We investigated performance-derived measures of executive control, and their relationship with self- and informant reported executive functions in everyday life, in treatment-naive adults with newly diagnosed Attention Deficit Hyperactivity Disorder  and in healthy controls (n = 35). Sustained attentional control and response inhibition were examined with the Test of Variables of Attention (T.O.V.A.). Delayed responses, increased reaction time variability, and higher omission error rate to Go signals in ADHD patients relative to controls indicated fluctuating levels of attention in the patients. Furthermore, an increment in NoGo commission errors when Go stimuli increased relative to NoGo stimuli suggests reduced inhibition of task-irrelevant stimuli in conditions demanding frequent responding. The ADHD group reported significantly more cognitive and behavioral executive problems than the control group on the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). There were overall not strong associations between task performance and ratings of everyday executive function. However, for the ADHD group, T.O.V.A. omission errors predicted self-reported difficulties on the Organization of Materials scale, and commission errors predicted informant reported difficulties on the same scale. Although ADHD patients endorsed more symptoms of depression and anxiety on the Achenbach System of Empirically Based Assessment (ASEBA) than controls, ASEBA scores were not significantly associated with T.O.V.A. performance scores. Altogether, the results indicate multifaceted alteration of attentional control in adult ADHD, and accompanying subjective difficulties with several aspects of executive function in everyday living. The relationships between the two sets of data were modest, indicating that the measures represent non-redundant features of adult ADHD. Attention Deficit Hyperactivity Disorder (ADHD) is a common early-onset neurodevelopmental syndrome with an estimated prevalence of 2.2% for males and 0.7% for females The recent clinical understanding that ADHD may persist into adulthood has resulted in an increase in referrals of adults without a childhood diagnosis. This poses challenges of diagnosis as it is difficult retrospectively to obtain accurate information on childhood behavior, and because the diagnostic criteria give limited consideration to the heterogeneity of the disorder and its developmental course The manifest symptoms of ADHD may change over time Because attention is a basic, but multifaceted function upon which all neurocognitive processes rely, dysfunction of components of attention may partly underlie difficulties with complex executive function such as planning, problem solving, and decision-making. A well-known clinical observation is that persons with ADHD can engage sustained attentional effort when highly motivated for a task or activity In order to better understand the neurocognitive and behavioral executive deficits associated with adult ADHD there is a need for more detailed characterization of dysfunctions and the conditions modulating their expression. The objective of the present study was to examine attentional and behavioral control in treatment-naive adults with newly diagnosed ADHD, using a task paradigm which requires sustained attention and entails experimental manipulation of important parameters of attention and response control. A secondary aim was to explore whether cognitive performance on a laboratory-based task of sustained attention is associated with subjective reports of executive function.Although deficits in sustained and selective attention are thought to influence modern living skills, such as time management, driving a car in complex urban environments, or using technically advanced communication media, their importance for complex cognitive functions and behavior are infrequently addressed We employed the Test of Variables of Attention (T.O.V.A.) Importantly, a study by Advokat and coworkers showed that adults with ADHD differed from non-clinical adults and adults with psychiatric disorders, but not adults with learning disorders, on errors of omission, reaction time, and reaction time variability in the Conner's CPT Based on the extant literature on cognitive difficulties in adult ADHD We hypothesised that impaired sustained attention in our cohort of adult ADHD patients would be reflected in an increased rate of Go signal omission errors and variable response speed to detected Go signals in the T.O.V.A. Furthermore, we expected that impaired inhibitory motor control, as indexed by the rate of NoGo commission errors, would be particularly pronounced in task conditions with a high strength of response prepotency, such as when the frequency of Go signals increases relative to NoGo signals.In light of the long-standing concern about the ecological validity of laboratory-derived measures of executive control Patients with ADHD  were recruited from a consecutive series of adult patients referred to the Department of Neuropsychology, Helgeland Hospital, in the time period from 2008 to 2011. All patients were referred from specialist mental health services or primary care physicians for a second opinion evaluation of suspected ADHD.A comparison group of 35 healthy controls were recruited from three medium-size companies in the Helgeland area to match the patient group on the variables age, years of completed education, and sex . From lists of all employees, those who fulfilled the matching criteria for a patient were contacted via telephone and asked to participate in the study. A random draw was conducted in cases where more than one employee fulfilled the matching criteria.All participants were questioned about their past and present somatic and psychological health, as well as completed education. Criteria for exclusion were: a) history of mild to severe traumatic brain injury, b) neurological disorder, c) history of severe memory problems, d) diabetes, e) metabolic disorder, f) psychotic symptoms, g) alcohol and/or substance abuse requiring treatment, and h) visual or auditory sensory loss.Inclusion in the ADHD group was based on the DSM-IV criteria for ADHD The Adult Self-Report (ASR) of the Achenbach System of Empirically Based Assessment (ASEBA) was completed by all participants in order to obtain an independent ADHD score, status in relation to work or study, as well as neuropsychiatric comorbidity rd edition (WAIS–III) The patient and healthy control samples were of Western European descent, thus representative of the ethnic composition of the region. All participants had Norwegian as first language. They were right-handed, except for one ADHD patient and one healthy control who were left-handed. Prior to inclusion in the study, all participants were tested for auditory (audiometry test) and vision (optometry test) deficits. They had either normal acuity or vision corrected by optical lenses. All had normal hearing. None had received stimulant medications prior to or during participation in the study. The general IQ of all participants was assessed with the full version of the Wechsler Adult Intelligence Scale, 3All participants gave written, informed consent to take part in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics – North Norway, and was conducted in agreement with the Helsinki Declaration.The T.O.V.A. (version 7.3) st half of the task (comprising quarters 1 and 2), and 77.5% (n = 252) of the trials during Condition 2  which represents the 2nd half (comprising quarters 3 and 4) of the task. The stimuli are presented in a fixed random frequency per quarter. The task is to respond as quickly as possible to the Go signals  by pressing a microswitch, and to inhibit responding to the GoNo signals . The varying Go/NoGo ratio allows examination of the effects of differing response demands on performance.One of the two geometric figures is presented for 100 milliseconds every 2 seconds. The designated Go signal is presented 22.5% (n = 72) of the trials during Condition 1  which constitutes the 1The T.O.V.A. software program precisely records all responses, nonresponses, and response times. We analyzed the primary performance parameters Go signal reaction time and reaction time variability, Go signal omission errors, and NoGo signal commission errors for each quarter, half, and total of the task.Reaction time is the measure of time taken to respond correctly, from the onset of the Go signal until the microswitch (having millisecond precision) is pressed. The reaction time score is the average of the correct Go response times, in which the sum of all correct reaction times is divided by the number of Go stimuli and is calculated in milliseconds. The formula used is as follows: Reaction time  =  ∑ Correct Response Times/# targets.Reaction time variability is the participant's reaction time variance or inconsistency in reaction times. The score is reported as the standard deviation of the mean correct Go signal reaction times; i.e., Reaction time variability  =  (∑ Response Times – Mean Correct Response Time)2/# Correct Responses.Omission errors are recorded when participants do not respond to the Go signals, and are measured as a ratio of the participant's correct responses to Go signals to the actual number of Go signals presented minus the number of anticipatory responses to Go signals: Omission errors  =  # Omissions/# Go stimuli - # Go stimuli Anticipatory Responses. Anticipatory responses are measures of guessing which stimulus will or will not be presented, and is also explained as a strategy to react to any stimulus as soon as possible Commission errors are recorded when the participant fails to inhibit responding and incorrectly presses the button to NoGo signals. The score is measured as a ratio of the incorrect responses to NoGo signals to the actual number of NoGo signals presented minus the number of anticipatory responses to NoGo signals: Commission Errors  =  (# Commissions/# NoGo stimuli - # NoGo stimuli Anticipatory Responses) X 100.http://www.tovatest.com/clinicalsupport/TOVA_SEI_worksheet.pdf). The SEI is based on the presence of response patterns that are not characteristic of clinical disorder and by lack of internal consistency in reaction time scores across specific response types. We employed a cut-off criteria for exclusion of SEI  = 3, indicating strong evidence of possible symptoms exaggeration. None of the participants had a SEI score of 3. Thirty-two patients and 34 controls had no evidence of symptom exaggeration . One healthy control and 4 ADHD patients had some evidence of possible symptom exaggeration . We included these patients for further analyses as other assessment, including validity of BRIEF-A self-report and clinical interview, gave no evidence of compromised validity.All individual T.O.V.A. protocols were evaluated with regard to validity in accordance with the recommendations and criteria provided in the T.O.V.A. 7 Symptoms Exaggeration Index (SEI) Worksheet , Infrequency scale raw score of 3 or higher (maximum score is 5), and Inconsistency scale raw score of 8 or higher (maximum score is 10) indicate possible invalid protocols Prior to being scheduled for cognitive testing, the participants had been instructed to forgo taking any medication, nicotine or alcohol as the T.O.V.A. is sensitive to the therapeutic effects of stimulants At the time of cognitive testing, ADHD patients and healthy controls filled out the BRIEF-A and ASR self-report. For the patients, one close relative, friend or colleague completed the BRIEF-A and the ASEBA informant report. For all participants, the T.O.V.A. was done in the morning, in a room without environmental distractions. It was individually administered in accordance with the general task requirements. Standardised instruction was given verbally by a trained test administrator for the practice session and for the T.O.V.A. The participants were told that the test measures the ability to pay attention, that two different kinds of squares would flash on the computer screen, and that the squares would differ only in that one would have a small hole near the top and one would have a small hole near the bottom . They weStatistical Product and Service Solutions for Windows st vs. 2nd half of the T.O.V.A., and additionally 1st vs. 3rd quarter for commission errors), and one between-subjects factor (Group: ADHD vs. control). Greenhouse-Geisser epsilon corrected p-values, along with uncorrected degrees of freedom are reported. Effect size was computed employing partial eta squared (η2). Significant interaction effects were decomposed using follow-up ANOVAs.Except for the analysis of between-group differences in gender composition with chi square statistic, the demographic