Attention-Deficit/Hyperactivity
Disorder in Adults
George E. Tesar and Raul J. Seballos
P S Y C H I AT R Y A N D P S Y C H O L O G Y
DEFINITION AND ETIOLOGY
Attention-deficit/hyperactivity disorder (ADHD) is the current diag-
nosis for what was previously labeled minimal brain damage, minimal
brain dysfunction, hyperkinetic impulse disorder, and hyperactive child
syndrome.1 Contrary to popular belief, at least 60% of children with
ADHD continue to exhibit features of the disorder during adult-
hood. ADHD in adults is associated with significant psychiatric mor-
bidity and higher than average rates of divorce, unemployment,
substance abuse, and motor vehicle accidents.2 Poor adjustment and
performance can have an erosive effect on self-esteem, leading to
clinically significant anxiety or depression, or both, which are often
S E C T I O N  11 
the presenting features of adult ADHD in the primary care setting.
PREVALENCE AND RISK FACTORS
ADHD is a neurobiologic disorder with strong genetic determinants.
Strict application of diagnostic criteria has been associated with a
mean prevalence of 5% to 7% across studies of children and adoles-
cents.3 Approximately 60% to 70% of affected children transition
into adulthood with some or all of the signs and symptoms of the
disorder.3
Family and genetic studies have shown ADHD to be the most
heritable of psychiatric disorders.4 Results from the National Comor-
bidity Survey Replication estimated a 4.4% prevalence of current
ADHD in the U.S. adult population.5 There was a high rate of psy-
chiatric comorbidity in ADHD adults: 38% had a mood disorder,
47% had an anxiety disorder, 15% had a substance-use disorder, and
nearly 20% had an impulse-control disorder. The odds of having
both ADHD and another disorder were highest for drug dependence
(odds ratio [OR], 7.9), dysthymia (OR, 7.5), and bipolar disorder
(OR, 7.4).5
PATHOPHYSIOLOGY AND NATURAL HISTORY
A variety of neurochemical and neuroanatomic deficits have been
associated with ADHD.1,6,7 Studies employing structural neuroimag-
ing point to an absence, in persons with ADHD, of the frontal lobe
asymmetry seen in normal controls1; in control subjects (no ADHD),
the right frontal lobe tends to be larger than the left. Structural and
functional neuroimaging studies have demonstrated decreased func-
tion and size of the prefrontal cortex, anterior cingulate, caudate
nucleus, and cerebellar vermis in ADHD children, and most (but not
all) studies demonstrate this deficit on the right.6-8
Candidate gene selection is based on the hypothesis that deficient
dopamine availability contributes to ADHD. Genes studied include
those relevant to production of proteins involved in dopamine syn-
thesis (dopa decarboxylase, the enzyme responsible for conversion of
l-dopa to dopamine), inactivation (the dopamine and norepineph-
rine transporters), and degradation (catechol-O-methyltransferase)
and in dopamine receptor activity (especially the dopamine D4 recep-
tor).7 No one gene or its protein derivatives has been found to have
a consistent relation with ADHD, which suggests that like most
psychiatric disorders, ADHD is the consequence of polygenetic
influences.
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SIGNS AND SYMPTOMS
The manifestations of ADHD in adults are generally less obvious
than in children. Adults tend not to exhibit the impulsive, overactive
behavior distinctive of many ADHD children and adolescents.1,2
Common dysfunctional behavioral patterns in adults with ADHD
include task avoidance, waiting until the last moment to complete a
task, completing all but the most important tasks, and taking on new
tasks before finishing others (Table 1).2 Impatience, irritability, and
explosiveness are common as well. Common comorbidities compli-
cate the array of signs and symptoms that ADHD adults can present
with. Abnormal mood, vocational and interpersonal problems, and
substance abuse are often the problems that patients present with
when the underlying primary diagnosis is ADHD.
DIAGNOSIS
Diagnostic criteria have been developed for children and adolescents
(Box 1)9 but not specifically for adults. Despite having clinically
significant ADHD, many adults do not fulfill the threshold of six or
more criteria defined for children and adolescents. This points to the
fundamental problem of employing a descriptive nosology to define
clinical disorders. Future editions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM) will struggle with this dilemma
until the pathophysiologic mechanisms of specific psychiatric disor-
ders such as ADHD are better understood.
Figure 1 is an algorithm for diagnosing ADHD in the adult
patient. The core criteria for the diagnosis of adult ADHD is the
evidence of the disorder during childhood, symptom persistence,
and functional impairment.3 Determining whether the patient ful-
filled these criteria depends almost exclusively on the patient’s
knowledge of his or her childhood behavior and school performance.
Most adults with ADHD recall some evidence of problems related to
either inattention or hyperactivity during childhood. Trouble sitting
still, frequent fighting, temper outbursts, tendency to daydream, or
suboptimal school performance is typical. Those with clinically sig-
nificant ADHD who report successful school performance may have
compensated with higher-than-average intellectual strengths, had an
insufficiently challenging curriculum, or simply do not remember
accurately. School performance records or collateral information
from parents can be very helpful. Published questionnaires can be
used to capture the necessary information and can assist with (but
not confirm) the diagnosis (Box 2). Ultimately, however, the clini-
cian must rely on the patient’s veracity and accuracy of recall.
There is no diagnostic laboratory test for ADHD. Neuropsycho-
logical testing can be used to determine whether or not a learning
disability is present (e.g., dyslexia), but it cannot confirm the diag-
nosis of ADHD (by definition, not a learning disability). Although
neuroimaging and genetic testing offer attractive diagnostic
potential, they are not sufficiently specific or sensitive for routine
clinical use.
The difficulty of diagnosing ADHD in adults results largely from
the nonspecificity of this behavior-symptom complex. Compound-
ing the lack of specificity, many adults with long-standing undiag-
nosed and untreated ADHD develop secondary mood, anxiety, or
 Attention-Deficit/Hyperactivity Disorder in Adults 1007

