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Cited by 837Attention Deficit Hyperactivity DisorderMental Health Treatment and AccessChild and Adolescent Psychosocial and Emotional Development

The descriptive epidemiology of DSM-IV adult ADHD in the world health organization world mental health surveys

Open access
on behalf of the WHO World Mental Health Survey Collaborators, Fayyad, John, Sampson, Nancy A., Hwang, Irving, Adamowski, Tomasz, Aguilar-Gaxiola, Sergio, Al-Hamzawi, Ali, Andrade, Laura H. S. G. +18 more·2017·ADHD Attention Deficit and Hyperactivity Disorders
DOI 10.1007/s12402-016-0208-3PMC PMC5325787
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Abstract

We previously reported on the cross-national epidemiology of ADHD from the first 10 countries in the WHO World Mental Health (WMH) Surveys. The current report expands those previous findings to the 20 nationally or regionally representative WMH surveys that have now collected data on adult ADHD. The Composite International Diagnostic Interview (CIDI) was administered to 26,744 respondents in these surveys in high-, upper-middle-, and low-/lower-middle-income countries (68.5% mean response rate). Current DSM-IV/CIDI adult ADHD prevalence averaged 2.8% across surveys and was higher in high (3.6%)- and upper-middle (3.0%)- than low-/lower-middle (1.4%)-income countries. Conditional prevalence of current ADHD averaged 57.0% among childhood cases and 41.1% among childhood subthreshold cases. Adult ADHD was significantly related to being male, previously married, and low education. Adult ADHD was highly comorbid with DSM-IV/CIDI anxiety, mood, behavior, and substance disorders and significantly associated with role impairments (days out of role, impaired cognition, and social interactions) when controlling for comorbidities. Treatment seeking was low in all countries and targeted largely to comorbid conditions rather than to ADHD. These results show that adult ADHD is prevalent, seriously impairing, and highly comorbid but vastly under-recognized and undertreated across countries and cultures.

Integrity signals

Registry

Crossref · 10.1007/s12402-016-0208-3

Cites

66 of 66 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

13 of 43 cited sources checked · 7 supported · 0 flagged · accuracy not yet measured

  • Interpretationcitation

    Previously reported higher male-to-female ADHD ratios may have been a function of referral or treatment bias, as a higher proportion of boys than girls with ADHD receive treatment.

    “This finding suggests that previously reported higher ratios may have been a function of referral or treatment bias, as it is known that a higher proportion of boys than girls with ADHD receive treatment”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Derks et al. 2007 source
  • Premisecitation

    Other WMH research on treatment seeking for mental disorders has shown that the most important barrier is failure to recognize that the symptoms of the disorder constitute evidence of an 'illness' that could profit from treatment.

    “Other WMH research on treatment seeking for mental disorders has shown that the most important barrier is failure to recognize that the symptoms of the disorder constitute evidence of an “illness” that could profit from treatment”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Andrade et al. 2014 source
  • Findingown data

    The WMH surveys replicated the negative association between age and ADHD prevalence found in meta-analysis, despite the sample's truncated age range of 18-44.

    “Meta-analysis finds that this association is negative (Simon et al. 2009), a result that we replicate in the WMH surveys despite the fact that the age range of our sample was truncated (18–44)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Simon et al. 2009 source
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.
  • Premiseown data

    This WMH result is inconsistent with other evidence suggesting that adult ADHD is associated with low family income.

    “This result is inconsistent with other evidence suggesting that adult ADHD is associated with low family income”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Martel 2013 source

      The Results report lower family income in the ADHD diagnostic groups, and the Discussion links lower family income to increased ADHD symptoms. But the study concerns children, not adults, so it does not establish the claimed association for adult ADHD. Page numbers were not supplied. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Findingcitation

    Individuals with remitted ADHD have the same significantly elevated risk of some subsequent secondary disorders, such as alcohol use disorder, as those with active ADHD.

    “Our retrospective finding that individuals with remitted ADHD have the same significantly elevated risk of some subsequent secondary disorders such as alcohol use disorder as those with active ADHD”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Tuithof et al. 2012 source

      Section 3.1 reports that respondents with ADHD had a significantly elevated risk of developing alcohol use disorder before adjustment for conduct disorder. The paper does not compare remitted with active ADHD, so it cannot support the claim that their risks are the same. It also reports that the ADHD–alcohol use disorder association was no longer significant after adjustment for conduct disorder. Page numbers were not available in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.
  • Classified as probably not a substantial claim. 26
  • May combine two claims. 42

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Retrospective reports were used to date age-of-onset of each lifetime disorder using probing methods that have been shown experimentally to improve accuracy of recall.