data were analyzed using independent samples t-test with Group  as between-subjects factor. Group differences in the four T.O.V.A. parameters Go signal reaction time, reaction time variability, omission errors, and NoGo signal commission errors were analyzed using repeated measures analysis of variance (ANOVA). The ANOVAs were defined by one repeated measure factor  in the ADHD self-report versus ADHD informant report analysis. Because of these findings, a more restrictive significance level, ≤.025, than the typical.05 level was set for all variables in the univariate F-tests One-way between-groups multivariate analyses of variance (MANOVA) were conducted to examine differences between a) ADHD and healthy control self-report scores, and b) ADHD self-report and ADHD informant report scores on the BRIEF-A. For each group comparison, one MANOVA included scores on the 9 scales as dependent variables.Pearson product-moment correlation coefficients (two-tailed test) were used to test within-group relationships between T.O.V.A. standard scores and BRIEF-A scale T-scores, and between T.O.V.A. standard scores and T-scores on the scales Depression Problems and Anxiety Problems from the ASR-ASEBA. Average T.O.V.A. scores for the total of the task were subjected to correlation analyses. For the ADHD group, a follow-up analysis of significant correlations was performed using standard multiple regression analysis to test whether T.O.V.A. performance scores predicted scores on the BRIEF-A self- and informant report. We tested the overall fit of the model and the relative contribution of each of the predictors to the total variance explained.Alpha for statistical analyses were set to p ≤.05, with the exception of an alpha level of ≤.025 for the MANOVAs conducted on BRIEF-A scale scores.Go signal reaction time and reaction time variability: There was a significant main effect of condition    = 84.94, p<.001, η2 = .55) reflecting that reaction times to detected Go signals were longer in the 1st compared with the 2nd half of the T.O.V.A. across groups. A marginally significant effect of group   = 3.86, p = .053, η2 = .05) was consistent with the tendency for generally less speedy reactions in the ADHD group relative to the control group. For reaction time variability a significant main effect of condition   = 10.36, p = .002, η2 = .13) was found, which reflected that reaction times were less consistent in the 2nd compared with the 1st half of the T.O.V.A. for both groups.F  = 10.78, p = .002, η2 = .14). There were no significant condition x group interactions for reaction time   = .832, p = .365, η2 = .01), or reaction time variability   = 1.36, p = .248, η2 = .02).However, the ADHD group had significantly greater reaction time variability relative to the control group across conditions   = 13.45, p<.001, η2 = .16) and group   = 4.11, p = .046, η2 = .06) reflecting that both groups made more omission errors in the 2nd compared with the 1st half of the T.O.V.A., but that the ADHD group made significantly more omission errors to Go signals across conditions compared to the controls. There was a non-significant trend for a condition x group interaction   = 2.94, p = .091, η2 = .04) in that ADHD patients tended to make more omission errors relative to controls in the 2nd half of the task.NoGo signal commission errors: The analyses revealed a significant main effect of condition   = 88.88, p<.001, η2 = .56), indicating more commission errors in the 2nd  compared with the 1st  half of the T.O.V.A. across groups. There was a trend-level main effect of group   = 3.56, p = .063, η2 = .05) reflecting that the ADHD group tended to make more commission errors during the entire task compared to the controls. The condition x group interaction was not significant   = 1.96, p = .166, η2 = .03).st and 3rd quarters of the task.In order to test the hypothesis that adults with ADHD would be particularly prone to impulsive responding in task conditions with a high response demand, we conducted a separate repeated measure ANOVA that included the 1F  = 65.31, p<.001, η2 = .49), was due to the sensitivity to increased response demand occurring from the 1st to the 3rd quarter across groups. A main effect of group   = 4.77, p = .032, η2 = .07) was modified by a significant condition x group interaction   = 4.07, p = .048, η2 = .06). A follow-up ANOVA revealed a significant group difference in commission errors in the 3rd quarter   = 4.89, p = .030, η2 = .25) when there was a steep increase in the number of Go relative to NoGo signals   = 22.43, p<.001; Wilks' Lambda  = .22; η2 = .78). When the results for the dependent variables were examined separately, all scales showed highly significant  group differences   = 1.45, p = .157; Wilks' Lambda  = .81; η2 = .19). The omnibus univariate tests were, however, significant (p's <.02) for all scales with the exception of Organization of Materials. Inspection of the mean T scores  or the Behavioral Regulation Index . The healthy control self-report scores were without exception in the normal range for the scales as well as the Metacognition Index , and the Behavioral Regulation Index .ADHD self- and informant report: There were significant correlations between Go signal omission errors and self-reported scores on the BRIEF-A scales Initiate (r(33)  = −.40, p  = .019), Plan/Organize (r(33)  = −.34, p = .047), as well as between Organization of Materials and three out of four T.O.V.A. variables, namely omission errors (r(33)  = −.54, p = .001), commission errors (r(33)  = −.45, p = .007), and reaction time variability (r(33)  = −.35, p = .042).self-report was also observed for informant report: omission errors (r(32)  = −.40, p = .019), commission errors (r(32)  = −.54, p = .001), and reaction time variability (r(32)  = −.35, p = .046). There was also a significant correlation between commission errors and the Task Monitor scale scores (r(32)  = −.40, p = .020).The same pattern of associations involving the BRIEF-A Organization of Materials scale as seen for rd quarter had a stronger relationship to BRIEF-A scores than the total commission error score. There were no significant correlations between ADHD self-report and commission error in the 3rd quarter, but ADHD informant report showed a significant correlation between 3rd quarter commission error and the Organization of Materials scale (r(32)  = −.35, p = .041). However, the association was weaker than for the total commission error score (r(32)  = −.54, p = .001).Due to the significant group by condition interaction for commission error in the T.O.V.A., we conducted an additional analysis to explore whether commission error in the 3There were no significant correlations between the T.O.V.A. measures and the ASEBA Depression Problems or Anxiety Problems scales.Healthy control self-report: There were no significant correlations of the T.O.V.A. variables with the BRIEF-A or the ASEBA DSM scale scores   = .47, p = .005), and between the ASR DSM Anxiety Problems and the BRIEF-A scales Initiate (r(32)  = .47, p = .005), Working Memory (r(32)  = .38, p = .029), and Shift (r(32)  = .45, p = .007).informant reported scores on the ASEBA DSM Depression Problems and the BRIEF-A scales Initiate (r(32)  = .56, p = .001), Working Memory (r(32)  = .51, p = .002), Plan/Organize (r(32)  = .53, p = .001), Task Monitor (r(32)  = .50, p = .003), Shift (r(32)  = .40, p = .018), and Emotional Control (r(32)  = .35, p = .040). The analysis revealed additional significant correlations between the ASEBA DSM Anxiety Problems and the BRIEF-A scales Working Memory (r(32)  = .37, p = .034), and Shift (r(32)  = .35, p = .043).There were also significant correlations between Healthy control self-report: There were significant correlations between self-reported scores on the ASR DSM Depression Problems and the BRIEF-A scales Initiate (r(30)  = .43, p = .015), Working Memory (r(30)  = .35, p = .048), Plan/Organize (r(30)  = .36, p = .040), Task Monitor (r(30)  = .58, p = .001), Inhibit (r(30)  = .50, p = .004), Emotional Control (r(30)  = .59, p = .001), and Self-Monitor (r(30)  = .58, p.001). A significant negative correlation between the ASEBA DSM Anxiety Problems and the Organization of Materials scale (r(30)  =  −.39, p = .028) was also observed , and 35% for the ADHD informant report   for the ADHD self-report, whereas commission errors made the strongest unique contribution  for the ADHD informant report when the variance explained by the other variables was controlled for.The full model containing all three predictors explained 37% of the variance in Organization of Materials for the ADHD  p<.001) . Of the The main aim of the current study was to examine attention and motor response control in treatment-naive adults with newly diagnosed ADHD. Using a Go/NoGo paradigm (T.O.V.A.) requiring sustained visual attention we found that in comparison to demographically matched healthy controls, the ADHD group had performance deficits that indicated both inattention and impulsive responding. Importantly, reduced task performance was significantly associated with higher self- and informant ratings of selective aspects of cognitive executive difficulties on the BRIEF-A. In the following, the findings will be discussed in relation to previous studies and implications for clinical evaluation of adult ADHD.Reaction times to correctly detected Go signals in the T.O.V.A. were significantly longer for both groups in the first half of the task where Go signals occurred infrequently, compared to the higher response demand of the second half. Task event rate has been seen as a key probe of central nervous system activation processes, and has been found to differ between ADHD and healthy children. Metin and coworkers found a disproportionate slowing of reaction times in ADHD children relative to controls in the condition of slow event rates in a Go/NoGo task Also, both groups showed greater reaction time variability in the second half of the T.O.V.A. when the task required more frequent responding. However, the ADHD group had more inconsistent reaction times compared to the healthy controls for the total duration of the task, indicating difficulties with sustained attention. Previous ADHD literature has argued that inconsistent response time can be seen as a behavioral marker of inattention in ADHD Accompanying the prolonged and more variable reaction times to detected Go signals, adults with ADHD made more Go signal omission errors during the entire T.O.V.A. than healthy controls. This finding is in agreement with other studies employing CPTs in studies of adult ADHD st quarter) versus the initial phase of high (3rd quarter) motor response demand demonstrated significant condition-dependent differences between the groups. The ADHD group made significantly more commission errors compared to controls when the response demand increased. This shows that experimental manipulation of response prepotency was effective in evoking response inhibition difficulties in the adult ADHD group. The reduction in motor response control, but not in other performance parameter, when the Go/NoGo ratio changed from low to high response demands might reflect dysfunction in specific aspects of neural networks. Condition-dependent impairment in motor inhibition on a laboratory task may be a useful proxy for the relative context-dependence of real-life impulsive behavior in patients with ADHD Deficient inhibitory control in adult ADHD has been reported previously A possible explanation for the diversity of executive problems in ADHD has been proposed in a model of inhibitory control The examination of group differences in subjective concerns related to executive functioning revealed that the ADHD patients exhibited significantly higher scores on both the summary dependent BRIEF-A variable computed in the multivariate statistical analysis, as well as on every single scale, relative to the healthy controls. The scores were 2 SDs or more above the scores of the healthy control group on most scales. Also, compared to the US normative values The comparison of ADHD self- and informant report did not show a significant group difference on the BRIEF-A summary variable. However, the analyses of the BRIEF-A scales separately revealed significant group differences on all but one scale. The ADHD informant scores did not exceed the US normative cut-off score, indicating that the informants viewed the patient's behavior as less burdensome than the patients themselves. Interestingly, worries concerning working memory had the strongest effect size whether ADHD self-report was compared with informant report or healthy control self-report.To our knowledge, few studies have used the BRIEF-A to assess executive function in adult