Jump to: Page
Content, Site
Navigation, Site
Search,

You are seeing this message because your web browser does not support basic
web standards. Find out more
about why this message is appearing and what you can do to make your experience
on this site better.

Search the BMJ

BMJ

BMJ Journals

BMJ Careers

BMJ Learning

Evidence Centre

BMJ Group

Search this site:

Advanced search

Register
for free services | Subscribe |
Sign In

Home

Research

Methods
and Reporting

Education

Clinical
review

Practice

Shortcuts

Endgames

News

Comment

Editor's
choice

Editorials

Letters

Rapid
responses

Features

Observations

Head
to head

Analysis

Views
& reviews

Obituaries

Minerva

Fillers

Blogs

Podcast

Topics

Clinical
topics

Non-clinical
topics

Series

Theme issues

Video

Print
Issues

Last
seven days

Past weeks
(Monday-Sunday)

Print issue

Rapid
responses

Polls

Debates

Blogs

Podcasts

Video

Academic medicine

US highlights

BMJ USA 2001-2005

About BMJ

Explore
the BMJ

Home > Comment > BMJ
2010;340:c547, doi: 10.1136/bmj.c547 (Published 26 March 2010)

Published 26 March 2010, doi:10.1136/bmj.c547
Cite
this as: BMJ 2010;340:c547

Head to Head

Is ADHD a valid diagnosis in adults? No

Joanna Moncrieff, senior lecturer and honorary
consultant psychiatrist1, Sami Timimi,
consultant child and adolescent psychiatrist and visiting professor of child
and adolescent psychiatry, Lincoln University2

1 University College London and North East London Mental Health
Trust, UCL Department of Mental Health Sciences, London W1W 7EJ, 2
Lincolnshire Partnership NHS Foundation Trust, Sleaford, NG34 8QA

Correspondence to: J Moncrieff j.moncrieff{at}ucl.ac.uk

Philip Asherson and colleagues argue that the
concept of ADHD in adults is valid (doi:10.1136/bmj.c549) but
Joanna Moncrieff and Sami Timimi believe that it is
supported by little more than aggressive marketing

Interest in adult attention deficit hyperactivity disorder (ADHD)
has grown rapidly in some countries because drug companies have
realised that it provides an "expanding and lucrative market"
for stimulants and related drugs.1
They have promoted the concept by suggesting that common behaviours,
such as forgetting car keys, may be symptoms,2 and
many adults are being diagnosed who were never diagnosed as children.
We explain why little more than aggressive marketing is available to
support adult ADHD.

Diagnostic validity

Whether childhood ADHD is a valid and useful diagnosis is disputed
on many grounds, including lack of physical or psychological
markers, high comorbidity rates, difficulty in differentiating
normal symptoms from pathological ones, inconsistent clustering
of symptoms, differing cultural perceptions and variation of
diagnosis across sex and class,3 and
serious adverse outcomes being more strongly related to co-occurring
problems such as conduct disorder and familial conflict.4
Even if we accept childhood ADHD as valid, the validity of adult ADHD
does not automatically follow. ADHD has its origins as a childhood
disorder. Symptoms such as impulsivity and hyperactivity are defined
and understood as developmental problems, and field trials for
developing the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, criteria for ADHD used children and
adolescents only.5
Definitions of adult ADHD include numerous aspects of mental
functioning and behaviour that are not usually examined in
children—such as mood swings, irritability, stress intolerance,
anger, and risk taking—and play down central features of
childhood ADHD such as hyperactivity.6
Moreover, nearly 90% of adults diagnosed with ADHD have at least one
other psychiatric diagnosis, and many have two,7
pointing to high comorbidity with more established diagnoses. Recent
guidelines from the National Institute for Health and Clinical
Excellence (NICE) noted that adult ADHD overlaps with various
personality disorders, as well as depression, anxiety, and modern
conceptions of bipolar and bipolar spectrum disorder.8
Although some research suggests that adult ADHD symptoms are
associated with academic impairment and problems with work and
driving,9 we
do not know how much of this is just normal variation or is related
to comorbid conditions.

Longstanding problematic patterns of behaviour in adults are
usually referred to as personality traits or disorders. A more
robust evidence base is surely required before accepting a concept
such as adult ADHD, which departs from established views of the
nature of behavioural problems, has a large overlap with other
diagnoses, and has only a tenuous association with the childhood
disorder.

