Attention-Deficit/Hyperactivity Disorder

Key Features

• 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)

• Prevalence in adults is estimated to be 4–5%

Clinical Findings

• Although begins in childhood, symptoms persist into adulthood in approximately two-thirds of patients

• Presenting symptoms in adulthood tend to be inattention, restlessness, and impulsivity, whereas hyperactivity has often improved

• Other findings include

  • Careless mistakes

  • Being easily sidetracked

  • Having trouble keeping deadlines or with organization

  • Losing belongings

  • Forgetfulness in daily chores/tasks

  • Feeling restless (eg, may leave a seat though expected to remain)

  • Feeling "driven by a motor"

  • Interrupting others

  • Cannot wait his or her turn

Diagnosis

• At least 5 inattention symptoms or 5 hyperactivity/impulsivity symptoms are required to meet criteria for ADHD

• It is often useful in making this diagnosis to have patients provide questionnaires to other adult observers, including those who knew them during childhood, such as parents

Treatment

Medication

• Methylphenidate and amphetamine are the most effective treatments

• Atomoxetine, a nonstimulant

  • Second-line agent

  • FDA-approved for ADHD

  • Affects norepinephrine and dopamine transport and makes more of these neurotransmitters available in the brain

• Bupropion could be considered in patients in whom a stimulant is contraindicated or who also suffer from major depression

• Desipramine, a tricyclic antidepressant, could be considered in patients who have concomitant depression or neuropathic pain

• Guanfacine and clonidine, used primarily to treat hypertension, have some efficacy in ADHD

Behavioral and Other Treatments

• Psychoeducation regarding ADHD should be given to all patients

• There is some evidence that cognitive behavioral therapy can help residual symptoms after medication management has been optimized