ADHD. In a study investigating the factor structure of the BRIEF-A, the adult ADHD group reported significantly greater difficulties than healthy controls on scales encompassing the Metacognition Index, whereas scales belonging to the Behavioral Regulation Index showed a trend-level group difference In two studies using the BRIEF-A to measure effects of medication on executive function, the results showed clinically elevated baseline scores on several scales The healthy control group showed no significant associations between the BRIEF-A or the ASR DSM scales and results on the T.O.V.A. A lack of significant correlations between task performance and scores on the ASR DSM mood scales were also seen for the ADHD group, but there were moderate negative correlations between T.O.V.A. results and a subset of BRIEF-A scales belonging to the Metacognition Index. The significant correlations between reaction time variability and error rates for both ADHD self-report and informant report on the Organization of Materials scale may suggest a particular relevance of the attention and behavior regulation problems detected on the T.O.V.A. to organizational difficulties in everyday situations. Notably, the follow-up multiple regression analyses revealed that T.O.V.A. performance measures qualified as significant predictors of both self- and informant reported problems with organizing and keeping track of personal belongings often associated with impairment at work and in home life.There were significant associations between both self- and informant reported BRIEF-A and ASEBA DSM mood scores. A moderate negative correlation between the BRIEF-A subscale Organization of Materials and ASEBA DSM Anxiety Problems for the healthy control group self-report indicated that a low level of anxiety was associated with a greater level of perceived organizational difficulties.The predominantly moderate positive correlations between BRIEF-A and ASEBA DSM scores for both self- and informant report for both groups indicate that increased emotional distress was associated with an increased level of perceived executive difficulties in everyday life. This is in accordance with the growing evidence for a brain-based association between executive function and mood The clinical nature of the study in some ways limits the ability to generalize the results to the total adult ADHD population. The study included adults who had mainly been referred from psychiatric outpatient clinics, and reported major problems in several aspects of living such as adaptation to the requirements for education and work life. The consequence is that the results may not be representative for adults with ADHD who are able to compensate for some of their deficits and therefore have a better adjustment to the demands of adulthood.The clinical group studied is known to have high intra- and inter-individual variability in both cognitive function and in overt behavioral symptoms We carefully assessed the validity of the scores obtained from both the BRIEF-A and the T.O.V.A., and related the findings to information collected in clinical interview. Thus we followed Roth and colleagues advice to base validity assessments on data from multiple sources i.e., from validity scales to clinical information The comparison of results on the BRIEF-A with US normative data may represent a limitation. Similarly to another Norwegian study by Løvstad and colleagues Few studies have focused on adult ADHD and impairment of executive functions after the early twenties The present study combined behavioral measures of attentional control and response inhibition with self- and informant report measures of executive function. The results showed that a clinical ADHD group reporting a high degree of executive difficulty in daily living was significantly impaired on a laboratory task demanding sustained attention and response inhibition. Moreover, performance on the cognitive task significantly predicted perceived organizational difficulties. Altogether, the findings indicate that in a clinical cohort of treatment-naive adults with ADHD-combined type, the problems with inattention and inhibitory control are largely similar to those reported in childhood ADHD.Although this study demonstrated impaired performance on the T.O.V.A., along with self- and informant reported problems in executive function, we have not fully characterized adult ADHD cognitively and behaviorally, and cannot recommend use of single performance measures or rating scales for diagnostic purposes. However, because the T.O.V.A. measures central aspects of attention and impulsivity under controlled conditions, it can give a useful contribution to a thorough functional assessment of ADHD. The BRIEF-A can serve a similar purpose. With its nine theoretically and empirically derived clinical scales, important aspects of executive functioning from both self- and informant report perspectives can be evaluated. Importantly, Gioia and coworkers recommended the BRIEF not to be used as a diagnostic tool by itself, but should best be used within the context of a broad clinical evaluation


Few studies have examined the impact of childhood attention deficit hyperactivity disorder (ADHD) symptoms on adult ADHD functional outcomes. To address this issue dimensionally, ADHD symptoms in childhood and adulthood and their relation to educational deficits and work disability are studied in a clinical sample of adult patients with previously untreated ADHD. About 250 adults diagnosed systematically with ADHD according to DSM-IV were prospectively recruited. Primary outcomes were high school dropout and being out of the work last year. Childhood ADHD symptoms, sex differences, comorbidities of other mental disorders, and adult ADHD symptoms were examined by historical data, clinician interviews, and questionnaires. High levels of ADHD symptom severity in childhood were related to dropping out of high school [odds ratio (OR) = 3.0], as were higher numbers of hyperactive–impulsive symptoms in childhood. Significantly, more women than men were long-term work disabled (OR = 2.0). After adjusting for age and gender, persisting high levels of ADHD inattention symptoms in adulthood (OR = 2.5), number of comorbid disorders, and particularly anxiety disorders were significantly related to long-term work disability. Childhood hyperactive–impulsive symptoms and overall severity of childhood ADHD symptoms were associated with high school dropout rates; however, persisting ADHD inattention symptoms and comorbid mental disorders in adulthood were more correlated to occupational impairment. These findings underline proposals for studies on early recognition and interventions for ADHD and psychiatric comorbidity. They further suggest that inattentive symptoms be a focus of adult ADHD treatment and that workplace interventions be considered to prevent long-term work disability. Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental condition characterized by age-inappropriate levels of inattention, hyperactivity, and impulsivity (H/I)  under 70 based on the Wechsler Adult Intelligence Scale IV Wechsler .n = 283) was 32.4 (SD = 10.9) years, and for males 31.5 (SD = 10.7) years. By evaluation for inclusion, 262 patients (42 %) were eligible. Twelve did not consent to take part, leaving a total of 250 stimulant naïve adult patients for the study.During the ascertainment of participants, 620 referred patients were assessed for eligibility (May 2009–December 2010). The mean age of the females   was conducted by the clinicians. It is a structured diagnostic interview for DSM-IV Axis I disorders , blinded for other informants’ ratings. Collateral information about current symptoms and impairment were also obtained in the majority of cases from a close relative invited to participate during the DIVA interview with the patient.To obtain diagnoses, two board-certified psychiatrists examined each patient for inclusion criteria. The ADHD diagnosis was ascertained by a multistage and multisource procedure according to DSM-IV-TR criteria  Long-term work disability defined as being out of work in the past year, by being fully out of paid work, ordinary school, or studies due to disability for the last 12 months before enrollment in the study. Data on education were supplemented with historical data collected from school grades, and these measures were ascertained by face-to-face interview with the patients.Our two primary outcome measures were: (1) Because DSM-IV ‘subtypes’of ADHD have been criticized  Hayes . ExclusiThe study was approved by The Regional Committee for Medical and Health Research Ethics of South-Eastern Norway and The Norwegian Social Science Data Services and has therefore been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and later amendments. After a complete description of the study was provided to the subjects, all participants gave written informed consent prior to their inclusion in the study.t tests when the assumption of normal distribution was met, and otherwise with nonparametric tests. The level of significance in the univariate analyses was a priori set at p < 0.01 due to numbers of tests planned. All tests were two sided. The continuous scores of the WURS-25, and ASRS inattention subscale were categorized into low, moderate, and high level by the quartiles to get a more clinically relevant representation.All statistical analyses were carried out by The PASW statistics (version 17) for Windows package. Data from the clinician administered MINI on comorbid mental disorders are aggregated within each diagnostic category presented such as any panic disorder or obsessive compulsive disorder are represented as any anxiety disorder. The data were initially analyzed by descriptive methods. On the group level, categorical variables were analyzed using the chi-square test and stratified in order to explore sex effects  and their 95 % confidence interval (95 % CI) were estimated as measure of strength of associations, and the level of two-tailed significance was set at A total of 250 patients participated. Their mean age was 32.6 (SD = 9.8) years, and 52 % were females. Only five patients (2 %) had received an ADHD diagnosis before 18 years of age. None had previously received any targeted ADHD treatment or stimulant medication. Table p < 0.01). Regarding severity of childhood symptoms by the WURS, males reported less medical problems in childhood (p < 0.01), and more school-related problems (p < 0.01) compared to females, but no significant differences in overall childhood ADHD symptom scores were observed between the sexes. Likewise, we did not found any significant sex differences in the number of DIVA-assessed childhood ADHD symptoms.Many patients reported problems with getting involved in fights with peers in childhood (43 %) indicating impulsive behavior, a tendency that was significantly more common in males than females Table . A substp < 0.05) which consisted mainly of antidepressants (>90 %), to a lesser degree anxiolytics and sedatives. Such medication was related to higher number of comorbid disorders (p < 0.01) (not shown in the tables).A large proportion of the total sample had at least one comorbid mental disorder (75 %), and 55 % had two or more such disorders (not shown in the table). Except for more males having antisocial behavior, we found no significant differences between the sexes Table . A signip < 0.01), particularly for inattentive symptoms (p < 0.01). Self-reported current ADHD symptoms differed correspondingly with a significant tendency for more frequent symptoms reported by females than males on the ASRS full scale (p < 0.01) and the inattentive subscale (p < 0.01).The number of clinician assessed ADHD symptoms in adulthood by the DIVA was significantly higher for females (p < 0.01), and more females (58 %) were reported with disability or rehabilitation pension than males (41 %) (p < 0.01) (Table p < 0.01).A considerable proportion of the sample (56 %) had not completed a secondary school program equivalent to high school; no significant difference between the sexes was observed. However, more males (53 %) than females (36 %) were in paid work or ordinary studies at enrollment in the study p < 0.0, and morp < 0.01)  and had been assessed by the clinicians as having significantly more DSM-IV ADHD symptoms and H/I-symptoms in childhood (DIVA) (p = 0.01). No significant differences were found for comorbid mental disorders or ADHD symptoms in adulthood (ASRS) between the two education categories. Mean age at inclusion into the study was higher among those who had completed high school  school and risk to get into fights with peers during childhood was significantly associated with likelihood of not completed high school when entered one at a time in the regression analyses. After adjusting for sex, these associations remained significant (p < 0.05).Previous assessment by p < 0.01). To control for confounding of disruptive behavior, the number of H/I-symptoms in childhood was entered into the regression model adjusted for risk to get into fights with peers (M.I.N.I.