Attention Deficit Disorder in Adults

1. See Also
   1. Attention Deficit Disorder in Children
   2. School Problem Evaluation
   3. ADHD Diagnosis
   4. ADHD Differential Diagnosis
   5. ADHD Comorbid Conditions
   6. ADHD Non-Pharmacologic Management
   7. ADHD Medications
   8. Dextroamphetamine (Dexedrine, Dextrostat, Adderall) or Lisdexamfetamine (Vyvanse)
   9. Methylphenidate (Ritalin, Methylin, Concerta)
   10. Atomoxetine (Strattera)
2. Epidemiology
   1. Attention Deficit Disorder of childhood continues into adulthood in up to 30% of cases
3. Differential Diagnosis: Decreased attentiveness
   1. See ADHD Differential Diagnosis
   2. Hearing Impairment
   3. Thyroid disorders
   4. Liver disease
   5. Sleep Apnea
   6. Drug Interactions
   7. Mental health conditions
      1. Anxiety Disorder
      2. Major Depression
      3. Bipolar Disorder
      4. Obsessive Compulsive Disorder
      5. Substance Abuse
      6. Personality Disorder (Antisocial Personality, Borderline Personality)
      7. Learning Disorders
      8. Intellectual Disability
   8. Medication adverse effects
      1. Corticosteroids
      2. Antihistamines
      3. Anticonvulsants
      4. Caffeine
      5. Nicotine
4. Contraindications: Stimulants
   1. Hypertension
   2. Tachycardia
   3. Arrhythmia
   4. Psychosis
   5. Bipolar Disorder
   6. Severe Anorexia
   7. Tourette Syndrome
5. Precautions: Stimulant safety in adults
   1. 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]
   2. Stimulant Diversion and Abuse
      1. Stimulant Abuse
         1. Overall Stimulant Abuse rate in adults: 2%
         2. Stimulant Abuse by adults aged 18 to 25 years: 4-6%
         3. Novak (2007) Subst Abuse Treat Prev Policy 2:32 [PubMed]
      2. Diversion (giving or selling medications to others)
         1. College student rate of use of non-prescribed stimulants: 8%
6. Evaluation
   1. See Attention Deficit Disorder regarding history questions
   2. Evaluate for contraindications to Stimulant Medications
      1. Vital Signs
         1. Blood Pressure (evaluate for Hypertension)
         2. Heart Rate (evaluate for Tachycardia)
      2. Electrocardiogram
         1. Evaluate for Arrhythmia
         2. Variable recommendations as to whether to obtain Electrocardiogram prior to starting Stimulant Medication
7. Diagnosis
   1. See ADHD Diagnosis
   2. Proposed changes to upcoming DSM-V for diagnosis of ADHD in Adults
      1. Onset of observed ADHD symptoms by age 12 years (instead of current cirteria of age 7 years)
      2. Four diagnostic criteria positive in either Inattention or Hyperactive categories (instead of current 6 criteria required)
   3. Diagnostic tools
      1. Adult ADHD Self-Report Scale SymptomChecklist v1.1 (ASRS)
         1. http://webdoc.nyumc.org/nyumc/files/psych/attachments/psych_adhd_checklist.pdf
8. Associated Conditions
   1. See ADHD Comorbid Conditions
9. Management
   1. Same management and medications apply to adults as they do in children
      1. See ADHD Management
      2. See ADHD Medication
10. Prevention: Stimulant Diversion and Abuse
    1. Initiate Controlled Substance Agreement (contract)
    2. Implement random drug screening
    3. Regular follow-up visits (e.g. every 6 months)
11. References
    1. Post (2012) Am Fam Physician 85(9):890-896 [PubMed]