    “Retrospective reports were used to date age-of-onset of each lifetime disorder using probing methods that have been shown experimentally to improve accuracy of recall (Knäuper et al. 1999).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Knäuper et al. 1999 source

      The Current Approach describes revised NCS questions that prompted a more thorough memory search, and the Methods and Procedures evaluates their use for major depression. The Discussion says indirect indicators suggest improvement, but the absence of a gold standard prevents a direct measure of accuracy; it does not establish experimental improvement in recall accuracy for each lifetime disorder. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    This finding is consistent with previous research showing that adult attention deficits are elevated among people who are divorced.

    “This finding is consistent with previous research showing that adult attention deficits are elevated among people who are divorced”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Bouchard and Saint-Aubin 2014 source

      The Abstract and Discussion report poorer executive control among adults who had divorced and were currently cohabiting. The Discussion specifies that these deficits were observed only in that subgroup, not among divorced people who had remarried, so the claim is too broad. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Adult ADHD is associated with substantial impairments in productive role functioning, social role functioning, and most strongly in cognitive functioning.

    “Our results regarding role impairments are also consistent with much previous research in showing that adult ADHD is associated with substantial impairments in productive role functioning (Kupper et al. 2012), social role functioning (Bouchard and Saint-Aubin 2014), and most strongly in cognitive functioning (Ivanchak et al. 2012)”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites Kupper et al. 2012 source
    • cites Bouchard and Saint-Aubin 2014 source

      The Abstract and Conclusion link attention deficits with divorce, a social or relational consequence. But the study sampled couples from the general population and did not establish that its participants had adult ADHD, so it does not directly support the claim about social role impairment in adults with ADHD. The productive and cognitive functioning clauses have separate citations and are not attributed to this paper. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites Ivanchak et al. 2012 source

      The section “Adult ADHD-Associated Cognitive Impairment and Comorbidities” reports that cognitive deficits related to ADHD can persist into adulthood and possibly the geriatric years. It does not compare the strength of cognitive impairment with productive or social role impairment, so it does not establish the claim’s “most strongly” qualifier. No page number is available in our copy. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The WMH finding of high comorbidity in ADHD is consistent with much previous research.

    “Our finding of high comorbidity in ADHD is consistent with much previous research”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Babcock and Ornstein 2009 source
    • cites Karlsdotter et al. 2016 source
    • cites Mao and Findling 2014 source
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • Classified as probably not a substantial claim.

    Premisecitation

    Recent community cohort studies have suggested that there may be cases of 'adult onset' ADHD among individuals without a prior history of ADHD in childhood.

    “Recent community cohort studies have suggested that there may be cases of “adult onset” ADHD among individuals without a prior history of ADHD in childhood”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites Agnew-Blais et al. 2016 source
    • cites Caye et al. 2016a source
    • cites Moffitt et al. 2015 source

  • May combine two claims.

    Findingown data

    Logistic regression in the ACDS clinical reappraisal sample predicted DSM-IV/ACDS diagnoses of adult ADHD from CIDI symptom questions with good diagnostic classification accuracy, AUC .86.

    “Logistic regression analysis was used in the ACDS clinical reappraisal sample to predict DSM-IV/ACDS diagnoses of adult ADHD from CIDI symptom questions. Diagnostic classification accuracy was good, with area under the receiver operating characteristic curve (AUC) of .86.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Both threshold and sub-threshold childhood ADHD were associated with significant reductions in odds of completing college, but persistence of childhood ADHD into adulthood was not associated with educational attainment.

    “We found that while both threshold and sub-threshold childhood ADHD were associated with significant reductions in odds of completing college, persistence of childhood ADHD into adulthood was not associated with educational attainment”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Retrospective reports of childhood ADHD symptoms are sufficiently accurate to estimate childhood ADHD prevalence and persistence.
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    All but one of the ORs for disability remain significantly elevated in the range 1.5-2.1 after controlling for comorbid disorders, the exception being an insignificant association of current ADHD with disability in self-care.