-Plus). With this adjustment, the association to noncompletion then became statistically nonsignificant. However, alternatively adjusting for occurrence of antisocial-/conduct disorder symptoms (M.I.N.I.-Plus), the number of H/I-childhood symptoms maintained statistically significant (p < 0.01) as a predictor of high school dropout (not shown in the tables).The WURS-25 category of ADHD symptom severity ‘high’ (score ≥70) predicted noncompletion of high school with OR = 3.0. This indicates a threefold increased risk of not attaining upper secondary education. Higher numbers of child ADHD H/I-symptoms also remained significantly related to noncompletion of high school after adjustment for sex (out of work or study was significantly higher than among those working (Table The majority of the sample was not in paid work or study (56 %) at the time of referral, and 51 % had not been in paid work or study in the past year due to disability. Half of the sample also received a disability or rehabilitation pension, reflecting long-term work disability , particularly anxiety disorders in both sexes, and antisocial or conduct disorder among females . A significant proportion of the patients in the group of long-term work disability used or had used a medicine for anxiety or depression in the past year . Those out of work or study last year also had significantly higher ASRS inattention scores compared with those in work or study (p < 0.01). The patients who were not working also showed a tendency toward having more inattentive symptoms in adulthood (p = 0.04) assessed by DIVA  were related to increased likelihood of being out of work last year  remained significantly related to not being in work last year with adjusted OR = 1.6 . The statistically significant associations found between the ASRS inattention high score category and the dependent variable of work disability , the hyperactive–impulsive childhood symptoms remained a statistically significant predictor of high school dropout (not shown in the tables), indicating this association was partially independent of antisocial behaviors.Longitudinal studies of children with follow-up in youth and young adulthood have found adverse educational outcomes associated with the severity of childhood ADHD symptoms  as in the general Norwegian population (33 %) of patients in our total sample had not completed high school  in accordance with reported prevalences from prior studies of adult ADHD. The total number of comorbid disorders did not differ significantly between the sexes or between those who did and did not complete high school. Of adult factors with significant relation to long-term work outcome, number of comorbid disorders correlated marginally with selected childhood factors and thus may reflect an independent factor of child ADHD symptoms.Some studies have shown worse outcome in childhood ADHD with co-occurring psychopathology Pliszka , and simOur study has several strengths. A novel contribution of the study is the dimensional examination of whether level of disability in adulthood is related to number of childhood criteria met. The sample comprised treatment naïve, adult ADHD patients and represented a wide age-span, both genders and comorbid conditions. We had historical data from school and consultations with former educational psychology services and health care services data. Collateral independent information was collected for the majority of the patients to ascertain childhood data. All patients in the present study were examined with structured diagnostic interviews by trained clinicians, and evaluations were not based on self-reported questionnaires or retrospective data only.A large proportion of the patients were previously undiagnosed concerning ADHD, though many had been recognized with learning difficulties or behavioral problems in childhood. Gjervan et al.  from NorHowever, our findings have to be viewed within the limitations of the design and methods applied. It is a cross-sectional study based on data from a clinical sample. Our findings of statistically significant associations do not imply causal relationships. Furthermore, investigators were not blind to the participants’ diagnostic status, which could have influenced their assessments. However, the data from parents and patients were collected independently; parents did not know the ratings of the patients and vice versa. Still, retrospective data are possibly distorted by current symptoms, which may bias estimates of association.The clinical variables are not presented together in the regression model due to significant inter-correlation. Effects of multicollinearity were expected to occur in the multivariate analysis, and thus, comorbidity as a confounder could not be fully accounted for.Severity of ADHD symptoms and a high load of child hyperactive–impulsive symptoms in childhood were associated with dropout from school and fewer years of attained education, indicating an increased risk for unfavorable educational outcomes related to these symptoms in childhood and adolescence. Persistence of more inattentive symptoms in adulthood was associated with greater occupational impairment, and additional adult comorbidity was a major predictor of long-term work disability.Our findings emphasize the serious consequences of ADHD in childhood and adulthood in terms of functional outcomes and may suggest that early recognition and intervention for ADHD and comorbid mental disorders are of importance to improve the long-term outcome for ADHD patients. Our work further emphasizes the importance of addressing inattentive symptoms in the treatment of adult ADHD and calls for adequate workplace measures to prevent long-term work disability.


Attention deficit hyper activity disorder (ADHD) is a developmental disorder, most often diagnosed in childhood, and characterized by hyperactivity and inattention that negatively impacts one's ability to function and fulfill social and personal obligations. Individuals with past history of ADHD may enlist in the military under certain conditions, however the full impact of military training and deployment of later in life ADHD symptoms is unclear. It is of particular interest how military experience may affect ADHD in remission and if such individuals might be at elevated risk for relapse of ADHD symptoms.We performed a systematic review f the available literature including the Department of Defense (DOD) guidelines for both eligibility to enlist and fitness for deployment based on reported history and current symptomatology of ADHD.The after care for veterans with ADHD relapse is inconsistent and presents with number of challenges. We evaluate the DOD policies regarding the implications of ADHD for fitness for military service and post-combat mental health.The full extend of the interaction between pre-existing ADHD and post-combat PTSD are not fully understood. The development of comprehensive and clear algorithms for diagnosing and treating ADHD in the military before and after deployment will have a strong positive impact on the quality of care delivered to soldiers and veterans. Attention deficit hyper activity disorder (ADHD) is a developmental disorder, most often diagnosed in childhood, and characterized by hyperactivity and inattention that negatively impacts one's ability to function and fulfill social and personal obligations. The natural course of the disorder may follow two different trajectories. In some cases, the symptoms spontaneously remit to the level of not affecting function by early adulthood. In other cases, the symptoms may persist from childhood to adolescence to adulthood and continue to compromise function. ADHD can be successfully treated with both pharmacological and behavioral interventions; however, treatment gains are generally short-lived. Moreover, those who experience continuous ADHD symptoms need to continue treatments with stimulant and non-stimulant medications. There is still a debate in the literature regarding the impact of past, presumably resolved ADHD, as well as current but successfully managed ADHD on functioning and mental health characteristics in adulthood. This debate has significance for military personnel during training and deployment as well as combat veterans seeking treatment following deployment. The Department of Defense (DOD) has clear guidelines for both eligibility to enlist and fitness for deployment based on reported history and current symptomatology of ADHD. While those with a history of ADHD may actually fair quite well during military training or when in non-combat roles, combat exposure may increase vulnerability for relapse of ADHD and other psychiatric conditions. This paper evaluates the DOD policies regarding the implications of ADHD for fitness for military service and post-combat mental health via a systematic review of the available literature since 2000. We also use illustrative case studies to highlight special clinical considerations associated with past or current ADHD in the context of other deployment-related conditions such as posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) among others that may further complicate readjustment. As several neurobiological mechanisms have been related to ADHD symptoms, we will first discuss ADHD developmental trajectories and neurobiology.ADHD is among the most prevalent developmental disorders in childhood . The other 50% will show remission of clinically meaningful symptoms of the disorder. It should also be noted that for persisters the presentation of symptoms changes with age so that overt hyperactivity diminishes whereas inattention presents itself, such as difficulties with organization, time management, and procrastination. Further, ADHD symptoms that persist in adulthood are possibly related to some persistent neurobiological perturbations. Such biological perturbations have been studied in respect to brain morphology and functions as well as brain neurochemistry since agents that affect dopamine and norepinephrine have been used successfully to remediate ADHD symptoms, as described below.The positive clinical effects of stimulants such as methylphenidate and amphetamines have drawn attention to the role of monoamines  in the pathophysiology of ADHD. More specifically, noradrenaline affects postsynaptic alpha (2A)-receptors in the prefrontal cortex (PFC) resulting in strengthening the connectivity among neurons while dopamine affects D (1) receptors, resulting in reduction of the “noise” from environmental input Arnsten, . PFC is Numerous studies have linked abnormalities in brain morphology, functions, and connectivity to hyperactivity and inattention observed in ADHD. For instance, morphological magnetic resonance studies have shown delayed cortical maturation  in children with ADHD versus non-affected controls  dysfunction that manifests early in life and persists throughout a lifetime  and hypoactive medial prefrontal regions  will have implications for treatment of overlapping and unique features of ADHD versus comorbidities. As effective as stimulants can be for the reduction of ADHD symptoms  establishes the criteria for deployment. DOD memorandum declares conditions such as schizophrenia and bipolar disorder as automatic disqualifiers for deployment—as for other conditions, including ADHD, the criteria require that the soldier will have to be functionally stable for at least 3 months. Additional considerations in determining fitness for deployment include the need for medication treatments. Stimulants are the first line of pharmacological treatment for ADHD; they are also controlled substances and as such they are deemed as potentially problematic during deployment due to issues of storage, procurement, and abuse potential.Despite these, further and more detailed investigations are needed to determine what might be the full extent of the relationship between ADHD symptoms and the highly stressful environments of the military service. It stands to reason to suggest that it is appropriate to establish more stringent criteria for deployment over enlistment while considering the fundamental differences between training and deployment in relation to environmental stress level and unpredictability. To summarize, it appears appropriate to have two different sets of guidelines that can address adequately the differences in environmental factors that can impact the