Psychological Medicine, 2006, 36, 159–165.

f 2005 Cambridge University Press

doi:10.1017/S003329170500471X First published online 3 May 2005. Printed in the United Kingdom

REVIEW ARTICLE

The age-dependent decline of attention deficit hyperactivity disorder:

a meta-analysis of follow-up studies
S T E P H E N V. F A R A O N E 1 *, J O S E P H B I E D E R M A N 2, 3 AND E R I C M I C K 2,3
1
Medical Genetics Research Program and Department of Psychiatry, SUNY Upstate Medical University,
Syracuse, NY, USA ; 2 Pediatric Psychopharmacology Unit of the Child Psychiatry Service, Massachusetts
General Hospital, Boston, MA, USA; 3 Harvard Medical School, Boston, MA, USA

ABSTRACT
Background. This study examined the persistence of attention deficit hyperactivity disorder
(ADHD) into adulthood.
Method. We analyzed data from published follow-up studies of ADHD. To be included in the
analysis, these additional studies had to meet the following criteria : the study included a control
group and it was clear from the methods if the diagnosis of ADHD included subjects who did not
meet full criteria but showed residual and impairing signs of the disorder. We used a meta-analysis
regression model to separately assess the syndromatic and symptomatic persistence of ADHD.
Results. When we define only those meeting full criteria for ADHD as having ‘ persistent ADHD’,
the rate of persistence is low, y15 % at age 25 years. But when we include cases consistent with
DSM-IV’s definition of ADHD in partial remission, the rate of persistence is much higher, y65 %.
Conclusions. Our results show that estimates of ADHD’s persistence rely heavily on how one defines
persistence. Yet, regardless of definition, our analyses show that evidence for ADHD lessens with
age. More work is needed to determine if this reflects true remission of ADHD symptoms or is due
to the developmental insensitivity of diagnostic criteria for the disorder.