Table 1  Common Dysfunctional Behavior Patterns in Adults with ADHD

Behavior Description Short-Term Gain and Long-Term Loss

Anticipatory avoidance Magnifying the difficulty of a pending task and doubts Defers short-term stress but often creates a self-fulfilling
about being able to complete it prophecy because the task looms ahead and can seem
Results in rationalizations to justify procrastination overwhelming when facing a deadline

S E C T I O N  11 
Brinkmanship Waiting until the last moment (e.g., the night before) to Deadline-associated stress can be focusing, but this tactic
complete a task, often when facing an impending leaves little room for error and can yield a substantial result
deadline

Pseudoefficiency Completing several low-priority, manageable tasks (e.g., Creates sense of productivity by reducing items on a to-do
checking e-mail) but avoiding high-priority tasks (e.g., a list but defers a more difficult project
project for work)

 
Juggling Taking on new, exciting projects and feeling busy without It is easier to become motivated to start a novel project than

P S Y C H I AT R Y A N D P S Y C H O L O G Y
completing projects already started to complete an ongoing one
Pattern usually results in several incomplete projects

ADHD, attention-deficit/hyperactivity disorder.

Adapted with permission from Rostain AL, Ramsay JL: Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry 2006;5:13-27.

Box 1  Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Diagnostic Criteria ● Runs about or climbs excessively in situations where these activities are
● Meets symptom criteria considered inappropriate; in adolescents or adults, this feature may be
● Some inattention or hyperactivity-impulse symptoms causing impair- limited to subjective feelings of restlessness
ment are present before age 7 years ● Has difficulty in playing or engaging in leisure activities quietly
● Some impairment from symptoms present in two or more settings (e.g., ● Is on the go or acts as if driven by a motor

home, school or work, social) ● Talks excessively

● Clear evidence of clinically significant impairment in social, academic,

or occupational functioning Impulsivity

● Blurts out answers before questions are completed
Symptom Criteria ● Has difficulty awaiting turn (impatient)
At least six symptoms of inattention or at least six symptoms of hyperac- ● Interrupts or intrudes on others (e.g., butts in on conversations, games)

tivity or impulsivity have persisted for at least 6 months and occur often
enough to be maladaptive and inconsistent with developmental level.
Inattention
● Fails to pay close attention to details or makes careless mistakes in
Exclusion Criteria
● Symptoms do not occur exclusively during course of a pervasive devel-
opmental disorder, schizophrenia, or psychotic disorder.
● Symptoms are not better accounted for by another mental disorder

