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Funding for this expert roundtable supplement has been provided by an educational grant from Eli Lilly and Company.
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc.
The Mount Sinai School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Medications proven effective in treating childhood ADHD are also successful in treating adult ADHD.
Funding for this activity has been provided by an educational grant from Eli Lilly and Company. In this expert roundtable supplement, Margaret Weiss, MD, PhD, presents a comprehensive overview of complications surrounding differential diagnosis in adults with ADHD.
Clinicians are now fully aware and in agreement that ADHD is common and treatable in all ages; however, most remain uncomfortable applying this information into practice. The objective of this discussion is to frame an approach to translating expertise in differential diagnosis and management of comorbidity in ADHD into knowledge translation for primary care physicians and psychiatrists. The National Comorbidity Survey Replication (NCS-R) was the first epidemiological study of adults to evaluate ADHD in the context of other psychiatric illnesses and disabilities.3 Kessler and colleagues3 demonstrated that the majority of adults with ADHD have a complicating clinically significant comorbid disorder, and up to 50% of patients with ADHD have a complicating mood or anxiety disorder (Slide 1). Patterns of comorbidity between children and adults with ADHD are similar.4 Developmental disorders such as learning disabilities or autism spectrum disorders are more readily recognized and assessed in young children. A common anecdotal comment in the empirical work on ADHD is that patients who screen positive for ADHD in non-ADHD clinics overlap with the patients who have been treatment resistant. Barkley and Murphy9 recently published preliminary findings examining the extent to which the high levels of comorbidity seen in ADHD populations is specific to this disorder or common to psychopathology in general.
Education on ADHD in adults has attempted to simplify principals of differential diagnosis.
Both bipolar disorder and ADHD patients may experience racing thoughts, hyperactivity, talkativeness, impulsivity, and distractibility.
Diagnosis of dysthymia as a distinct mood disorder requires evidence of chronic low mood and two other symptoms, most of which are problematic in ADHD. There is a high rate of personality disorders in adults with ADHD.14 A personality disorder is a defined maladaptive and repetitive pattern of behavior and interaction with others. Certain comorbid conditions, such as depression and drug use, are interesting in that the lifetime prevalence of the comorbidity greatly exceeds the current prevalence.15 In practice, the majority of adults with ADHD have had a significant problem with one or the other of these two difficulties at some point in their life, but a much smaller proportion are in the midst of such an episode at the time of assessment.
Subthreshold residual symptoms can be clinically significant, particularly when the patient is challenged with medications that unmask or trigger relapse of previous difficulties.
In the revised CADDRA guidelines that will appear in the Fall of 2007, two new knowledge translation tools will be made available to facilitate assessment of comorbidity and differential diagnosis in ADHD. The Weiss Symptom Record (WSR) is a way of collecting information on developmental, Axis I, and Axis II disorders in any age group and from any informant and an approach that is sensitive to child and adult disorders. In the context of the raised expectations and tremendous enthusiasm for the therapeutic opportunity presented by adults with ADHD, it is important to understand that patients included in research data from clinical trials are a selected sub-sample in which significant comorbidities have often been excluded. Although the word treatment typically brings to mind medication or psychosocial therapy, treatment of ADHD really begins at the evaluation stage. A frequent occurrence in developing a treatment plan is the decision that more information is needed prior to proceeding with treatment. Reviewing data from the evaluation and what one has learned about the patient is helpful in setting the stage for developing the treatment plan. It is important to inform the patient of both what is currently known about ADHD and what is not known.
While there are several psychiatric comorbidities that are commonly associated with ADHD, there are also issues that result from having ADHD that are often mistaken for comorbidities. Developing a treatment plan involves selecting an initial treatment strategy, as well as a time frame and a method with which to evaluate the effect of that particular treatment on the patient’s chief complaint and primary area of impairment. The Food and Drug Administration-approved medication choices are the stimulants mixed amphetamine salts or dexmethylphenidate, or the nonstimulant atomoxetine.
In terms of psychosocial treatments for ADHD, one must consider the fit between the patient, expectations, and the environment. There are several recommendations for psychosocial treatment that have not been evaluated specifically for ADHD, but are assumed to be helpful in that population because they are helpful to most other people.
In a primary care setting or one where the practitioner has not had experience with ADHD, the challenge is to identify  someone with previously undiagnosed ADHD. Some of the greatest clinical successes are patients who have ADHD and mild mood symptoms or demoralization, where the ADHD has not been previously treated. Another common presentation is when an individual reports ADHD symptoms but also has a very prominent personality disorder that clearly affects his relationships above and beyond the effects of the ADHD symptoms.
A common clinical presentation is the individual who presents with a substance use disorder and a history of ADHD. There is now increased awareness of ADHD in adults and many more treatment options for ADHD.
On a positive note, it seems that adults are better able to tolerate side effects than children. ADHD is often treated with psychostimulant medications, which work by binding to dopamine transporters in striatum, and norepinephrine (NE) transporters in several brain regions. The nonstimulant atomoxetine, approved by the Food and Drug Administration for the treatment of ADHD, binds selectively to the NE transporter, thereby increasing NE diffusely and DA in the prefrontal cortex. In general, all medications that are useful in treating ADHD in children are also effective in adults.
Dextromethylphenidate extended-release (ER) and mixed amphetamine salts ER are both FDA approved for adults.
