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 use disorder, 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.
ADHD is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity. It has a chronic course with symptoms that begin in early childhood but often persist into adult life. Diagnosis of ADHD in adulthood requires ancillary information supporting onset of symptoms in childhood (before 12 years of age). Another key element of the definition is that symptoms manifest in two or more settings, for example both at home and in work. Symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. Impulsivity may remain problematic in adults even when hyperactivity has diminished. Comorbid disorders are present in more than 75% of adult cases.
This topic covers the management of ADHD in adults only. See also ADHD in children.
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 use disorders
- thrill-seeking behavior
- driving accidents
- unable to pay attention to details resulting in "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, dislikes, or is reluctant to engage in tasks that require maintaining mental effort
- frequently loses things needed for tasks or activities
- frequently forgetful in daily activities
- 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 "on the go", acting as if "driven by a motor"
- often talks excessively
- often interrupts with answers before questions have been completed
- often has difficulty waiting for his/her turn (e.g., while waiting in line)
- often interrupts or intrudes on others (e.g., interrupting conversations)
- increased criminal justice system involvement
- 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
- Depression in adults
- Bipolar disorder in adults
- Generalized anxiety and other anxiety disorders
- Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR)
- World Federation of ADHD International consensus statement
ADHD: what is it?
Coping strategies for teenagers and adults with ADHDMore Patient leaflets
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