stronger. At the same time, 1/3 of the late-onset ADHD sufferers were no longer diagnosed with ADHD after one year.21
    • Puberty is associated with a strongly altered dopaminergic innervation in the PFC. The PFC is particularly vulnerable to dopaminergic stimulation during this time. This explains the fluctuating behavior of adolescents between the poles of novelty seeking and strong withdrawal. The strong dopaminergic vulnerability in this developmental phase further explains the dangers of alcohol and drug abuse or excessive media consumption. These can cause permanent disorders of the dopamine system, which increases the risk of impulsivity, addiction or psychosis.22
      Prolonged cortical maturation in the frontoparietal network has a favorable effect on the final performance of the brain, while acceleration, e.g. through too much dopaminergic stimulation, has an unfavorable effect.23 In both ADHD and giftedness, the maturation of the brain is slowed down.
      See ⇒ Giftedness and ADHD In the section ⇒ Differential diagnosis of ADHD in the chapter ⇒ Diagnostics
  • Anxiety symptoms at the age of 15 make mental disorders in early adulthood much more likely24
    • Anxiety disorder: 4.9-fold
    • Depression: 4.8-fold
    • ADHD, ASD or developmental disorder: 3.4-fold
      This could be a further indication that middle adolescence represents a second particularly vulnerable developmental window alongside early childhood.
  • One theory assumes a post-maturation of brain functions. However, not every delay in brain maturation is also a sign of ADHD. In the case of giftedness, there is a delay in the development of the cortex that corresponds exactly to the delay until the first cortex thickness maximum occurs in ADHD.
    ⇒ ADHD and giftedness.
  • Another theory is that certain regions of the brain take on compensatory tasks so that the child’s ADHD deficits can be corrected as a result.25
  • Another model assumes that certain childhood ADHD deficits persist throughout life.25
  • A study of adults with persistent ADHD found an imbalance between the connections in the brain within the default mode network on the one hand and those between the default mode network and the areas that support attention and cognitive control on the other. In adults whose ADHD was remitted, these differences did not exist.2627
  • A comparison of partially remitted with non-remitted adolescents found a significantly lower activation of the vlPFC in partial remission. This improvement in vlPFC efficiency correlated with performance on a go/no-go task and was intermediate between ADHD diagnosis and normal controls.28
  • A gene analysis study found four genome-wide significant loci for childhood ADHD and one for late onset ADHD. Elevated polygenic risk scores for ADHD (ADHD-PRS) were found in persistent ADHD. Childhood ADHD showed greater genetic overlap with hyperactivity and autism as well as the highest burden of rare protein truncating variants in evolutionarily restricted genes. Late onset ADHD, on the other hand, showed greater genetic overlap with depression and no increased burden of rare protein-truncating variants.13

3. Late onset ADHD: first occurrence in adulthood

New research results from several long-term studies also show that ADHD can also be diagnosed for the first time in adulthood. Depending on the study, this occurs in 0.4% to 10% of ADHD cases. For example, a study of young adults with ADHD found that only 12.6% had already been diagnosed with ADHD in childhood.29 This means that ADHD could be diagnosed for the first time after the age of 6 or 12 much more frequently than previously assumed.
We are skeptical as to whether ADHD actually occurs for the first time in adulthood (late onset). We assume that it already existed before then and was covered up by intensive coping. This kind of coping takes a lot of energy and is not always sustainable. If the strength is used up at some point, the coping facade collapses and the ADHD becomes visible. In adults, the gender ratio of people with ADHD is (almost) balanced.30
Women with a late diagnosis in particular suffer from the most severe symptoms and often comorbidities such as anxiety disorders or depression, which are a typical consequence of long untreated ADHD.
On the other hand, women are more susceptible to developing emotional disorders that start later (on average in adolescence), such as depression, dysthymia, various anxiety disorders or eating disorders. Sex hormones are often discussed as possible causes.31
A high oestrogen level alleviates deficits in learning and memory.32 This could possibly explain why ADHD symptoms are often not detectable in girls during their school years and only become more apparent in women from the age of 35.

3.1. Late-Onset ADHD: late-onset or late-diagnosed ADHD?

Until DSM IV, the criteria for the diagnosis of ADHD stipulated that the first symptoms must have appeared by the age of 7. With DSM 5, this was increased to an age of 12 years.

Recent findings from population-based longitudinal studies suggest that in a subset of people with ADHD, ADHD symptoms only increase after childhood and they first meet the criteria for ADHD in later adolescence or early adulthood.333435363710293839 One study found 45% of people with ADHD who were first diagnosed as adults did not have ADHD in childhood. They showed lower hyperactivity/impulsivity symptoms and higher education. We see both of these as indications of a higher probability of an overlooked diagnosis in childhood with good coping skills40

The updated European consensus on the treatment and diagnosis of ADHD in adults from 201841 points out that many people with ADHD have a poor memory and therefore have difficulty remembering events and details of their childhood and that there are reports of adults documenting the first onset of symptoms after the age of 12.4243

If the age by which the first symptoms must have appeared is set at 16, 99% of people with ADHD are covered, according to one study.44
This means that every hundredth case of ADHD still has its first symptoms after the age of 16. Assuming a prevalence of 8% for ADHD, this would mean 64,000 people in Germany, and at 5%, 40,000 people would have late-onset ADHD after the age of 16.
It is usually found that at least one symptom was highly pronounced in adolescence, which could indicate incorrect diagnosis in adolescence.45

Another study found in a survey of young adults with ADHD that only 12.6% already had ADHD in childhood.46 This means that ADHD could “appear” for the first time after the age of 6 or 12 (late onset) much more frequently than previously assumed. There is now clear evidence from extensive cohort studies in various countries that ADHD can also “appear” for the first time in adulthood.47 One study showed that in children with ADHD, the symptoms disappeared in up to 95% of people with ADHD in adulthood, while a significant proportion of adults with ADHD did not “have” ADHD as children.48 Several long-term studies over 20 to 40 years show that ADHD in children and ADHD in adults often affect separate groups of people. Moreover, in adults, gender participation was balanced, while in children there was still a male predominance. This could also indicate a separation of the groups of people.4950515230
We do believe that ADHD usually existed earlier and was just not diagnosed - whether due to ignorance on the part of doctors or therapists, due to intensive coping (e.g. in the case of high giftedness) or due to a good structure in the parental home, which is no longer present in independent adult life. Nevertheless, some questions remain unanswered.53
Regardless of this, it is of no use to adult persons with ADHD if they are denied treatment in adulthood due to a lack of childhood diagnosis. There are no reports that the usual treatment methods (especially stimulants) are less effective or less effective in late onset ADHD. In this respect, special observation by the attending physician may make sense, but refusing treatment would be a breach of the physician’s duty of care. We see this in particular when a doctor refuses a diagnosis in adulthood solely on the basis of a lack of primary school reports, although the symptoms show a full ADHD picture. The notoriously poor long-term memory of persons with ADHD and the ADHD-symptomatic increased disorganization, in which the retrievable storage of primary school reports by the person with ADHD himself would almost be an argument against ADHD, cannot justify a refusal of a diagnosis in such a case for this reason alone.

One publication reports that the severity of ADHD should be milder if it occurs later.36 This is in contrast to reports that late-diagnosed women in particular tend to have more severe symptoms with strong comorbidity (depression, anxiety).52
The risk of being (diagnosed with) ADHD for the first time in adulthood also appears to be related to comorbidities. (ADHD)-typical comorbidities existing in childhood seem to increase the risk of developing ADHD in old age - just as (which has been known for some time) ADHD in childhood increases the risk of developing typical comorbidities in adulthood.5455

A long-term study found that of 318 children with birth problems, at age 40 those who had developed ADHD as a child were only 21% ADHD, but had poorer educational attainment, more ADHD symptoms and executive problems. Those who had attention problems as a child but not full-blown ADHD had 6.6% ADHD at age 40; those who did not show attention problems as a child had 6% ADHD. Controls without birth problems had 1.6% ADHD at 40.56 Accordingly, around 6 to 6.6 % of those children with birth problems and 1.6 % of those without birth problems could be diagnosed with ADHD for the first time at the age of 40.

A study of 488 consecutive patients admitted to a special outpatient clinic for dementia found ADHD in 7 patients who were initially suspected of having an early form of Alzheimer’s dementia. These 7 persons with ADHD of “very late onset ADHD” or “senile onset ADHD” had four characteristics in common:57

  • significantly younger (< 65 years) than the overall study population
  • predominantly inattention-related symptoms
  • latent manifestation
  • stressful life event before the manifestation (stress experience)

4. ADHD symptoms change in adults

The DSM IV criteria for ADHD describe the symptoms of children and not specifically those of adults.58
The symptoms of ADHD in adults change considerably compared to those of ADHD in children.5960 Hyperactivity in particular is significantly reduced. Symptoms such as inner restlessness, inability to relax and “constantly having to be active” come to the fore.

One study reports a linear decline in hyperactivity from 6 to 2.9 points between the ages of 8 and 16.61 Inattention only fell from 5.8 to 4.9 points in the same period.
However, another study shows that hyperactivity - measured here using infrared movement sensors during the performance of attention tests - is a better discriminator than attention problems, even in adults. Even in people with ADHD-I, a predominantly inattentive subtype, hyperactivity / restlessness of movement was found to be significantly higher than in non-affected people.62

Adults have a far greater opportunity to organize their lives in such a way that the peculiarities of ADHD (short attention span, high distractibility, preference for fast task switching) are no longer a burden but an advantage. Children have to submit to strict external control - especially at school. The trait of people with ADHD (and especially people with ADHD-HI) of increased intrinsic and reduced extrinsic motivation is a hindrance in a purely extrinsically motivating school environment.63

For the sake of completeness, it should be noted with regard to Friedman that the frustration of people with ADHD of doing something they are not really interested in and which, by its very nature, they are not particularly good at (which applies to all people, but is particularly true for people with ADHD) causes considerable stress. It is well known that people with ADHD react more intensely to stress. All ADHD symptoms are classic stress symptoms. People with ADHD have an overreactive stress response system.
⇒ ADHD as a chronic stress regulation disorder

Barkley has drawn up a list of typical symptoms of ADHD in adults and verified them through research. Physical hyperactivity decreases significantly, inner restlessness becomes more visible. Inattention also decreases significantly.