Effect sizes of approved medications in adult ADHD are approximately half what they are in children. Some medications that are used off-label for ADHD are approved by the FDA for other indications in adults, including bupropion,4 guanfacine,5 and modafinil.6,7 Bupropion has the most supporting data of any of the non-approved treatments in adults. Medications that treat conditions other than ADHD can generally be used to treat those same conditions when they are present with ADHD. Using short-acting stimulant treatments as the primary modality requires multiple daytime doses to cover the same time period. The efficacy of MAS XR was evaluated in 255 adults with ADHD in a 4-week, randomized, double-blind, placebo-controlled study.1 Treatment was associated with a statistically and clinically significant reduction in ADHD symptoms, as assessed by the ADHD Rating Scale at endpoint, with the greatest improvement in symptoms occurring in the 60-mg dose group. The current approach to treating adult ADHD with relatively higher doses dates to the mid-1990s, when a study utilizing MPH IR in adults with ADHD showed a robust drug response rate. Dexmethylphenidate ER was tested in 5-week parallel group design trial in adults with ADHD comparing placebo with 20 mg, 30 mg, and 40 mg doses under double-blind conditions.12 All three dosages were more effective than placebo, reducing mean ADHD-RS total scores by 36% to 46% versus 21% with placebo. Interestingly, there seemed to be incremental improvement with extended usage of atomoxetine in an open-label extension study.15 This raises the question about how atomoxetine should be dosed, over what period of time, and how to best measure improvement in adults.
The mixed dopaminergic noradrenergic agent bupropion is approved for depression in adults and used off-label for ADHD in children and adults. Risk for substance abuse is a particular concern in adults with ADHD since stimulants are schedule II controlled substances and longitudinal studies of children with ADHD have found an increased risk for substance abuse. A related question is whether it is possible to develop new medications for ADHD with low potential for abuse and diversion (ie, giving or selling the medication to others). Understanding the relationships among ADHD and comorbid disorders is of particular importance in treating adults with ADHD. The notion that anxiety symptoms could be secondary to ADHD would only apply if the anxiety were restricted to performance situations or other contexts in which impairment from ADHD is evident.
One study examined the rates of improvement in children with ADHD and anxiety disorders after treatment with stimulant medication (MAS XR).20 ADHD symptoms improved as would be expected without comorbidity. As a general rule, all treatments that are effective for ADHD in children are effective in adults as well, and all three medication classes which are approved for ADHD in children are also approved for use in adults. There has been an explosion of data regarding medication treatment of ADHD over the past 10 years, and this is especially true with regard to treatment of adults. Q: Increasing publicity about ADHD treatment has raised expectations in many people who have long-standing failures, that the problem may be simple and responsive to a quick fix.
Q: Cinicians often say that they have to use higher medication doses than the label indicates to achieve the best response.
ADHD exerts a substantial toll on the lives of its sufferers and their families.1,19 This article explores the social and personal impact of ADHD on the lives of adults with this disorder, and the clinical challenges and opportunities for improving patient care through appropriate diagnosis and treatment. ADHD has a wide-ranging impact on adult lives, manifesting as educational, interpersonal, physical, emotional, and work-related difficulties.
Adults with ADHD, especially those with comorbid conduct or oppositional defiant disorder histories, are more likely to engage in behaviors resulting in incarceration. Because the DSM-IV-TR indicates that impairments from ADHD must have an onset during childhood, diagnosis involves establishing the presence of symptoms during childhood as well as assessing current impairment.22 The DSM-IV-TR requirement for manifestation of symptoms before 7 years of age relies on parental, peer, or self-memories of childhood occurrences or records for verification. Differences in ADHD presentation based on culture and gender pose another diagnostic challenge. Maintaining a high index of suspicion for the presence of ADHD in adults is a key aspect in making a correct diagnosis. After screening, accurate diagnosis of ADHD requires a multifaceted approach including assessments of history, present symptoms, and functional impairment (Table 4).15,40,51,53 An accurate diagnosis requires sufficient presenting symptoms from the patient, with a pervasive course since childhood, and confirmation of childhood symptoms by an outside informant. Complete evaluation of an adult with suspected ADHD should also include assessment of comorbid psychiatric diagnoses and underlying medical conditions.52 Some medical conditions may have symptoms overlapping those of ADHD or can themselves account for certain attentional symptoms. Once the diagnosis is made, patient involvement is a key element in the success of managing ADHD in adults. After patient and family education, other treatment principles can help improve therapeutic outcomes. Stimulants are the first line of treatment for ADHD.3 Stimulants, including methylphenidate and amphetamines, have been widely and successfully used in children for decades.
Amphetamine and methylphenidate preparations are available in both immediate- and extended-release formulations. In 2005, the possibility of suicidal ideation with atomoxetine led to an FDA boxed warning similar to that for antidepressant medications for children and adolescents, but no such warning was required in adults based on analysis of the adult studies. The FDA has recently approved the use of two long-acting stimulants in adults with ADHD: a prolonged-release formulation of methylphenidate and lisdexamfetamine dimesylate, a long-acting prodrug.
