Attention deficit hyperactivity disorder in adults

Last reviewed: 5 Sep 2023

Last updated: 04 Jan 2023

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.

Definition

ADHD is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity.[1] It has a chronic course with symptoms that begin in early childhood but often persist into adult life.[1] Diagnosis of ADHD in adulthood requires ancillary information supporting onset of symptoms in childhood (before 12 years of age).[1] Another key element of the definition is that symptoms manifest in two or more settings, for example both at home and in work.[1] Symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. Impulsivity may remain problematic in adults even when hyperactivity has diminished.[1] 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

More key diagnostic factors

Risk factors

family history of ADHD
male sex
psychosocial adversity
other environmental factors

More risk factors

Diagnostic investigations

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

More 1st investigations to order

Investigations to consider

urine drug screen
electroencephalogram
brain imaging (CT or MRI)
polysomnography
computer-based program

More investigations to consider

Treatment algorithm

ONGOING

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

Contributors

Authors

Marios Adamou, MD, MSc, LL.M, MA, MBA, PhD, FRCPsych, FFOM

Consultant Psychiatrist

South West Yorkshire NHS Partnership Foundation Trust

University of Huddersfield

Huddersfield

Disclosures

MA has provided consultancy to Takeda the manufacturer of Elvanse.

Acknowledgements

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.

Disclosures

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.

Peer reviewers

Gianni Faedda, MD

Lucio Bini Mood Disorders Center

New York

Disclosures

GF has been reimbursed by Astra Zeneca, the manufacturer of Seroquel, for attending several conferences.

David W. Goodman, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins School of Medicine

Baltimore

Disclosures

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.

Differentials
- Depression in adults
- Bipolar disorder in adults
- Generalized anxiety and other anxiety disorders
More Differentials
Guidelines
- Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR)
- World Federation of ADHD International consensus statement
More Guidelines
Patient leaflets
ADHD: what is it?
Coping strategies for teenagers and adults with ADHD
More Patient leaflets
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Attention deficit hyperactivity disorder in adults

Summary

Definition

History and exam

Key diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

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

Contributors

Authors

Marios Adamou, MD, MSc, LL.M, MA, MBA, PhD, FRCPsych, FFOM

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Gianni Faedda, MD

Disclosures

David W. Goodman, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice