Diagnosis, Continuation, and Remission of ADHD in Adulthood

Theresa R. Cerulli, MD: This might be a good opportunity, while we’re discussing the clinical burden of ADHD, to bring up Dr Maggie Sibley’s data in the “green journal” [American Journal of Psychiatry] in February 2022, with regard to applying some of the science to her data as to what happens over time with ADHD. In outcomes, are these patients remitting? Are they fully treated in adulthood? Is it different in childhood vs adulthood in the pattern with regard to remission?

David W. Goodman, MD: I can take that initially, and then Rakesh can join in. Maggie’s data add to the literature that have been following the longest published trial for ADHD in adults, at 33 years. To say that we don’t understand ADHD and how it develops is not supported by the literature. Her data suggest that 90% of children and adolescents continue to have ADHD into adulthood. You don’t lose your ADHD because you retire at age 65. It’s important to understand it’s a neurobiological disorder that’s lifelong. If you have it in childhood, most people will continue to have it in adulthood. Rakesh, you’re a child psychiatrist, so what are your thoughts?

Rakesh Jain, MD, MPH: David, you’re right. There are certain disorders that simply don’t fade into the sunset. They just don’t. ADHD appears to be a condition that has a very high persistence rate. Because we’re speaking to clinicians who may not have kept up with the literature, please be aware that it’s firmly established that we have a high-prevalence disorder, and it’s incredibly neurobiologically based. In fact, the majority of individuals will continue manifesting, not just the neurobiological aspects of the disorder but also the impairment.

The data you were referencing, David, is so impactful. It talks about persistence of the symptoms. In adult years, the symptoms can go up and down depending on whether the demands are greater or lesser. In adult life, we see an up-and-down swing in what’s required. You’re about to enter a new job. Your ADHD symptoms may manifest itself in such a way that it becomes an impairment. Maybe you’re in a well-settled environment where it impacts you less. But this disorder, in the majority of people, doesn’t take a break. Clinicians really need to be cognizant of that.

David W. Goodman, MD: We say that it’s anchored in childhood and adolescence. Yet when you look at the National Comorbidity Survey Replication study, 75% of the adults had not been diagnosed as children. I’m concerned that clinicians are going to find making the diagnosis based on whether you were diagnosed as a child. If you weren’t diagnosed as a child or adolescent, you probably don’t have it. Let’s be careful of that. Yes, it starts in childhood and adolescence, but you don’t have to have been formally diagnosed to get diagnosed in adulthood, or even later in life at age 50, 60, and 70 years old.

Greg Mattingly, MD: David, you’re making a really important point, that you have to have some symptoms that go back early in life. “What were you like as a kid? I got distracted at times. Were you ever diagnosed with ADHD? Absolutely not. I had problems, but I always got by.” The people most likely to come in and get an adult diagnosis are women more than men, people with higher IQs, and people who have tried to advance their careers or advance their educations. They’ve had the symptoms since they were younger, but eventually they hit a threshold and those symptoms, as Rakesh said, start causing impairment.

Even though you didn’t get diagnosed as kids, 75% won’t have had a diagnosis. Women slip through the cracks. People with higher IQs who are able to compensate, even though they have ADHD, are more likely to slip through the cracks. Eventually, you tend to hit a ceiling where your symptoms start causing impairment.

Theresa R. Cerulli, MD: As the neuropsychiatrist in the group, when I think of Dr Maggie Sibley’s data, I picture the course of ADHD being almost like MS [multiple sclerosis], with a remitting-relapsing pattern with ADHD. Even for those who have reached the threshold criteria for remission, which varies from study to study, tend to relapse. That pattern is more consistent with ADHD.

Transcript Edited for Clarity