The following symptoms predominate in adults:

  • Inattention (reduced by up to 40 % compared to children)
    Attention problems decrease by up to 40% in adults compared to children and adolescents (the decrease is thus less than that of the other main symptoms).64 These figures are taken from the data in Biedermann’s publication. We cannot understand why the specialist literature interprets them differently. However, the decline in attention problems in adults that can be read from the data is consistent with our perception (at least for some people with ADHD). One study reports a linear decline in inattention from 5.8 to 4.9 points between the ages of 8 and 16.61
    Other sources, however, report an increase in inattention at the age of65 and consistent attention problems and executive problems from working memory between the ages of 60 and 94, some of which stemmed from depression.66
  • Hyperactivity (reduced by up to 60 % compared to children)
    Hyperactivity transforms into inner restlessness in adulthood (Barkley) and decreases by up to 60% compared to children/adolescents6461 We suspect that this is not so much a transformation as that the symptoms of inner tension become more clearly visible after the hyperactivity has subsided.
  • Impulsiveness (reduced by up to 60 % compared to children)
    According to various sources, impulsivity is said to decrease by up to 60% compared to children / adolescents646761
    Another study found no change in impulsivity with age.65
  • Emotional overreactivity (increased in adults)68
  • Affect lability69
  • Disorganization69

One study found four patterns of hyperactivity and inattention between childhood and adulthood:70

  • Hyperactivity
    • was low, stay low
    • was high, decreased
  • Inattention
    • was low, remained low
    • was high, continued to rise

Some changes can also be measured neurophysiologically.

While there is a reduction in striatal and prefrontal dopa decarboxylase activity in children with hyperactivity,71 this is not reproducible in adults with ADHD-HI.72 Furthermore, no increase in HVA was detectable in the CSF of adults with ADHD. This also indicates that persistent ADHD in adulthood has an altered pathophysiological basis.73 However, the HVA value is merely a global value for dopamine metabolism, whereas in ADHD the dopamine level of different brain regions must be differentiated.

Adults apparently have a significantly lower number of dopamine transporters in the striatum than children. For every 10 years of age, there is a decrease of 7 %, with the decrease being significantly higher up to around 40 years of age than thereafter. In 50-year-olds, the number of DATs is only about half as high as in 10-year-olds.7475
At the same time, the number of dopaminergic neurons decreases with age. The amount of phasically released and basal extracellular dopamine in the striatum remains the same.76

The problems and quality of life impairments of older adults with ADHD are similar to those of younger adults with ADHD, according to a study. This suggests that there is no long-term improvement with further ageing during adulthood.77

Reif, on the other hand, assumes that inattention decreases only slightly, while emotional dysregulation becomes stronger in adulthood.78
We believe that emotional dysregulation is a more accepted trait in children (“immaturity”), whereas it is perceived as inappropriate in adults. We therefore wonder whether emotional dysregulation is actually increasing in adults with ADHD or whether emotional imbalance is already present in children with ADHD, but is still perceived as acceptable and therefore not as an ADHD symptom - as we suspect is the case with internal tension, which is perceived in adulthood after physical hyperactivity decreases. We want to research this in more detail.

5. Treatment for adults

In adults, significantly lower amounts of stimulants are usually required to correct the dopamine and noradrenaline deficit in the reinforcement system and in the dlPFC, which could be related to the fact that the excess of dopamine transporters compared to children apparently partially regresses.
A (starting) dosage of stimulants as for children would therefore be medical malpractice. Irrespective of this, stimulant treatment should always be started with dosages of 2.5 mg / below the smallest packaging dosage sizes for sensible dosing with stimulants.

6. Remission in adulthood

One study examined adults three times at 7-year intervals, from an average age of 34 to an average age of 47, and showed a remission rate of 5.7%.79
One individual case reported a complete remission of his clear adult ADHD-C as a result of a corona infection. After three quarters of a year, the ADHD symptoms slowly returned. It is quite conceivable that diseases alter the dopamine system. Just as certain viral diseases can be a risk for ADHD because they can trigger a dopamine and noradrenaline deficiency, this is also possible in the opposite direction.

7. ADHD in old age

There are few studies on the symptoms, diagnosis and treatment of ADHD in older adults.80

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