ESSENTIALS OF DIAGNOSIS
Persistent patterns of inability to sustain attention, excessive motor activity/restlessness/impulsivity, or both.
Symptoms interfere with daily functioning.
Symptoms began prior to age 12 and in at least two settings (ie, school/work, home, with friends/family).
Attention-deficit/hyperactivity disorder (ADHD) begins in childhood; however symptoms persist into adulthood in two-thirds of patients, with half of those still requiring medication to aid in functioning. The prevalence of ADHD in adults is estimated to be 4–5%. In some patients, ADHD is not diagnosed during childhood because they may not have presented for assessment or were able to compensate for symptoms at the time. The specific presenting symptoms in adulthood tend to be inattention, restlessness, and impulsivity, whereas hyperactivity has often improved. At least five inattention symptoms (such as making careless mistakes, being easily sidetracked, trouble keeping deadlines or with organization, losing belongings, being forgetful in daily chores/tasks) are required to meet criteria for this subtype of ADHD, or five hyperactivity/impulsivity symptoms (such as feeling restless and leaving a seat though expected to remain, feeling “driven by a motor,” interrupting others, cannot wait his or her turn) for this subtype. It is often useful to have patients provide questionnaires to other adult observers, including those who knew them during childhood, such as parents. This collateral data can help prevent diagnosing ADHD in someone who is seeking stimulants but without symptomatology as well as aid in making the diagnosis, since evidence shows that many adults who do have ADHD often underreport symptoms.
Stimulants such as methylphenidate and amphetamine are the most effective treatment. These come in short-acting and long-acting formulations. Caution should be used prior to prescribing these mediations to assess for potential substance abuse or diversion as well as for comorbid mood disorders that may not respond well to a stimulant. Atomoxetine, a nonstimulant, is a second-line FDA-approved agent for ADHD. It affects norepinephrine and dopamine transport and makes more of these neurotransmitters available in the brain. Bupropion also has evidence of efficacy and may be considered in patients in whom a stimulant is contraindicated or in those who also suffer from major depression. Desipramine, a tricyclic antidepressant, can be effective for ADHD and may be considered in patients who have additional needs, such as a concomitant depression or neuropathic pain. Guanfacine and clonidine are two additional nonstimulant medications used primarily to treat blood pressure but with some efficacy in ADHD as well.
B. Behavioral and Other Treatments
Psychoeducation regarding ADHD should be given to all patients. Many patients are able to implement behavioral changes that either improve their functioning, such as creating calendars and organizational schemes or doing tasks in multiple timed short spurts, or can help them avoid tasks that are challenging for them in favor ...