Drug treatment

A major driver behind the increased popularity of diagnosing adult
ADHD is the idea that it responds to treatment with stimulant drugs.
Studies in children show that stimulants can improve attention and
reduce activity levels in the short term, but that they have little
impact on quality of life or academic performance and initial
beneficial effects are not sustained on long term follow-up.10
Even the NICE guidelines recommend restricting stimulant use to
children with the most severe symptoms, or those in whom other
treatments have failed.8
NICE, however, recommends stimulants as first line treatment for
everyone with adult ADHD. This recommendation was made on the basis
of three randomised controlled trials, two of which were conducted
by a group at Harvard, which was found to have substantial
conflicts of interests.11
The third was a small crossover study of three weeks’ duration that
comprised 45 subjects. A recent meta-analysis of a larger group of
methylphenidate studies found no significant difference between drug
and placebo in studies that used the generally superior parallel
group design (effect size 0.36, 95% confidence interval –0.17 to
0.88), as opposed to crossover studies. It also showed that trials by
the Harvard group reported substantially higher effects than
others.12
The only long term drug trial yet published (atomoxetine) was
negative for its main outcomes at six months.13
With regard to risks, stimulants are known to increase heart rate and
blood pressure, and prolonged recreational use can result in
myocardial infarction and stroke.14

Physical and psychological dependence are a further potential
problem, and in countries with high rates of stimulant prescribing,
much is diverted on to the black market.15
Popularising the diagnosis of adult ADHD also encourages people to
regard longstanding behavioural problems as amenable to a quick fix,
thus introducing, undebated, a form of cosmetic psychopharmacology
that fits into our increasingly hyperactive lifestyles but at a price
of distancing us from our own psychosocial resources and
abilities.

Conclusion

The speed with which the diagnosis of adult ADHD has been accepted,
its vagueness, and the lack of evidence for the usefulness of
specific treatments indicate that it is the latest of several
medical and psychiatric fashions, which have been fuelled by
the interests of the drugs industry. More research and debate
is needed before the diagnosis is embraced and widespread stimulant
prescribing becomes the norm, otherwise we may face a scandal
similar to the overprescribing of benzodiazepines.

Cite this as: BMJ 2010;340:c547

Both authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf
(available on request from the corresponding author) and declare: 1)
no financial support for the submitted work; 2) no relationships with
any companies that may have an interest in the submitted work in the
past three years; 3) their spouses, partners, or children have
no financial relationships that may be relevant to the submitted
work; 4) they are members of the Critical Psychiatry Network.

Provenance and peer review: Not commissioned;
externally peer reviewed.

References

Lead Discovery. Adult ADHD—therapeutic opportunities.
2004. https://www.leaddiscovery.co.uk/reports/813/Adult_ADHD_Therapeutic_Opportunities.

Food and Drugs Administration. FDA warning letter RE:
NDA 21-411. Strattera (atomoxetine HCl). MACMIS ID#: 13282. 2005. http://pharmcast.com/WarningLetters/Yr2005/Jun2005/EliLilly0605.htm.

Timimi S, Leo J, eds. Rethinking ADHD: from brain to
culture. Palgrave Macmillan, 2009.

Barkley RA, Fischer M, Smallish L, Fletcher K. Young
adult follow-up of hyperactive children: antisocial activities and drug use.
J Child Psychol Psychiatry 2004;45:195-211.[CrossRef][Web
of Science][Medline]

Weiss M, Murray C, Weiss G. Adults with
attention-deficit/hyperactivity disorder: current concepts. J Psychiatr
Pract 2002;8:99-111.[CrossRef][Medline]

NHS choices. Attention deficit hyperactivity disorder
(ADHD). 2008. www.nhs.uk/Conditions/Attention-deficit-hyperactivity-disorder/Pages/Symptoms.aspx?url=Pages/What-is-it.aspx&r=1&rtitle=Attention+deficit+hyperactivity+disorder+-+Symptoms.

McGough JJ, Smalley SL, McCracken JT, Yang M, Del’Homme
M, Lynn DE, et al. Psychiatric comorbidity in adult attention deficit
hyperactivity disorder: findings from multiplex families. Am J
Psychiatry 2005;162:1621-7.[Abstract/Free Full Text]

National Institute for Health and Clinical Excellence.
Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in
children, young people and adults. Guideline number 72. 2008. www.nice.org.uk/nicemedia/pdf/CG72NiceGuidelinev3.pdf.