In June 2008, the FDA approved the use in adults of a formulation of methylphenidate (MPH) in which the drug is released via an osmotic release oral system (OROS). In April 2008, the FDA approved the use in adults of a new once-daily stimulant, lisdexamfetamine dimesylate (LDX), the first long-acting prodrug indicated for the treatment of ADHD in children and adults. In addition to pharmacotherapy, nonpharmacologic interventions, such as helping the patient restructure their environment, develop organizational skills, and create better coping strategies, may be beneficial in adults with ADHD.16 Because ADHD affects the entire family, treatment interventions may involve the spouse and children in restructuring of task sharing, planning, and day-to-day functioning.
The Algorithm presents a schematic to select a specific psychotherapy for target symptoms and impairments.87 A thoughtful conceptualization and application of psychotherapy will prevent the therapist from being distracted. Adult ADHD remains under-recognized, underdiagnosed, and undertreated by clinicians in the US.
Stimulants that have been used in the pediatric ADHD population for decades are effective and well tolerated in adults. The development of diagnostic tools and treatment guidelines, coupled with the use of effective and tolerable medications and effective management of comorbid conditions, should improve the quality of care for adult patients with ADHD. In this new study, researchers examined whether medications used primarily to treat ADHD are associated with an increased risk of heart attack, sudden cardiac death, or stroke in adults. Furthermore, results were similar when restricting the category of users to new users or to those with or without ADHD. Stimulant products and atomoxetine should generally not be used in patients with serious heart problems, or for whom an increase in blood pressure or heart rate would be problematic. Patients treated with ADHD medications should be periodically monitored for changes in heart rate or blood pressure. Patients should continue to use their medicine for the treatment of ADHD as prescribed by their healthcare professional.
On November 1, 2011, the FDA communicated the results of a study in children and young adults treated with ADHD medications that also did not show an increased risk of serious cardiovascular events. Psychological treatments for adhd in adults include education about the illness, participation in an adhd support group, and skills training on a variety of topics. Some drugs used for adult adhd can be dangerous for people with certain medical conditions. Treatment for adult adhd varies depending on the individual, but research has shown prescription stimulants, also called psychostimulants, offer the most effective first-line approach for treating the majority of both adult and child add patients.Understanding add adhd in adults.
Adults with ADHD experience decreased productivity and underachievement in the form of chronic lateness, poor management of time and money, inattention to detail, and forgetfulness. The most commonly prescribed medications are stimulants, such as methlyphenidate, amphetamines, and dextroamphetamines.
Weiss is director of research for the Division of Child Psychiatry, University of British Columbia, and senior scientist for the Child and Family Research Institute in Vancouver, British Columbia. Feedback from primary care focus groups from symposia on the assessment of ADHD in Canada suggest that efforts that have gone into knowledge translation of adult ADHD have been insufficient in dealing with assessment and treatment issues of differential diagnosis and comorbidity. Comorbidity dictates treatment response, and as long as clinicians remain uncomfortable with differential diagnosis and identification of other disorders, we will continue to be stymied in bringing treatment to those who need it.
While it is difficult to provide safe and effective treatment of ADHD without evaluating comorbidity, it is also difficult to provide such treatment for a comorbidity in an ADHD patient without identifying and addressing the ADHD. They found that adults with ADHD have significant comorbidities with depressive disorders, anxiety, alcohol use, cannabis use, other substance use, oppositional defiant disorder (ODD), conduct disorder, personality disorders, sleep problems, learning disabilities, and autism spectrum disorder.
It is thought that bipolar disorder can be distinguished by the prominence of mood symptoms, and that grandiosity, racing thoughts, decreased need for sleep, and hypersexuality are more specific to bipolar disorder.10 Adults with ADHD often have problems with anger and mood lability. Provision of combined treatment is optimal, but the resources, skills, and evidence base to guide differential diagnosis and dual diagnosis treatment is scant.
The clinical implications of lifetime diagnosis for current management is unknown, although some research indicates that lifetime depression may be a significant moderator of treatment response for ADHD. There is greater comorbidity in cross-sectional samples of adults with ADHD than there is in prospective cases followed over time, suggesting a referral bias in which those who present in adulthood have both persistent ADHD symptoms and other problems as well. These tools must be user friendly and free of charge, and need to include both developmental and adult onset Axis I and Axis II conditions.
Many of the patients observed in a publicly funded clinic would not be eligible for the clinical trials that form our evidence base. Stein receives research support from Cephalon, Eli Lilly, McNeil, and Novartis; and receives honoraria and compensation for service on the advisory boards of Cortex, McNeil, Novartis, Pfizer, and Shire. The first pillar of treatment is a good evaluation, followed by development of a specific treatment plan that includes targeting associated impairments and building upon the individual’s unique strengths or protective factors. For example, a physician evaluating a college student may request a neuropsychological or psychometric assessment to determine if accommodations are warranted. Taking the time to perform a careful and comprehensive evaluation may enhance future treatment compliance, as it instills confidence that the treating physician understands the problems at hand and cares about the patient’s well being.
It is increasingly the case that people self-diagnose their own ADHD based on Internet information and popular books1 about the disorder; however, many of these sources propagate myths.
For example, a patient with ADHD who is doing poorly academically and has been doing poorly socially for many years is likely to be demoralized and frustrated. Examples of target outcomes for an ADHD patient include impulsivity at work or at school; a secondary target may be mood, sleep, or the effect on the family.
There are numerous other medications that are effective in treating ADHD as well (Slide 3).

While patients often request immediate-release agents, many clinicians are uncomfortable prescribing them to ADHD patients due to their difficulties with time management.