    “Nonetheless, all but one of the ORs remain significantly elevated in the range 1.5–2.1 in the latter models, the exception being an insignificant association of current ADHD with disability in self-care.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The WMH results regarding 12-month adult ADHD treatment are broadly consistent with much other research showing that only a minority of people with mental disorders obtain treatment and that this treatment rate is lower in less developed than developed countries.

    “Our results regarding 12-month adult ADHD treatment, finally, are broadly consistent with much other research in showing that only a minority of people with mental disorders obtain treatment and that this treatment rate is lower in less developed than developed countries”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Wang et al. 2007 source
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    ORs for comorbidity with individual disorders were in the range between 2.5 (major depressive disorder) and 15.0 (oppositional defiant disorder), 4.4 with any comorbid disorder, and increasing with number of comorbid disorders (3.0 with exactly one, 6.2 with exactly two, and 9.6 with three or more).

    “ORs were in the range between 2.5 (major depressive disorder) and 15.0 (oppositional defiant disorder) with individual comorbid disorders, 4.4 with a summary variable of having any comorbid disorder, and increasing ORs with number of comorbid disorders (3.0 with exactly one comorbid disorder, 6.2 with exactly two, and 9.6 with three or more”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Current prevalence of adult ADHD in the total sample averaged 2.8% across surveys, with range 0.6-7.3% and inter-quartile range 1.8-4.1%.

    “Current prevalence of adult ADHD in the total sample averaged 2.8% across surveys, again with high range (0.6–7.3%) and inter-quartile range (1.8–4.1%)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Childhood ADHD was not significantly associated with respondent age at interview, current employment status, current marital status, or current income.

    “childhood ADHD was not significantly associated with respondent age at the time of interview (which, as noted above, was in the age range 18–44), current (at the time of interview) employment status, current marital status, or current income”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The WMH retrospective estimate of childhood ADHD prevalence was 3.3% in high-income countries, 2.2% in upper-middle-income countries, and 0.6% in low-/lower-middle-income countries.

    “The WMH retrospective estimate of 3.3% in high-income countries is intermediate between these two estimates, while the estimate of 2.2% in upper-middle-income countries is lower and the estimate of 0.6% in low-/lower-middle-income countries substantially lower”
    Quote in the paperSubstantial claim
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    The WMH surveys found the same odds ratio of 1.6 for adult ADHD among boys versus girls, due to the absence of a significant sex difference in persistence of childhood ADHD into adulthood.

    “We also found the same OR for adult ADHD due to the absence of a significant sex difference in persistence of childhood ADHD into adulthood”
    Quote in the paperSubstantial claim
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    The WMH series includes a much wider range of countries than the meta-analysis and finds a strong association between country income level and ADHD prevalence.

    “the WMH series includes a much wider range of countries and, as with childhood ADHD, finds a strong association between country income level and prevalence”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    Respondents with adult ADHD were significantly less likely than other respondents to be currently married, due to an elevated odds of being previously married.

    “we found that respondents with adult ADHD are significantly less likely than other respondents to be currently married due to an elevated odds of being previously married”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • May combine two claims.

    Findingown data

    The ORs associated with the AD-only subtype did not differ meaningfully from those associated with the HD subtype, with each having the same median (1.6) and very similar inter-quartile ranges.

    “the ORs associated with the AD-only subtype did not differ meaningfully from those associated with the HD subtype, with each of the two having the same median (1.6) and very similar inter-quartile ranges (1.1–2.0 for AD-only; 1.2–2.2 for HD).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All but one of the ORs for secondary disorders associated with remitted ADHD were elevated (ORs = 1.1-2.7, median 1.6, IQR 1.2-2.0) and nearly half were statistically significant.

    “all but one of the ORs for secondary disorders associated with remitted ADHD were elevated (ORs = 1.1–2.7, with a median of 1.6 and inter-quartile range of 1.2–2.0) and nearly half were statistically significant”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The same basic sociodemographic patterns were found with subthreshold childhood ADHD with the exception that prevalence was inversely associated with age at interview.

    “The same basic sociodemographic patterns were found with subthreshold childhood ADHD with the exception that prevalence was inversely associated with age at interview ( χ12=12.3, p < .001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The proportions treated in mental health specialty and general medical sectors were similar to each other and considerably higher than the proportions treated in human services (4.9%) or CAM (4.4%) sectors.