course of neuropsychiatric disorders like ADHD. It seems appropriate to have somewhat stricter criteria for fitness for deployment; however, it should be noted that further narrowing of such criteria may unintentionally lead to under-reporting. Conversely, criteria that is too-loose lead to missed opportunities for appropriate diagnosing and treatment. In this next section, we will review the available literature on ADHD among military populations.Studies that examined the association between pre- and post-deployment mental disorders Taubman,  found thA few reports have examined the PTSD and ADHD comorbidity in both children and adults in terms of overlapping and unique clinical factors. Ford et al.  found thThe purported relationship between preexisting ADHD and late-in-life PTSD poses some serious challenges for the post-deployment rehabilitation of veterans. First, clinicians should consider the possibility that any particular sets of problems may not be exclusively related to a singular disorder  but could be shared by other conditions. It has been shown that behaviors like distractibility, poor attention to tasks, frustration with difficult tasks and alike are present in children with trauma or abuse  that may have been positively influenced by military environment to only re-occur with environmental change and may have been further influenced by military-related trauma. Establishing the presence of attention problems before the military service supports the diagnosis of ADHD independent of possible PTSD. In contrast, the onset of attention problems following focal trauma in the absence of symptoms in childhood/adolescence is suggestive of PTSD with attention problems independent of ADHD (see case below).N is a 29-year-old male who served in the Army and was deployed overseas on combat mission. He has a sense of fulfilled duty but also feels very conflicted about his combat experience as he lost close friends and also “I saw things that I did not sign up for.” After military discharge he returned to his home town to live with family and started running his own private business—however, he gradually started losing interest in managing the business “the way I should,” spends less time at work, delegates most of the work to his associates and has no patience to go over the details of how to sustain and make the business grow. He finds it difficult to read long passages and to comprehend balancing his accounts. “I used to love books and was great at math in high school.” He often finds himself distracted from business activities either by thoughts about his deployment or “visions” when he sees people who he was fighting against. “We shoot at them and kill them but then they get up and stare at me.” He also describes similar types of dreams and on days after such nightmares he finds it particularly difficult to get out of bed and follow his daily routine.Many factors may account for symptoms of poor attention and distractibility in veterans who will seek treatment in the VA system. The VA has implemented a system of check lists and reminders that will prompt clinicians to look for symptoms of PTSD, TBI, suicidal behaviors, substance use and the alike. However, screening for ADHD is not high on this priority list and it is possible that inattention will be attributed to conditions other than ADHD. Undiagnosed and untreated ADHD may have a significant negative impact particularly for veterans who enroll for secondary education mainly because of the effects of ADHD on the ability to perform academic work. From a clinical standpoint proper identification of ADHD based on past and present history will inform a specific treatment plan and remediation strategies.Given the current state of research into the symptom composition of ADHD and PTSD, a thorough clinical assessment remains the gold standard for proper differential diagnosis for veterans with trauma exposure and attention problems. As symptoms of ADHD may remit by late adolescence/early adulthood, “remission” does not always mean a full disappearance of these symptoms but rather changes in persons’ experience ; however, individuals with predominantly inattentive symptoms may remain undiagnosed until later in life. A detailed interview should be able to elicit a pattern of attention problems with some level of functional impairment that precedes military service and possible military-related trauma. These patterns may include self-reports of underperformance in school, failing tests despite understanding the material (due to careless mistakes or easy distraction) and that homework assignments took too long to complete. Clinicians should ask about additional data such as available school records  with teachers’ impressions and recommendations; when possible an interview with a spouse/significant other could be conducted after obtaining patient's consent.There are several scales that assess adult ADHD symptoms and their impact on functioning. These include Conners’ Adult ADHD Rating Scale  and tend to manifest in multiple settings , symptoms of PTSD are by definition related to either a focal trauma and chronic trauma exposure and are often associated and/or triggered by specific environmental factors. In Various treatments, both biological and psychosocial, have been developed to address the prominent symptoms of ADHD and PTSD. Cognitive-behavioral interventions should be considered and discussed for all cases of attention/cognitive deficits related to ADHD, PTSD or TBI in veterans. Clinicians should review learning styles and preferences, identify triggers and distractors and counsel patients on behavioral changes that could improve day-to-day functioning. These behaviors may include outlining preparatory steps before starting an assignment, using frequent breaks and time management charts, employing self-reminders by the use of electronic devices. It is also important to assess the baseline severity of functional impairment—in cases of ADHD the symptoms should be present in more than just one setting—and help patients to identify the most pressing problems and develop a personal “matrix” to assess possible treatment benefits .Among the many factors influencing treatment recommendations, there are two important considerations: 1) clinicians assessment as to what is the impact of symptoms on person's functioning and 2) patient's attitude toward therapy versus medications. Existing evidence suggests that psychotherapy  was preferred over medications  and that this preference was related to how the treatment was perceived to reduce PTSD symptoms  and non-stimulant (atomoxetine); alpha-2 agonists have been approved for children only although adult data are available. In addition, there is some evidence for clinical benefits in adult ADHD from bupropion, venlafaxine, modafinil and other drugs , these might have a different effect in persons with PTSD. The biology of PTSD is linked to persistent states of exaggerated sensitivity of various components of hypothalamic–pituitary axis (HPA) that patients may experience as states of high anxiety, hypervigilance, and recurrent panic attacks. These could be further exacerbated by pharmacological interventions aimed to benefit ADHD while on the contrary complicating comorbid PTSD. Therefore, it might be prudent to initiate stimulants at low doses and proceed with incremental dose changes; in general, possible side effects of stimulants are managed by discontinuation of the stimulant and in most cases these side effects are time limited. Similarly, as benzodiazepines could be very helpful with diminishing the intensity and the frequency of panic attacks, they may in turn exacerbate attention problems since psychomotor slowing is a common side effect of benzodiazepines.The successful management of these types of problems is dependent on adequate psycho-education with respect to both expected benefits and potential limitations/side effects. The clinician must emphasize that these treatments, although potentially very effective, do not provide “cure” for these conditions. Second, the clinician and patient need to discuss short-term versus long-term treatments. For instance, both stimulants and benzodiazepines have considerable abuse potential so it is probably best not to prescribe them simultaneously for extended amount of time. The clinician also has to instruct and work with the patient to assure reliable monitoring of the drug by starting with limited supplies and encouraging patient to take full accountability of his medications. With certain exceptions, refills for “lost” or “missing” medications should be discouraged. In addition to detailed substance use history, clinicians should request random urine toxicology to identify co-occurring drug use. Third, patients should be counseled and educated on alternative agents. These may include non-stimulants  receptor agonists) for ADHD and antidepressant SSRIs and gabaergic compounds  for PTSD. These agents lack abuse potential and therefore do not require the strict monitoring that is the standard of care for stimulants and benzodiazepines. The above outlined topics could be illustrated with the following vignette.K is a 28-year-old male requesting treatment for persistent attentional problems. He reports that in high school his grades are “just good enough to pass” and that he felt unmotivated and bored in class and “never did homework.” Although not formally diagnosed with ADHD, he remembers that teachers had encouraged his parents to seek psychological evaluation, which they never did. K enlisted in the military because “I knew I can never make it in college.” K was evaluated while in the service and was diagnosed with adult ADHD for which he received Adderall with positive effects. He reports that his work benefited as he felt more organized and focused. He also experienced focal combat-related trauma with subsequent flashbacks, nightmares, and panic attacks—the latter triggered specifically by airplane travel. After military discharge, he presented requesting continuation of treatment at the VA clinic stating that he needs Adderall in order to manage his academic work as he enrolled in college—the way the medicine helped with his military job suggested to him that he will be better able to do school work with the medicine. He was interested in therapy to resolve emotional issues related to his combat exposure and after several months of trauma-focused therapy, his flashbacks and nightmares have mostly resolved. As he continues to experience panic attacks specifically related to airplane travel (he traveled often for job interviews), he was prescribed a small amount of Clonazepam 1 mg tabs to take as needed for plane travel and these prescriptions were closely monitored. Taking into consideration the presence of anxiety symptoms, Adderall was changed to atomoxetine (Strattera) that was similarly beneficial and K was able to successfully complete his Bachelor's degree.Despite the progress, several areas related to the interplay between ADHD and PTSD in military service personnel remain poorly explored. Current recommendations for restricted duty are based on limited empirical data. Available evidence suggests that military personnel with preexisting and new-onset mental health conditions did not differ in the ability to perform their jobs. In addition, despite the high relapse rate of attentional and anxiety disorder during deployment, the majority of soldiers who seek mental health in-theater did not have known preexisting disorders, therefore factors other than prior mental health concerns clearly influence resilience during combat (Rona et al., In this paper, we reviewed DOD guidelines that allow for individuals with ADHD to enlist for military service. Preexisting ADHD may certainly affect soldiers’ participation in basic training and performance in theater. Under conditions of traumatic stress, individuals with ADHD may experience a relapse of ADHD symptoms as well as the development of new symptoms of inattention and other cognitive deficits that could be attributed to military-related PTSD. We suggest that proper understanding of the developmental aspects of ADHD and PTSD will inform the diagnostic procedures and will help clinicians to differentiate between these conditions. Further, clinicians’ knowledge about the neurobiological underpinnings of ADHD and PTSD should inform the choice of appropriate treatment strategies considering the use of both psychotherapy and psychopharmacological regimens alone or in combinations. The development of comprehensive and clear algorithms for diagnosing and treating ADHD in the military before and after deployment will have a strong positive impact on the quality of care delivered to soldiers and veterans.