INTRODUCTION should be considered a valid disorder (Barkley,

1997; Faraone, 2000 ; Faraone et al. 2000).
In contrast to most other psychiatric disorders,
The idea that ADHD is rare in adulthood was
investigators and clinicians debate the validity of
given credibility by Hill & Schoener (1996) who
attention deficit hyperactivity disorder (ADHD)
fit a mathematical model to the rates of persist-
in adults. Some assert that most cases of ADHD
ence reported by studies that had followed
remit in adulthood ; they conclude that adult
ADHD children from childhood to adolescence
ADHD is very rare (Shaffer, 1994 ; Hill &
Schoener, 1996). If so, most referred cases must or adulthood. Their model, which predicted an
exponential decline in the rate of ADHD, esti-
be due to referral artifacts or missed differential
mated the rate of adult ADHD to range from
diagnoses. Others claim that many cases of
ADHD persist into adulthood and that, even 0.8 % at age 20 to 0.05 % at age 40 years. Given
that long-term outcome studies are the touch-
when its childhood age at onset is established
stone for judging the course of a disorder, these
by retrospective self-reports, ADHD in adults
results appeared to provide strong support for
the idea that ADHD is not a lifelong disorder.
* Address for correspondence: Dr Stephen Faraone, Department Although the current rate of residual ADHD
of Psychiatry, SUNY Upstate Medical University, 750 East Adams
St., Syracuse, NY 13210, USA. was available for some of the studies available
(Email : faraones@upstate.edu) to them, they only analyzed the persistence rates
159
160 S. V. Faraone et al.
defined by meeting full criteria for the disorder.
This method counts as ‘ remitted’ former
ADHD children who continue to have impair-
ing symptoms, despite failing to meet all diag-
nostic criteria (cases that DSM-IV would code
as ADHD in partial remission). Thus, Hill and
Schoener studied what Keck et al. (1998) refer
to as syndromatic persistence, i.e. the main-
tenance of full diagnostic status. They did not
address symptomatic persistence, i.e. the main-
tenance of partial diagnostic status with im-
pairment.
Although studies of syndromatic persistence
are useful for understanding the natural history
of a disorder, clinicians also need studies of
symptomatic persistence to fully understand the
prognosis of a disorder. For example, if follow-
up studies of schizophrenia had only reported
rates of syndromatic persistence, the prognosis
of schizophrenia would seem much better than
we know it to be from studies of symptomatic
persistence. Indeed, after their initial psychotic
episode is stabilized, many schizophrenic pa-
tients continue to show disabling symptoms
even though they do not meet criteria for the
disorder. Although this issue is relevant for most
psychiatric disorders, it is especially relevant
for ADHD given the ongoing debate over the
validity of this diagnosis in adults.
Our prior research suggest that studies of
syndromatic persistence may give an overly
optimistic view of the long-term outcome of
ADHD (Biederman et al. 2000). We found that,
at the age of 19 years, 38% of children had the
full ADHD diagnosis, 72 % would show per-
sistence of at least one-third of the symptoms
required for the diagnosis and 90 % showed
evidence of clinically significant impairment.
Thus, Hill & Schoener’s (1996) review of
ADHD follow-up studies may have provided an
overly optimistic view of the prognosis of
ADHD. Providing an accurate understanding
of the persistence of ADHD has important
clinical implications. If, based on Hill &
Schoener’s (1996) review, clinicians assume
ADHD is rare in adulthood, they are likely to
view potential cases with skepticism. In con-
trast, the view that adult ADHD is a prevalent
disorder would alert clinicians that the diagnosis
should be considered in adults presenting with
histories of ADHD-like symptoms. To clarify
this issue and provide a more complete view of
prognosis, we completed an analysis of ADHD
outcome studies including both studies of
syndromatic persistence and symptomatic per-
sistence.
METHOD
Selection of studies
We used a Medline search of the scientific
literature to identify outcome studies of ADHD.
To be included in the analysis, these studies had
to meet the following criteria : the study in-
cluded a control group and it was clear from the
methods if the diagnosis of ADHD was made
based on using full criteria or with modified
criteria that required some ADHD symptoms
and evidence of residual and impairing signs of
the disorder. All the studies reported in Hill &
Schoener’s (1996) review met these criteria.
For each study selected for analysis, Table 1
shows the number of subjects in the study, the
mean age of the study group at baseline, the diag-
nostic system used to define ADHD, the mean
age at follow-up, and the number and per cent
of cases that showed ADHD at follow-up.
Horizontal lines in the table group together
studies that report data from the same sample at
different follow-up intervals. An asterisk in the
last column indicates studies that used a residual
diagnosis of ADHD. These studies did not re-
quire subjects to meet full diagnostic criteria for
ADHD at the follow-up assessment. Instead,
they diagnosed ADHD if the subject showed
impairing signs of the disorder.
Statistical analysis
To analyze the persistence rates in Table 1, we
used a meta-analysis binomial-logit regression
model, which modeled the persistence rate of
each study as a function of age at follow-up
baseline age, and diagnostic approach (full
versus residual). We also included interactions
of predictors with follow-up age. The analysis
weighted each study by the number of subjects
recruited at the baseline assessment. The data in
Table 1 include multiple reports from several
sites. When there is more than one report for
a single site, the data correspond to either
different follow-up ages or different diagnostic
approaches (full versus subthreshold diag-
noses). Data points from the same site are not
 The age-dependent decline of ADHD 161

Table 1. Prospective follow-up studies of attention deficit hyperactivity disorder (ADHD)

Age range or
mean at Age at ADHD
baseline Diagnostic system follow-up persistence

Study n Mean Recruitment Follow-up Mean n %

Mendelson et al. (1971) 83 9.9 DSM-II a

DSM-II a
13.4 42 50
Borland & Heckman (1976) 20 7.5 DSM-IIa DSM-IIa 30.4 10 50*

Mannuzza & Gittelman (1984) 36 7.9 DSM-II DSM-III 17.4 12 33

Mannuzza & Gittelman (1984) 36 7.9 DSM-II DSM-III 17.4 13 36*
Gittelman et al. (1985) 101 9.3 DSM-II DSM-III 18.3 31 31
Gittelman et al. (1985) 101 9.3 DSM-II DSM-III 18.3 40 40*
Mannuzza et al. (1991) 94 7.3 DSM-II DSM-III 18.5 21 22
Mannuzza et al. (1991) 94 7.3 DSM-II DSM-III 18.5 41 43*
Mannuzza et al. (1993) 91 9.3 DSM-II DSM-III, IIIR 25.5 7 8
Mannuzza et al. (1993) 91 9.3 DSM-II DSM-III, IIIR 25.5 10 11*
Mannuzza et al. (1998) 85 7.3 DSM-II DSM-IIIR 24.1 3 4
Mannuzza et al. (1998) 85 7.3 DSM-II DSM-IIIR 24.1 3 4*

