Prospective Follow-up Studies of ADHD: Helping Establish a Valid Diagnosis in Adults

Abstract

The Journal of the American Academy of Child and Adolescent Psychiatry has long been recognized and valued as a leading publication in the field. As such, many of the articles published in it have focused on attention-deficit/hyperactivity disorder (ADHD), a condition that affects 5% to 10% of the school-aged population, and is the most common child psychiatric disorder.The Journal has also played a role in publishing many of the controlled prospective follow-up studies of children with ADHD into adolescence and adulthood. As this editorial will outline, these studies helped establish the fact that ADHD often persists into adolescence and adulthood, and thus laid the groundwork for the validity of the ADHD diagnosis in adulthood, which is now generally accepted.The National Comorbidity Survey,1Kessler R.C. Adler L. Barkley R.A. 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: 716-723Crossref PubMed Scopus (1972) Google Scholar which involved close to 10,000 individuals, documented a 4.4% adult prevalence of ADHD. However, several decades ago, “hyperactivity” was thought to be a condition exclusive of childhood, one that children outgrew as they entered adolescence. This belief was largely fueled by the fact that hyperactivity tended to decrease with age2Biederman J. Wilens T. Mick E. et al.Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type.Am J Psychiatry. 2000; 157: 816-818Crossref PubMed Scopus (1080) Google Scholar and so was less evident over time. However, early controlled prospective follow-up studies clearly documented that symptoms of the syndrome and associated social, academic, and emotional impairment continued into adolescence.3Weiss G. Minde K. Werry J. et al.Studies on the hyperactive child: VIII Five-year follow-up.Arch Gen Psychiatry. 1971; 24: 409-414Crossref PubMed Scopus (219) Google Scholar, 4Gittleman R. Manuzza S. Shenker R. et al.Hyperactive boys almost grown up: I Psychiatric status.Arch Gen Psychiatry. 1985; 42: 937-947Crossref PubMed Scopus (798) Google Scholar, 5Barkley R.A. Anastopoulos A.D. Guevremont D.G. et al.Adolescents with attention deficit hyperactivity disorder: patterns of behavioral adjustment, academic functioning, and treatment utilization.J Am Acad Child Adolesc Psychiatry. 1991; 30: 752-761Abstract Full Text PDF PubMed Scopus (199) Google Scholar An article published in the Journal in 1998 further helped establish the fact that the condition continued into adolescence.6Biederman J. Faraone S.V. Taylor A. et al.Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample.J Am Acad Child Adolesc Psychiatry. 1998; 37: 305-313Abstract Full Text PDF PubMed Scopus (122) Google Scholar Clinicians, mainly pediatricians and child psychiatrists, who had a developmental focus, and who saw the continued difficulties of their patients as they progressed into adolescence, readily accepted the evidence that ADHD persisted into adolescence.However, the suggestion that ADHD may continue into adulthood was met with considerable resistance and skepticism. This, although several investigators pointed out the familial nature of this condition7Biederman J. Faraone S.V. Keenan K. et al.Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples.Arch Gen Psychiatry. 1992; 49: 728-738Crossref PubMed Scopus (649) Google Scholar and others stressed its familial genetic aspects.8Faroane S.V. Doyle A.E. The nature and heritability of attention-deficit/hyperactivity disorder.Child Adolesc Psychiatr Clin North Am. 2001; 10: 299-316PubMed Google Scholar There may be a number of reasons for this resistance and skepticism. One may be the fact that, although the clinicians who treat children and adolescents are the same, those who treat adults are likely to be different. Thus, pediatricians and child psychiatrists tend to treat children and adolescents with ADHD, whereas physicians in general or family practice or general psychiatrists tend to treat adults. Furthermore, ADHD is a condition that is highly comorbid,9Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder.J Clin Psychiatry. 2004; 65: 3-7PubMed Google Scholar, 10Cumyn L. French L. Hechtman L. Comorbidity in adults with attention-deficit/hyperactivity disorder.Can J Psychiatry. 