Despite increasing knowledge of attention deficit hyperactivity disorder (ADHD) across the life span, there is still little research on adults’ own experiences of being diagnosed with ADHD. The aim of the present study was to explore and describe patients’ experiences and perceptions of being diagnosed with ADHD in adulthood. The study can be seen as an attempt to validate the diagnosis from a patient perspective.Twenty-one adults diagnosed with ADHD were individually interviewed. The interviews were open-ended and exploratory, analysed with a qualitative phenomenographical approach, and the results were described in categories.the diagnosis in focus). It was experienced as providing self-knowledge and increased value, but could also cause devaluation and concern about identity (identity in focus). It meant help to achieve a better life, but was also perceived to restrict possibilities and cause disappointment over lack of professional help. It could lead to a wish for an earlier diagnosis that could have spared suffering, as well as to a changed view of the participants’ relatives (life in focus). All but one of the interviewees expressed important positive consequences of being diagnosed with ADHD. About half of them acknowledged negative aspects of being diagnosed, but none regretted going through the neuropsychiatric evaluation.Positive experiences were dominant, but there was a complex intra- and inter-individual variation of experiences. Descriptions focused on the diagnosis, on identity, and on life. The diagnosis was described as explaining a previously inexplicable life history, but was also questioned, both as a phenomenon and in relation to the individual (From a patient perspective, there are major positive consequences of being diagnosed with ADHD, compared to the undiagnosed situation. Knowledge of the individual’s combination of experiences is important for professionals, as these experiences can affect well-being and interfere with treatment. Negative experiences in particular might need to be addressed in the treatment work. Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood-onset psychiatric disorders, with an estimated prevalence of 5-7% in children and adolescents e.g. ,2). It a. It a2])Estimating the prevalence of adult ADHD is difficult because the DSM clinical criteria have not been validated for the adult population  and the diagnosis of ADHD. Instead, they target certain aspects of the phenomenon, such as effects on coping, or related phenomena, such as symptoms. Some of the studies have assessed younger populations  in the end … I’ve been searching for my entire life and trusted that someone would finally understand that something isn’t right” (10). The interviewees no longer needed to put energy into trying to find explanations for the feeling of being different and for unsuccessful behaviours or negative events that were previously difficult to understand: “It was a relief to find out what was wrong, why I got into fights, why I always quit my job, why I always get tired of people, and why I always get so pissed off at everyone” (6). Their life histories were given a new meaning: “I can filter myself and the world around me through it [the diagnosis] … I can explain why things happened before or I can explain what may happen after” (1).Some positive traits were attributed to ADHD and perceived as resources, such as creativity, new thinking, passion, quickness and productivity: “I see ADHD as something positive, almost more positive than negative. I wouldn’t have been able to get everything done if I hadn’t had ADHD … Everyone could probably use a bit of ADHD at some point in their lives to clear things up” (15). ADHD could contribute to an interesting and exciting life: “If I could choose a life without ADHD, I wouldn’t choose it, I would like to have it … you get to have a pretty fun life, I think … there’s a lot happening all the time with me” (1). A person with ADHD was described as being spontaneous, funny, and “a little crazy” in a positive way.There were different degrees of doubt concerning the ADHD diagnosis, and various reasons and arguments were expressed. Firstly, the actual existence of ADHD as a diagnosis was questioned. Some interviewees expressed the idea that modern society is not adapted for everybody, or that symptoms regarded as ADHD-related could instead be caused by adverse childhood conditions or by external factors in the society/environment: “These symptoms, I think they’ve also become an effect of the way we live” (18). The question of where to draw the diagnostic boundaries was raised.I’ve had discussions with people and I’ve said that I have ADHD, then I got the answer ‘really, you do? But you’re so calm, you never get angry’ … Many people believe that I don’t have ADHD … their picture of ADHD is something else … I don’t fit into their picture. (7)Secondly, the interviewees had experienced questioning over the accuracy of their diagnosis, both by themselves and by others. One reason for this was that the individual did not seem to fit into the stereotypical conception of what a person with ADHD is like, or did not resemble other people with ADHD in their circle of acquaintances:If the individual had been diagnosed with other conditions prior to ADHD, the ADHD diagnosis could lose some of its credibility. Not responding to medication or responding well to non-medical therapy were other reasons for questioning the correctness of the diagnosis. Finally, the diagnosis could be perceived as unnecessary: “I don’t need to have a diagnosis to have problems with certain things … I work with what I have to work with, then whether or not it’s ADHD, it just isn’t so damned important to me” (18).Then I was sad because my behaviour has been a little special, since I’ve been extremely cocky … so then I started thinking about it, hell they think I’m a fool, not that I have ADHD, but just purely for my behaviour, that I always look like I’m not listening. (1)The focus of this category was on learning about oneself and one’s functioning: “You gain deeper insight into who you are, that’s what you really want, who am I, what am I doing?” (1). A new self-understanding developed: “You gain better self-awareness, because you aren’t always what you think you are” (3). New insights could change the understanding of how oneself and one’s behaviour were experienced by others:Everything, like half my life, all I’ve done, all the feelings I’ve had, might not have been so right … that I’ve been false in some way, that it wasn’t right to think this way, and act this way … you do things wrong, everyone who criticized you, suddenly it feels like they were right, that I have fought against them and tried to do things my way. (6)When certain characteristics and behaviours were connected to ADHD, they could be revised and perceived as wrong and unwanted:When problems and difficulties were seen as symptoms of a diagnosis, they could be painfully transformed from temporary to lifelong: “Now I have this shit, I thought, because I knew there was no way to get better, there are no tricks to become healthy … so it’s a handicap … I have to live with it” (1).Being diagnosed with ADHD was described by the participants as legitimizing difficulties and unacceptable behaviours, thus improving their self-worth as well as other people’s views of them.You don’t feel nearly as stupid any more … I don’t have to be ashamed any more, I know it’s a disease, I can’t do anything about it, it isn’t my fault, it’s hereditary, before it was that you were careless and lazy. (15)The interviewees perceived the ADHD diagnosis as improving their value and creating a more positive self-conception. Having ADHD was less harmful to identity than being characterized as “stupid”, “lazy”, “angry”, “bad tempered”, “aggressive”, or “crazy”:The diagnosis could reduce the feeling of guilt, as the individual became less responsible for failures and misbehaviours: “It isn’t my fault that I’m a bad person in some cases” (1). Even the experience of being disabled and abnormal could be reduced: “Before I didn’t know why I was like that, and then I felt more abnormal … now I feel more normal, loads of people have ADHD” (14). The diagnosis seemed to be separated from the self: “There was nothing wrong with me … I just had a diagnosis” (20).I felt that I shouldn’t set such high standards for myself, but I would accept that I’m the way I am, and I wouldn’t come down on myself and think ‘you’re an idiot, everyone can do this’, yes, everyone who has that ability, but I don’t have that ability. (13)The experience of increased value meant treating themselves kindly and not tolerating bad treatment from others: “I’ve probably become tougher, I think … now I know why they can’t get on my case … I don’t have to take any crap” (7). Individuals respected their limitations: “Before, it was more that I wanted to be normal and keep up with others, now it’s more that I’m normal, it’s just too much for me … why do something I can’t manage?” (14). They reduced their demands on themselves and judged themselves less harshly:The interviewees, within this category, experienced their ADHD diagnosis as making it easier to communicate their problems to others: “When I didn’t know what it was, I didn’t know how to explain it either” (7). When an individual’s shortcomings were interpreted in terms of ADHD, they became legitimate and other people’s understanding of them changed, resulting in a changed attitude and a kinder treatment: “They excuse me, they think ‘she isn’t crazy … she just has ADHD’” (20). It was experienced as less disparaging to have ADHD than to be categorized as, for example, “a disruptive child”, “impolite”, or “nonchalant”: “I’d rather be stamped with the ADHD diagnosis than walk around and have people think I’m weird” (12) and “It’s stranger to be weird or different or a difficult child than to have a diagnosis” (16). After they were diagnosed, people did not think as badly of them as before, and irritation and demands were reduced: “People treat me very differently now, a huge difference … I’ve had contact with social services for many years … I’ve felt like they were treating me as though I’ve been lazy and not wanting to achieve anything, and now they’ve completely changed their tone” (7). Instead of being “punished”, adjustments were made and they were shown consideration and indulgence: “Finally they understand what it’s like for me, and society can accept me for who I am” (3). The interviewees no longer had the same need to lie, cheat, or find excuses to avoid or cover up failures and difficulties, in order to preserve their value in relation to others: “Nobody wants to say ‘I’m worthless’, and that’s why I’ve been forced to cheat in school many times … if they’d just given me an extra five minutes, I would have managed it” (3).I don’t say ADHD, I say that I have dyslexia, ADHD sounds so ugly in everyday speech … I heard adults who were talking about it yesterday … then they said ‘yes, it’s typically the damn kids with ADHD’ … My daughter doesn’t know it, ADHD is still very ugly at their age. They bully each other on the playground and ‘fucking DAMP kid’ is a term that is used a lot. (15)Within this category, the ADHD diagnosis was experienced as decreasing a person’s value: “You’re worth a little less than other people [when you have ADHD]” (18). The experience of devaluation could spring from the comparison of oneself to others: “I want to be like everyone else” (4) and “I don’t want to be worse than others … there’s something wrong with me … I don’t work like the others” (11). It could also be the result of stigmatization, in the sense of having a characteristic which makes a person differ from the norm in a certain context, resulting in devaluation :I don’t You become a different person in the eyes of others, you might not be respected for who you are and your thoughts and opinions are not valued as highly as before … She checks the situation all the time as though there is something sick about me, that I’m someone weird … (6)The devaluation was described in terms of being, for example, “different”, “stupid”, or “less capable”: “When I’m a bit depressed I sometimes think it feels a little like a defect” (8). The diagnosis was associated with “shame” and “low status”, and with being “judged” and “disrespected”:I didn’t want special treatment in front of others and in front of myself … Just because I have a diagnosis, it means you should have extra help because you can’t manage things like all the others manage and then you feel a bit handicapped. (20)The interviewees described feeling excluded, like an outsider; not belonging to the “healthy world”, but to an outgroup: “Now it’s like I have this diagnosis, OK now I get to join this club” (11). Being in need of help and receiving special treatment could in itself be stigmatizing:Sometimes the interviewees did not reveal their diagnosis to others because they were afraid of being looked down on: “I don’t tell anyone, when you’re an adult you don’t want to seem too stupid” (5). One approach to reduce the negative effect on identity was to point out that they only fulfilled some of the ADHD criteria: “I say that I have ADHD and that I have only two things in it … they shouldn’t think that I have everything” (5).Some interviewees spoke about the possibility that the ADHD diagnosis might interfere with identity, raising questions and worries concerning identity. Concern was expressed as to whether one could remain the same person after having been assigned a diagnosis of ADHD: “Do I have to start all over again or will I become someone else now, I was confused” (6). There were worries about how to retain one’s individuality and identity, both in relation to oneself: “It’s easy for me to over-interpret things through the lens of ADHD … it’s like I identify with this” (11) and in relation to others: “I’m still me … I don’t want to be seen as an ADHD person, I want to be seen as [says her name] …” (11).Another issue was how much of an individual’s characteristics and behaviour could be explained by ADHD: “How much of me is ADHD, of what I do? … Do I have ADHD only when I get angry or do I have ADHD all the time?” (6).Being in need of help could serve as an important motivating factor for wanting a neuropsychiatric evaluation: “First I had an evaluation made that I ignored … it felt silly to get some diagnosis … but then I realized that I need help … I have no life …” (8). The search for help prior to being diagnosed had sometimes been desperate: “I pretended to be an alcoholic because I was thinking, they get help, they get loads of help” (10). Individuals represented in this category felt that being diagnosed could improve the possibilities of having a good – normal – life. The knowledge of what they were dealing with made it possible to try to do something about it themselves or to seek professional help: “It’s hard to do anything about it if you don’t know what it’s all about” (8).The interviewees experienced their ADHD diagnosis as opening possibilities of receiving help from the people around them in daily life and from different institutions in society such as health and medical care, the social insurance office, the employment agency, and the social services: “A person who is just angry, they have no guidelines in the same way … but when I got a diagnosis, it was more, ‘oh great, so that’s how we should deal with it’” (14).One consequence could be reduced suffering: “… chance for a normal or comfortable life instead of a life of torment … because it’s been a torment considering that my body is so restless” (9). Another effect was improved functioning: “The medicine works so that I can manage for a whole day and then I feel it’s far more likely I’ll be able to cope with a real job, and that’s really great” (17). Sometimes effects on the individual’s behaviour could be of vital importance: “It was untenable before … the medicine has made me grow up … it’s OK for a 20-year old to behave immaturely, but as a 30-year-old, it isn’t accepted …” (19).In my case it was a life, a life with dignity … The diagnosis and the medicine together and then suddenly doors are opening everywhere … I can finally do things I’ve longed to do … like read, knit and go to the gym … I have a positive feeling within me that life is beautiful. (10)The change in living conditions could be powerful. This was sometimes described as necessary or life-saving:I couldn’t vacuum because the vacuum hose bending was enough to make me so angry that I started to break things. It was almost like things got better just from knowing that it was ADHD, because not knowing why I was so angry just built up my irritation. (14)When the interviewees understood their own reactions in terms of ADHD, they knew what to expect from themselves, and were less likely to get angry with themselves when, for example, they got to the point of losing their concentration or their temper. Instead, they could focus their energy on managing the situation:In the past, I could make an explanatory model based on others … like, I could have the perception that I’m a genius, the others are stupid … now I mainly think that there’s a risk of me being a burden to others … if there is any opportunity for me to improve my behaviour or who I am, obviously I do it. (1)When they recognised a certain behaviour as having been caused by ADHD, they no longer defended it but instead regarded it as incorrect, motivating them to try to change it:avoiding situations where they had to face major limitations related to ADHD, compensating , and fighting (e.g. to defy impulses or the feeling of restlessness):I am impulsive and can just do an about-face … and then I might think ‘it’s just an impulse, it doesn’t have to be that way, it’s just the way it feels right now’ … I have to think a bit harder because I can easily become annoyed, angry at things or people and stuff and that may not always be the case if I think about things a little longer. (8)The interviewees described looking at themselves from a different perspective: “I feel like I’m constantly looking for kicks … you get a completely different picture of it … as an adult, I think either I have to replace it with something else or I quite simply have to shape up” (3). Their new understanding of their own difficulties could inspire a search for ways of handling their ADHD symptoms, resulting in different strategies: … then you sit down properly and read, the end result will be positive. I know it’s hard, so then I bloody well have to do it … You have to deal with driving a car too … when it’s hard to stick to the speed limit, because it’s slow, I know why I think it’s slow, and then I might as well follow the speed limit. (1)This could improve their ability to handle different situations in daily life. One interviewee said that the knowledge of having ADHD had helped him become a better driver, and also a better parent through enabling him to read to his children:Another person described how the ADHD diagnosis made her avoid potentially harmful situations: “I would never dare to take drugs … because I know what it would certainly mean for me” (10).I think the diagnosis made me more motivated to do it, because now I know what I’m doing is right, otherwise I would have done it at random and thought maybe it was right, but now I know it’s absolutely correct. (3)The diagnosis also acted as a motivating factor through confirming pre-existing coping strategies:There was some concern that an ADHD diagnosis might limit their possibilities in life, either through being an obstacle in relation to society or through the loss of self confidence.Still, it’s a threat, I’ve managed for 35 years and it feels like everything would suddenly be ruined now I have a diagnosis, that suddenly I might not be suitable for some stuff because no one knew this before … now suddenly it’s on file somewhere, somewhere in some database it says that I have the diagnosis of ADHD … it’s just that you don’t know how it can be twisted, that you have a diagnosis, how the authorities will treat it, even though it is a disability. (15)Some interviewees expressed the worry that the surrounding world, society, and different authorities could judge them differently and more negatively if they had a diagnosis of ADHD, resulting in other people distancing themselves from them, difficulties starting a relationship, or difficulties obtaining for example employment, a certain education, life insurance, or a driving licence. As a consequence of this, the interviewees ruminated over whether or not they should tell others about their diagnosis: “You wouldn’t say at a job interview, ‘yes, by the way, I have ADHD,’ because then you probably won’t get the job … If I meet a guy, how do I tell him about this?” (11). There was also concern that the diagnosis might be recorded in various places and used against them:They told me it would be very difficult for me to have a management position … but what if I’m not like that, then it becomes an obstacle for me, because then I might believe it myself … You become very limited because you already find out when they are doing the workup and making the diagnosis that there are some tasks you can manage and others you can’t and some stuff you do and say may be because of it [ADHD], and then you believe it yourself and then you live based on that … I don’t really dare, no, but I’m not like everyone else, I have ADHD, I might not manage this because that’s what everyone around me and my psychologists are saying and it’s OK for me to be weird, I get to say strange stuff because I’m always excused anyway … They build my life in a way, in that they set limits and they give assistance that might or might not be needed. (20)The essence of this category was concern that an individual might not be as disabled as the ADHD diagnosis might imply; that a person’s possibilities in life might be underestimated because of the diagnosis, resulting in the diagnosis working as a self-fulfilling prophecy. Gaining knowledge of the difficulties associated with ADHD, during the diagnostic process, could result in a loss of self-confidence and the courage to try, for example, certain jobs or educational opportunities. One could lose one’s freedom and start living according to the diagnosis, letting the diagnosis guide one’s choices and thereby avoiding things which are considered difficult or impossible for people with ADHD. Certain behaviours were excused when related to ADHD, resulting in decreased motivation to change:The interviewees, represented in this category, described experiences of being left without the expected follow-up, help, and treatment after completion of the diagnostic process: “Then [after being diagnosed] they just dismissively sent me away with nothing, I was one of the crowd who was done … a failure, a betrayal from the healthcare system” (4). Their hopes of being offered professional information, advice, tools, means of assistance, medication, or conversational therapy were not fulfilled. They stressed the need for combining different treatment approaches: “It’s a huge handicap … I won’t get healthy just because I take a pill, I don’t think so, but you probably have to combine it … counselling and pills” (16).The experience of being met by ignorance from different helping authorities/institutions was also included in this category.You might have had a completely different life if it had been discovered earlier … if they had prescribed those drugs … if I had received these assistive devices … then I would have been