ADHD in Adults: What the Science Says

It was published by Guilford Press. In the publisher's record the hardcover edition is dated October 2007; in library and bookshop records the copyright year is mostly 2008. The paperback edition came in November 2010. The publisher gives 489 pages.

I could not find a verified Turkish edition, so I write it under its original title. I translated the titles of the fourteen chapters below myself.

Let me say one thing up front. This piece was written by looking at the book's table of contents, the publisher's page, published reviews and the articles that came out of the studies the book is based on. I do not claim to have read the four hundred eighty-nine pages page by page. In the places where I infer what is inside a chapter only from its title, I will say so separately.

Three authors, two studies

You already know Russell A. Barkley on this site from another of his books: the guide for adults he wrote for general readers. This book is of a different kind. It is not a guide, and it is not a theory text either. It is a data report.

Kevin R. Murphy was the clinician who directed the adult ADHD clinic at the University of Massachusetts Medical School. According to the publisher's author note, he carried out all the clinical evaluations in the book's clinical adult study. Today he runs his own adult ADHD clinic in Central Massachusetts. Mariellen Fischer was a pediatric neuropsychologist and professor at the Medical College of Wisconsin; she was a co-investigator on the long-term study in Milwaukee and the principal investigator at that site.

These two studies are the book's two legs. The first is the follow-up into adulthood of people who were diagnosed as hyperactive as children in Milwaukee. According to the articles describing the same cohort, the children were evaluated between 1978 and 1980, followed for at least thirteen years, and set against a comparison group drawn from the community: about 150 hyperactive children and around 70 controls. The second is the UMASS study: a clinical sample of adults who came seeking help and were newly diagnosed. A 2010 article by Barkley and Murphy using this sample mentions 146 adults with ADHD, 97 clinical controls and 109 community controls. I could not verify the exact numbers in the book chapter by chapter; these are the figures from the accompanying articles.

The starting idea: the criteria were written for children

The publisher's description states the objection openly: the current diagnostic criteria do not accurately reflect how adults experience ADHD, and the book points the way to better criteria that put executive function deficits at the center.

To understand the weight of this sentence, you have to look at that period. The DSM-IV symptom list had been written by looking at children and carried over to adults almost as it was. What does the item "leaves seat in classroom" mean for someone who is thirty? The things that really disrupt an adult's life, such as not being able to set up a plan, not being able to set priorities, not being able to see a deadline, were missing from the list or appeared only indirectly. Barkley's theory already called these executive function. This book is an attempt to test the theory with data.

Its timing matters too. According to the review in the Journal of Nervous and Mental Disease, the book came right on time because it appeared while the DSM-V revision was under way. The Canadian Journal of Psychiatry, for its part, says it is a must-read for those following that process in which adult-specific criteria were being debated.

Table of contents: diagnosis first

The first half of the book deals with diagnosis.

1. Introduction. 2. The History and Prevalence of ADHD in Adults. 3. Diagnostic Criteria in Adults. These three are the groundwork. I infer their content from their titles: how the subject was carried over to adults, how often it is seen, what the existing criteria are.

4. Identifying ADHD in the Adult: Making the Diagnosis in the UMASS and Milwaukee Studies. How the two samples were built, who was counted as having ADHD. The reliability of the study depends on this. As someone who studied law, I am used to looking first at who the witness is in an evidence file; this is the chapter to read with that eye.

5. The Usefulness of DSM Symptoms and the Question of Age of Onset. Which DSM items distinguish an adult with ADHD, and how defensible the requirement is that symptoms began before age seven. This requirement was later raised to twelve in DSM-5; the book is a product of the period when that debate was going on.

6. Impairment in Major Life Activities. 7. Identifying New Symptoms of ADHD in Adulthood. The seventh chapter is, I think, the heart of the book's objection. As cited in a later study, Barkley and Murphy showed in a 2006 article that the executive function criteria they proposed were useful in diagnosis. The study Kessler and colleagues published in Archives of General Psychiatry in 2010 (Barkley is among its authors) also found that executive function items such as planning, prioritizing, deadlines and self-discipline predicted adult ADHD most consistently and most distinctively. I described how it looks in everyday life in the article on ADHD symptoms in adults.

The areas of life

The second half spreads the picture out into life.

8. Comorbid Psychiatric Disorders and Psychological Maladjustment. I could not verify the details of this chapter. The title says it looks at the diagnoses that occur together in adults with ADHD and at overall psychological adjustment.

9. Educational and Occupational Functioning. In the 2006 article on the Milwaukee cohort, the hyperactive group was found to have had fewer years of education, lower grades, a higher likelihood of being fired and lower job performance. The severity of childhood conduct disorder also separately predicted many of the outcomes. In other words, not everything can be put down to ADHD, and that needs to be noted.

10. Substance Use and Antisocial Behavior. According to the 2004 article on the same cohort, the hyperactive group was ahead of the control group in antisocial behavior and arrests, but the groups differed only on the drug-related dimension. The strongest predictor of hard drug use was lifetime conduct disorder. What matters for a person with ADHD reading this chapter is that the finding highlights not everyone with ADHD, but the subgroup that also has conduct disorder.