schoolwork, work, or other activities
● Has difficulty sustaining attention in tasks or play activities
● Does not seem to listen when spoken to directly
● Does not follow through on instructions and fails to finish schoolwork,
chores, or work duties (not due to oppositional behavior or failure to
understand)
● Has difficulty organizing tasks and activities
● Avoids, dislikes, or is reluctant to engage in tasks requiring mental
effort (e.g., schoolwork, homework)
● Loses things necessary for tasks or activities (e.g., written instructions,
school assignments, textbooks, pencils, tools, toys)
● Is easily distracted by extraneous stimuli
● Is forgetful in daily activities
Hyperactivity
● Fidgets with hands or feet and squirms in seat
● Leaves seat in classroom or other situations where remaining seated is
expected
(e.g., mood disorder, anxiety disorder, dissociative disorder, personality
disorder).
Situational Notes
Symptoms might not be observable when the patient is in highly struc-
tured or novel settings, engages in interesting activity, receives one-
on-one attention or supervision, or is in a situation with frequent
rewards for appropriate behavior.
Symptoms typically worsen in situations that are unstructured, minimally
supervised, or boring or that require sustained attention or mental
effort.
In adolescents (or adults), symptoms include restlessness (rather than
hyperactivity, as seen in children), impaired academic performance,
low self esteem, poor peer relations, and erratic work record.

Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association,
2000.

substance-use disorders, alone or in combination, that become the DIFFERENTIAL DIAGNOSIS

focus of clinical attention and obscure detection of the more funda-
mental problem with attention. The National Comorbidity Survey
Replication showed that many adults with ADHD are receiving treat-
ment for other comorbid mental or substance-use disorders but not
for ADHD.5
Virtually any type of distress, regardless of the cause, can interfere
with normal attention. Therefore, the feature that distinguishes
ADHD from other causes of inattention is a lifelong pattern of
the behavior-symptom complex. When this criterion is not met,

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 1008 Attention-Deficit/Hyperactivity Disorder in Adults

Figure 1  Algorithm for assessing and

1a. If patient reports, alludes to, or exhibits treating attention-deficit/hyperactivity
signs or symptoms in one of the three categories . . . disorder (ADHD).  y/o, years old.

Affective Behavioral Cognitive

P S Y C H I AT R Y A N D P S Y C H O L O G Y

• Depressed mood • Restlessness • Forgetfulness

• Anxiety • Impatience • Poor memory
• Frustration • Poor work or school • Trouble paying
performance attention
• Alcohol or drug abuse • Poor self esteem

1b. . . . inquire about symptoms in the other categories.

Are they consistent with a diagnosis of ADHD (Box 1)?

Yes No

3. ADHD symptoms have been 3a. Consider alternative

present since 7 y/o or younger No diagnoses (Table 2)
 

Yes ?
S E C T I O N  11 

3b. Obtain collateral 3b. Confirms ADHD

No
information symptom-onset in childhood
Yes

4. Inquire about family history of documented ADHD or symptoms, cognitive

patterns, or behaviors suggestive of ADHD in family members (including parents,
grandparents, aunts, uncles, cousins)

5. Have patient complete ADHD Does not 6a. Re-evaluate patient’s

questionnaire (Box 2) support responses to previous questions
ADHD

Supports 6b. Propose treatment for ADHD

ADHD (see Figure 2)

Box 2  Rating Scales Used in Diagnosing Attention-Deficit/Hyperactivity Disorder

Adult ADHD Self-Report Scale (AASRS) Symptom Checklist
PDF available at http://www.med.nyu.edu/psych/assets/adhdscreen18.pdf
(accessed March 20, 2009).
Barkley ADHD Behavior Checklist for Adults
In Barkley RA (ed): Attention-Deficit Hyperactivity Disorder: A Hand-
book for Diagnosis and Treatment, 3rd ed. New York, Guilford Press,
2006.
Conners’ Adult ADHD Rating Scales (CAARS)Available for purchase from
http://www3.parinc.com/products/product.aspx?Productid=
CAARS# (accessed March 20, 2009).
Wender-Utah Rating Scale (WURS)Available at http://168.144.150.122/
Wender%20Utah%20Rating%20Scale%20checklist.pdf (accessed
March 20, 2009).