able to get an education … I would have had a greater chance … because now you were just classified as the difficult pupil in the class. (19)This category included feelings of disappointment, frustration, anger, and sadness over not having been diagnosed earlier in life: “I think I felt sadness … lost time … how badly I was treated … it was, well, the whole thing, everything in those years [before the diagnosis] … ” (10). These feelings sprang from the belief that early diagnosis could have spared them suffering and provided possibilities of a better life through the understanding, help, treatment, and increased self-knowledge that followed diagnosis. Thoughts were expressed that an early diagnosis could have resulted in a different childhood: “ … if my mother had known what I know now, she would have treated me differently, just as I’m changing the way I treat my child” (3). Failures in school and working life could have been avoided:I get a little angry that I didn’t get an answer earlier, I mean then maybe my life would have been different, maybe I would have lived together with the father of my children … the relationship ended because my mood just got worse and worse, so if I had received this diagnosis 10 years ago, maybe we would still be living together, peacefully and harmoniously, and the children might have been less stressed. If I drop a pot in the kitchen now, everyone becomes terrified. They think I threw it. (16)Relationships might have been saved:Painful experiences of being taken advantage of and maltreated might have been avoided: “I could have been more on my guard … If I had been the way I am now [after diagnosis and treatment], I would probably not have suffered as badly back then as I did … ” (10).Other difficult experiences that the interviewees believed might have been avoided included drug and alcohol abuse, criminality, depression, anxiety and fatigue syndrome, as well as the pain of being misunderstood and punished by others and blaming themselves for shortcomings due to lack of an alternative explanation: “Imagine if someone had figured out ten years ago that I had ADHD, then I’d have been spared all of this, wouldn’t have had to go to jail, maybe I’d have had a real job today … wouldn’t have had to live the life I’ve lived” (6).I: Have you ever thought about what it would have been like if you hadn’t been worked up, diagnosed and treated?IP: Yes, I have, I probably would have killed myself, actually. (21)The interviewees’ belief in the positive impact of early diagnosis seemed to be based on their having experienced pronounced improvement of their well-being and possibilities in life after being diagnosed:IP: What should I think about my daughter’s behaviour, is there any way I can begin now to compensate for, for her then … I’m still not at all sure that she is in the same spectrum as I am, but I have to constantly be aware so that she doesn’t get into trouble.I: But how do you think your knowledge about the diagnosis can help her?IP: By perhaps not setting demands that are impossible for her to meet, which could have quite dramatic consequences for her self-confidence, by showing patience in areas where I normally wouldn’t. (1)The knowledge of having a hereditary disorder made the interviewees wonder whether their close relatives, such as parents and children, suffered from the same condition. This awareness could increase their understanding of their own parents: “My mother has strong ADHD, I can say, though she hasn’t been diagnosed, and being diagnosed myself has helped me to understand her better” (3). It could also trigger grief over parents who had not been offered any help because they were never diagnosed: ” … I get very sad when I think about it, because I am mainly thinking about my mother, who has it, but doesn’t know it” (1). Some individuals also actively looked for ADHD symptoms in their own children, because they considered early diagnosis and help important in order to avoid the suffering they had experienced themselves prior to diagnosis:the diagnosis in focus). It was experienced as providing self-knowledge and increased value, but could also cause devaluation and raise questions of identity (identity in focus). It was described as bringing about a better life situation, but also as restricting possibilities and causing disappointment over lack of professional help. Sadness and anger were expressed in relation to a wish for earlier diagnosis that might have spared suffering. A changed view of relatives was described (life in focus). One possible explanation for the intra-individual variety is that an individual exists in different contexts, such as family, friends, school, the workplace, and different authorities; reactions to (and consequences of) an ADHD diagnosis can vary between these contexts. An individual’s ways of relating to these different contexts can result in a variety of seemingly incompatible experiences and perceptions.The positive consequences of being diagnosed with ADHD were dominant in this material. However, there was a rich and complex intra- and inter-individual variety of different experiences. Descriptions were focused on the diagnosis, on identity, and on life. The diagnosis was described as explaining a life history that was previously hard to understand, but the diagnosis was also questioned, both as a phenomenon and in relation to the individual .The results showed that individuals experience major benefits from being diagnosed with ADHD as compared to the pre-diagnostic situation. All participants would have chosen to go through the neuropsychiatric evaluation that resulted in an ADHD diagnosis again, had they been undiagnosed at the time of the interview. This could be seen as their overall value judgement of being diagnosed with ADHD. The experience of the diagnosis can, however, be connected to, and influenced by, the experience of the diagnostic process. One of the interviews (18) was dominated by negative consequences, and we cannot rule out the possibility that it is the opinion of the neuropsychiatric evaluation that is reflected in the overall value judgement. Our general impression from the interviews was that the neuropsychiatric evaluation was regarded as an important learning situation, where the individuals got to know themselves better, as well as a situation where their experiences were validated.All but two of the interviewees welcomed ADHD as a satisfying explanation for the difficulties and failures they had experienced, and for the feeling of being different. The diagnosis gave relief, as it brought an end to the feeling of confusion, the frustration of not understanding, and the energy-consuming search for an explanation. The same experience of life becoming more comprehensible through the diagnosis of ADHD was described by Young and co-workers  and by FThe category “I can help myself” was a key result, which, to our knowledge, has not been described in previous studies. Within this category, the diagnosis can be seen as a potential resource in treatment work. Following the ADHD diagnosis, certain behaviours were revised, no longer considered parts of oneself, but re-characterized as symptoms of a disorder, and thus regarded as wrong and unwanted. In this way the diagnosis in itself seemed to serve as a strong motivating factor for change, enabling individuals to mobilize their own resources and change their behaviour, resulting in increased well-being and improved functioning in everyday life.Our results suggest that many individuals diagnosed as adults have a past life history of suffering, not only related to ADHD symptoms but also to the absence of a satisfying explanation for the difficulties they have experienced. This results in confusion and frustration; being misunderstood, negatively judged, and badly treated; not receiving adequate help; and blaming oneself for failures in different areas of life, resulting in a low self-worth. Whether or not these individuals would have had a more positive life history had they been diagnosed during childhood is impossible to determine in retrospect, but this was a commonly expressed view in the material. More than half of the interviewees expressed a wish for earlier diagnosis that could have spared suffering and made life turn out differently, in line with findings by others ,29,30.ADHD, both diagnosed and undiagnosed, has the potential to interfere with and affect a person’s identity in a number of different ways. It is clear that the ADHD symptoms border on what is considered one’s personality: “ADHD is part of my personality” (3). Some of the interviewees had not only come to terms with having ADHD, but did not want to be without it. They believed that certain parts of the ADHD symptomatology contributed in an important positive way to their personality and life. The perception of ADHD as an advantage was also described by Fleischmann and Fleischmann .Despite the above positive descriptions, about half of the participants also expressed substantial negative consequences of being diagnosed with ADHD. It seems important for professionals to be aware that these negative aspects exist, so that individuals can be offered help to deal with them. The category “The diagnosis causes decreased value” is a reminder that the problem of stigmatization is real and needs to be addressed. In the studies mentioned above by Young and co-workers  and ToneAlthough our study revealed both positive and negative experiences, and the interview stage was not concluded until no new experiences emerged, it is impossible to ensure that the full variation of experiences in a population is covered. Moreover, even though some experiences might be the same, the results cannot automatically be generalized to other populations. The individuals were recruited from the same specialized clinic, they had all been motivated to go through a neuropsychiatric evaluation, and the group was relatively homogenous in terms of age and time since diagnosis. In addition, it was necessary to exclude individuals with severe comorbid conditions in order to isolate the phenomenon. Finally, the experiences found here undoubtedly also reflect the socio-cultural context in which the participants live. Therefore, individuals who, for example, are more reluctant to seek help, have a different comorbid setup, or live in a society with different views on ADHD might have different experiences.The dominance of perceived positive consequences of being diagnosed with ADHD support that adults who may have undiagnosed ADHD should be offered a neuropsychiatric evaluation. Furthermore, the lack of early detection seems to carry potential negative effects. Our interviewees highlighted the importance of the transition between the diagnostic and treatment processes, as they expressed experiences of abandonment after the neuropsychiatric evaluation was complete. Diagnosis of ADHD should be followed by a broad offer of treatment and follow-up characterized by an overall view of the individual’s life situation, self-perception and health care needs, and not merely focused on medication.It is especially important for professionals to be aware of potential negative consequences of being diagnosed. Patients’ experiences can affect well-being and interfere with different treatments. Some positive experiences can be considered resources (e.g. “I can help myself”) while negative experiences might create obstacles . Knowing a person’s combination of experiences can improve cooperation and facilitate planning of treatment to meet individual needs. Knowledge of the rich palette of different experiences can facilitate introduction of alternative or complementary ways of thinking.Finally, using patients’ perspectives on diagnoses may be a further step in validating psychiatric diagnoses.