    “The proportions treated in these two sectors were similar to each other and considerably higher than the proportions treated in either the human services (4.9%) or CAM (4.4%) sectors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    ADHD was the temporally primary disorder in the vast majority of cases of comorbidities involving mood disorders (86.0-94.0%), anxiety disorders other than specific phobia (70.5-90.2%), and substance use disorders (94.8-99.1%).

    “we found ADHD to be the temporally primary disorder in the vast majority of cases of comorbidities involving mood disorders (86.0–94.0%), anxiety disorders other than specific phobia (70.5–90.2%), and substance use disorders (94.8–99.1%)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Odds ratios for disability outcomes are between 3.8 (95% CI 2.9-4.8) for cognition and 2.1 (95% CI 1.4-3.3) for self-care.

    “Odds ratios for these outcomes are between 3.8 (95% CI 2.9–4.8) for cognition and 2.1 (95% CI 1.4–3.3) for self-care.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Childhood ADHD prevalence was significantly related to country income level, with prevalence of 3.3% in high-, 2.2% in upper-middle-, and 0.6% in low-/lower-middle-income countries.

    “Prevalence was significantly related to country income level, with prevalence of 3.3% in high, 2.2% in upper-middle-, and 0.6% in low-/lower-middle-income countries”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Prevalence of DSM-IV/CIDI ADHD in childhood averaged 2.2% across surveys, with range 0.1-8.1% and inter-quartile range 0.9-2.9%.

    “Prevalence of DSM-IV/CIDI ADHD in childhood averaged 2.2% across the surveys, but had an extremely wide range (0.1–8.1%) and inter-quartile range (0.9–2.9%)”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Part II respondents were weighted to adjust for differential within and between household probabilities of selection, selection into Part II, and deviations between the sample and population sociodemographic-geographic distributions.

    “Part II respondents were weighted to adjust for differential within and between household probabilities of selection, selection into Part II, and deviations between the sample and population sociodemographic–geographic distributions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationnone given

    The countries in the WMH initiative are not representative of all countries in the world or even within their region.

    “The countries in the initiative are in no way representative of all countries in the world or even within their region of the world”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Design-based Taylor series method implemented in SAS was used to adjust for weighting and clustering of observations.

    “The design-based Taylor series method (Wolter 1985) implemented in the SAS software system (SAS Institute Inc. 2008) was used to adjust for the weighting and clustering of observations.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wolter 1985

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The interview schedule was translated using a standardized WHO translation, backtranslation, and harmonization protocol.

    “The interview schedule was developed in English and translated into other languages using a standardized WHO translation, backtranslation, and harmonization protocol (Harkness et al. 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Harkness et al. 2008

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    Adult ADHD is prevalent, seriously impairing, and highly comorbid but vastly under-recognized and undertreated across countries and cultures.

    “These results show that adult ADHD is prevalent, seriously impairing, and highly comorbid but vastly under-recognized and undertreated across countries and cultures.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    If the assumption of constant association between CIDI responses and clinical diagnoses across countries is incorrect, the results will be biased.

    “If this assumption is incorrect, the results will be biased.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The association between CIDI responses and clinical diagnoses is constant across countries.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Bilingual supervisors from each country were trained and supervised by the WMH Data Collection Coordination Centre to guarantee cross-national consistency in field procedures.

    “Bilingual supervisors from each country were trained and supervised by the WMH Data Collection Coordination Centre to guarantee cross-national consistency in field procedures (Pennell et al. 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Pennell et al. 2008

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The imputation equation used here was somewhat less refined than in the earlier US study because not all countries included all predictors used in the US imputation equation.

    “The imputation equation used here was somewhat less refined than in the earlier US study because not all countries included all predictors used in the US imputation equation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Response rates ranged from 45.9% (France) to 97.2% (Colombia) and had a weighted mean of 68.5% across surveys.

    “Response rates ranged from 45.9% (France) to 97.2% (Colombia) and had a weighted mean of 68.5% across surveys.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The multiple imputation approach generates unbiased prevalence estimates with good precision under the model when AUC is high and the population to which results are extrapolated are equivalent to the population in which the imputation was calibrated.

    “this approach generates unbiased prevalence estimates with good precision under the model when, as in our case, AUC is high and the population to which results are extrapolated are equivalent to the population in which the imputation was calibrated”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Kessler et al. 2006 source
    • The authors state this as an assumption: The population to which results are extrapolated is equivalent to the population in which the imputation was calibrated.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Meta-analysis shows that parental SES is inversely related to childhood ADHD, with children from low-SES families having an ADHD prevalence close to twice that of other children.

    “Meta-analysis shows, consistent with this expectation, that parental SES is inversely related to childhood ADHD, with children from low-SES families having an ADHD prevalence close to twice that of other children”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Russell et al. 2016 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The WMH data focused on respondent SES rather than parental SES.

    “The WMH data focused on respondent SES rather than parental SES”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    An inverse association between parental SES and childhood ADHD is expected by virtue of the high heritability of childhood ADHD along with an association of ADHD with low socioeconomic attainment.

    “we would expect an inverse association with parental SES by virtue of the high heritability of childhood ADHD (Posthuma and Polderman 2013) along with an association of ADHD with low socioeconomic attainment (Polderman et al. 2010)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Posthuma and Polderman 2013 source
    • cites Polderman et al. 2010 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous WMH analyses have shown that the pattern of obtaining care for emotional problems in multiple service sectors in high-income countries is typical of people with a wide range of other DSM-IV disorders and is not unique to ADHD.

    “Previous WMH analyses have shown that this pattern of obtaining care for emotional problems in multiple service sectors in high-income countries is typical of people with a wide range of other DSM-IV disorders and is not unique to ADHD (Wang et al. 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Wang et al. 2007 source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisereasoning

    A higher proportion of subthreshold childhood cases will become threshold cases in adulthood when DSM-5 diagnostics are used, because DSM-5 requires only 5 symptoms of either AD or HD for adult ADHD compared to 6 in DSM-IV and 6 for childhood cases in both DSM-IV and DSM-5.

    “a higher proportion of subthreshold childhood cases will become threshold cases in adulthood when DSM-5 diagnostics are used, as DSM-5 requires only 5 symptoms of either AD or HD for a diagnosis of adult ADHD compared to 6 in DSM-IV and 6 for childhood cases in both DSM-IV and DSM-5”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A subsequent meta-analysis concluded that the true male-to-female prevalence ratio of ADHD is closer to 2.45:1 in non-referred community samples, whereas earlier estimates indicated a ratio of 9:1.

    “Although earlier estimates indicated a male-to-female ratio of 9:1, a subsequent meta-analysis concluded that the true prevalence ratio is closer to 2.45:1 in non-referred community samples”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Polanczyk and Jensen 2008 source

  • May combine two claims.

    Interpretationreasoning

    The WMH results suggest that risk of temporally secondary disorders does not return to the population level after ADHD remission, implying that factors other than the impairment caused by ADHD account for the associations of remitted ADHD with subsequent onset of temporally secondary disorders.

    “That the WMH results suggest that this risk does not return to the population level after ADHD remission consequently implies that factors other than the impairment caused by ADHD account for the associations of remitted ADHD with subsequent onset of temporally secondary disorders”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Adult ADHD is more prevalent than childhood ADHD, and this pattern is true consistently in high-, upper-middle-, and low-/lower-middle-income countries.

    “Surprisingly, these results suggest that adult ADHD is more prevalent than childhood ADHD and that this pattern is true consistently in high (3.6 vs. 3.3%)-, upper-middle (3.0 vs. 2.2%)-, and low-/lower-middle (2.8 vs. 2.2%)-income countries.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The most consistently documented sociodemographic correlate of ADHD is sex, with prevalence consistently higher among boys than girls and a higher relative prevalence of the predominantly inattentive subtype among girls than boys.

    “Perhaps the most consistently documented correlate is sex, with prevalence consistently higher among boys than girls and a higher relative prevalence of the predominantly inattentive subtype among girls than boys”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Rucklidge 2010 source

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    If role impairments that remit with ADHD remission played a part in predicting subsequent onset of temporally secondary disorders, risk of these disorders would be expected to return to the general population level with ADHD remission.

    “implying that if these role impairments, which are known to remit with the remission of ADHD, played a part in predicting subsequent onset of temporally secondary disorders, we would expect that risk of these disorders would return to their level in the general population with the remission of ADHD”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A recent quantitative analysis of worldwide studies reported pooled current prevalence estimates of 6.5% for children and 2.7% for adolescents.

    “A recent quantitative analysis of worldwide studies reported pooled current prevalence estimates of 6.5% for children and 2.7% for adolescents”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Polanczyk et al. 2007 source

  • Classified as probably not a substantial claim.

