Attention Deficit Hyperactivity Disorder (ADHD) in Adults

Background

• Attention deficit hyperactivity disorder (ADHD) is a pattern of behavior including inattention and/or hyperactivity/impulsivity present in multiple settings that impairs social and academic or work performance and typically begins in childhood.
• ADHD has a strong genetic component.
• Depression, anxiety, substance use disorders, and other psychiatric conditions are common in patients with ADHD.
• Complications of adult ADHD include employment, financial, and interpersonal difficulties, as well as an increased risk of driving accidents and suicide.

Evaluation

• Commonly reported symptoms of ADHD include poor concentration, disorganization, failure to complete projects, poor work or academic performance, impulsivity, and difficulty controlling temper.
• A physical examination is aimed at distinguishing ADHD from endocrine and neuropsychiatric disorders.
• Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) criteria for the diagnosis of ADHD in children and adults include:
  • at least 5 symptoms from the specific subtype category to diagnose ADHD inattention or hyperactivity/impulsivity subtypes and ≥ 5 symptoms from each category to diagnosis ADHD combined type
  • several symptoms present before age 12 years (if undiagnosed in childhood, this is established by a retrospective assessment of childhood symptoms)
  • criteria met in ≥ 2 settings (home, school, or work, or with friends or relatives)
  • clear evidence that symptoms interfere with or reduce the quality of social, academic, or occupational functioning
  • symptoms present for ≥ 6 months, symptoms more frequent than expected, and if they directly affect social, academic, or occupational activities
• A diagnosis is based on a full evaluation of the clinical presentation rather than a single psychological or biological diagnostic test.
• Clinical interview tools which can be used to help establish the diagnosis of ADHD include:
  • Diagnostic Interview for ADHD in Adults (DIVA)
  • Adult ADHD Self-report Scale V1.1 (ASRS V1.1)
  • Connors' Adult ADHD Rating Scale (CAARS) for DSM-IV criteria
• Consider a referral for a psychological/neuropsychological assessment to assist with the diagnosis.

Management

• Offer medication if symptoms are still causing significant impairment in more than 1 functional domain after a conservative management approach (Strong recommendation).
• Offer stimulant medication as the first-line pharmacological treatment in adults (Strong recommendation).
  • Stimulant classes of medication with evidence for efficacy in adult ADHD include amphetamines and methylphenidate. Both classes come in immediate release and long-acting formulations.
    • Begin with the lowest dose possible and titrate approximately every 2 weeks to reach the lowest effective dose.
    • Controlled-release formulas are more commonly used and may be less likely to be abused due to increased difficulty snorting or injecting the medication.
  • Common adverse effects include anorexia, weight loss, headache, hypertension, tachycardia, affect lability, insomnia, dry mouth, nervousness, abdominal pain, nausea, and vomiting.
  • Avoid stimulants during pregnancy and lactation. (Stimulants are Pregnancy Category C and are contraindicated during lactation.) (Strong recommendation)
• Offer the nonstimulant atomoxetine as the second-line pharmacological treatment in adults or in patients intolerant of amphetamines (Strong recommendation).
• Consider cognitive behavioral therapy (CBT) as an adjunct to medication or as an alternative to medication in patients who cannot tolerate or decline medications (Weak recommendation).
• Follow patients regularly to monitor blood pressure and pulse, assess the efficacy of therapy, and assess for medication adverse effects.
• Identify comorbid psychiatric conditions and treat along with ADHD.