Often, ADHD diagnoses are missed because the comorbid disorder is more prominent or is one that the practitioner is more accustomed to screening for based upon their own training. This is a difficult management situation because these patients are highly invested in ADHD treatment being the sole solution to their problem and have little motivation for changing their personality despite the obvious negative impact on their interpersonal relationships. Many adolescents and adults with undertreated or poorly treated ADHD develop substance abuse disorder.6 In this case, the critical question is which treatments to select given that there is some risk of abuse and diversion with stimulants. However, there is a very limited scientific literature for selecting among different treatment options, as the majority of treatment studies have compared a single medication to a placebo, rather than comparing several medications or using crossover designs. It may be that many of the adverse events observed in children in response to stimulants, such as loss of appetite and insomnia, appear to be less significant in the adult populations. This is supported by findings from neuroimaging studies that show differences in glucose utilization during positron emission tomography scans, and blood oxygen levels during magnetic resonance imaging (MRI) scans in adults with ADHD. However, FDA approval of medications for treatment in adults is a relatively new phenomenon. The latter is approved at a maximum dose of 20 mg in adults, compared to 30 mg in children.
There are a variety of reasons for this, including the higher placebo response rate and, in some cases, the lower maximum approved dose in adults.
Use of guanfacine and modafinil in adults is mainly extrapolated from results of studies in children.
Because attention and self-regulatory control are required for a variety of activities and not only academic and occupational functions, and because adults often work longer and later than children, it stands to reason that they would require a longer duration of medication effects (up to 12–16 hours).
The ER formulation of mixed amphetamine salts (MAS XR) last ~10–12 hours, while the IR formulations of mixed amphetamine salts and d-amphetamine last ~6 hours (Slide 1). The approval of only the 20-mg dose reflects the FDA finding that differences in clinical response at higher doses in forced dose titration trials were not large enough to justify the potential for increased adverse effects. Improvement in ADHD symptoms with MPH treatment was significantly different from placebo beginning at week 3.
The recommendation is to begin with 40 mg in adults,13 although many clinicians begin with 25 mg and titrate the dose upward more slowly, often with weekly dose adjustments, to reach a target dose of 100 mg. Several open studies and case reports but only a handful of controlled studies address the question of how to treat individuals with ADHD and comorbid substance abuse. Most diversion seems to be motivated by the desire to improve cognitive function and not abuse per se; however, stimulants have potential for abuse, primarily when administered intravenously (IV) or intranasally (IN).
The clinical presentation of ADHD and comorbid anxiety disorder is illustrative of this point. Some of these conditions are of specific interest in adults (eg, substance use disorder) or present somewhat differently in adults (eg, mood disorders) than in children. When symptoms of multiple disorders are present, it is important to prioritize the approach to treatment, giving most attention to the disorders that are most severe and associated with the highest degree of impairment.
Unfortunately, there are few studies that provide empirical data regarding treatment of ADHD and comorbidity, as the large majority of research is conducted in non-comorbid subjects. Stein: It begins with a careful evaluation, which results in a comprehensive diagnosis and treatment plan that describes the symptoms, impairments, and strengths of the individual, and whether the symptoms meet the profile of ADHD.
Newcorn: One of the problems we have in identifying ADHD in adults as compared to children is that we do not know how to account for personality development. There is risk in providing improper treatment for another condition when one focuses on ADHD incorrectly, as well as in not treating ADHD properly.
Clearly, recognizing and being able to treat ADHD in adulthood is an important new therapeutic opportunity. The symptoms, deficits, and consequences associated with ADHD have a profound negative impact on the lives of patients and their families. Controlled studies1,20 demonstrate that adults with untreated ADHD have poorer educational performance and attainment, significantly more marriages, greater likelihood of problems making friends, and a higher incidence of interpersonal problems than those without ADHD.
In a study at the Utah State Prison of 102 randomized male inmates 16–64 years of age, 26 received a positive diagnosis of ADHD (having significant symptoms both as children and adults). Nonetheless, it is prudent to be alert for suicidality in all patients with ADHD regardless of the choice of treatment and, in particular, in those patients with comorbid mood, anxiety, and substance use disorders.
LDX is a therapeutically inactive molecule, but after oral ingestion it is converted to l-lysine, a naturally occurring essential amino acid, and active d-amphetamine, responsible for the drug’s activity.
Its prevalence and the absence of relevant professional clinical training indicate a need to educate physicians and other healthcare providers who encounter the challenging task of diagnosing ADHD in adults. Management of ADHD in adulthood requires the clinician to rule out fairly common medical conditions, such as hypertension, that may be exacerbated by stimulant treatment. Improved recognition and treatment of ADHD should result in improved productivity in academic, work, and home environments, and should enhance quality of life for both patient and family. Data analysis suggested that patients who were currently or had just begun taking ADHD medications were at no greater risk for serious cardiovascular events than those patients who never, or had not recently, taken the medication. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults [published online before print December 12, 2011].