ADHD, attention-deficit/hyperactivity disorder.

other diagnoses must be considered (Table 2). Adults with ADHD
are at greater risk for having or developing mood, anxiety, and
substance-use disorders.5 Accurate diagnosis of these disorders
and determining whether they are comorbid or secondary to
ADHD have important implications for treatment selection and
prognosis. Successful treatment of a comorbid disorder reduces
symptom burden, but it does not affect the symptoms and behav-
ior of ADHD. On the other hand, successful treatment of ADHD
can result in improvement of secondary anxiety, depression, or
substance abuse. Certain disorders that are commonly associated
with or have features that can mimic ADHD are listed in
Table 2.

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 Attention-Deficit/Hyperactivity Disorder in Adults 1009

Table 2  Differential Diagnosis of Attention-Deficit/Hyperactivity Disorder

Diagnosis DSM IV-TR Feature(s) Shared with ADHD

Mood Disorders
Major depression 296.2-3 Trouble concentrating; trouble initiating and completing tasks

Dysthymia 300.4 Trouble concentrating; trouble initiating and completing tasks

S E C T I O N  11 
Depression NOS 311 Trouble concentrating; trouble initiating and completing tasks

Bipolar disorder 296.4-6 Distractability, hyperactive behavior

Cyclothymia Distractability, hyperactive behavior

 
Anxiety Disorders

P S Y C H I AT R Y A N D P S Y C H O L O G Y
Generalized anxiety disorder 300.02 Inattention, distractability

Social anxiety disorder 300.23 Performance anxiety, task avoidance (especially tasks performed in front of others), unsatisfying
social interaction

Obsessive-compulsive disorder 300.3 Repetitious activity

Anxiety disorder NOS 300.00 Inattention, distractability

Substance-Use Disorders
Nicotine dependence 305.10 Poor job performance and socialization

Commonly comorbid with ADHD

Alcohol abuse or dependence 305.0/303.90 Poor job performance and socialization

Commonly comorbid with ADHD

Cannabis abuse or dependence 305.20/304.30 Poor job performance and socialization

Commonly comorbid with ADHD

Impulse-Control Disorders
Intermittent explosive disorder 312.34 Impulsivity, aggression

Impulse control disorder NOS 312.30 Impulsivity, trouble with task completion

Learning Disorders
Learning disorder NOS 315.9 History of poor school and job performance

Early onset dementia 290.10 Poor attention, forgetfulness

Mild MR 317 Trouble with learning, reading, attention

Personality Disorders
Borderline personality disorder 301.83 Impulsivity, aggression

Antisocial personality disorder 301.7 Impulsivity, aggression, history of poor school and job performance

ADHD, attention-deficit/hyperactivity disorder; DSM IV-TR, Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision; MR, mental retardation;
NOS, not otherwise specified.

TREATMENT
Figure 2 is a management algorithm. Optimal treatment of adult
ADHD invariably requires pharmacotherapy. Adding life-skills
coaching or cognitive-behavioral therapy, or both, in either indi-
vidual or group settings can further improve outcome, but by them-
selves they are generally insufficient. Partners and family members
can benefit from better understanding of the impact of ADHD on
the patient’s behavior and interpersonal style.2
Baseline measures of weight, heart rate, and blood pressure
should be obtained before starting stimulant or nonstimulant medi-
cation. The patient with a history of cardiovascular abnormalities, in
particular structural heart disease (e.g., idiopathic hypertrophic sub-
aortic stenosis) should avoid stimulant medication in favor of a
nonstimulant agent such as atomoxetine, bupropion, or modafanil.
Treatment of such patients should involve close collaboration with
an internist or cardiologist.
Medications
The standard of care for adults has evolved largely from studies in
children, and the medications used in adults are the same as those
used in children and adolescents with ADHD (Table 3).

