Attention Deficit/Hyperactivity Disorder (ADHD), Adult

Basics

Adult ADHD involves inattention and/or hyperactivity-impulsivity causing impairment in multiple settings.
Complications include employment, financial, interpersonal difficulties, driving accidents, and suicide risk.
Often begins in childhood; 30-60% continue to meet criteria as adults.
Subtypes: hyperactivity-impulsivity predominant, inattentive predominant, combined (most common).

Strong genetic component: heritability ~0.8, explaining ~65% phenotypic variance.
First-degree relatives have 4–5 times greater risk.
Risk factors include maternal smoking, obesity, diabetes during pregnancy, lead exposure, prematurity, neglect, infections, and neurodevelopmental disorders.

Symptoms: poor concentration, disorganization, project incompletion, poor work performance, temper control issues.
DSM-5 criteria: ≥5 symptoms of inattention or hyperactivity/impulsivity; symptoms before age 12; present in ≥2 settings; impair functioning; duration >6 months.
Exclude effects of medications, thyroid disorders, head trauma, liver disease, seizures.
Family history and comorbid neuropsychiatric disorders assessed.

Hearing impairment, thyroid disorders, sleep deprivation/apnea, phenylketonuria, OCD, lead toxicity, substance abuse.

Adult ADHD screening scales: Childhood Symptom Scale, Wender Utah Rating Scale, Adult ADHD Rating Scale IV, Adult Self-Report Scale, Conners Adult Rating Scale.
Lab tests: TSH, ECG if cardiac risk, urine toxicology to exclude substance abuse.
Consider polysomnography if sleep disorder suspected.

Stimulants are first line if no substance abuse; titrate dosage and formulation individually.
Nonstimulants used if abuse risk, comorbidities, or stimulant intolerance.
Medication trials may be needed to optimize response.

Methylphenidate (Concerta, Ritalin), dexmethylphenidate (Focalin), dextroamphetamine/amphetamine (Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse).
Available in short, intermediate, long-acting, and patch formulations.
Monitor for side effects: hypertension, tachycardia, insomnia, weight loss, GI upset, anxiety, tics, rare psychosis, priapism.

Atomoxetine (Strattera): effective, low abuse potential, onset up to 4 weeks; monitor liver enzymes and suicidality.
Antidepressants: bupropion effective, especially with comorbid depression; tricyclics also used.
Alpha-2 agonists (guanfacine, clonidine): less studied in adults; useful for comorbid tics or disruptive behaviors.
Combination therapy may be considered in stimulant-resistant cases.

Cognitive-behavioral therapy (CBT) beneficial adjunct, especially for executive dysfunction.
Emerging evidence for memantine adjunct with methylphenidate to improve executive function.

Limited evidence for fatty acid supplements; mild benefit from removing artificial food colorings.
Behavioral therapy with rewards and supportive environments effective.

Coordinate smooth transition from pediatric to adult care to prevent treatment lapses.
Monitor for side effects and treatment efficacy regularly; use screening checklists.

Persistent challenges with attention, impulsivity, and organization impact social and occupational functioning.
Effective treatment improves quality of life.

Comorbid psychiatric disorders: major depressive disorder, anxiety, OCD, tic disorders.

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Asherson P, Bushe C, Saylor K, et al. Efficacy of atomoxetine in adults with ADHD: integrated analysis. J Psychopharmacol. 2014;28(9):837-846.
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Millichap JG, Yee MM. The diet factor in ADHD. Pediatrics. 2012;129(2):330-337.
Sonuga-Barke EJS, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses. Am J Psychiatry. 2013;170(3):275-289.
Feldman HM, Reiff MI. Clinical practice: ADHD in children and adolescents. N Eng J Med. 2014;370(9):838-846.

Adult ADHD features inattention, impulsivity, hyperactivity, associated with impaired self-esteem and interpersonal difficulties.
Psychotropic medications combined with cognitive behavioral therapy are central to management.
Substance abuse comorbidity requires cautious use of nonstimulants.
Close monitoring for efficacy and side effects is essential.