25-13: Attention-Deficit/Hyperactivity Disorder

While attention-deficit/hyperactivity disorder (ADHD) begins in childhood, symptoms persist into adulthood in approximately two-thirds of patients, with half of those still requiring medication to aid in their functioning. The prevalence of ADHD in adults is estimated to be 4–5%. ADHD is never diagnosed in some patients during childhood because they may not have presented for assessment at that time 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.

A. Pharmacologic

Stimulants such as methylphenidate and amphetamine are the most effective treatment, with some of the largest effect sizes for medication treatment in psychiatric disorders. These come in both short-acting and long-acting formulations. Caution should be used to assess for potential substance abuse or diversion as well as for comorbid mood disorders that may not respond well to a stimulant prior to prescribing these medications. Atomoxetine, a nonstimulant, is a second-line agent that is FDA-approved for ADHD; it affects norepinephrine and dopamine transport and makes more of these neurotransmitters available in the brain. Bupropion has evidence of efficacy as well 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, also 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 of complementary tasks they are more suited to (ie, selecting jobs that value more activity rather than sustained focus, or sharing in the chores at home that do not require attention to detail). Cognitive behavioral therapy has some evidence for helping residual symptoms after medication management has been optimized.