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 1010 Attention-Deficit/Hyperactivity Disorder in Adults

Figure 2  Treatment algorithm for

1. Educate patient about rationale and scope of treatments for ADHD patients who meet diagnostic criteria for
attention-deficit/hyperactivity disorder
(ADHD).  CNS, central nervous system;
2. Does patient prefer nonpharmacologic approach to treatment? BP, blood pressure; CNS, central nervous
system; HR, heart rate.
P S Y C H I AT R Y A N D P S Y C H O L O G Y

No Yes

2a. Is patient a poor candidate for CNS 2b. Provide limited coaching or refer
stimulant use because of: to therapist skilled in
• Cardiovascular disease? cognitive-behavioral therapy
• Current or past substance abuse?
• History of stimulant intolerance?
• Personal preference for nonstimulant Yes
medication?

No
Obtain baseline weight,
heart rate, and blood pressure

HR>110 or BP>140/90?
 
S E C T I O N  11 

No Yes

3b. Prescribe
nonstimulant
3a. Prescribe a 4. Follow-up office visit every 2–4 weeks until (e.g., atomoxetine,
CNS stimulant stable dose is achieved. Medication modafanil, is
(Table 3) adjustments can be made by telephone or bupropion)
e-mail between office visits if necessary. (Table 3)

Effective? Effective?
Continue treatment
No Yes and see every 1– Yes No
3 months

5b. Consider trial of CNS

stimulant with approval of
cardiologist or internist.

Central nervous system (CNS) stimulants such as dextroamphet- Onset of Effect

amine, methyphenidate, and dexmethylphenidate are the drugs of
choice for ADHD in both children and adults. Their therapeutic
effect is associated with enhancement of central dopaminergic and
noradrenergic activity.1 CNS stimulant compounds augment synap-
tic catecholamine concentrations by triggering presynaptic release of
dopamine (and to a lesser extent norepinephrine) and also by block-
ing their reuptake.7 Drugs that influence both dopaminergic and
noradrenergic function (e.g., dextroamphetamine, methylphenidate,
dexmethylphenidate) are stimulants, and those that have less or no
impact on dopamine and more on norepinephrine are nonstimu-
lants, such as atomoxetine (Strattera). Other nonstimulant agents
whose mechanism of action in ADHD is not fully understood include
bupropion and imipramine.
Dose
The dosage of medication must be individualized by increasing
gradually to maximal benefit while avoiding side effects. These prin-
ciples hold for both stimulant and nonstimulant drugs. Clinical
experience suggests a fine line between too little and too much
medication.
Stimulant drugs have a rapid onset of effect. Clinical effects are felt
within 15 to 30 minutes of oral administration, and peak blood levels
are achieved within approximately 2 hours. It can take a week or
more, however, to achieve full therapeutic effect. Assessing the
patient’s response to medication must account for exposure to cir-
cumstances that affect attention (e.g., comorbid disorders, environ-
mental stress) and how effectively the patient monitors his or her
response to medication. The nonstimulants work more gradually
and can take days to weeks to achieve a full therapeutic effect.
The stimulants come in immediate-release and sustained-release
forms (see Table 3). Immediate-release forms last anywhere from 2
to 6 hours, necessitating 2 to 4 doses daily. Sustained-release forms
last 8 to 12 hours, permitting once- or twice-daily dosing.
Side Effects
Stimulant side effects are typically dose related and include nausea,
headache, jitteriness, tics, high blood pressure, and high heart rate.
They also have potential for abuse. Patients with baseline tachyar-
rhythmia, hypertension, or structural heart disease are at high risk

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 Attention-Deficit/Hyperactivity Disorder in Adults 1011

Table 3  Medications for Attention-Deficit/Hyperactivity Disorder

Dose* Duration
Drug Trade Name Dosage Form (mg) (mg) (h) Frequency Comments

CNS Stimulants
Dexmethylphenidate Focalin 2.5, 5, 10 5-20 3-6 tid-qid Dextroisomer of methylphenidate
Start at 50% of current daily dose

S E C T I O N  11 
to convert from methylphenidate
Focalin XR 2.5, 5, 10 10-20 8-10 qd-bid Dextroisomer of methylphenidate
Start at 50% of current daily dose
to convert from methylphenidate