Biederman J, Petty C, Fried R, Fontanella J, Doyle AE,
Seidman LJ, et al. Impact of psychometrically defined deficits of executive
functioning in adults with attention deficit hyperactivity disorder. Am J
Psychiatry 2006;163:1730-8.[Abstract/Free Full Text]

Jensen PS, Arnold LE, Swanson JM, Vitiello B, Abikoff
HB, Greenhill LL, et al. 3-year follow-up of the NIMH MTA study. J Am Acad
Child Adolesc Psychiatry 2007;46:989-1002.[CrossRef][Web
of Science][Medline]

Harris G, Carey B. Researchers fail to reveal full
drug pay. New York Times 2008 Jun 8.

Koesters M, Becker T, Kilian R, Fegert JM, Weinmann S.
Limits of meta-analysis: methylphenidate in the treatment of adult
attention-deficit hyperactivity disorder. J Psychopharmacol
2009;23:733-44.[Abstract/Free Full Text]

Adler LA, Spencer TJ, Levine LR, Ramsey JL, Tamura R,
Kelsey D, et al. Functional outcomes in the treatment of adults with ADHD.
J Atten Disord
2008;11:720-7.[Abstract/Free Full Text]

Westover AN, McBride S, Haley RW. Stroke in young
adults who abuse amphetamines or cocaine: a population-based study of
hospitalized patients. Arch Gen Psychiatry 2007;64:495-502.[Abstract/Free Full Text]

Sumnall HR, Woolfall K, Cole J, Mackridge A, McVeigh
J. NICE guidance on ADHD. Diversion and abuse of methylphenidate in light of
new guidance. BMJ 2008;337:a2287.[Free Full Text]

(Accepted 14 December 2009)

CiteULike
Complore
Connotea
Del.icio.us
Digg
Facebook
Reddit
StumbleUpon
Technorati
Twitter    What's this?

Relevant Articles

Is ADHD a valid diagnosis in adults? Yes

Philip Asherson, Marios Adamou, Blanca Bolea, Ulrich Muller, Susan Dunn
Morua, Mark Pitts, Johannes Thome, and Susan Young
BMJ 2010 340: c549.
[Extract]
[Full Text]

Diversion and abuse of methylphenidate in light of new
guidance

Harry R Sumnall, Kerry Woolfall, Jon Cole, Adam Mackridge, and Jim
McVeigh
BMJ 2008 337: a2287. [Extract]
[Full
Text]

Rapid Responses:

Read all Rapid
Responses

Underprovision of NHS psychiatry is the real issue

Neil MacFarlane
bmj.com, 28 Mar 2010 [Full text]

Lessons from the History of ADHD

Matthew PC Smith
bmj.com, 1 Apr 2010 [Full text]

This Article

Extract

PDF of
print issue

Respond
to this article

Read responses
to this article

Alert
me when this article is cited

Alert
me when responses are posted

Alert
me when a correction is posted

View citation map

Services

Email
this article to a friend

Find
similar articles in BMJ

Find
similar articles in PubMed

Add
article to my folders

Download
to citation manager

Request
Permissions

Google Scholar

Articles by Moncrieff, J.

Articles by Timimi, S.

PubMed

PubMed
Citation

Articles by Moncrieff, J.

Articles by Timimi, S.

Related Content

Child
and adolescent psychiatry (paedatrics)

Child
and adolescent psychiatry

Competing
interests (ethics)

Mood
disorders (including depression)

Sociology

Relevant
Articles

Bookmark with

What's this?

What's new

Last 7
days

Past weeks

Current print issue

Rapid
responses

Blogs

Podcasts

Blogs

Podcasts

Keep updated

Latest
from BMJ

BMJ
simple search

Follow BMJ on
twitter

Services

Submit an article

Subscribe/Activate

Request
permissions

Tools

Email
to friend

Print
this page

Online poll

Find
out more on bmj blogs>

Resources

Readers

Authors

Reviewers

Media

BMA members

Advertising and sponsors

Subscribers

Rapid responses for this article

Underprovision
of NHS psychiatry is the real issue Neil MacFarlane

Lessons
from the History of ADHD Matthew PC Smith

More

Print issues

Current issue contents

Current cover image

Past issues

Subscribe

Contact us - Privacy policy - Web site terms &
conditions - Revenue sources - Site map

HighWire Press - Feedback - Help - © 2010 BMJ Publishing Group Ltd.