Cardiovascular effects of methylphenidate, amphetamines and atomoxetine in the treatment of attention-deficit hyperactivity disorder. Furthermore, i advise the patient that their credibility in my eyes is very fragile and easily destroyed, and that i will not continue treating someone who fails to remain clean and sober anyone who fails to keep appointments and anyone who gives me any reason to believe he or she is misusing the medication in any way. In the past, the first treatment typically offered to adults with adhd has been stimulant drugs.Learn about the diagnosis and treatment of adhd in adults, which often goes undiagnosed. There are no psychological evaluations or laboratory tests that can confirm an ADHD diagnosis, and doctors familiar with childhood ADHD often have difficulty detecting adult ADHD due to its changed presentation. Stimulants and atomoxetine, a relatively new nonstimulant medication, are generally considered the best options for initial pharmacologic treatment. Stein, PhD, reviews evaluation, comorbidity, and development of a treatment plan in this population.
The first edition of the Canadian Attention Deficit Disorder Resource Alliance (CADDRA) practice guidelines2 addressed this issue by providing criteria to distinguish simple from complex cases of ADHD and recommended that only the latter be referred for consultation to a specialist. However, all of the available diagnostic interviews and rating scales have been either child based or adult based; what has never been tested is whether this migration of diagnoses with age is a function of the questions asked, changing environmental challenges across the life span, or actual age of onset. Similarly, just as it is cost effective to screen for comorbid disorders in an ADHD clinic, the same applies for ADHD screening in clinics treating other problems. It is easy to identify ADHD patients who have had hard lives but seem to keep fighting against all odds with an enthusiasm to keep trying.
Patients with ADHD live with a condition that annoys others, and they do not always see why. These examples have been selected to illustrate that even for the experts, differential diagnosis in adults with ADHD presents a challenge.
This has significant consequences for our understanding of developmental outcomes and the burden of illness represented by untreated ADHD.
The Structured Clinical Interview for DSM-IV-TR (SCID-IV)17 does not include ADHD, ODD, learning disabilities, sleep disorders, autism spectrum, personality disorders, or Tourette’s syndrome. The Turgay Symptom Screener is a DSM-IV based scale for use by any informant to assist with diagnosis in children and adolescents. These patients are often disappointed to learn that for one or another reason they cannot take medication or that medication will not fix other more serious problems such as substance abuse, bipolar disorder, or personality disorder. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Characteristics of adults with attention deficit hyperactivity disorder plus substance use disorder: the role of psychiatric comorbidity. A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state. Personality differences related to smoking and adult attention deficit hyperactivity disorder. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study.
This discussion will focus on therapeutic management, including the implications of comorbidity on management of ADHD in adults, as well as some of the key treatment options. For example, some sources claim that people with ADHD are creative and fun to be around, but these sources often do not focus on the cumulative impairments and frequent comorbidity associated with the disorder. All of the treatment options should be reviewed, and the one with the most favorable risk-benefit ratio selected (Slide 2). Certainly the more complex the therapeutic regimen, the more difficulty a patient will have in following it, and once-a-day treatments are often easier to follow.
For example, it is very common to combine medication treatment of ADHD with CBT for comorbid anxiety or mood disorders, or with coaching, marital, or family therapy. A treatment strategy should be developed in anticipation of suboptimal  response to the first agent. Medication may help, but unless the patient understands what their learning disorder is and receives additional supports, they are going to continue to struggle. On the other hand, this is a symptom constellation with poor prognosis and usually limited motivation for treatment or for tolerating initial treatment failures. In addition, the populations selected for ADHD  studies may differ in several ways, including degree and presence of comorbidity, from patients who are treated in clinics. However, adults are certainly a challenge because of the wide range of impairments they display and because of their increased risk for medical comorbidities. Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Adolescents with ADHD: patterns of behavioral adjustment, academic functioning, and treatment utilization. OROS MPH is approved for use in children and adolescents, but is the most frequently used MPH formulation in adults.
Lack of medication coverage at any time during the day can negatively affect a variety of functional domains, such as motivation, decision-making, and cognitive and affective functions. IR formulations of stimulants may also carry a higher risk for diversion or abuse than the long-acting formulations because they produce more rapid escalations in plasma level and are cleared relatively quickly. This illustrates the challenge involved in demonstrating that doses routinely used in clinical practice with adults, with which many clinicians find the greatest level of improvement, are labeled as being incrementally effective based on clinical trials data. Adults with severe symptoms showed significantly greater improvement with the 60-mg dose of MAS XR compared with placebo and the 20-mg dose, and numerically but not statistically greater improvement compared to the 40-mg dose. The effect size of atomoxetine in double-blind studies in adults was relatively modest, at slightly less than 0.4.
They are not quite as obvious as they are in children, and it may take a while to fully appreciate changes following treatment. Bupropion could be a good choice for patients with ADHD and comorbid depression because it is approved for depression with has demonstrated activity in ADHD. Findings have been mixed, with separation from placebo in some studies but not others.16,17 Some preliminary findings suggest that substance abuse improves when ADHD is successfully treated. Thus, even if the drug is used via IV or IN, it does not produce the rapid increase in plasma level observed with IV or IN administration of other stimulants, which would considerably lower its potential for abuse.
Individuals with ADHD, who often have impairments in performance and repeated experience of failure, might reasonably be expected to approach new situations with a certain degree of fear and trepidation.
Overall, there was not a statistically significant change in anxiety symptoms with treatment, but the study was not adequately powered to detect such changes.
As a corollary, it is important to consider whether ADHD is also present in adults with other psychiatric disorders, since these can often mimic or mask ADHD symptoms. Effect sizes for treatment of ADHD symptoms are approximately half of what they are in children, when approved doses are examined. If it is likely that the comorbid condition is a result of ADHD, or if ADHD is the most impairing condition, one should proceed with treatment of ADHD first. Important next steps are to more closely study the treatment of ADHD and comorbidity, with particular attention to presentation in adults, and to develop specific approaches relevant to this under-identified and under-treated population. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial.
Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults.J Child Adolesc Psychopharmacol. Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. There is emerging literature on personality disorders and personality styles in ADHD youths followed over time.
Some of them have another disorder that is worse than ADHD, but there is also a percentage of patients who do not meet the impairment criteria for ADHD. But one also needs to consider possible psychological factors that could contribute to the enduring nature of ADHD in adults. Barriers to diagnosing ADHD in adults include diagnostic criteria developed and field-tested in children, nonspecificity of symptoms, high incidence of comorbid disorders that could mask or distract from the ADHD diagnosis, variation in presenting symptoms by gender and ethnicity, and lack of definitive diagnostic tools.
An additional 22 inmates showed varying patterns of ADHD symptoms throughout childhood and adulthood, while seven had exhibited ADHD symptoms only during childhood, and seven showed ADHD symptoms only as adults.33 Of 129 inmates of a German prison for adolescent and young adult male prisoners, ADHD (using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition34 criteria) was diagnosed in 45%. Further, symptoms may become apparent only in more challenging situations, such as at home with its demands for multitasking, and be less prominent in a work environment chosen for its suitability for ADHD.16,54 Adaptive skills, intelligence quotient, and environmental demands may make it difficult to enumerate the six of nine symptom criteria or to validate the two-domain criterion of the DSM-IV-TR. A recent study identified a group of 79 adults who fulfilled all criteria for ADHD except for onset of symptoms before 7 years of age. Response to pharmacotherapy, psychotherapy, or both can be monitored by using the assessment scales through the course of treatment to evaluate target symptom changes. The critical factor in distinguishing many of these conditions from ADHD is the absence of childhood cognitive or behavioral symptoms consistent with ADHD.
Providing long-term support and encouragement at follow-up sessions is intrinsic to the treatment process and can also serve to significantly increase the often poor treatment adherence seen in ADHD.
Patients with poorly controlled hypertension may not be eligible for stimulant treatment until their blood pressure is well controlled.91,92 Before prescribing stimulants, clinicians should ensure that the patient has no structural cardiac abnormalities or other serious cardiac problems that may place him or her at increased vulnerability to the sympathomimetic effects of stimulant drugs.
The selection of short-acting or long-acting ADHD treatments varied by specialty, with long-acting agents representing 56% of primary care prescriptions, 64% of psychiatrist prescriptions, and 79% of pediatric prescriptions.
Updated DSM-IV-TR diagnostic criteria that recognize adult-specific symptoms and reconsider age-threshold criteria for symptom onset are needed. Significant cardiac disease in most cases precludes the use of stimulants in both adults and children. Future research may demonstrate whether intervention for ADHD can reduce morbidity and mortality from tragic outcomes associated with ADHD such as increased rates of motor vehicle accidents, suicide, and substance abuse and dependence.
Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder.
Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning.
Prospective study of tobacco smoking and substance dependencies among samples of ADHD and non-ADHD participants.

Young adults with attention deficit hyperactivity disorder: subtype differences in comorbidity, educational, and clinical history.
Screening and diagnostic utility of self-report attention deficit hyperactivity disorder scales in adults. Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults.
Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members.
Stability of executive function deficits into young adult years: a prospective longitudinal follow-up study of grown up males with ADHD.
A psychoeducational program for children with ADHD or depression and their families: results from the CMAP Feasibility Study. A randomised, double-blind, placebo-controlled trial of dexamphetamine in adults with attention deficit hyperactivity disorder.
Long-term safety and effectiveness of mixed amphetamine salts extended release in adults with ADHD. Treatment of attention deficit hyperactivity disorder in children and adolescents: safety considerations. A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit hyperactivity disorder. A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults.
Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder. A double-blind, placebo-controlled, crossover study of osmotic release oral system methylphenidate in adults with ADHD with assessment of oppositional and emotional dimensions of the disorder. Lisdexamfetamine dimesylate and mixed amphetamine salts extended-release in children with ADHD: a double-blind, placebo-controlled, crossover analog classroom study.
A double-blind, randomized, placebo- and active-controlled, 6-period crossover study to evaluate the likability, safety, and abuse potential of lisdexamfetamine dimesylate (LDX) in adult stimulant abusers. Psychotherapy of attention deficit hyperactivity disorder in adults: a pilot study using a structured skills training program. A Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnosis, Treatment. Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach.
Adults with ADHD benefit from cognitive behaviorally oriented group rehabilitation: a study of 29 participants.
The more than 150,000 participants were between the ages of 25 and 64 years and had received prescriptions for methylphenidate, amphetamine, or atomoxetine. There appeared to be no association between any specific medication and a cardiac event or with longer duration of current use. In addition, results were similar for participants who were the ages of 25 through 44 and 45 through 64 years during follow-up.
This may affect the professional as well as personal life of an individual.Treatment for adult adhd is similar to treatment for childhood adhd, and. Psychosocial treatment, in conjunction with pharmacologic treatment or alone in patients with mild ADHD, is highly effective at controlling adult ADHD symptoms. Adults with ADHD show significant comorbidities with depressive disorders, anxiety disorders, substance use, oppositional defiant disorder, personality disorders, sleep problems, and learning disabilities. This strategy has been in large part successful, but it has not solved the problem of addressing service needs because most ADHD adults are complex cases, and there are few psychiatrists providing back-up expertise in adult ADHD.