2009; 54: 673-683PubMed Google Scholar and the rate of comorbidity tends to increase with age. Therefore, as the person ages, comorbid conditions such as anxiety, depression, substance-use disorder, and antisocial personality disorder increase and are most evident, and the underlying ADHD is less so. Adults with ADHD are usually diagnosed with and treated for the comorbid conditions and the ADHD goes undiagnosed and untreated. Until recently, medical students and residents received no teaching or training in adult ADHD and thus tended not to think of it as a possible diagnosis, so adults with ADHD were largely undiagnosed and untreated.Long-Term Controlled Prospective Follow-up StudiesIt is the long-term controlled prospective follow-up studies of children with ADHD and matched controls followed into adolescence and adulthood that did much to establish the validity of the ADHD diagnosis in adults. Many of these important studies were published in the Journal. I will highlight just a few.In 1991, Rachel G. Klein and Salvatore Mannuzza wrote a review article, entitled “Long-term Outcome of Hyperactive Children.”11Klein R.G. Mannuzza S. Long-term outcome of hyperactive children: a review.J Am Acad Child Adolesc Psychiatry. 1991; 30: 383-387Abstract Full Text PDF PubMed Scopus (316) Google Scholar In it, the researchers pointed out that the dysfunction documented during the adolescence of children with ADHD continues in adulthood (although at a lower rate) and is characterized by antisocial personality and (nonalcohol) substance-use disorder, which at times is associated with criminality. The authors pointed out that attempts to identify children most likely to have poor outcome have been largely unsuccessful. It was not until 2007, some 16 years later, that a long-term controlled prospective follow-up study clearly stated that childhood antisocial behaviors, lower socioeconomic status, and IQ predicted adult criminality.12Satterfield J.H. Faller K.J. Crinella F.M. et al.A 30-year prospective follow-up study of hyperactive boys with conduct problems: adult criminality.J Am Acad Child Adolesc Psychiatry. 2007; 46: 601-610Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar Furthermore, 3 years of multimodal treatment of hyperactive boys 6 to 12 years of age was insufficient to prevent later adult criminality.In another long-term controlled prospective follow-up study, Mannuzza et al. reported the outcome at the average age of 24 years of 85 probands (82% of the childhood cohort) and 73 controls (94% of the original control cohort).13Mannuzza S. Klein R.G. Bessler A. et al.Educational and occupational outcome of hyperactive boys grown up.J Am Acad Child Adolesc Psychiatry. 1997; 36: 1222-1227Abstract Full Text PDF PubMed Scopus (219) Google Scholar The investigators found that the probands completed significantly less formal schooling than controls (about 2 years less on average) and had lower ranking occupational positions than controls.The continuity of ADHD symptoms and negative long-term outcome was described in another controlled prospective follow-up study from Sweden that was published by Peder Rasmussen and Christopher Gillberg in 2000.14Rasmussen P. Gillberg C. Natural outcome of ADHD with developmental coordination disorder at age 22 years: a controlled, longitudinal, community-based study.J Am Acad Child Adolesc Psychiatry. 2000; 39: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (567) Google Scholar In this study, the investigators evaluated 55 of 61 subjects with ADHD with or without comorbid developmental coordination disorder and 46 of 51 age-matched controls at age 22. Continuing ADHD symptoms, antisocial personality disorder, alcohol abuse, criminal offending, reading disorders, and low educational level were over represented in the ADHD/developmental coordination disorder groups.More recently, in yet another long-term controlled prospective follow-up study of children with ADHD followed into adulthood, Barkley and colleagues described the adult outcome at the mean age of 20 years of 149 hyperactive and 72 community controls.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 16Barkley R.A. Fischer M. Smallish L. et al.Young adult outcome of hyperactive children: Adaptive functioning in major life activities.J Am Acad Child Adolesc Psychiatry. 