    Premisecitation

    A recent meta-analysis failed to find a significant gender difference in persistence of ADHD into adulthood.

    “which failed to find a significant gender difference in persistence of ADHD into adulthood”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Caye et al. 2016b source

  • May combine two claims.

    Interpretationreasoning

    The results reported on associations of adult ADHD with secondary comorbid disorders and disability are likely conservative; true associations are likely larger than those estimated.

    “the results reported here on the associations of adult ADHD with secondary comorbid disorders and disability are likely to be conservative; that is, that the true associations are likely to be larger than those estimated here.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The analysis made no attempt to distinguish subsamples of respondents with pure and comorbid ADHD or to determine which comorbid disorders were most likely to be the presenting complaints.

    “our analysis made no attempt to distinguish subsamples of respondents with pure and comorbid ADHD or to determine which comorbid disorders were most likely to be the presenting complaints”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premiseown data

    The significant association of childhood ADHD with reduced educational attainment is consistent with a meta-analysis, but no previous research on educational attainment and persistence of childhood ADHD into adulthood was known to the authors.

    “The significant association of childhood ADHD with reduced educational attainment is consistent with the results of a meta-analysis (Polderman et al. 2010), but we are unaware of any previous research on educational attainment and persistence of childhood ADHD into adulthood”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Polderman et al. 2010 source

  • May combine two claims.

    Interpretationreasoning

    The significant inverse association of age with current adult ADHD was due to component associations including a significant inverse association of age with subthreshold childhood ADHD, an insignificant trend inverse association of age with childhood threshold ADHD, and a significant trend inverse association of age with adult persistence of ADHD among childhood cases.

    “The significant inverse association of age with current adult ADHD was due to several component associations that can be seen in other columns of the table. These include a significant inverse association of age with subthreshold childhood ADHD, an insignificant trend inverse association of age with childhood threshold ADHD, and a significant trend inverse association of age with adult persistence”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Given no guarantee that the model holds in all WMH countries, caution is needed in interpreting results regarding prevalence estimates.

    “Given that we have no guarantee that the model holds in all WMH countries, caution is consequently needed in interpreting results regarding prevalence estimates.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    With the change of the age-of-onset requirement from DSM-IV to DSM-5 (from 7 to 12 years), many respondents classified as subthreshold cases would have been threshold cases.

    “With the change of the age-of-onset requirement from DSM-IV to DSM-5 (from 7 to 12 years), many of the respondents classified as subthreshold cases would have been threshold cases”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Retrospective reports of childhood ADHD symptoms are sufficiently accurate to estimate childhood ADHD prevalence and persistence.

  • May combine two claims.

    Study design and conductreasoning

    Clinical reappraisal interviews were administered only in a minority of WMH countries, so uncertainty remains about how far the favorable concordance results generalize to all countries.

    “these clinical reappraisal interviews were administered only in a minority of WMH countries, so some uncertainty still exists in the extent to which the favorable results generalize to all countries”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CIDI diagnoses are valid across all WMH countries.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    This lack of awareness has been noted in the past and has led to calls for increased public and professional training on how to diagnose adult ADHD.

    “This lack of awareness has been noted in the past and has led to calls for increased public and professional training on how to diagnose adult ADHD”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Asherson et al. 2012 source

  • May combine two claims.

    Interpretationreasoning

    The significant association of current adult ADHD with being unmarried was due to a significantly elevated odds of childhood threshold ADHD with being previously married at the time of interview (OR 1.4; 95% CI 1.1-1.9) in addition to insignificant trend associations of being previously married and never married with persistence among childhood threshold and subthreshold cases.

    “The significant association of current adult ADHS with being unmarried was due to a significantly elevated odds of childhood threshold ADHD with being previously married at the time of interview (OR 1.4; 95% CI 1.1–1.9) in addition to insignificant trend associations of being previously married and never married with persistence among childhood threshold and subthreshold cases.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The WMH collaborators have developed a screening scale based on follow-up analyses of WMH respondents in the USA, and this screening scale has been validated in a number of countries.

    “The WMH collaborators have developed a screening scale of this sort based on follow-up analyses of WMH respondents in the USA (Kessler et al. 2005), and this screening scale has been validated in a number of countries (e.g., Lozano et al. 2016; Morin et al. 2016; Sjolander et al. 2016).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Kessler et al. 2005 source
    • cites Lozano et al. 2016 source
    • cites Morin et al. 2016 source

  • May combine two claims.