This means that our skills in diagnosing developmental disorders in adults or prodromes of adult syndromes in children is limited. If ADHD is common but rarely diagnosed in specialized treatment populations at risk, the likelihood is that specialty clinics are failing to screen for or treat this condition. Comorbidity of ADHD impacts compliance, treatment persistence, insight, self-regulation, attendance, and treatment response. There are several areas of differential diagnosis where the symptoms overlap between ADHD and another disorder is extensive, but treatment of the two disorders are distinct.
The Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS) is not written for use in adults, although it has been used for adults.18 Diagnostic interviews developed specifically for ADHD in adults do not address differential diagnosis from other disorders. The scale is designed to alert clinicians to clusters of problems that might otherwise be missed and allow for documentation of symptoms by different informants over time. Furthermore, it provides an opportunity for the physician to educate the patient about his disorder, and to describe how treatments are delivered, monitored, and revised. Often, these individuals do not respond to antidepressants, which are typically tried first with adults with mood and ADHD symptoms.
However, for many individuals the duration of treatment is too limited even with the long-acting treatments, resulting in multiple doses even with these agents. Other psychosocial treatments, such as coaching, are helpful to adults with ADHD, although these services are difficult to obtain in some areas. ADHD specialists typically see patients who have previously been diagnosed or treated for mild depression or dysthymia.
Unlike children, they must administer their own medications and seek appropriate and effective psychosocial treatments which are often not easy to find.
Stimulant treatment increases activation in brain regions implicated in attention and executive function in subjects with ADHD scanned with MRI while performing tests of inhibitory control.
The idea that medications that are relatively rapid in their onset of effect may require more extended time before showing incremental improvement is intriguing, and speaks to the complexities in appreciating, tracking, and measuring treatment response in adults with ADHD. Hence, it stands to reason that some degree of anxiety may be secondary to the experience of having ADHD. For example, we had a case of a first-year medical student who had taken an online questionnaire about ADHD symptoms and thought he had ADHD. Many patients have the mistaken impression that if they have ADHD, and it has not been diagnosed, then treatment may also cure their learning disability, substance problem, personality difficulties or mood disorder. Thus, it is possible that psychosocial interventions will become increasingly important in treating adults with ADHD in the future, regardless of whether or not they are also taking medication. Goodman is director of the Adult Attention Deficit Disorder Center of Maryland at Johns Hopkins at Green Spring Station, assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, and director of Suburban Psychiatric Associates, LLC. Given the relatively high prevalence of ADHD compared with other psychiatric disorders, clinicians should maintain a high index of suspicion and integrate screening for ADHD into all routine psychiatric evaluations. Recent data from Verispan13 indicates that prescriptions for ADHD medications for adults ≥18 years of age grew steadily from January 2003 through October 2007. Interviewing family members greatly improves the clinician’s ability to correctly identify ADHD, as others often remember impairments that the patient has forgotten or failed to recognize. When examined by patient age, long-acting agents accounted for 78% of ADHD prescriptions in pediatric patients (0–17 years of age), but only 49% of adult ADHD prescriptions. Clinical trials of LDX in children have demonstrated significant improvements in ADHD rating scale scores compared with placebo and consistent times to maximum plasma LDX levels among the subjects.111,112 Similar results have been seen in adults.
Meanwhile, clinicians can improve patient care and provide a better quality of life for these patients and their families by maintaining a high index of suspicion for ADHD, making screening for the disorder an intrinsic part of the standard psychiatric evaluation, and implementing a multifaceted approach to the diagnosis and treatment of adult ADHD.
Each medication user was matched to two nonusers by study site, birth year, sex, and calendar year, for a total of 443,198 users and nonusers. For better or for worse, you may go headlong into situations and find yourself in potentially risky circumstances. Attention deficit hyperactivity disorder (adhd) in adults.Adhd symptoms, diagnosis, and treatment. However, symptoms that result from ADHD, such as mood symptoms or lability, are often mistaken for comorbid disorders.
Newcorn, MD, provides a discussion on the pharmacologic options available for adults with ADHD, considering dosages specific to adults and common comorbidities.
The thought disorder associated with ADHD is apparent to any skilled clinician who has to routinely take a history from these patients.
The family doctor or psychiatrist in practice has to assess and manage ADHD without these advantages and often without easy access to expert consultation. There is no validated diagnostic interview appropriate to the spectrum of difficulties associated with ADHD in adults. It is of particular utility in assisting adult clinicians to assess developmental disorders in adults, and child clinicians in identifying early-onset adult disorders (such as personality disorder, eating disorder, or substance use). Hence, the next step after an initial evaluation may be referral for further consultation or evaluation. In reality, many people do not outgrow ADHD, although often hyperactivity symptoms decline or become more subtle.2 Therefore, it is important to educate patients about what is and is not known about ADHD, including the limits of our current scientific knowledge about this disorder (Slide 1). Usually, contacting ADHD support groups such as CHADD or ADA is helpful in finding local professionals with this expertise. For patients who present with a clear history of  ADHD, it is often best to treat the ADHD first, while monitoring the mood symptoms in response to the treatment. There are some data that suggest that one can treat the ADHD with stimulants without exacerbating the substance abuse,7 although there is need for further study in this controversial area. A related question is whether this anxiety improves if the ADHD is treated or whether it represents an independent problem.