Dextroamphetamine Dexedrine 5 10-30 3-6 bid-tid

Dexedrine spansule 5, 10, 15 10-30 6-8 qd-bid Dexedrine spansule

 
P S Y C H I AT R Y A N D P S Y C H O L O G Y
Methylphenidate Concerta 18, 27, 36, 54 18-54 10-12 qd The FDA-approved max dosage in
children and adolescents is
54 mg qd, but doses of
108 mg qd have been used
successfully in children and adults
Metadate ER† 10, 20 20-60 6-8 qd-bid
Metadate CD 10, 20, 30, 40, 50, 60 8-10 qd-bid
Methylin 5, 10, 20 15-45 3-6 tid-qid
5/5 mL, 10/5 mL solution
Methylin ER† 6-8 qd-bid
Ritalin 5, 10, 20 10-40 3-6 tid-qid
Ritalin SR 20 6-8 qd-bid
Ritalin LA 20, 30, 40 6-8 qd-bid Lasts longer than SR

Mixed-amphetamine Adderall 5, 7.5, 10, 12.5, 15, 20, 30 6-8 qd-bid

salts Adderall XR 5, 10, 15, 20, 25, 30 20-60 8-10 qd-bid
Vyvanse 30, 50, 70 30-100 12 qd-bid Pro-drug

Selective Norepinephrine Reuptake Inhibitor

Atomoxetine Strattera 10, 18, 25, 40, 60 40-100 24 qd-bid Better than placebo, but not as
effective as CNS stimulants in
controlled trials for ADHD

Alternative Medications‡
Bupropion Wellbutrin 75, 100 150-450 24 tid
Wellbutrin SR 100, 150, 200 150-450 24 bid
Wellbutrin XL 150, 300 150-450 24 qd

Desipramine Norpramin 10, 25, 50, 75, 100, 150 100-200 24 qd

Modafinil Provigil 100, 200 100-400 qd

ADHD, attention-deficit/hyperactivity disorder; CNS, central nervous system; FDA, U.S. Food and Drug Administration.
*The last dose is the FDA-approved maximum daily dosage in children.
†
There is no obvious difference between these two products in terms of dosage, duration, and efficacy.
‡
These agents may be effective in some instances of ADHD but have not been shown in controlled trials to be more effective than placebo. They are not approved by
the FDA for treating ADHD.

for stimulant-induced aggravation of these abnormalities. The non-
stimulant atomoxetine can cause increases in heart rate and blood
pressure, but it is far less likely to do so than stimulants are. Its most
common side effects include dry mouth, nausea, and sexual difficul-
ties. Nonstimulants have no abuse potential.
PREVENTION AND SCREENING
It is reasonable to expect that timely and effective treatment should
reduce the risk of psychosocial morbidity associated with ADHD. A
small but growing body of evidence suggests that patients with
ADHD who are treated for it have less substance abuse, better work
and academic performance, and better outcomes in general than
those who are not treated.10
If the extensive psychosocial morbidity of ADHD can be pre-
vented, then it stands to reason that it should be identified and
treated as early as possible. In fact, many adults go through life
without recognizing they have ADHD. This, as well as the complex
comorbidities (e.g., depression, anxiety, substance abuse) that often
trigger a request for help, make it difficult to detect ADHD.
Three validated patient self-report instruments are available to
screen for ADHD in adults; alternatively, they can be used to sub-
stantiate a physician’s clinical impression. The World Health Orga-
nization (WHO) Adult Self-Report Screener (ASRS) for Adult
Attention Deficit Disorder (ADD) includes six questions rated on a
scale from 0 to 4 (0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4
= very often). The maximum score is 24; the higher the score, the
more likely that ADHD is present. The Wender Utah Rating Scale