2006; 45: 192-202Abstract Full Text Full Text PDF PubMed Scopus (694) Google Scholar The hyperactive group had significantly lower educational performance, with 32% failing to complete high school. They were also fired from more jobs and had higher employer-rated ADHD and oppositional defiant disorder symptoms and lower job performance compared with the community group. The hyperactive group also had more social problems, with fewer close friends. More men in the ADHD than in the control group had become parents (49% versus 38%), and more had been treated for sexually transmitted diseases (49% versus 16%).We thus see that these and other long-term controlled prospective follow-up studies of children with ADHD followed into adulthood laid the ground work for the documentation and acceptance that ADHD is a condition that often continues into adulthood, where its symptoms result in significant academic, occupational, social, and emotional impairment. The diagnosis is complicated by its high rate of comorbidity. The fact is that ADHD symptoms are often ego syntonic and patients may accommodate to their symptoms in their choice of work and life partners. Thus, despite significant occupational and social problems, the patient may not clearly identify his/her symptoms. Corroboration of symptoms from employers and significant others is not always possible and the standard school setting and teacher reports to help in the diagnosis are usually lacking. However, successful treatment of these patients requires the identification of ADHD symptoms and the effective treatment of ADHD and any comorbid conditions.It should be stressed, however, that the persistence of ADHD into adulthood is variable. In general, some 40% to 60% of patients go on to have significant clinical problems in adulthood.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 17Weiss G. Hechtman L. Hyperactive Children Grown Up: ADHD in Children, Adolescents, and Adults. Guilford Press, New York1986Google Scholar, 18Bussing R. Mason D.M. Bell L. et al.Adolescent outcomes in childhood attention deficit hyperactivity disorder in a diverse community sample.J Am Acad Child Adolesc Psychiatry. 2010; 49: 595-605Abstract Full Text Full Text PDF PubMed Google Scholar Factors that result in persistence versus remission have been explored and probably involve a combination of patient, family, and treatment parameters.19Hechtman L. Predictor of long-term outcome in ADHD.Pediatr Clin North Am. 1999; 45: 1039-1052Abstract Full Text Full Text PDF Scopus (59) Google ScholarThanks to the studies published in the Journal and outlined in this editorial, ADHD in adulthood is recognized and accepted as a valid diagnosis. Field trials have been carried out in adults with ADHD to improve the DSM-V diagnostic criteria and make these more appropriate for adults with the disorder.In summary, ADHD in adults is a prevalent condition estimated to affect 4.4% of the general population.1Kessler R.C. Adler L. Barkley R.A. 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: 716-723Crossref PubMed Scopus (1972) Google Scholar It is associated with significant educational, social, occupational, and emotional impairment. Its recognition, diagnosis, and effective treatment can improve the lives of many patients and their families. The long-term controlled prospective follow-up studies of children with ADHD, many of which were first published in the Journal and discussed in this editorial, helped establish the validity of this condition in adults and promoted the diagnosis and treatment of patients who had previously gone undiagnosed and untreated. The Journal of the American Academy of Child and Adolescent Psychiatry has long been recognized and valued as a leading publication in the field. As such, many of the articles published in it have focused on attention-deficit/hyperactivity disorder (ADHD), a condition that affects 5% to 10% of the school-aged population, and is the most common child psychiatric disorder. The Journal has also played a role in publishing many of the controlled prospective follow-up studies of children with ADHD into adolescence and adulthood. As this editorial will outline, these studies helped establish the fact that ADHD often persists into adolescence and adulthood, and thus laid the groundwork for the validity of the ADHD diagnosis in adulthood, which is now generally accepted. The National Comorbidity Survey,1Kessler R.C. Adler L. Barkley R.A. 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: 716-723Crossref PubMed Scopus (1972) Google Scholar which involved close to 10,000 individuals, documented a 4.4% adult prevalence of ADHD. However, several decades ago, “hyperactivity” was thought to be a condition exclusive of childhood, one that children outgrew as they entered adolescence. This belief was largely fueled by the fact that hyperactivity tended to decrease with age2Biederman J. Wilens T. Mick E. et al.Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type.Am J Psychiatry. 2000; 157: 816-818Crossref PubMed Scopus (1080) Google Scholar and so was less evident over time. However, early controlled prospective follow-up studies clearly documented that symptoms of the syndrome and associated social, academic, and emotional impairment continued into adolescence.3Weiss G. Minde K. Werry J. et al.Studies on the hyperactive child: VIII Five-year follow-up.Arch Gen Psychiatry. 1971; 24: 409-414Crossref PubMed Scopus (219) Google Scholar, 4Gittleman R. Manuzza S. Shenker R. et al.Hyperactive boys almost grown up: I Psychiatric status.Arch Gen Psychiatry. 1985; 42: 937-947Crossref PubMed Scopus (798) Google Scholar, 5Barkley R.A. Anastopoulos A.D. Guevremont D.G. et al.Adolescents with attention deficit hyperactivity disorder: patterns of behavioral adjustment, academic functioning, and treatment utilization.J Am Acad Child Adolesc Psychiatry. 1991; 30: 752-761Abstract Full Text PDF PubMed Scopus (199) Google Scholar An article published in the Journal in 1998 further helped establish the fact that the condition continued into adolescence.6Biederman J. Faraone S.V. Taylor A. et al.Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample.J Am Acad Child Adolesc Psychiatry. 1998; 37: 305-313Abstract Full Text PDF PubMed Scopus (122) Google Scholar Clinicians, mainly pediatricians and child psychiatrists, who had a developmental focus, and who saw the continued difficulties of their patients as they progressed into adolescence, readily accepted the evidence that ADHD persisted into adolescence. However, the suggestion that ADHD may continue into adulthood was met with considerable resistance and skepticism. This, although several investigators pointed out the familial nature of this condition7Biederman J. Faraone S.V. Keenan K. et al.Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples.Arch Gen Psychiatry. 1992; 49: 728-738Crossref PubMed Scopus (649) Google Scholar and others stressed its familial genetic aspects.8Faroane S.V. Doyle A.E. The nature and heritability of attention-deficit/hyperactivity disorder.Child Adolesc Psychiatr Clin North Am. 2001; 10: 299-316PubMed Google Scholar There may be a number of reasons for this resistance and skepticism. One may be the fact that, although the clinicians who treat children and adolescents are the same, those who treat adults are likely to be different. Thus, pediatricians and child psychiatrists tend to treat children and adolescents with ADHD, whereas physicians in general or family practice or general psychiatrists tend to treat adults. Furthermore, ADHD is a condition that is highly comorbid,9Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder.J Clin Psychiatry. 2004; 65: 3-7PubMed Google Scholar, 10Cumyn L. French L. Hechtman L. Comorbidity in adults with attention-deficit/hyperactivity disorder.Can J Psychiatry. 2009; 54: 673-683PubMed Google Scholar and the rate of comorbidity tends to increase with age. Therefore, as the person ages, comorbid conditions such as anxiety, depression, substance-use disorder, and antisocial personality disorder increase and are most evident, and the underlying ADHD is less so. Adults with ADHD are usually diagnosed with and treated for the comorbid conditions and the ADHD goes undiagnosed and untreated. Until recently, medical students and residents received no teaching or training in adult ADHD and thus tended not to think of it as a possible diagnosis, so adults with ADHD were largely undiagnosed and untreated. Long-Term Controlled Prospective Follow-up StudiesIt is the long-term controlled prospective follow-up studies of children with ADHD and matched controls followed into adolescence and adulthood that did much to establish the validity of the ADHD diagnosis in adults. Many of these important studies were published in the Journal. I will highlight just a few.In 1991, Rachel G. Klein and Salvatore Mannuzza wrote a review article, entitled “Long-term Outcome of Hyperactive Children.”11Klein R.G. Mannuzza S. Long-term outcome of hyperactive children: a review.J Am Acad Child Adolesc Psychiatry. 