Lambert et al. (1987) 59 7.7 DSM-II DSM-III 14.3 25 43

Lambert (1988) 59 9.3 DSM-II DSM-III 18.3 47 80*

Barkley et al. (1990) 123 4–12 DSM-IIIRb DSM-IIIR 14.9 88 72

Barkley et al. (1990) 123 4–12 DSM-IIIRb DSM-IIIR 14.9 102 83*
Barkley et al. (2002) 147 4–12 DSM-IIIRb DSM-IV 21.1 78 58
Barkley et al. (2002) 147 4–12 DSM-IIIRb DSM-IV 21.1 89 66*

Feldman et al. (1979) 81 10.0 DSM-IIa DSM-IIa 15.5 35 43

August et al. (1983) 22 10.7 DSM-IIa DSM-III 14.2 19 86*
Weiss et al. (1985) 63 6–12 DSM-IIa DSM-III 25.1 42 66*
Cantwell & Baker (1989) 35 5.5 DSM-III DSM-III 9.7 28 80
Offord et al. (1992) 48 4–12 DSM-III DSM-III 8–16 16 34

Hart et al. (1995) 106 9.4 DSM-IIIR DSM-IIIR 10.4 89 77

Hart et al. (1995) 106 9.4 DSM-IIIR DSM-IIIR 11.4 90 85
Hart et al. (1995) 106 9.4 DSM-IIIR DSM-IIIR 12.4 92 84

Claude & Firestone (1995) 52 7.3 DSM-III DSM-IIIR 19.7 26 50

Biederman et al. (1996) 128 10.5 DSM-IIIR DSM-IIIR 14.5 109 85*
Biederman et al. (1996) 128 10.5 DSM-IIIR DSM-IIIR 14.5 78 61

Rasmussen & Gillberg (2000) 50 7 DSM-IIIc DSM-IV 22 28 56*

Rasmussen & Gillberg (2000) 50 7 DSM-IIIc DSM-IV 22 24 48

Yan (1996) 197 10.0 DSM-IIa DSM-IIIRd 25.5 140 70*

Studies grouped within horizontal lines report data from the same sample at different follow-up intervals.
* Residual ADHD diagnosis.
a
Diagnostic system not stated but completed in DSM-II era.
b
Diagnoses shown to be equivalent to DSM-III-R.
c
Diagnoses shown to be equivalent to DSM-III.
d
Diagnostic system not stated but completed in DSM-III-R era.

statistically independent of one another. If not to distributional assumptions. All computations

addressed, non-independence leads to inaccu-
rate estimates of statistical significance. To deal
with this issue, the variance estimates were
adjusted using Huber’s formula (Huber, 1967),
a ‘theoretical bootstrap ’ that produces robust
statistical tests. The method works by entering
the site scores (i.e. sum of scores within sites)
into the formula for the estimate of variance.
The resulting F statistics and p values are robust
used STATA 8.0 (Stata Corporation, 1992).
RESULTS
We first evaluated the estimates of persistence
from Table 1 for outliers. Data were stratified
by diagnostic criterion used at follow-up
(residual or full diagnostic status) and age at
follow-up (child/adolescent, <18 years of age ;
162 S. V. Faraone et al.

0 F F RR
R
0·8 F
F
F
R R
Log of persistence

–1 0·6 F R F R
F F F R
F F R
0·4 R
R
F F F
–2
0·2 F

F
–3

Rate of persistence
R
0·0
Full Residual Full Residual 10 15 20 25 30
Child/Adolescent Adult Age at follow-up
FIG. 1. Identification of outliers in extant data.
F F RR
R
0·8 F
F
F
or adult, o18 years of age). Fig. 1 shows evi- R R
dence for statistical outliers in two samples 0·6 F R F R
reporting residual diagnoses. The points in F F F R
Fig. 1 that fall far outside the range covered 0·4 F F R
R
R
by the standard deviation correspond to the F F F
rate of residual diagnoses at follow-up in the 0·2 F
Mannuzza et al. (1993, 1998) publications.
Thus, our subsequent analyses were conducted R
F

