> Table of Contents > Attention Deficit/Hyperactivity Disorder, Adult
Attention Deficit/Hyperactivity Disorder, Adult
Yash Kothari, MD
Hugh R. Peterson, MD, FACP
image BASICS
  • Adult attention deficit hyperactivity disorder (adult ADHD) is a psychiatric condition resulting in inattention and/or hyperactivity or impulsivity. It is typically associated with a combination of low self-esteem, dysfunctional or unstable social relationships, and impaired academic/job performance.
  • Adult ADHD has been shown to affect a significant portion of the adult population; >30% of patients diagnosed with ADHD as a child will continue to meet criteria as adults. Some others who no longer meet strict criteria still have significant residual ADHD traits (1).
  • During transition from pediatric to adult care, poor control of high-risk behaviors during a hiatus of ADHD treatment can lead to increased morbidity.
DESCRIPTION
  • Symptoms include difficulty concentrating, impulsivity, and hyperactivity/overactivity
  • The three main types of ADHD are (i) hyperactivity-impulsivity predominant, (ii) inattentive predominant, and (iii) mixed.
  • Cost to society in 2010 U.S. dollars estimated to be $105 to $194 billion from decreased productivity, lost income, and “spillover” costs ($33 to $43 billion) paid by families (1).
EPIDEMIOLOGY
Prevalence
General population prevalence for adult ADHD 2.5-4.4%, but population prevalence declines with age (2,3).
Genetics
ADHD patients often have first-degree relatives with ADHD. Some genes have been correlated with ADHD, although not necessary or sufficient for diagnosis (4).
RISK FACTORS
History of childhood and adolescent ADHD diagnosis, particularly symptoms of hyperactivity and/or impulsivity, persisting into adulthood. ADHD is more frequent in males than females (3).
COMMONLY ASSOCIATED CONDITIONS
  • Substance use and substance abuse disorders
  • Mood disorders
  • Anxiety disorders
  • Intellectual disabilities
  • Obsessive-compulsive disorder (OCD)
  • Tic disorders
image DIAGNOSIS
  • Diagnosis is made from patient's history and detailing patient's current level of functioning in at least two different settings (e.g., work and home).
  • It is particularly important to gather history of patient's childhood and school performance. ADHD symptoms should be present before age 12 years. If no diagnosis or concern for ADHD as a child, it is unlikely to be diagnosed as an adult.
  • DSM-5 criteria are used for adults as well as children.
PHYSICAL EXAM
  • Physical exam is key to ruling out other medical conditions.
  • Focus on thyroid and neurologic examinations; look for findings suggestive of substance abuse.
  • Record BP and baseline weight; monitor if starting medical treatment.
DIFFERENTIAL DIAGNOSIS
Hearing impairment; hyperthyroidism/hypothyroidism; sleep deprivation; sleep apnea; phenylketonuria; OCD; lead toxicity; substance abuse (5)[A]
DIAGNOSTIC TESTS & INTERPRETATION
  • Adult ADHD screening tools: Retrospective scales include the Childhood Symptom Scale and the Wender Utah Rating Scale; current symptom scales include the Adult ADHD Rating Scale IV, Adult Self Report Scale Symptom Checklist, and the Connor Adult Rating Scale. These scales can take 5 to 20 minutes to complete.
  • Provider/patient screening checklist
    • http://help4adhd.org/documents/AdultADHDSelfReportScale-ASRS-v1-1.pdf
    • http://webdoc.nyumc.org/nyumc_d6/files/psych_adhd_screener.pdf
  • ECG with concerns for cardiac disease in patient or family history
  • Record baseline blood pressure, pulse, and BMI.
Initial Tests (lab, imaging)
  • Thyroid-stimulating hormone (TSH)
  • Liver function test monitoring (with atomoxetine)
  • Rapid plasma reagin (RPR) or VDRL (Venereal Disease Research Laboratory) test
  • Serum lead levels (pending history)
Follow-Up Tests & Special Considerations
  • A history of childhood behaviors is helpful, but adult patients often don't accurately recall childhood symptomology.
  • Seek the patient's permission to speak with family/friends/prior physicians and to seek school records and results of any psychological assessments.
  • Inquire about family history of ADHD, family and personal substance abuse, and tic disorders to facilitate formulation of an accurate diagnosis and recognition of high-risk behaviors.
  • Caution against stimulant use in pregnancy because of high risk of low fetal birth weight and preterm birth. Risks and benefits of treatment must be discussed in detail with patient and preferably with her spouse (6)[B].
  • Caution against use of stimulants in adult patients with cardiac history.
image TREATMENT
  • Most of the research and medication trials have been performed in children.
  • There is increasing evidence that stimulants and nonstimulants used in children are also effective in adults (5)[A].
GENERAL MEASURES
When prescribing stimulant medications for adults with ADHD, watch for misuse, abuse, and diversion of prescription medications. When substance abuse is not present, stimulants are first-line treatment for ADHD and highly efficacious. There are multiple formulations of stimulants, and patients may require trials of different dosages, formulations, and medications before an optimal response in symptoms and functions is achieved.
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MEDICATION
  • Psychotropic medications play a large part in the treatment of ADHD symptoms. Medications should be titrated slowly to effective dose to avoid side effects.
  • Stimulants are more effective than antidepressants or nonstimulants, but up to 30% discontinue medications because of side effects.
  • Stimulants can be divided into two different classes: Methylphenidate and amphetamine come in both short- and long-acting preparations.
  • Antidepressants studied for ADHD include bupropion, which has been shown to have a medium effect compared with stimulants (6)[A].
First Line
  • Stimulants: methylphenidate (Concerta, Ritalin), dexmethylphenidate (Focalin), dextroamphetamine/amphetamine (Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse)
    • Methylphenidate preparations are available in short-acting, intermediate-acting, long-acting, and patch formulations.