1991; 30: 383-387Abstract Full Text PDF PubMed Scopus (316) Google Scholar In it, the researchers pointed out that the dysfunction documented during the adolescence of children with ADHD continues in adulthood (although at a lower rate) and is characterized by antisocial personality and (nonalcohol) substance-use disorder, which at times is associated with criminality. The authors pointed out that attempts to identify children most likely to have poor outcome have been largely unsuccessful. It was not until 2007, some 16 years later, that a long-term controlled prospective follow-up study clearly stated that childhood antisocial behaviors, lower socioeconomic status, and IQ predicted adult criminality.12Satterfield J.H. Faller K.J. Crinella F.M. et al.A 30-year prospective follow-up study of hyperactive boys with conduct problems: adult criminality.J Am Acad Child Adolesc Psychiatry. 2007; 46: 601-610Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar Furthermore, 3 years of multimodal treatment of hyperactive boys 6 to 12 years of age was insufficient to prevent later adult criminality.In another long-term controlled prospective follow-up study, Mannuzza et al. reported the outcome at the average age of 24 years of 85 probands (82% of the childhood cohort) and 73 controls (94% of the original control cohort).13Mannuzza S. Klein R.G. Bessler A. et al.Educational and occupational outcome of hyperactive boys grown up.J Am Acad Child Adolesc Psychiatry. 1997; 36: 1222-1227Abstract Full Text PDF PubMed Scopus (219) Google Scholar The investigators found that the probands completed significantly less formal schooling than controls (about 2 years less on average) and had lower ranking occupational positions than controls.The continuity of ADHD symptoms and negative long-term outcome was described in another controlled prospective follow-up study from Sweden that was published by Peder Rasmussen and Christopher Gillberg in 2000.14Rasmussen P. Gillberg C. Natural outcome of ADHD with developmental coordination disorder at age 22 years: a controlled, longitudinal, community-based study.J Am Acad Child Adolesc Psychiatry. 2000; 39: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (567) Google Scholar In this study, the investigators evaluated 55 of 61 subjects with ADHD with or without comorbid developmental coordination disorder and 46 of 51 age-matched controls at age 22. Continuing ADHD symptoms, antisocial personality disorder, alcohol abuse, criminal offending, reading disorders, and low educational level were over represented in the ADHD/developmental coordination disorder groups.More recently, in yet another long-term controlled prospective follow-up study of children with ADHD followed into adulthood, Barkley and colleagues described the adult outcome at the mean age of 20 years of 149 hyperactive and 72 community controls.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 16Barkley R.A. Fischer M. Smallish L. et al.Young adult outcome of hyperactive children: Adaptive functioning in major life activities.J Am Acad Child Adolesc Psychiatry. 2006; 45: 192-202Abstract Full Text Full Text PDF PubMed Scopus (694) Google Scholar The hyperactive group had significantly lower educational performance, with 32% failing to complete high school. They were also fired from more jobs and had higher employer-rated ADHD and oppositional defiant disorder symptoms and lower job performance compared with the community group. The hyperactive group also had more social problems, with fewer close friends. More men in the ADHD than in the control group had become parents (49% versus 38%), and more had been treated for sexually transmitted diseases (49% versus 16%).We thus see that these and other long-term controlled prospective follow-up studies of children with ADHD followed into adulthood laid the ground work for the documentation and acceptance that ADHD is a condition that often continues into adulthood, where its symptoms result in significant academic, occupational, social, and emotional impairment. The diagnosis is complicated by its high rate of comorbidity. The fact is that ADHD symptoms are often ego syntonic and patients may accommodate to their symptoms in their choice of work and life partners. Thus, despite significant occupational and social problems, the patient may not clearly identify his/her symptoms. Corroboration of symptoms from employers and significant others is not always possible and the standard school setting and teacher reports to help in the diagnosis are usually lacking. However, successful treatment of these patients requires the identification of ADHD symptoms and the effective treatment of ADHD and any comorbid conditions.It should be stressed, however, that the persistence of ADHD into adulthood is variable. In general, some 40% to 60% of patients go on to have significant clinical problems in adulthood.