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 1012 Attention-Deficit/Hyperactivity Disorder in Adults
(WURS) was originally used as a research instrument and validated
as a screener subsequently. A score of 46 or more obtained from
adding the ratings on items 3-7, 9-12, 15-17, 20, 21, 24-29, 40, 41,
51, 56, and 59 is highly predictive of a diagnosis of ADHD. The
Conner Adult ADHD Rating Scales (CAARS) elicit self reports and
observer ratings. Further information about these scales and their
acquisition is available in Box 2.
P S Y C H I AT R Y A N D P S Y C H O L O G Y
SPECIAL POPULATIONS
Geriatric Patients
There is no age limit for the diagnosis of ADHD. Geriatric-age
patients with a diagnosis of ADHD can benefit considerably from
appropriate treatment. Older patients are more likely, however, to
have coexisting cardiovascular abnormalities that warrant careful
monitoring during treatment with stimulant medication.
Potential Substance Abusers
The challenge for the prescribing physician is to keep stimulant
medications out of the hands of persons prone to drug or alcohol
addiction. The risk of stimulant-induced substance abuse in uncom-
plicated adult ADHD is minimal. This risk liability is further reduced
by the use of long-acting agents (see Table 3). Effective treatment of
S E C T I O N  11 
ADHD should reduce the risk of substance abuse, especially when
substance abuse is secondary to ADHD. For persons with ADHD and
comorbid substance abuse or dependence, the treatment of choice
includes a nonstimulant agent such as atomoxetine, buproprion, or
imipramine. A blanket policy of refusal to prescribe CNS stimulants
to patients with a history of drug abuse, however, is ill advised. In all
cases, substance abuse must be stabilized first, and ADHD treatment
can be initiated as soon as the substance abuse is stabilized.
Patients with Cardiovascular Disease
CNS stimulant medications are relatively contraindicated in patients
with hypertension, cardiac arrhythmia, tachycardia, coronary artery
disease, and structural heart disease (e.g., idiopathic hypertrophic
subaortic stenosis). Nonpharmacologic therapies or nonstimulant
medications should be tried first in such patients. If these are inef-
fective, however, and the fully informed patient desires a trial of
stimulant medication, it should be prescribed with careful monitor-
ing in conjunction with the supervision of a cardiologist or internist
to minimize the risk of adverse outcome.
Epileptic Patients
CNS stimulants do not cause a clinically significant reduction in
seizure threshold and therefore can be used safely in patients with
epilepsy.
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Pregnant Women
All CNS stimulant drugs are listed as class C and should therefore be
avoided if possible during pregnancy.
Summary
l Adult attention-deficit/hyperactivity disorder (ADHD) is a
familial disorder with first manifestations before age 7
years.
l At least 60% of children with ADHD continue to exhibit
clinically significant features of the disorder as adults.
l ADHD is among the most heritable of psychiatric disorders.
l Undiagnosed or untreated ADHD is associated with
significant morbidity, including higher-than-expected rates
of maladaptive behavior, family problems including
divorce, problematic employment, substance abuse, motor
vehicle accidents, and secondary mood and anxiety
disorders.
l The primary treatment for adult ADHD is a
methylphenidate- or amphetamine-based compound
supplemented when necessary with structured, skills-based
cognitive-behavioral therapy.
Suggested Readings
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor-
ders, 4th ed, text rev. Washington, DC: American Psychiatric Association, 2000.
Barkley RA: Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and
Treatment, 2nd ed. New York: Guilford Press, 1998, pp 3-55.
Biederman J, Safren SA, Seidman LJ, et al: ADHD: Applying practice guidelines to
improve patient outcome and executive function. J Clin Psychiatry 2006;67:2014-
2025.
Hudziak JJ, Derks EM, Althoff RR, et al: The genetic and environmental contributions
to attention deficit hyperactivity disorder as measured by the Conners’ Rating
Scales-Revised. Am J Psychiatry 2005;162:1614-1620.
Kessler RC, Adler L, Barkley R, et al: The prevalence and correlates of adult ADHD in
the United States: Results from the national comorbidity survey replication. Am J
Psychiatry 2006;163:716-723.
Lamberg L: ADHD often undiagnosed in adults. Appropriate treatment may benefit
work family social life. JAMA 2003;290:1565-1597.
McGough JJ, Barkley RA: Diagnostic controversies in adult attention deficit hyperactiv-
ity disorder. Am J Psychiatry 2004;161:1948-1956.
Pliszka SR: Neuroscience for the Mental Health Clinician. New York: Guilford Press,
2003, pp 147-150.
Rostain AL, Ramsay JL: Adults with ADHD? Try medication and psychotherapy. Curr
Psychiatry 2006;5:13-27.
Vaidya CJ, Bunge SA, Dudukovic NM, et al: Altered neural substrates of cognitive
control in childhood ADHD: Evidence from functional magnetic resonance imaging.
Am J Psychiatry 2005;162:1605-1613.
References
For a complete list of references, log onto www.expertconsult.com.