    • Ritalin LA may be used for patient's naive to stimulants. It can be started at 20 mg daily and dose titrated by 10 mg increments weekly to symptoms response. Maximum dose of 60 mg/day.
    • Concerta ER is another option in adults up to 65 years of age. Starting dose of 18 mg/day; adjust in increments of 18 mg weekly until symptoms improve. Maximum dose of 72 mg/day. Concerta also has an oral osmotic release to decrease abuse potential.
    • Amphetamines also come in immediate-release preparations and sustained-release preparations.
    • Dextroamphetamine is commonly used (half-life of 4 to 6 hours) with an initial dose of 5 mg twice daily; titrate up by 5 mg weekly to maximum of 20 mg twice daily. Caution: Immediate-release preparations have high abuse potential.
    • Dextroamphetamine/amphetamine (Adderall) is a 75%/25% mix that also comes in an extended-release form. Initial dosing can be started at 5 mg twice daily for short-acting or 20 mg once daily for long-acting, and increased by 5 mg/week for short-acting and 10 mg/week long-acting to a maximum of 40 to 60 mg total daily.
    • Lisdexamfetamine (Vyvanse) is an extended-release stimulant that is a prodrug requiring metabolization to active component, dextroamphetamine.
    • Dextroamphetamine can be initiated at 30 mg daily and titrated by 10 to 20 mg weekly to a maximum of 30 to 70 mg daily.
    • Common side effects of stimulants include hypertension (HTN), tachycardia, insomnia, weight loss, stomach upset, increased anxiety/irritability, or worsening of tics (6)[A].
  • Nonstimulants: Atomoxetine (Strattera) has been shown effective in adults with ADHD when compared to placebo (7)[B]. It may be given as a single dose or split dose and has low abuse potential, making it a better choice over a stimulant medication for patients with substance abuse history. Onset of effect may take up to 4 weeks. Atomoxetine may require dose adjustments with strong inhibitors of cytochrome P2D6 (e.g., Paxil or Prozac). Also, there are rare cases of liver damage associated with these medications. Monitor for increased suicidal thinking.
  • Antidepressants: best used for those at high risk or with history of substance abuse disorder
    • Bupropion (Wellbutrin) is an antidepressant effective in adults with ADHD symptoms (6)[A].
ISSUES FOR REFERRAL
Patients with comorbid conditions may need referral for diagnosis and treatment. Consider cardiology consult for patients with known cardiac issues who may require stimulant treatment. Consider referral to obstetrician experienced in high-risk pregnancies when treating pregnant women with ADHD.
ADDITIONAL THERAPIES
Cognitive-behavioral therapy can be useful in conjunction with medication to help patient modify and cope with symptoms.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Vitamin-mineral supplementation is an area of active research that holds promise for improved ADHD treatment (8)[A].
image ONGOING CARE
Transfer from pediatric to adult care must be closely coordinated to avoid hiatus in treatment.
FOLLOW-UP RECOMMENDATIONS
  • Close follow-up of medication as dose is titrated.
  • Continue to monitor for medication side effects.
  • Repeat screening checklists to quantify benefit of interventions as needed.
  • Reinforce behavioral change (e.g., self-initiated through cognitive-behavioral therapy), which is the essential goal of long-term management.
REFERENCES
1. Doshi JA, Hodgkins P, Kahle J, et al. Economic impact of childhood and adult attention-deficit/hyperactivity disorder in the United States. J Am Acad Child Adolesc Psychiatry. 2012;51(10): 990.e2-1002.e2.
2. Simon V, Czobor P, Bálint S, et al. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194(3):204-211.
3. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723.
4. Gatt JM, Burton KL, Williams LM, et al. Specific and common genes implicated across major mental disorders: a review of meta-analysis studies. J Psychiatr Res. 2015;60:1-13.
5. Castells X, Ramos-Quiroga JA, Bosch R, et al. Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2011;(6):CD007813.
6. Verbeeck W, Tuinier S, Bekkering GE. Antidepressants in the treatment of adult attention-deficit hyperactivity disorder: a systematic review. Adv Ther. 2009;26(2):170-184.
7. Asherson P, Bushe C, Saylor K, et al. Efficacy of atomoxetine in adults with attention deficit hyperactivity disorder: an integrated analysis of the complete database of multicenter placebo-controlled trials. J Psychopharmacol. 2014;28(9):837-846.
8. Rucklidge JJ, Frampton CM, Gorman B, et al. Vitamin-mineral treatment of attention-deficit hyperactivity disorder in adults: double-blind randomised placebo-controlled trial. Br J Psychiatry. 2014;204:306-315.
Additional Reading
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  • Mongia M, Hechtman L. Cognitive behavior therapy for adults with attention-deficit/hyperactivity disorder: a review of recent randomized controlled trials. Curr Psychiatry Rep. 2012;14(5):561-567.
  • Post RE, Kurlansik SL. Diagnosis and management of adult attention-deficit/hyperactivity disorder. Am Fam Physician. 2012;85(9):890-896.
Codes
ICD10
  • F90.9 Attention-deficit hyperactivity disorder, unspecified type
  • F90.1 Attn-defct hyperactivity disorder, predom hyperactive type
  • F90.0 Attn-defct hyperactivity disorder, predom inattentive type
Clinical Pearls
  • Adult ADHD results in inattention, easy distractibility, hyperactivity, and impulsive behavior; it is associated with low self-esteem, problematic interpersonal relationships, and difficulty meeting academic and job expectations.
  • Psychotropic medications plus cognitive-behavioral treatments are the cornerstone of management.
  • Substance abuse is a common comorbidity; recommend use of nonstimulant medication in those at high risk