both with and without these data. 0·0

Using all studies (including the two outliers)
we found a statistically significant association
between age at assessment and the rate of per-
sistence for the full [odds ratio (OR) 0.83, 95%
confidence interval (CI) 0.74–0.93; Wald’s
x2=10.3, df=1, p=0.001) but not the residual
(OR 0.89, 95 % CI 0.78–1.03; Wald’s x2=2.5,
df=1, p=0.1) diagnostic criterion. We did not
find a statistically significant interaction be-
tween follow-up age and diagnostic approach
(Wald’s x2=0.8, df=1, p=0.4). Fig. 2 shows the
nature of symptom decline stratified by follow-
up diagnostic criterion. Actual data points are
plotted with the letter ‘ F ’ for studies using full
diagnoses and ‘R ’ for studies using residual
diagnoses. The two fitted curves graph the
predicted values from the regression models for
full and residual diagnoses. As Fig. 2 a shows,
studies using a full threshold diagnosis of
ADHD reported a greater remission at each
age than studies using a residual diagnosis.
When the statistical outliers were removed from
the estimate of age-dependent persistence of the
residual diagnosis (Fig. 2 b) the slope of the age
decline is reduced (OR 0.96, 95% CI 0.87–1.05 ;
Wald’s x2=0.7, df=1, p=0.4). The odds ratios
from these models represent the probability of
10 15 20 25 30
Age at follow-up
FIG. 2. Persistence of full (F) and residual diagnosis (R) of ADHD.
(a) All studies ; (b) excluding outliers. Predicted rate of persistence for
full diagnoses (–––) and residual diagnoses (– – –).
persistence of ADHD symptoms associated
with a 1-year change in age. Thus, the prob-
ability of an individual with ADHD meeting full
criteria for ADHD 1 year later is 83 % while the
probability that that individual would continue
to have residual symptoms of the disorder 1 year
later is 96 %.
The fit of our models improved when strat-
ifying by outliers. The correlation between actual
persistence rates and the persistence rates pre-
dicted by the model was 0.62 when we included
outliers (p<0.001) and 0.76 when outliers were
accounted for (p<0.001). We found no signifi-
cant effects for either baseline age (z=1.3,
p=0.2) or its interaction with follow-up age
(z=0.15, p=0.9).
DISCUSSION
Our meta-analysis of ADHD follow-up studies
has produced some intriguing results but these
 The age-dependent decline of ADHD
should be interpreted in the context of several
limitations. Although meta-analysis regression
provides a method for pooling data across
studies, it cannot correct for the deficiencies of
the individual reports. As Fig. 2 b shows, only
one data-point followed subjects into their
thirties and only eight followed subjects into
their twenties. This limits our ability to draw
conclusions about ADHD in older adults. This
problem is highlighted by the large impact that
outlying observations had on our estimates of
age-dependent symptom decline (Mannuzza
et al. 1993, 1998). Why these data were such
extreme outliers is not clear, but it may have
been because that study excluded hyperactive
children whose primary reason for referral was
aggressive behavior. Since hyperactive children
with aggressive behavior are at greatest risk for
continued ADHD in adulthood (Hechtman,
1992), the low rate of ADHD adulthood
reported by that study is likely to be an under-
estimate.
Despite these limitations, our pooled analysis
of ADHD outcome studies confirms the prior
work of Barkley et al. (2002) and Biederman
et al. (2000) who concluded that the apparent
prognosis of ADHD depends on what definition
of persistence one uses. When we define only
those meeting full criteria for ADHD as having
‘persistent ADHD’, the rate of persistence is
low, y15 % at age 25 years. But when we in-
clude cases consistent with DSM-IV’s definition
of ADHD in partial remission, the rate of
persistence is much higher, y40–60 %, with
the higher estimate excluding the outlying ob-
servations.
Given that the prevalence of ADHD in
childhood is y8 % (Faraone et al. 2003), these
data suggest the prevalence of adult ADHD at
age 25 years should range from 1.2 % for the
narrow full-threshold diagnosis of ADHD and
3.2% when including cases in partial remission.
This range is consistent with Murphy &
Barkley’s (1996) survey of 720 adults applying
for or renewing their drivers licenses in the
state of Massachusetts. In this sample, 4.7 %
of adults met DSM-IV criteria for ADHD
based on a rating scale assessment. Similarly,
Heiligenstein et al. (1998) examined 448 college
students not selected for any psychiatric
diagnosis. Four per cent of the students met
