From the Emerging Adulthood SIG

ADHD in Emerging Adults: Conceptualization & Treatment Considerations

ADHD in Emerging Adults: Conceptualization & Treatment Considerations

By Traci M. Kennedy, PhD, University of Pittsburgh
& Lauren Oddo, PhD, LCP, Partners in Parenting, PC

Attention-deficit/hyperactivity disorder (ADHD) affects about 10% of children in the United States (Danielson et al., 2024). Although historically believed to be constrained to childhood, ADHD is a neurodevelopmental disorder that can affect individuals across the lifespan. In particular, ADHD can be a prominent challenge during the key period of emerging adulthood (ages 18-25), an often complicated transition from adolescence to adulthood. ADHD in emerging adulthood is garnering increased recognition among providers, researchers, educators, young people, and caregivers, as ADHD diagnoses and treatment during this developmental period are on the rise. This article provides an overview of key considerations for ADHD in emerging adulthood, including symptom presentation and course, treatment, and management of ADHD as young people increase their autonomy during this critical transition. 

ADHD Diagnosis, Presentation, & Course in Emerging Adulthood

Despite past estimates that ADHD persists into adulthood for about 2/3 of youth (Faraone et al., 2006), more recent evidence suggests that the course of ADHD over time may actually be more nuanced. Whereas previous estimates of persistence have assessed whether an individual, followed from childhood, meets diagnostic criteria at a single point in time, data from the Multimodal Treatment of ADHD Study (MTA) illustrate that when viewing symptom trajectories across time, most individuals with ADHD fluctuate in their symptom presentation and their diagnostic ADHD status. Sibley et al. (2022) found that 64% of individuals diagnosed with ADHD – Combined Presentation in childhood experienced a “fluctuating” symptom course across adolescence and emerging adulthood , characterized by waxing and waning symptoms and impairment, including periods of complete remission (in the absence of treatment) and periods of ADHD recurrence. Only 9% of the sample experienced long-term, sustained recovery from ADHD over multiple years through the end of the MTA follow-up period. Therefore, the course of ADHD across emerging adulthood is likely for most to be characterized by substantial change rather than stability. Research examining contributors to fluctuations between periods of ADHD remission and recurrence is needed to better understand this course. 

Turning to individuals who never received a diagnosis of ADHD in childhood, emerging adults and older adolescents are increasingly presenting for a first-time ADHD diagnosis and/or medication (e.g., Olfson et al., 2014). For instance, between 2009 – 2013, diagnoses of ADHD increased 36% in adults – twice the increase in youth over the same time period (Fairman et al., 2020). This is more than 8 times the adult ADHD prevalence in 1996 (though is likely partially due to the increase in age of onset criterion from 7 to 12 per the DSM in 2013). Evidence from longitudinal birth cohort studies seemed to initially suggest that this pattern represents a “late-onset” type of ADHD (Agnew-Blais et al., 2016; Caye et al., 2016; Moffitt et al., 2015), contrary to the widely accepted conceptualization of ADHD as a childhood-onset disorder. However, more recent examination of the details of “late-onset” cases indicates that in 95% of cases, co-occurring disorders could not be ruled out as better explaining the symptoms and impairment (most commonly heavy substance use; Sibley et al., 2018). Thus, providers must take care to avoid false positive diagnoses in adults and carefully assess the potential influence of comorbid symptoms and diagnoses – particularly since comorbidities with ADHD are extremely common (e.g., substance use disorders, anxiety disorders, mood disorders), making it difficult to tease apart whether comorbid symptoms represent separate disorders co-occurring with ADHD or differential diagnoses better explaining the ADHD symptoms (Danielson et al., 2024; Kessler et al., 2006; Sobanski, 2006). Among the minority of adolescent-onset cases that persisted into adulthood, the authors of this study from the MTA concluded that they more likely represent “late-identified” ADHD rather than late-onset, given histories of high IQ and other potentially compensatory strengths in childhood that may have masked early symptoms and/or impairment (see also Rivas-Vazquez et al., 2023 and Taylor et al., 2022).