The DSM-IV-TR would classify these patients as having a diagnosis of ADHD not otherwise specified (NOS) because they do not fulfill the age-at-onset criterion for ADHD.22 Gathering additional ADHD impairment data from family, friends, and school records from before 7 years of age can be helpful in many cases.
It can also be helpful to obtain school records to identify or corroborate childhood manifestations of ADHD.40 However, valuable supplementary information from family members or school records may often be somewhat difficult to obtain for adult patients no longer residing near their parents or schools.
Extended-release preparations of methylphenidate, dexmethylphenidate, mixed amphetamine salts, and lisdexamfetamine are approved by the US Food and Drug Administration for use in adults without age restrictions. Most adverse events were mild or moderate in each treatment group and few patients discontinued treatment because of an adverse event. Longer-acting forms of stimulants and nonstimulants can improve convenience and extend control of ADHD symptoms in challenging adult environments and potentially may help decrease, but by no means eliminate, the likelihood of stimulant abuse and diversion.
The types of adhd medicines include stimulants and nonstimulants.Medications to treat adult adhd. Anxiety disorders, depressive disorders, and substance use disorders are common among adults with ADHD. Comorbidity with ADHD impacts treatment compliance, treatment response, and patient insight. An adult who is oppositional argues with the doctor, fights the system, blames his boss, or blames his child’s teacher.
When one informs these patients that they have ADHD, they are surprised to find their diagnosis includes the term hyperactivity. Even more important, while structured diagnostic interviews have improved interrater reliability for research purposes, they have had minimal impact on improving interrater reliability in clinic settings. Items were chosen for high specificity with each diagnostic cluster to facilitate differential diagnosis.
At the same time, I am mindful that some patients respond better to one treatment for ADHD than another.
It is important to remember that patients classified as having a diagnosis of ADHD NOS will also usually respond to approved treatments, as recently reported by Biederman and colleagues.58 In an open-label trial in 36 adults with late-onset ADHD NOS, an extended-release preparation of methylphenidate was associated with statistical and clinical improvement of ADHD symptoms. In a recent analysis96 of US prescribing patterns, long-acting medications were still being used more commonly to treat ADHD in children and adolescents (78%) than in adults (49%), though adults may have even greater problems with treatment adherence and drug abuse and diversion than those ≤18 years of age. It briefly addresses prevalence, diagnostic and differential.Adhd treatment is just as important for adults as it is for children. Due to different presentation, comorbidities, and the need to establish long-term, continuous symptoms, many primary care physicians are hesitant to diagnose and treat adult ADHD. Insufficient data on the interaction between ADHD and comorbidities impedes proper diagnosis and treatment.
Patients with ADHD may have episodic-like deterioration in functioning because living with ADHD is characterized by developmental hurdles, variable performance, and reactivity. Once again, educating the patient about the course of the disorder and strategies for evaluating treatment response should increase the likelihood of a successful strategy even if the initial treatment choice is not successful. The idea that there is actually a neurobiologically-based diagnosis that offers an explanation for a variety of these problems can be quite powerful, and this recognition can add a very important dimension to evaluating and treating adults with ADHD. So, if the dose has to continuously be increased, it is important to consider the possibility that the patient is only a partial responder to the medication being used, and try a different medication.
A self-awareness of symptoms can be difficult for people who have lived most of their lives with the illness. Alternative medications offer options to those patients with stimulant intolerance or special clinical circumstances such as active substance abuse.
I guess pulling together info from diverse sources can be pretty challenging for someone with add. Stimulant medications include methylphenidate and its derivatives, like.Psychological treatments for adhd in adults include education about the illness, participation in an adhd support group, and skills training on a variety of topics. Flagrant disregard of authority is often alternatively perceived by adult psychiatrists as narcissistic or grandiose.
Although the answers currently remain unknown, sleep research remains relevant to assessment and treatment of ADHD in adults. This is a distinct group of patients who would be difficult to identify in most adult settings.
These measures are designed to provide a cross check on the mental status to improve comfort and confidence in recognizing when a case is complex to assist in identifying possible comorbid conditions that could represent a contraindication to treatment.
It also suggests that the way adults are likely to experience themselves and rate their level of improvement is different than in children. It may be possible to use another medication equally or more effectively, and at a lower dose. Food and Drug Administration-approved pharmacologic treatments for adult ADHD include stimulants, dexmethylphenidate, and the nonstimulant atomoxetine. For example, data from long-term studies of treatment response in adults with ADHD suggest there may be incremental improvement over time. Education of patients and their families is an important facet of treatment that can improve adherence and optimize outcome. However, clear and distinct rules for differential diagnosis, establishment of comorbidity, and evidence-based guides to treatment and sequence of treatment remain controversial.
Pharmacologic therapy includes short- and long-acting stimulants as well as second-line nonstimulant medications.
Short-acting stimulants may be inconvenient and have the potential for diversion and misuse.
Short-acting stimulants are likely to result in poorer adherence and have a higher risk for diversion or abuse.
New treatments on the horizon may offer options better fitting the needs of adults with ADHD.
Risk of abuse is a major concern; stimulant treatments are controlled substances, and children with ADHD show increased risk of substance abuse.

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