    Interpretationreasoning

    The finding that the vast majority of treatment is for other disorders is consistent with the finding that a substantial part of the impairment of respondents with adult ADHD is associated with comorbid disorders.

    “The finding that the vast majority of treatment is for other disorders is consistent with the finding that a substantial part of the impairment of respondents with adult ADHD is associated with comorbid disorders”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    Calibration was carried out only in the USA, which was an outlier in terms of prevalence, raising questions about the accuracy of the diagnostic threshold in other countries.

    “calibration was carried out only in the USA, which was an outlier in terms of prevalence, raising questions about the accuracy of the diagnostic threshold in other countries”
    Quote in the paperSubstantial claim
58 of 58

  • The authors state this as an assumption.

    The association between CIDI responses and clinical diagnoses is constant across countries.

    “This approach implicitly assumes that the association between CIDI responses and clinical diagnoses is constant across countries.”

  • The paper relies on this without support.

    Existing epidemiological studies vary widely in measures, classification systems, and data collection procedures, making cross-national comparison challenging.

    “A challenge in comparing cross-national results, though, is that existing epidemiological studies vary widely in measures, classification systems, and data collection procedures.”

  • The authors state this as an assumption.

    The population to which results are extrapolated is equivalent to the population in which the imputation was calibrated.

    “under the model when, as in our case, AUC is high and the population to which results are extrapolated are equivalent to the population in which the imputation was calibrated”

  • The paper relies on this without support.

    Respondents 45 years and older may not recall symptoms that they experienced in childhood.

    “The restriction on the age range was imposed based on a concern about the effects of recall bias among older respondents whereby respondents 45 years and older may not recall symptoms that they experienced in childhood.”

  • The paper relies on this without support.

    Retrospective reports of childhood ADHD symptoms are sufficiently accurate to estimate childhood ADHD prevalence and persistence.

    “Another limitation of the current study is that childhood ADHD was assessed retrospectively”
    “recall bias could lead to underreporting the number of childhood ADHD symptoms”

  • The paper relies on this without support.

    CIDI diagnoses are valid across all WMH countries.

    “all diagnoses were based on fully structured lay diagnostic interviews rather than semi-structured clinical research diagnostic interviews”
    “these clinical reappraisal interviews were administered only in a minority of WMH countries”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • About 2.8% of adults meet ADHD criteria.

    “A meta-analysis of 20 studies encompassing 13 countries and seven regions/metropolitan areas, involving more than 26,000 participants, estimated that 2.8% of adults meet criteria for ADHD”

    From The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder (2021) · cites this paper as Fayyad et al., 2017

    The Results (ADHD prevalence in childhood and persistence into adulthood) report that current adult ADHD prevalence averaged 2.8% across surveys. Methods and materials (Samples; Field procedures) describe 20 WMH surveys and 26,744 respondents assessed for ADHD, but the paper presents a pooled survey analysis, not a meta-analysis of 20 studies. Its listed survey locations also do not support the stated breakdown of 13 countries and seven regions or metropolitan areas. (LLM, conf=0.89)

    Experimental — accuracy not yet measured

  • The WHO World Mental Health Surveys across 20 nations revealed that the prevalence of persistent adult ADHD based on DSM-IV was 2.8%.

    “The WHO World Mental Health Surveys (WMHS) across 20 nations have revealed that the prevalence of persistent adult ADHD based on DSM-IV was 2.8% [28].”

    From The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis (2021) · cites this paper as [28]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Direction of the education association is reversed

    Minor

    The results call the association between childhood ADHD and educational attainment positive, but explain it by saying ADHD prevalence is higher among people with less than a college education. That describes an inverse association with educational attainment.

