Attention Deficit Disorder in Adults

Aka: Attention Deficit Disorder in Adults, Adult ADHD, ADHD in Adults, Adult Attention Deficit Disorder

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II. Epidemiology

  1. Attention Deficit Disorder of childhood continues into adulthood in up to 30% of cases
    1. U.S. Prevalence has increased to 14.6% in 2022 (was estimated at 4.4% in 2006)
    2. Adamis (2022) J Atten Disord 26(12): 1523-34 [PubMed]

III. Pathophysiology

  1. See Attention Deficit Disorder

IV. Associated Conditions

  1. See ADHD Comorbid Conditions
  2. Adults with Attention Deficit have a hIgher risk of complications
    1. Unemployment
    2. Educational underachievement
    3. Financial problems
    4. Substance Abuse or misuse
    5. Criminality
    6. Accidents (MVA, workplace)

V. Differential Diagnosis: Decreased Attentiveness

  1. See ADHD Differential Diagnosis
  2. Hearing Impairment
  3. Thyroid disorders
  4. Liver disease
  5. Sleep Apnea
  6. Traumatic Brain Injury
  7. Mental health conditions
    1. Anxiety Disorder
    2. Major Depression
    3. Bipolar Disorder
    4. Obsessive Compulsive Disorder
    5. Posttraumatic Stress Disorder
    6. Substance Abuse
    7. Personality Disorder (Antisocial Personality, Borderline Personality)
    8. Learning Disorders
    9. Intellectual Disability
  8. Medication adverse effects
    1. Drug Interactions
    2. Corticosteroids
    3. Antihistamines
    4. Anticonvulsants
    5. Caffeine
    6. Nicotine

VI. Diagnosis

  1. See ADHD Diagnosis
  2. Changes in DSM-V for diagnosis of ADHD in Adults
    1. Onset of observed ADHD symptoms by age 12 years (instead of prior cirteria of onset age <7 years)
      1. Lack of symptoms before age 12 years excludes Attention Deficit Disorder
    2. Five diagnostic criteria positive in either Inattention or Hyperactive categories (instead of prior 6 criteria required)
  3. ADHD Specific Diagnostic tools
    1. Adult ADHD Self-Report Scale SymptomChecklist v1.1 (ASRS)
      1. https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf
  4. Contributing mental health conditions and collateral information
    1. Obtain childhood medical records, school transcripts
    2. DSM-5-TR self-rated level 1 cross-cutting symptom measure
      1. https://unified.co.grant.wi.gov/wp-content/uploads/Symptom-Measure.pdf
  5. Precautions
    1. First degree ADHD Family History significantly increases ADHD likelihood
    2. ADHD patients may have high functioning in one area, while failing in other areas despite considerable effort

VII. Evaluation

  1. See Attention Deficit Disorder regarding history questions
  2. Evaluate differential diagnosis (see above)
  3. Evaluate for contraindications to Stimulant Medications
    1. See precautions below
    2. Vital Signs
      1. Blood Pressure (evaluate for Hypertension)
      2. Heart Rate (evaluate for Tachycardia)
    3. Electrocardiogram
      1. Evaluate for Arrhythmia
      2. Variable recommendations as to whether to obtain Electrocardiogram prior to starting Stimulant Medication

VIII. Management: General

  1. Same management and medications apply to adults as they do in children
    1. See ADHD Management
    2. See ADHD Medication
  2. Consider mental health measures and counseling (esp. for those not meeting criteria for ADHD Diagnosis)
    1. May consider neuropsychological diagnostic testing (often delayed months and costs >$1000)
    2. Psychoeducational Counseling
    3. Mindfulness
    4. Cognitive remediation
    5. Cognitive Behavioral Therapy for adults with ADHD
      1. Young (2020) J Atten Disord 24(6): 875-88 [PubMed]
    6. Other techniques with weaker evidence
      1. Group dialectical behavioral therapy
      2. Hypnotherapy