DSM-IV criteria for ADHD.
163
Any theory of ADHD must explain the
apparent waning of symptoms over time, which
in Fig. 1 is evident from both full and residual
diagnoses. Although on the face of it, these re-
sults suggest that ADHD attenuates over time,
the finding of symptom reduction with age may
reflect the developmental insensitivity of the
DSM-IV, not the natural history of ADHD. As
Barkley (1997) and Faraone (2000) have argued,
developmental change makes it difficult for
ADHD children to meet criteria for ADHD as
they age.
For ADHD, DSM-IV addresses development
in several ways. It cautions diagnosticians that
maturation mitigates symptoms ; they become
less conspicuous. Older children may be restless
and fidgety, but not overly hyperactive. With
age, inattention predominates as tasks at school
or work tax attentional capacity. Also, DSM-IV
notes that symptoms should be considered
present only if they are not consistent with
developmental level.
Despite these cautions, it is possible that the
DSM is not sufficiently sensitive to develop-
mental variations in symptom expression. Some
items that are relevant in childhood may simply
not apply in adulthood. For example, one
DSM-IV symptom of ADHD is ‘often leaves
seat in classroom or in other situations in which
remaining seated is expected ’. This is devel-
opmentally insensitive for two reasons. With
development, children mature and conquer
developmental challenges. Although remaining
seated is difficult at age 5 years, it becomes easier
with age as socialization and brain development
improve the child’s capacity for inhibiting
impulses. Also, development leads to changes in
the environment. For example, unlike school-
children, many adults are not required to sit for
several hours each day. Thus, they have fewer
opportunities to leave their seat.
The results of this study are limited by several
factors. Because this is a meta-analysis, the data
available from published reports over the past
three decades is often lacking. We could not
evaluate the impact of other psychiatric co-
morbidity, study design (e.g. employing dif-
ferential diagnosis, blindness, time referent)
consistently across all studies. We could also not
determine from this study whether the residual
symptoms : (a) occur in more than one setting
or (b) were symptoms of another co-morbid
164 S. V. Faraone et al.
disorder. This study also does not address the
putative functional impairments associated with
symptomatic persistence of ADHD. Thus, the
limited goal of this study was to document the
level of symptom expression in follow-up
samples of different ages, rather than to attempt
to understand the underlying causes or conse-
quences of residual ADHD symptoms.
Accurate knowledge about the prevalence of
disorders is essential for effective screening and
diagnosis. The belief that a disorder is rare
would be expected to make clinicians wary of
patients expressing ADHD symptoms. In con-
trast, the higher prevalence suggested by this
report and by the two community studies
(Murphy & Barkley, 1996 ; Heiligenstein et al.
1998) should motivate clinicians to be less sus-
picious that apparent cases of ADHD in adults
are false positives. Such a change would be
especially important in primary-care settings.
Faraone et al. (2004) showed that, although
adult ADHD is a substantial source of morbidity
in such settings, primary-care practitioners
(PCPs) are hesitant to diagnose ADHD in
adults in patients who had not been previously
diagnosed in childhood. The idea that ADHD is
rare in adulthood would be expected to worsen
the conservative use of the diagnosis in primary
care. In contrast, psychiatrists were more likely
to diagnose such patients by establishing a
retrospectively reported onset in childhood. The
idea that PCPs are more conservative with the
diagnosis of ADHD was further supported by
data showing that PCPs took a longer time
to make the diagnosis than did psychiatrists.
Identifying cases of adult ADHD requires care-
ful interviewing about symptoms of inattention,
restlessness, impulsivity and disorganization.
More research is needed of adults meeting
residual diagnostic criteria in order to better
understand the clinical correlates and associated
dysfunction in reference to both non-ADHD
adults and those that continue to meet full
diagnostic criteria.
ACKNOWLEDGEMENTS
This work was supported in part by grants
R01MH57934, R01HD37694, R13MH59126 to
Dr Faraone from the National Institutes of
Health.
DECLARATION OF INTEREST
None.
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