  • Low-income childhood and adult prevalence figures are misstated

    Minor

    The comparison gives 2.8% adult versus 2.2% childhood ADHD in low-/lower-middle-income countries, but the paper earlier reports 1.4% adult and 0.6% childhood prevalence for that income group. The comparison appears to repeat the overall figures instead.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 4

  1. Adler L, Spencer T (2004) The Adult ADHD Clinical Diagnostic Scale (ACDS), version 1.2. New York University School of Medicine, New York
  2. First M, Spitzer R, Gibbon M, Williams J (2002) Structured clinical interview for DSM-IV Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). Biometrics Research, New York State Psychiatric Institute, New York
  3. SAS Institute Inc (2008) SAS Software Version 9.2. SAS Institute Inc., Cary
  4. Sawilowsky S, Musial JL (1988) Modeling ADHD exponential decay. The ADHD Report 1988. 6(1):10–11

Cited by

Sorted by citations

Related

Authors
Collaborators, O. B. O. T. W. W. M. H. S., Fayyad, J., Sampson, N. A., Hwang, I., Adamowski, T., Aguilar-Gaxiola, S., Al-Hamzawi, A., Andrade, L. H. S. G., Borges, G., de Girolamo, G., Florescu, S., Gureje, O., Haro, J. M., Hu, C., Karam, E. G., Lee, S., Navarro-Mateu, F., O’Neill, S., Pennell, B.-E., Piazza, M., Posada-Villa, J., ten Have, M., Torres, Y., Xavier, M., Zaslavsky, A. M., & Kessler, R. C.
Affiliations
  • Institute for Development, Research, Advocacy and Applied Care (LB)
  • Harvard University (US)
  • Wroclaw Medical University (PL)
  • Universidade de São Paulo (BR)
  • Centro San Giovanni di Dio Fatebenefratelli (IT)
  • University College Hospital, Ibadan (NG)
  • Centro de Investigación Biomédica en Red de Salud Mental (ES)
  • University of Balamand (LB)
  • Chinese University of Hong Kong (HK)
  • University of Ulster (GB)
  • University of Michigan (US)
  • Universidad El Bosque (CO)
  • Universidad CES (CO)
Corresponding author
Fayyad, John
ORCID
Venue
ADHD Attention Deficit and Hyperactivity Disorders
Publisher
Springer Science and Business Media LLC
Published
2016-11-19
Volume
9
Issue
1
Pages
47-65
ISSN
  • 1866-6116 (ISSN-L)
  • 1866-6647
DOI
10.1007/s12402-016-0208-3
PMC
PMC5325787
OpenAlex
W2555957564
Cited by
824
References
64
Citations by year
2026: 69 · 2025: 95 · 2024: 136 · 2023: 127 · 2022: 101 · 2021: 84 · 2020: 95 · 2019: 64 · 2018: 28 · 2017: 22 · 2016: 1 · 2012: 1
FWCI
34.03
Type
journal article
Language
en
Open access
Licence
Locations
  • ADHD Attention Deficit and Hyperactivity Disorders (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Repositori digital de la UPF (Universitat Pompeu Fabra) (acceptedVersion)
  • Repositorio Institucional Universidad El Bosque (submittedVersion)
  • The Research Repository @ WVU (West Virginia University) (submittedVersion)
  • IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion, cc-by)
  • Ulster University Research Portal (Ulster University) (submittedVersion, other-oa)
  • University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
  • RECERCAT (Consorci de Serveis Universitaris de Catalunya) (submittedVersion, other-oa)
  • Universidad Peruana Cayetano Heredia Institutional Repository (submittedVersion, cc-by-nc-nd)
Funders
  • National Institute of Mental Health (R01 MH070884)
  • John D. and Catherine T. MacArthur Foundation
  • U.S. Public Health Service (R13-MH066849, R01-MH069864, R01 DA016558)
  • Fogarty International Center (FIRCA R03-TW006481)
  • Pan American Health Organization
  • Eli Lilly and Company
  • Ortho-McNeil Pharmaceutical
  • GlaxoSmithKline
  • Bristol-Myers Squibb
  • Pfizer Foundation
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
adult ADHD, prevalence, cross-national comparison, DSM-IV, Composite International Diagnostic Interview, comorbidities, role impairment, treatment seeking, childhood ADHD, subthreshold ADHD, income level, gender differences, educational attainment, anxiety disorders, mood disorders, substance use disorders, behavior disorders
MeSH terms
Adolescent, Adult, Attention Deficit Disorder with Hyperactivity, Mental Disorders, Developing Countries, Female, Health Surveys, Humans, Income, Male, Patient Acceptance of Health Care, Risk Factors, World Health Organization, Comorbidity, Prevalence, Developed Countries, Diagnostic and Statistical Manual of Mental Disorders, Young Adult

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-31.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-31.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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