What is the prevalence of adult hyperactive (combined) ADHD and what are the DSM‑5 diagnostic criteria for it?

Adult ADHD Hyperactive Type: Prevalence and Diagnosis

Adult ADHD affects approximately 2.5% of the global adult population, with the hyperactive-impulsive presentation (or combined presentation that includes hyperactivity) being less common than the predominantly inattentive type in adults due to age-related symptom decline. 1, 2

Prevalence of Adult ADHD

Overall Adult ADHD Prevalence

• The global prevalence of persistent adult ADHD (with childhood onset) is 2.58%, representing approximately 139.84 million affected adults worldwide 3
• When including symptomatic adult ADHD (regardless of childhood onset), prevalence increases to 6.76% or 366.33 million adults globally 3
• Up to 70% of individuals with childhood-onset ADHD continue experiencing impairing symptoms into adulthood, even if they no longer meet full diagnostic criteria 1, 2

Presentation-Specific Prevalence in Adults

• Hyperactive-impulsive symptoms decline substantially with age, making the predominantly hyperactive-impulsive presentation rare in adults 4
• Among adults who had childhood ADHD, 94.9% have current attention-deficit symptoms while only 34.6% have current hyperactivity symptoms 5
• The combined presentation (which includes both inattentive and hyperactive-impulsive symptoms) becomes less common in adulthood as hyperactive symptoms diminish 4, 5
• Adult persistence is much greater for inattention than for hyperactivity/impulsivity, fundamentally changing the presentation distribution from childhood 5

DSM-5 Diagnostic Criteria for Adult ADHD

Core Symptom Requirements

For adults (age 17 and older), at least 5 symptoms from either the inattentive OR hyperactive-impulsive category (or both for combined presentation) must be present for at least 6 months. 6

This represents a lower threshold than the 6 symptoms required for children ages 6-12 years 6

Hyperactive-Impulsive Symptom Domain

For the predominantly hyperactive-impulsive presentation or combined presentation, adults must demonstrate at least 5 of the following hyperactive-impulsive symptoms: 6

• Fidgets with or taps hands or feet, squirms in seat
• Leaves seat in situations when remaining seated is expected
• Feels restless (note: in adults, overt running/climbing is replaced by subjective restlessness)
• Unable to engage in leisure activities quietly
• "On the go" or acts as if "driven by a motor"
• Talks excessively
• Blurts out answers before questions are completed
• Difficulty waiting turn
• Interrupts or intrudes on others

Mandatory Age-of-Onset Requirement

• Several symptoms must have been present before age 12, even when diagnosis occurs in adulthood 6
• This represents a critical change from DSM-IV, which required onset before age 7 6
• When evaluating adults without prior diagnosis, clinicians must establish pre-12-year-old symptom presence through collateral history from parents, earlier teachers, or school records 6

Cross-Situational Impairment Requirement

• Symptoms and functional impairment must be documented in at least 2 major settings (home, work, school, social environments) 6
• Information must be gathered from multiple informants such as family members, partners, coworkers, or supervisors 6
• Clear evidence that symptoms interfere with or reduce quality of functioning in interpersonal, academic, or occupational domains is mandatory 6

Mandatory Exclusion Criteria

Critical pitfall: The following conditions must be ruled out as better explanations for symptoms: 6

• Other mental disorders: psychotic disorders, mood disorders, anxiety disorders, dissociative disorders, personality disorders
• Oppositional behavior, defiance, or hostility
• Substance use disorders (particularly important as marijuana and other substances can mimic ADHD symptoms) 6
• Trauma-related conditions including post-traumatic stress disorder
• Some adults may feign symptoms to obtain stimulant medication, requiring careful evaluation 6

Required Comorbidity Screening

The majority of adults with ADHD meet criteria for another mental disorder, making systematic comorbidity screening mandatory: 6

• Emotional/behavioral conditions: depression, anxiety, substance-use disorders, oppositional-defiant disorder, conduct disorder 6
• Developmental conditions: learning disabilities, language disorders, autism-spectrum disorders 6
• Physical conditions: tics, sleep disorders 6

Diagnostic Process for Adults

Initial Screening

• Use the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A for initial screening 6
• If screen is positive, complete ASRS Part B to further elucidate symptoms 6

Comprehensive Evaluation (if screening positive)

• Obtain collateral information from someone who knows the patient well (partner, family member, close friend) 6
• Collect DSM-based rating scales from relevant settings (workplace supervisors, educational settings if applicable) 6
• Document childhood symptom presence through retrospective history, ideally with corroboration 6
• Systematically screen for all required comorbidities 6

Important Clinical Considerations

Gender Disparities

• Men are more than twice as likely as women to receive ADHD diagnosis, primarily because hyperactive and disruptive behaviors are more easily observable 1
• Women with ADHD more commonly present with predominantly inattentive symptoms and comorbid internalizing conditions (anxiety, depression), contributing to underdiagnosis in females 1

Underdiagnosis in Adults

• Many adults with ADHD were never evaluated as children and remain undiagnosed, continuing to struggle with symptoms 7
• Adults often develop compensatory strategies that mask symptoms, making diagnosis more challenging 7
• The median age of childhood diagnosis is 7 years, meaning many current adults reached adulthood before widespread ADHD recognition 1