IX. Management: Medications

  1. Contraindications: Stimulants
    1. Uncontrolled Hypertension
    2. Coronary Artery Disease
    3. Cardiomyopathy
    4. Significant valvular heart disease
    5. Tachycardia
    6. Arrhythmia
    7. Psychosis
    8. Bipolar Disorder
    9. Severe Anorexia
    10. Tourette Syndrome
    11. Substance Abuse
  2. Precautions: Stimulant Use in adults with comorbid heart disease
    1. Sudden death events are reported at standard stimulant doses in adults and children
      1. Wigal (2009) CNS Drugs 23(suppl 1): 21-31 [PubMed]
    2. Large trials have demonstrated overall safety in adults without increased cardiovascular events or sudden death
      1. Habel (2011) JAMA 306(24): 2673-8 [PubMed]
  3. Precautions: Stimulant Diversion and Abuse
    1. Review Prescription Drug Monitoring Program (PDMP) at the time of each prescription and refill
      1. Evaluate for multiple prescribers and other controlled substances
    2. Stimulant Abuse
      1. Simulants increase Dopamine levels transiently (associated with reward Sensation)
      2. Overall Stimulant Abuse rate in adults: 2%
      3. Stimulant Abuse by adults aged 18 to 25 years: 4-6%
      4. Non-Cocaine stimulant related deaths reached >32,000 in U.S. in 2021
      5. Novak (2007) Subst Abuse Treat Prev Policy 2:32 [PubMed]
    3. Diversion (giving or selling medications to others)
      1. College student rate of use of non-prescribed stimulants: 8%
  4. Prevention: Stimulant Diversion and Abuse
    1. Initiate Controlled Substance Agreement (contract)
    2. Implement random Urine Drug Screening every 3 months
    3. Regular follow-up visits (e.g. every 6 months after the initial more frequent visits)
    4. Review Prescription Drug Monitoring Program
  5. Adverse Effects: Stimulants
    1. See ADHD Medication
    2. Hypertension (Blood Pressure increases 3-5 mmHg)
    3. Tachycardia (Heart Rate increases 5 bpm)
    4. Insomnia
    5. Headaches
    6. Decreased appetite and weight loss
    7. Mood Disorders (generalized anxiety, Major Depression)
  6. Agent Selection and Dosing
    1. Once daily agents (e.g. Adderall XR, Vyvanse) may result in better compliance
      1. Short acting, twice daily dosing may be higher risk of "stimulant crash"
      2. Take long-acting agents at least 12 hours before bedtime
      3. Consider afternoon immediate release dose for early wearing off of morning XR dose effect
    2. Adult ADHD patients may see better efficacy and tolerability with Amphetamine-based agents
      1. Contrast with Methylphenidate agents (more effective, tolerable in children)
      2. Cortese (2018) Lancet Psychiatry 5(9): 727-38 [PubMed]
    3. Start medications at low dose
      1. Titrate dosing on a weekly basis based on efficacy and adverse effects
    4. Avoid interacting agents that affect gastrointestinal absorption and urinary clearance
      1. See Dextroamphetamine for Drug Interactions
      2. For example, Antacids and Vitamin C may result in erratic stimulant absorption and clearance
  7. Clinic Visits
    1. Schedule monthly visits until patients reach functional improvement
    2. Evaluate Blood Pressure, Heart Rate, adverse effects and efficacy at each visits
    3. Longterm follow-up at least every 6 months while medications are prescribed
  8. Stopping medications
    1. Risk of stimulant withdrawal (Motor Ticks, confusion, irritability)
    2. Consider tapering doses off for patients on higher dose stimulants
  9. Medications
    1. See ADHD Medication
    2. Amphetamines
      1. See Dextroamphetamine
      2. Amphetamine-Dextroamphetamine (Adderall)
        1. Immediate Release: Start 5 mg orally once to twice daily (max: 40 mg/day)
        2. Extended Release (XR): Start 10 to 20 mg orally each AM (max: 60 mg/day)
      3. Dextroamphetamine (Zenzedi, Xelstrym)
        1. Immediate Release: Start 5 mg orally once to twice daily (max: 40 mg/day)
        2. Patch: Start 9 mg worn 9 hours on and 15 hours off (max: 18 mg on for 9 hours)
      4. Lisdexamfetamine (Vyvanse)
        1. Start 30 mg orally once daily (max: 70 mg orally daily)
    3. Methylphenidate
      1. See Methylphenidate
      2. Less effective and greater adverse effects in adults
    4. Non-Stimulant Medications
      1. Background
        1. Indicated in Stimulant Abuse or stimulant adverse effects (e.g. anxiety, Tachycardia, Insomnia)
        2. Full effect is delayed 4-8 weeks (unlike the immediate effects of Amphetamines)
        3. Avoid alpha-2 Agonists (e.g. Clonidine) due to lower efficacy in adults, as well as Orthostatic Hypotension
      2. Atomoxetine (Strattera) or Viloxazine (Qelbree)
        1. Effects may be delayed >1 month
        2. Consider in comborbid Anxiety Disorder
      3. Bupropion (Wellbutrin)
        1. Consider in comorbid Major Depression or Tobacco Cessation

X. References

  1. (2025) Presc Lett 32(8): 44-5
  2. Post (2012) Am Fam Physician 85(9):890-896 [PubMed]
  3. Olagunju (2024) Am Fam Physician 110(2): 157-66 [PubMed]

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