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 17Weiss G. Hechtman L. Hyperactive Children Grown Up: ADHD in Children, Adolescents, and Adults. Guilford Press, New York1986Google Scholar, 18Bussing R. Mason D.M. Bell L. et al.Adolescent outcomes in childhood attention deficit hyperactivity disorder in a diverse community sample.J Am Acad Child Adolesc Psychiatry. 2010; 49: 595-605Abstract Full Text Full Text PDF PubMed Google Scholar Factors that result in persistence versus remission have been explored and probably involve a combination of patient, family, and treatment parameters.19Hechtman L. Predictor of long-term outcome in ADHD.Pediatr Clin North Am. 1999; 45: 1039-1052Abstract Full Text Full Text PDF Scopus (59) Google ScholarThanks to the studies published in the Journal and outlined in this editorial, ADHD in adulthood is recognized and accepted as a valid diagnosis. Field trials have been carried out in adults with ADHD to improve the DSM-V diagnostic criteria and make these more appropriate for adults with the disorder.In summary, ADHD in adults is a prevalent condition estimated to affect 4.4% of the general population.1Kessler R.C. Adler L. Barkley R.A. 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: 716-723Crossref PubMed Scopus (1972) Google Scholar It is associated with significant educational, social, occupational, and emotional impairment. Its recognition, diagnosis, and effective treatment can improve the lives of many patients and their families. The long-term controlled prospective follow-up studies of children with ADHD, many of which were first published in the Journal and discussed in this editorial, helped establish the validity of this condition in adults and promoted the diagnosis and treatment of patients who had previously gone undiagnosed and untreated. It is the long-term controlled prospective follow-up studies of children with ADHD and matched controls followed into adolescence and adulthood that did much to establish the validity of the ADHD diagnosis in adults. Many of these important studies were published in the Journal. I will highlight just a few. In 1991, Rachel G. Klein and Salvatore Mannuzza wrote a review article, entitled “Long-term Outcome of Hyperactive Children.”11Klein R.G. Mannuzza S. Long-term outcome of hyperactive children: a review.J Am Acad Child Adolesc Psychiatry. 1991; 30: 383-387Abstract Full Text PDF PubMed Scopus (316) Google Scholar In it, the researchers pointed out that the dysfunction documented during the adolescence of children with ADHD continues in adulthood (although at a lower rate) and is characterized by antisocial personality and (nonalcohol) substance-use disorder, which at times is associated with criminality. The authors pointed out that attempts to identify children most likely to have poor outcome have been largely unsuccessful. It was not until 2007, some 16 years later, that a long-term controlled prospective follow-up study clearly stated that childhood antisocial behaviors, lower socioeconomic status, and IQ predicted adult criminality.12Satterfield J.H. Faller K.J. Crinella F.M. et al.A 30-year prospective follow-up study of hyperactive boys with conduct problems: adult criminality.J Am Acad Child Adolesc Psychiatry. 2007; 46: 601-610Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar Furthermore, 3 years of multimodal treatment of hyperactive boys 6 to 12 years of age was insufficient to prevent later adult criminality. In another long-term controlled prospective follow-up study, Mannuzza et al. reported the outcome at the average age of 24 years of 85 probands (82% of the childhood cohort) and 73 controls (94% of the original control cohort).13Mannuzza S. Klein R.G. Bessler A. et al.Educational and occupational outcome of hyperactive boys grown up.J Am Acad Child Adolesc Psychiatry. 1997; 36: 1222-1227Abstract Full Text PDF PubMed Scopus (219) Google Scholar The investigators found that the probands completed significantly less formal schooling than controls (about 2 years less on average) and had lower ranking occupational positions than controls. The continuity of ADHD symptoms and negative long-term outcome was described in another controlled prospective follow-up study from Sweden that was published by Peder Rasmussen and Christopher Gillberg in 2000.14Rasmussen P. Gillberg C. Natural outcome of ADHD with developmental coordination disorder at age 22 years: a controlled, longitudinal, community-based study.J Am Acad Child Adolesc Psychiatry. 