A number of factors may contribute to a first-time ADHD diagnosis in adulthood versus childhood. College students, for instance, may have unique considerations when assessing for ADHD, in part given their likelihood of cognitive strengths and high academic achievement throughout childhood (Lefler et al., 2021). It is especially common for women to receive a first-time ADHD diagnosis in adulthood (Skoglund et al., 2024). In fact, although ADHD is more prevalent in boys than girls in childhood (2:1), this ratio nearly equalizes by adulthood (1:1; Chung et al., 2019; de Zwaan et al., 2012; Debjani et al., 2012; Nussbaum, 2012). This may be related to their greater likelihood of having the inattentive presentation of ADHD, which is more easily missed throughout school age than typically more disruptive and obvious hyperactive/impulsive presentations (Owens et al., 2015) or may be misattributed to internalizing disorders, which predominate in girls (Young et al., 2020). The higher executive functioning demands imposed by college, full-time work, and other adult responsibilities can make the inattentive symptoms of ADHD and their functional impairments more evident for young women, leading them to seek a diagnosis and treatment (Young et al., 2020). We know little about whether the racial/ethnic disparities in ADHD diagnosis in childhood (Cenat et al., 2021) continue into adulthood, highlighting a critical focus for future research.

Treatments for Emerging Adults with ADHD

For young adults with ADHD, evidence-based interventions typically fall into three overarching categories: pharmacological treatment (Tcheremissine et al., 2008), psychosocial interventions (Nimmo-Smith et al., 2020), and academic accommodations (e.g., extended time on tests, testing in a distraction-reduced environment; Weyandt & DuPaul, 2008). Stimulant medications are effective in reducing ADHD symptoms; still, even those who report positive effects may require additional support to manage ADHD-related impairment. The most effective treatment approach for many emerging adults involves combining pharmacological and psychosocial interventions, in addition to academic accommodations as needed (Li & Zhang, 2024). Cognitive Behavioral Therapy (CBT) is among the most well-researched psychosocial interventions for ADHD. In CBT, emerging adults learn self-regulation strategies to better manage the thoughts and behaviors that contribute to impairment (e.g., Eddy et al., 2021; Hartung et al., 2022; Solanto et al., 2021).

When implementing CBT for emerging adults with ADHD, clinicians should be mindful of a few special population characteristics. Emerging adults should be viewed as a collaborator in their own care. Emerging adults with ADHD likely have prior intervention experiences and many express ambivalence about behavior change, as learning self-regulation skills to manage their symptoms and impairment can be effortful and require lifestyle modification. To resolve ambivalence, some CBT approaches work to explore the emerging adult’s intrinsic motivations and values, for instance through motivational interviewing (Meinzer et al., 2021). Understanding the emerging adult’s treatment history (including their perceptions of how helpful prior treatments were), is a key component of case conceptualization and treatment planning.

A common dilemma in CBT for emerging adult ADHD is how to appropriately increase the young adult’s autonomy and independence while also maintaining the external supports needed. This is particularly difficult given that ADHD is characterized by self-regulation problems; caregivers often feel compelled to step in and manage tasks for their child – like organizing their time or reminding them of responsibilities. While this support can be helpful in the short term, it can inadvertently hinder the young adult from developing the necessary skills and strategies to manage their life independently in the long term. It is important to consider how to involve caregivers and others in treatment, as the right level of involvement will vary for each individual and may change over time. The most effective approach is likely to gradually reduce caregiver support as the emerging adult develops the self-regulation strategies needed to manage their symptoms and impairment.

An emerging challenge in treatment is effectively incorporating technology. Digital tools can enhance treatment for ADHD, especially apps for self-management like task managers, alarms, and calendars (Knouse et al., 2022). However, more research is needed to determine the most effective digital approaches for various presenting problems in this population. One challenge is that digital tools often involve using phones or computers, which may present distractions that are difficult to manage. Collaborative planning with the emerging adult around how to incorporate digital tools, including monitoring the usefulness of the tool(s), is likely the best bet.

Given the high rates of comorbidity in emerging adults with ADHD, many treatments must also address commonly co-occurring issues, such as anxiety, depression, and problem substance use. Of note, a challenge in treating ADHD and co-occurring issues can be deciding how to sequence/structure care. Transdiagnostic CBT interventions are emerging to focus on shared mechanisms underlying ADHD and common comorbidities, which have the potential to streamline treatment. For instance, some have targeted behavioral activation and enhancing substance-free rewards to reduce depressive symptoms and problem alcohol and drug use in ADHD (Meinzer et al., 2021b). Other approaches, such as mindfulness-based interventions may help with anxious distress in adult ADHD (Cairncross et al., 2020).

Conclusion

ADHD persists well beyond childhood, and can be especially impairing as children transition into adulthood. Thus, increased focus on ADHD during emerging adulthood in research, clinical practice, and education will benefit the many young people with ADHD needing support to successfully navigate promises and pitfalls of young adulthood.

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