Adult attention deficit hyperactivity disorder (ADHD) is a common adult disorder, thought to be persistence of childhood ADHD. Prevalence of 2% to 5% in the general population and 10% to 20% in those with a common mental health disorder.
Characterized primarily by inner restlessness rather than hyperactivity; impatience; sensation seeking and excessive spending rather than impulsivity; inattention; and functional impairment with underachievement and disorganization.
Among those diagnosed with ADHD as children, by age 25 years only 15% retain the full ADHD diagnosis, although a much larger proportion (65%) fulfill the Diagnostic and Statistical Manual of Mental Disorders criteria for ADHD in partial remission.
Diagnosed by clinical history. Self-report should not be the main source of information. Collateral history is extremely useful. Neuropsychological testing can be of use in some cases.
About 75% of adults with ADHD will have at least one other mental health disorder, often anxiety, mood disorders, personality disorder, substance misuse, and other neurodevelopmental conditions.
ADHD as a primary condition is most clearly diagnosed when mood or anxiety disorders are not active. Treat obvious psychiatric disorders as normal and assess the effects of that treatment on cognition (attention, concentration, memory) carefully.
Stimulant medications (methylphenidate, amphetamine derivatives) are first-line treatment and nonstimulant medications, including atomoxetine, form second-line management.
Psychological therapies, including cognitive behavior therapy, metacognitive therapy, and dialectic behavior therapy, can be effective in reduction of symptoms in combination with medication.
Adult attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder presenting with inattentiveness, impulsivity, and hyperactivity, persisting into adulthood. Diagnosis can be made in either adulthood or childhood by 7 years of age (age limit increased in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition [DSM-5] to 12 years). Functional impairment is a criterion for diagnosis. Comorbid disorders are present in more than 75% of adult cases.
History and exam
Key diagnostic factors
- onset prior to age 12 years
- past or present academic dysfunction
- present or past occupational dysfunction
- familial and relationship dysfunction
- drug and alcohol misuse
- thrill-seeking behavior
- driving accidents
- fails to pay attention to details and careless mistakes at work, school, etc.
- has difficulty maintaining attention in tasks
- seems not to listen when being spoken to
- does not follow instructions and does not finish duties and assigned tasks (not due to misunderstanding or oppositional behavior)
- has organizational difficulties
- avoids and/or dislikes tasks that require maintaining mental effort
- frequently loses things needed for tasks or activities
- frequently forgetful in daily tasks
- fidgets often with hands or feet and moves in seat
- frequently leaves situations, rises from chair when remaining seated is expected
- often feels restless
- has difficulty engaging in leisure activities quietly
- often acts as though "on the go
- often talks excessively
- often interrupts with answers before questions have been completed
- often has difficulty waiting for his/her turn
- often interrupts or intrudes on others (e.g., interrupting conversations)
- increased criminality
- distracted easily by surroundings and external stimuli
- family history of ADHD
- male sex
- psychosocial adversity
- other environmental factors
1st investigations to order
- Conners Adult ADHD Rating Scale
- Brown Attention Deficit Disorder Scale
- World Health Organization Adult ADHD Self-Report Scale
- Wender Utah Rating Scale
- neuropsychological testing
Investigations to consider
- urine drug screen
- brain imaging (CT or MRI)
- computer-based program
ADHD without concomitant mood disorder or anxiety
ADHD with depression (with or without prominent anxiety)
ADHD with bipolar disorder (with or without prominent anxiety)
ADHD with anxiety disorder alone
Marios Adamou, MD, MSc, LL.M, MA, MBA, PhD, FRCPsych, FFOM
South West Yorkshire NHS Partnership Foundation Trust
University of Huddersfield
MA is a member of the UK Adult ADHD Network (UKAAN) executive committee, Adult ADHD and Autism Service at South West Yorkshire Partnership NHS Foundation Trust, and a board member of the Wigan and Northumberland Clinical Commissioning Groups. MA has received a National Institute for Health Research (NIHR) grant for use of AI in diagnosis of attention deficit hyperactivity disorder.
Professor Marios Adamou would like to gratefully acknowledge Dr Bridget Craddock, Dr S. Nassir Ghaemi, and Dr Elizabeth A. Whitham, the previous contributors to this topic.
BC declares that she has no competing interests. SNG has received research grants from Pfizer, served on the speakers' bureaus of Astra Zeneca and Pfizer, and received honoraria from Bristol Myers Squibb. Neither SNG nor his family hold equity positions in pharmaceutical corporations. EAW declares that she has no competing interests.
Gianni Faedda, MD
Lucio Bini Mood Disorders Center
GF has been reimbursed by Astra Zeneca, the manufacturer of Seroquel, for attending several conferences.
David W. Goodman, MD
Department of Psychiatry and Behavioral Sciences
Johns Hopkins School of Medicine
DWG has received research grants from Shire Pharmaceuticals. DWG has received speaking fees from Neuroscience Education Institute, Temple University, American Professional Society of ADHD and Related Disorders, Medscape, and WebMD. DWG has been a paid consultant to American Physician Institute for Advanced Professional Studies, Prescriber's Letter, Consumer Reports, Thomson Reuters, GuidePoint Global, Shire Pharmaceuticals, McNeil Pediatrics, Cephalon, Teva Pharmaceuticals, Lundbeck, Otsuka Pharmaceuticals, and Novartis.
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