2000; 39: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (567) Google Scholar In this study, the investigators evaluated 55 of 61 subjects with ADHD with or without comorbid developmental coordination disorder and 46 of 51 age-matched controls at age 22. Continuing ADHD symptoms, antisocial personality disorder, alcohol abuse, criminal offending, reading disorders, and low educational level were over represented in the ADHD/developmental coordination disorder groups. More recently, in yet another long-term controlled prospective follow-up study of children with ADHD followed into adulthood, Barkley and colleagues described the adult outcome at the mean age of 20 years of 149 hyperactive and 72 community controls.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 16Barkley R.A. Fischer M. Smallish L. et al.Young adult outcome of hyperactive children: Adaptive functioning in major life activities.J Am Acad Child Adolesc Psychiatry. 2006; 45: 192-202Abstract Full Text Full Text PDF PubMed Scopus (694) Google Scholar The hyperactive group had significantly lower educational performance, with 32% failing to complete high school. They were also fired from more jobs and had higher employer-rated ADHD and oppositional defiant disorder symptoms and lower job performance compared with the community group. The hyperactive group also had more social problems, with fewer close friends. More men in the ADHD than in the control group had become parents (49% versus 38%), and more had been treated for sexually transmitted diseases (49% versus 16%). We thus see that these and other long-term controlled prospective follow-up studies of children with ADHD followed into adulthood laid the ground work for the documentation and acceptance that ADHD is a condition that often continues into adulthood, where its symptoms result in significant academic, occupational, social, and emotional impairment. The diagnosis is complicated by its high rate of comorbidity. The fact is that ADHD symptoms are often ego syntonic and patients may accommodate to their symptoms in their choice of work and life partners. Thus, despite significant occupational and social problems, the patient may not clearly identify his/her symptoms. Corroboration of symptoms from employers and significant others is not always possible and the standard school setting and teacher reports to help in the diagnosis are usually lacking. However, successful treatment of these patients requires the identification of ADHD symptoms and the effective treatment of ADHD and any comorbid conditions. It should be stressed, however, that the persistence of ADHD into adulthood is variable. In general, some 40% to 60% of patients go on to have significant clinical problems in adulthood.15Barkley R. Murphy K.R. Fischer M. ADHD in Adults: What the Science Says. Guilford Press, New York2008Google Scholar, 17Weiss G. Hechtman L. Hyperactive Children Grown Up: ADHD in Children, Adolescents, and Adults. Guilford Press, New York1986Google Scholar, 18Bussing R. Mason D.M. Bell L. et al.Adolescent outcomes in childhood attention deficit hyperactivity disorder in a diverse community sample.J Am Acad Child Adolesc Psychiatry. 2010; 49: 595-605Abstract Full Text Full Text PDF PubMed Google Scholar Factors that result in persistence versus remission have been explored and probably involve a combination of patient, family, and treatment parameters.19Hechtman L. Predictor of long-term outcome in ADHD.Pediatr Clin North Am. 1999; 45: 1039-1052Abstract Full Text Full Text PDF Scopus (59) Google Scholar Thanks to the studies published in the Journal and outlined in this editorial, ADHD in adulthood is recognized and accepted as a valid diagnosis. Field trials have been carried out in adults with ADHD to improve the DSM-V diagnostic criteria and make these more appropriate for adults with the disorder. In summary, ADHD in adults is a prevalent condition estimated to affect 4.4% of the general population.1Kessler R.C. Adler L. Barkley R.A. 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: 716-723Crossref PubMed Scopus (1972) Google Scholar It is associated with significant educational, social, occupational, and emotional impairment. Its recognition, diagnosis, and effective treatment can improve the lives of many patients and their families. The long-term controlled prospective follow-up studies of children with ADHD, many of which were first published in the Journal and discussed in this editorial, helped establish the validity of this condition in adults and promoted the diagnosis and treatment of patients who had previously gone undiagnosed and untreated.