Philip Asherson MRCPsych, PhD Professor of Molecular Psychiatry & Honorary Consultant Psychiatrist, MRC Social Genetic Developmental Psychiatry, Institute of Psychiatry, UK MRC Social Genetic and Developmental Psychiatry Is there a late onset form of ADHD?
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Is there a late onset form of ADHD? · Defining Adult ADHD (DSM-5) Criteria A: 5 or more symptoms of inattention or hyperactivity-impulsivity Criteria B: Several symptoms present
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Philip Asherson MRCPsych, PhD
Professor of Molecular Psychiatry & Honorary
Consultant Psychiatrist,
MRC Social Genetic Developmental Psychiatry,
Institute of Psychiatry, UK
MRC Social Genetic and
Developmental Psychiatry
Is there a late onset form of ADHD?
Diagnostic criteria
What is ADHD
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
What is not ADHD
The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks of instructions
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, 2013
Criteria for Adult ADHD Diagnosis: DSM-5
Inattention Lack of attention to details, makes careless
mistakes
Difficulty sustaining attention
Does not listen when spoken to directly
Trouble completing or finishing job tasks
Problems organizing tasks and activities
Avoids or dislikes sustained mental effort
Loses and misplaces things
Easily distracted
Forgetful in daily activities
Hyperactivity Fidgetiness b(hands or feet) or squirming in
seat
Leaves seat when not supposed to
Restless or overactive
Difficulty engaging in leisure activities quietly
Always ‘on the go’
Talks excessively
Impulsivity
Blurts out answers before questions have been completed
Difficulty waiting in line or taking turns
Interrupts or intrudes on others when they are working or busy
American Psychiatric Association. Diagnostic and Statistical Manual (DSM) of Mental Disorders. 5th Edition
2013
DSM-5: Age-appropriate descriptions of ADHD
Inattention
• Mind elsewhere in the absence of obvious distractions
Assuming 5% prevalence of ADHD during middle childhood and 50% decline every 5 years • Estimated prevalence age 20 = 0.84% • Estimated prevalence age 30 = 0.21% • Estimated prevalence age 50 = 0.01%
Hill and Schoener
Developmental delay
5 10 15
NORMAL
ADHD
AGE
ADHD symptoms
Developmental deficit
5 10 15
NORMAL
ADHD
AGE
ADHD symptoms
Does ADHD persist?
ADHD symptom scores at 7 and 17 years
0 0.2 0.4 0.6 0.8 1 1.2
Control
ADHD
Age 17 years
Age 7 years
Taylor et al. 1996 Scores from PACAS interview
The age-dependent decline and persistence of attention-
deficit/ hyperactivity disorder throughout the lifetime
Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20
Estimates of adult ADHD prevalence based on longitudinal follow-up studies
Faraone meta-analysis 2006 • Full diagnosis of DSM-IV ADHD: 5% x 0.15 = 0.75%
• In partial remission: 5% x 0.65 = 3.3%
Prevalence of ADHD from US National Comorbidity Survey
Estimated prevalence of 4.4%
Kessler et al 2006, AmJPsych
• Six symptoms of either inattention or hyperactivity-impulsivity during last 6 months (A)
• Two or more symptoms before age 7 (B) • Some impairment in at least two areas of living during
the past 6 months (C) • Clinically significant impairment in at least one of these
areas (D).
Prevalence of adult ADHD
Fayyad et al., Br J Psychiatry. 2007 May;190:402-9.
4.1%
1.9%
7.3%
3.1%
2.8%
1.8%
1.9%
5%
1.2%
5.2%
3.4%
0 1 2 3 4 5 6 7 8
Belgium
Colombia
France
Germany
Italy
Lebanon
Mexico
Netherlands
Spain
USA
TOTAL
• Prevalence = 2.5% (95% CI: 2.1–3.1%)
Simon et al. Br J Psychiatry. 2009 Mar;194(3):204-11
Prevalence of adult ADHD
Estimates of adult ADHD prevalence based on longitudinal follow-up studies
Faraone meta-analysis 2006 • Full diagnosis of DSM-IV ADHD: 5% x 0.15 = 0.75%
• In partial remission: 5% x 0.65 = 3.3%
Potential problems with studies so far
• Child ADHD studies: clinical samples influenced by referral bias
• Adult ADHD studies: depend on retrospective recall
New ADHD meta-analysis 18,284 cases 33,836 controls
10 loci 8 look robust On the path!
Adult twin studies
1. Van Den Berg et al. Am J Med Genet B Neuropsychiatr Genet. 2006;141B(1):55-60; 2. Boomsma et al. 2010; PLoS ONE 5(5): e10621. 3. Larsson et al, JAMA Psychiatry 2011
Phenotype Self-ratings Age Heritability
ADHD (study 1) Self 18-30 0.40
ADHD (study 2) Self 18+ 0.30
ADHD (study 3) Self 20-28 0.39
ADHD (study 3) Self 29-37 0.35
ADHD (study 3) Self 38-46 0.33
Heritability rates based on concordance rates for ADHD diagnosis on Swedish national medical records
Larsson et al., 2013, Psychological Medicine
0.88
0.72
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Heritability overall Heritability in adults
Heritability
Questions
(1) Do children with ADHD grow out of the disorder by the age of 38 years?
(2) Does ADHD in adults reflect an adult onset condition that is distinct from childhood ADHD?
Two other population studies UK study Brazil study