11. Health, Lifestyle, Money Management and Driving. It fits four topics into one chapter. For driving there is the article Fischer and colleagues published in 2007 on the same cohort: 147 hyperactive young people with an average age of 21 and 71 controls. In the hyperactive group, tickets for reckless driving, driving without a license, leaving the scene of an accident and having the license suspended or revoked were more frequent. The driving article and the money management article on this site are the everyday side of this chapter. I could not verify the findings of the money section; I will not say anything beyond the title.

12. Sexuality, Dating and Marriage, Parenting and the Psychological Adjustment of Children. I could not verify the content of this one either. The title says it looks at the effect of ADHD reaching into relationships and into the next generation. There is a finding in the 2006 article that touches on this: in the hyperactive group, being treated for a sexually transmitted disease was more frequent.

The last two chapters

13. Neuropsychological Functioning. I could not verify what is inside this chapter. The same authors' 2010 article asks whether executive function test results or the person's own ratings better predict problems at work. Kamradt and colleagues found in 2014, in a different sample, that ratings of time management, self-restraint and emotion regulation made an additional contribution, beyond task performance, to problems in relationships, occupation and daily living. So the idea of a difficulty that does not show up in the test but does show up in life found support in an independent study as well.

14. Summary, Implications and Treatment Implications. The book is not a report of a treatment trial. The job of this chapter should be to list which interventions come to mind from the problems observed; not to give trial results.

Its strongest points

The first is scale. Following a group diagnosed in childhood into adulthood alongside a comparison group is expensive work that takes years. The published reviews give this its due. Faraone calls the book a "veritable tour de force." Choice says that despite the technical content, the writing is accessible. The review in Psychiatric Services finds the book rigorous and comprehensive.

The second is more than one source of information. The review in the Journal of Nervous and Mental Disease highlights the different measures and the multiple informants. In ADHD, who does the telling matters. According to a secondary summary of a 2002 article on the Milwaukee cohort, the persistence rate reported by parents came out much higher than what the young people reported themselves, and changing the definition of the disorder also changed the result. A study relying on a single source would have been misled.

The third is the wide scope. Education, work, driving, money, relationships, parenting in a single picture. This breadth shows that ADHD is not a list of symptoms but a burden within life.

Weak points and objections

First, the level of evidence. The book's strength is observational studies. An observational cohort shows which outcomes go together with ADHD; it does not show that an intervention works. That is why the chapter on treatment implications should be read as a piece of reasoning, not as a result of the evidence. In addition, confounding factors such as conduct disorder may be largely determining the results; the cohort's own articles say so.

Second, the sample. The Milwaukee children were gathered between 1978 and 1980 as "hyperactive children." The description of a 2019 article using the same cohort describes the sample as predominantly male. I think this shows that women with an inattentive presentation who are diagnosed in adulthood are not at the center of this book. The clinical sample is a separate problem: adults who seek help may differ from those who do not, and the abstract of the 2010 article says that the three groups were grouped according to ADHD severity.

Third, the date. The book was written before DSM-5. DSM-5 raised the age of onset from seven to twelve and lowered the number of symptoms required for ages seventeen and over from six to five; according to the American Psychiatric Association's fact sheet, the symptom criteria themselves stayed the same. So the book's main proposal did not make it into the official list: the executive function criteria, which I think are its newest idea. Then Moffitt and colleagues, in the article they published in 2015 with the Dunedin cohort, reported that those who met the criteria for ADHD in adulthood overlapped very little with the group diagnosed with ADHD in childhood (three people) and that the adult group did not show neuropsychological deficits in childhood. The authors say this needs replication. But this finding puts a serious question to the assumption of childhood onset on which the book rests. Keep this in mind while reading the book.

Fourth, a commercial context; not an accusation, but information the reader should know. Barkley's adult executive function scale (BDEFS) is also published by Guilford. The book that argues for making executive function a criterion and the tool that measures it are under the roof of the same publisher.

Finally, readability. The publisher says that tables, figures and boxes collect the results and methods; even so, for a reader with ADHD it is a long and dense text.

Who it is for, and who it is not for

For adults who are curious about where the diagnostic criteria come from. For clinicians, and psychology and medical students. For the person who asks "is adult ADHD real, what is the evidence" and wants an evidence file instead of a blog post. And for those who want to understand the background to the question of how adult ADHD is diagnosed.

I was diagnosed at 22. If this book had come into my hands back then, I think it would not have been useful to me. I would not recommend it to someone who has just been diagnosed and is looking for what to do: there is not a single practical page, and no emotional response either. There are other books for relief.

Its place on the shelf

Someone who has read Barkley's theory and asks "so what happened with the data" comes to this book; for the theory itself, see the ADHD and the Nature of Self-Control review. Thomas Brown's executive function book goes in the same direction but proposes a different theory. Rethinking Adult ADHD and The Adult ADHD Tool Kit, on the other hand, are practical books that tell you the thing this book leaves out, namely what to do. The data is in this book, the practice in those. For a plain explanation of the concepts, the executive functions article is enough.

My stance

I would put this book on the shelf not as a guide but as a source. Its value is not in saying that adult ADHD is real and serious, but in doing so together with an objection to the criteria, with a file whose witnesses are known. Its proposal did not make it into DSM-5, and Moffitt's question still stands unanswered. But for someone asking which item predicts life and why, this file is still the clearest point of reference.