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, with half of those still requiring medication

• 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; these come in short-acting and long-acting formulations

• Atomoxetine and viloxazine, nonstimulants

  • Second-line FDA-approved agents for ADHD

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

  • Viloxazine blocks the norepinephrine transporter but is also a 5HT2b antagonist and a 5HT1a agonist

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

• Desipramine could be considered in patients who have concomitant depression or neuropathic pain

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 or can help them avoid tasks that are challenging for them in favor of complementary tasks they are more suited to

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